Columbia ©nibergitp '^"^^ intteCitpofi^eto|9orfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/pathologytreatmeOObums THE PATHOLOGY AND TREATMENT YEI^EREAL DISEASES. BY FREEMAN J. BUMSTEAD, M.D.,LL.D., LATE PROFESSOR OF VEKEREAL DISEASBS AT THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW YORK : LATE SORGEON TO THE NEW YORK EYE AND EAR INFIRMARY ; CONSULTING SURGEON TO CHARITY HOSPITAL, ETC. ETC. FOURTH EDITION, REVISED, ENLARGED, AND IN GREAT PART REWRITTEN BY THE AUTHOR AND BY ROBERT W. TAYLOR, A.M.,M.D., PROFESSOR OF dKIN DISEASES 15 THE UNIVERSITY OF VERMONT ; ATTENDING SURGEON TO CHAKITT HOSPITAL, ETC. ETC. WITH ONE HUNDRED AND THIRTY-EIGHT WOOD-CUTS. P H I L A D E L P II I A : HENEY O. LEA 1879. Entered according to Act of Congress, in the year 1879, by HENRY C. LEA, in tlie Office of the Librarian of Congress. All rights reserved. COLLINS, P R I N T K K . PREFACE TO THE FOURTH EDITION. SixcE the publication of the hist edition of this work, the contributions to our knowledge of Venereal Diseases have been extremely numerous and important. They have included tissues of the human frame, as the brain and nervous system, which but a few years ago were supposed to be exempt from the ravages of syphilis, but which are now known to be the seat of its frequent manifestation. Additional light has been thrown upon many other affections and upon many questions of pathology, which were erroneously supposed to be exhausted. Increased interest has been awakened in this department in almost every civilized countr3^ Learned bodies, as the Pathological Society of London, have devoted session after session for months to the consideration and discussion of the more obscure forms of syphilis. Xew workers have constantly been entering the field, and the mass of material now at our disposal is simply immense. The time has gone by when a treatise upon any medical or surgical subject, giving solely the experience and views of the author, will find more than a limited number of readers. With- out undervaluing the experience of the author, both for its own sake and for the ability it gives him to weigh and sift the experi- ence of others, the chief object of the reader is to ascertain the present state of our knowledge upon the subject of which he reads. To accomplish this there must be collected for him, in a clear and acceptable form, every important fact and theory from many widely distributed sources to which he has no access, or which he would not have the time, and, possibly, not the ability to use, if he had them at hand. But in the present IV PREFACE TO THE FOURTH EDITION. instance, as now in many departments of science, the material to be collected was so scattered in various volumes of Transactions, in monographs, and in medical journals, and so many specialties had sprung up within this one specialty, that the labor involved in issuing a fourth edition of this work was recognized as formid- able, and even sufficient to afford some ground for the assertion made by one well versed in the subject, that: "In future it will be impossible to include Venereal Diseases in a single treatise ; they can only be studied and known in separate monographs." That, however, such a treatise on a level with our present knowledge was demanded by the Profession, and that, if well executed, it would not fail to meet with the same favorable reception which had been accorded to the three previous editions of this work, was never for a moment doubted by the author, whose chief embarrassment lay in the want of time and strength. Fortunately he was able to overcome this difficulty by the asso- ciation with him of a gentleman. Dr. R. W. Tajdor, of this city, who was already well known in the United States and abroad by his original contributions to our knowledge of Venereal Diseases, and who was admirably adapted, both by his own experience and by his extensive reading, to engage in a work which has occupied us conjointly for the last two years. Still further. Dr. E. G. Loring, Surgeon to the New York Eye Infirmary, who revised the Chapter on Diseases of the Eye in the last edition, kindly consented to do the same in this. We are also under great obligation to Dr. C. H. Knight for most valuable assistance rendered us in preparing the manuscript, and also for the very complete index appended to the work. As a result of these labors, the reader will find rather a new work than an old one revised, more portly in its dimensions than the last edition by 131 pages, but, as a reduced size of ty})e has been employed, the volume is estimated to contain about one-half more reading matter than its predecessor. There is not a chapter in the book which has not been revised and the attempt made to bring it up to our present knowledge. Entirely new chapters have been called for to include affections until recently unknown, PREFACE TO THE FOURTH EDITION. V and the greater part of the work has been rewritten from our present stand j)oint. A new feature of this edition has been the introduction of chapters upon certain diseases, which, although not strictl}'' venereal, are liable to be mistaken for such, and often come under the care of the venereal specialist ; we refer particu- larly to affections of the scrotal organs and to some simple affec- tions of the skin. The number of illustrations has been largely increased. It will be seen that metric weights, as well as the ordinary troy measures, have been given in all prescriptions; and the attempt has been made, though confessedly with many errors and omissions, to follow the "Abbreviations of the Titles of Peri- odicals," adopted by Dr. Billings in the Library of the Surgeon- General's Office. FEEEMAX J. BUMSTEAD. New York, Oct. 12, 1879. CONTENTS. Introduction I'AOB 17 PART I. GONORRHOEA AND ITS COMPLICATIONS. CHAPTER I — Urkthral Gonorrhoea in the Male Preliminary cousideratious Symptoms . . ' . Causes and nature of gonorrhoea Treatment ..... Abortive treatment . Treatment of the acute stage Treatment of the stage of decline Injections ..... Copaiba and cubebs . Expectant treatment . Obstacles to success of treatment Treatment of special symptoms CHAPTER II.— Gleet Symptoms Pathology Treatment Bougies Applications by means of the endoscope Injections ..... Deep urethral injections . Blisters ..... Separation of the affected surfaces CHAPTER III.— Balanitis Causes Symptoms Complications . Diagnosis Treatment CHAPTER IV.— Phimosis Congenital phimosis Accidental phimosis Treatment Circumcision 35 35 36 40 47 48 58 56 57 63 71 73 74 78 80 81 82 84 87 91 93 95 96 97 97 98 99 100 101 104 104 106 107 110 CONTENTS. CHAPTER v.— Paraphimosis Treatment ......... CHAPTER VI — Folliculitis and Peri-Urethral Phlegmon Folliculitis ......... Peri-urethral phlegmon ....... CHAPTER VII. — Inflammation of Cowper's Glands . CHAPTER VIII. — Affections of the Corpora Cavernosa . Chronic circumscribed iuflanimation of the corpora cavernosa CHAPTER IX — Lymphangitis and Adenitis Lymphangitis . , Adenitis .... CHAPTER X.— Swelled Testicle Causes Seat Symptoms Pathological anatomy Treatment Sedatives . Pulsatilla . Blood-letting Ice . Poultices . Strapping the testicle Antimonial frictions Solution of nitrate of silve Punctures . Iodoform . Induration of the epididymis CHAPTER XL— Hydrocele . Treatment Congenital Hydrocele . Encysted Hydrocele of the Testis Hydrocele of the Spermatic Cord CHAPTER XII.— Hematocele Hematocele of the Testis Hematocele of the Cord CHAPTER XIIL— Varicocele Treatment ..... CHAPTER XIV. — Gonorrhceal Prostatitis Acute Prostatitis . Symptoms Treatment Chronic Prostatitis Treatment CONTENTS. IX PAGE CHAPTER XV — Ctstitis 178 Treatment . . • ■ . . .180 CHAPTER XVI. — Inflammation of the Vesicul.e Seminalks . . . 182 CHAPTEPi XVII. — Gonorrhceal Pepitonxtis and Sub-peritoneal Abscess IN THE Male ........... 184 CHAPTER XVIII — GONORRHCEA IN AVOMEN 186 Causes 186 Symptoms 188 Gonorrhoea of the vulva ......... 189 Gonorrhoea of the vagina ......... 193 Gonorrhoea of the uterus ......... 195 Gonorrhoea of the urethra ........ 1(»7 Complications ............ 199 Vegetations . . . . . . . . . . .199 Ovaritis ............ 199 Diagnosis ............ 2OO Treatment ............ 2OI Blood-letting ........... 201 Batos and lotions .......... 201 Sedatives ............ 202 Injections ............ 202 Separation of the diseased surfaces ....... 20-5 Hip-baths ............ 206 "Latent GoNORRHCEA TN Women" 209 CHAPTER XIX. — GoNORRHOBA OF the Rectum, Nose, and Umbilicus . .211 GoNORRHCEA OF the Rectum ......... 211 Treatment ........... 212 GONORRHCEA OF THE MoUTH ......... 212 GoNORRHCEA OF the Nose •••...... 213 Umbilical Gonoerhcea .......... 213 CHAPTER XX. — Gonorrhceal Ophthalmia 214 Frequency ............ 214 Causes . . . . . . . . . • . . .215 Symptoms ............ 217 Diagnosis ............ 220 Treatment ••••........ 220 CHAPTER XXI. — Gonorrhceal Rheumatism . 227 Causes 229 Frequency 230 Seat ■ .... 231 Symptoms 233 Diagnosis ............ 237 Treatment ............ 239 CHAPTER XXII.— Vegetations 242 Treatment 244 CONTENTS. CHAPTER XXIII.— Herpes Phogenitalis . Treatment . . . • . CHAPTER XXIV. — Strictuee of the Urethra Anatomical Considerations . Strictures .... Spasmodic stricture . Permanent or organic stricture Seat .... Number Form .... Degree of contraction Pathology of stricture Abscess and fistula Bladder Ureters and kidneys . Genital organs . Symptoms of stricture Causes of stricture . Diagnosis of strictures Exploration of the urethra Shape and size of metallic instruments Catheters . Sounds Bougies Acorn-pointed sounds and bougies Urethrometers . Introduction of the catheter Treatment of strictures Constitutional means . Dilatation . Continuous dilatation Over-distention . Internal incision Rupture Caustics External perineal urethrotomy . Consequences of operations on strictures Hemorrhage .... Curvature of the penis Urethral fever .... Treatment of retention of urine I'uncture by the rectum Puncture above the pubes . Puncture through the symphysis Opening the urethra posterior to the stricture Treatment of extravasation Treatment of urinary abscess and fistula Proposed set of urethral instruments CHAPTER XXV.— Sexual Hypochondriasis 332 CONTENTS. PART II. THE CHANCROID AND ITS COMPLICATIONS. CHAPTER I. — The Chancroid or Simple Chancre The chancroidal poison Contagion Frequency of the chancroid Seat of the chancroid The chancroid from inoculation The chancroid from contagion Development Period of progress . Stationary period Reparative stage Number of chancroids Varieties of the chancroid Diagnosis of the chancroid Prognosis of the chancroid Pathological anatomy Treatment of the chancroid General treatment Abortive treatment . Destructive cauterization Local applications PAGE 839 339 343 346 348 351 352 852 354 355 356 357 358 359 363 363 365 365 365 , 366 , 369 CHAPTEFv II. — Peculiarities Dependent dpon the Seat of Chancroids Chancroils upon the Integument of the Penis Chancroids of the Fr^num . Sub-Preputial Chancroids Urethral Chancroids .... Chancroids of the Female Genital Organs Chancroids of the Anus and Rectum CHAPTER III.— The Chancroid Complicated with E TiON and with Phagedena . Inflamjiatory OK Gangrenous Chancroid Phagedenic Chancroid .... Serpiginous chancroid Sloughing phagedenic chancroid Treatment of phagedaena . XCESSIVE InFLAMMA- 373 373 373 374 376 377 381 383 383 385 385 38G 387 CHAPTER IV. — The Chancroid Complicated with Syphilis. — " Mixed Chancre" 390 CHAPTER v.— The Simple and Virulent Bubo 394 Frequency of buboes ......... 394 Seat of buboes ........... 395 The Simple Bubo 397 XU CONTENTS. PAGE The Virulent Bubo .......... 'iW Complications ..... ...... 404 " Bubon d'embl6e" .......... 405 Diagnosis of buboes .......... 406 Treatment of buboes .......... 407 Abortive measures .......... 408 Methods of opening buboes . . . . . . . .410 CHAPTER VI.— Ltmphitis 416 Simple Lymphitis . . . . . . . . . . .416 Virulent Lymph]tis .......... 416 PART III. SYPHILIS. CHAPTER I. — Introductory Remarks 419 Syphilitic Virus . . . . . . . . . .419 Syphilis commonly occurs but once in the same Person . . . 420 Syphilis possesses a period of Incubation ...... 423 The Order of Evolution of Syphilitic Symptoms, and the Classifica- tion founded thereon ......... 423 The Sources of Syphilitic Contagion ....... 429 The Modes of Syphilitic Contagion ....... 432 General Syphilis always follows a Chancre ..... 484 Syphilis pursues essentially the same course, whethf.r dkrived from a Primary or Secondary Lesion ; in the latter case, as in the FORMER, the INITIAL LESION IS A CHANCRE ...... 436 Syphilis has a Second Period of Incubation, which, although subject TO SOME Variation, is not Indefinite in its Duration . . . 437 CHAPTER II.— The Nature of Syphilis 439 CHAPTER III. — The Initial Lesion of Syphilis, or Chancre . . . 446 Seat of chancres ........... 445 Incubation of the chancre ......... 446 Symptoms ............ 448 Multiple herpetiform chancres ........ 450 Anomalous appearance ......... 450 Infecting balano-posthitis ......... 451 Induration of the chancre . . ...... 461 Relapsing induration ......... 466 Secretion ............ 456 Duration ............ 457 Termination ........... 457 Number of chancres ......... 458 Phagedsena 458 Condition of neighboring ganglia . 459 Diagnosis of the chancre 459 CONTENTS. Xlll PAGE Pathological anatomy 4(32 Treatment 466 Excision ............ 467 General treatment .......... 469 CHAPTER IV.— Special Indications FROM THE Seat OF Chancres . . 471 Chancres of the Urethra ......... 471 Chancres of the Anus .......... 472 Extra-Genital Chancres 473 Chancres of the Fingers ......... 473 Chancres of the Lips .......... 474 Chancres of the Buccal Cavity ........ 474 Chancres in the Female ......... 475 Of the fourchette and the vestibule ....... 47G Of the breast 477 Of the uterus 478 CHAPTER V. — Induration of THE Ganglia AND OF the Lymphatics . . 479 Induration of the Ganglia ......... 479 Its constancy ........... 479 Its seat 481 Time of its appearance ......... 482 Its course and termination ........ 483 Induration of the Lymphatics ....... 485 Treatment of induration of the ganglia and lymphatics . . . 486 CHAPTER VI.— State OF THE Blood; Stphilitic Fever; Affections of the Distant Lymphatic Ganglia ........ 487 State of the Blood .......... 487 Syphilitic Fever ........... 488 Affections of the Ganglia ......... 490 Engorgement of the superficial ganglia ...... 490 Deep lymphatic ganglia ......... 492 CHAPTER VII. — Cachexia, Chloro-an^emia, Asthenia .... 493 CHAPTER VIII.— Influence of Syphilis upon the Constitution . . 496 Influence of Syphilis upon Dibea.ses in General ..... 498 On acute diseases . . . . . . . . . . 498 On chronic diseases .......... 498 Influence of Syphilis upon Traumatism ...... 500 CHAPTER IX.— Prognosis of Syphilis 502 CHAPTER X. — Irritability of the Skin and Mucous Membranes. Changes in the Sensibility of the Skin ........ 507 CHAPTER XL— The Syphilides . General remarks upon Their course Absence of itching and pain Polymorphism . Color and pigmentation Tendency to assume a circular form lufluence of mercury 509 509 511 511 512 512 512 513 XIV CONTENTS. Influence of intercurrent diseases on the course of s Unusual modes of evolution The localization of the syphilides Characters of the scales and crusts Peculiarities of ulcers and cicatrices Odor of certain syphilitic lesions General hints in diagnosis . The Erythematous Syphilide Coexisting lesions and symptoms Diagnosis ..... The Papular Syphilides The miliary papular syphilide . The lenticular papular syphilide The small flat papular syphilide Mode of distribution . Coexisting symptoms and lesion Diagnosis . The large flat papular syphilide Prognosis . Diagnosis . Scaling papular syphilide of the palms and sole The Pustular Syphilides The acne-form syphilide . Prognosis . Diagnosis , The variola-form syphilide The impetigo- form syphilide The ecthyma-form syphilide Rupia .... The Bullous Syphilide . The Tubercular Syphilide . Diagnosis .... The Gummous Syphilide The Serpiginous Syphilide . The Pigmentary Syphilide . Malignant Precocious Syphilides Spontaneous Gangrene in the Course of Syphilis Local Treatment of the Syphilides philides page 513 514 514 514 515 515 516 516 518 519 520 520 522 522 522 525 525 525 528 528 529 631 632 533 533 634 536 638 641 643 544 548 549 555 568 559 562 563 CHAPTER XII. — Cutaneous Hemorrhage in Syphilis. 507 CHAPTER XIII. — Certain Simple Cutaneous Affections of the Genitals Eczema of the Scrotum and Penis Tinea Circinata Inguinalis . Scabies ...... Phtheiriasis Pubis Tinea or Pityriasis Versicolor . Lupus Erythematosus of the Penis 509 669 570 671 572 573 675 CHAPTER XIV. — Affections of the Appendages of the Skin Affections of the Hair ....... Affections of the Nails ...... 570 570 578 CONTENTS. XV PAGE CHAPTER XV. — General Remarks upon Affections of Mucous Membranes 583 Erythema ............ 683 Mucous Patches ........... 584 Treatment 589 CHAPTER XVI. — Affections of the Organs of Digestion .... 591 The Mouth 591 Erythema 591 Mucous patches . . . . . . . . . .591 Papules and vesicles . . . . . . . . • . 591 The Tongue 592 Sclerosis ............ 593 Superficial .......... 593 Deep 593 Gummata ........... 593 Superficial .......... 593 Deep . . . . . . • 593 Sublingual Gland ........... 595 Necrosis of the Maxillary Bones ....... 595 Gummy Tumor on the Soft Palate ....... 590 The Pharynx 598 Treatment of Lesions of the Mouth and Pharynx .... 599 The (Esophagus 601 Stomach and Intestines ......... 603 The Rectum ............ 605 The Liver 609 Chronic interstitial hepatitis ........ .609 Gummata ........... 610 Amyloid degeneration . . . . . . . . .611 The Spleen 612 Enlargement . . . . . . . . . . .612 Gummata 613 The Pancreas ........... 614 CHAPTER XVII. — Affections of the Organs of Respiration . . . 615 The Nose 615 Treatment of lesions of the nose ....... 616 The Larynx 616 Erythema 619 Superficial ulcerations ......... 619 Mucous patches ..... ..... 620 Deep ulcerations .......... 621 Gummy tumors .......... 622 Perichondritis ........... 622 Caries 622 Syphilitic aphonia 623 The Trachea ............ 623 Treatment of lesions of the larynx and trachea ..... 624 The I'.ronchi 625 The Lungs 626 Interstitial pneumonia ......... 626 Gummy tumors .......... 626 XVI CONTENTS. PAGE CHAPTER XVIII. — Affkctions of thr Organs of Circulation . . . 6^0 The Heart ............ 630 The Bloodvessels 631 CHAPTER XIX. — SECONrMRY and Tertiary Affections of the Genito- urinary Organs 633 Syphilitic Epididymitis . . . . . ' . . . . . 633 Syphilitic Orchitis . 633 Symptoms ........... 634 Pathological anatomy ......... 635 Diffused form ..... ..... 636 Circumscribed form ......... 636 Diagnosis 636 Treatment 638 Affections of the Vasa Deferentia the Vesicul^ Seminai.es, and the Prostate ........... 638 Affections of THE Penis ......... 639 Affections of the Ovaries. Fallopian Tubes, Uterus, and Vagina . 640 Exulcerative hypertrophy of the neck of the uterus .... 640 Affections of the Kidneys . ........ 641 Interstitial nephritis ......... 641 Gummy tumors . . ........ 642 CHAPTER XX — Affections of the Nervous System Predisposing causes . Affections of the Neighboring Bones Affections of the Dura Mater Affections of the Arachnoid and Pia Mater Affections of the Brain and Cord Affections of the Arteries . Affections of the Nerves Cerebral Syphilis sine Materia Prodromal Symptoms Syphilitic Tumors of the Nervous Meningeal Symptoms Syphilophobia Hemiplegia .... Syphilitic Epilepsy Syphilitic Paraplegia . Aphasia ..... Locomotor Ataxia . Chorea ..... Pseudo-general Paralysis Treatment System 643 644 644 645 645 646 640 649 651 651 653 654 656 656 658 659 660 661 661 6f51 662 CHAPTER XXL — Syphilitic Affections of the Muscles and their Acces- sories ............ 664 Diffuse form. Muscular contraction ....... 664 Muscular tumors .........; 666 Contraction of the jaws ......... 669 Affections of the Tendinous Sheaths and of the Tendons and Aponeu- roses ............ 668 Affections of the Bues^e ......... (J69 CONTENTS. XVll PAGE CHAPTER XXII. — Affections OF THE Fingers AND Toes. Dactylitis Syrni- LITICA 671 CHAPTER XXIII. — Affections of the Bones, Cartilages and Joints Late Osseous Affections luflammatory form. Osteo-periostitis Exostoses ..... Gummy form. Osteomyelitis . Dry caries ..... Syphilitic cicatrices in bone Treatment ..... Affections of the Cartilages Affections of the Joints Arthralgia ..... Synovitis ...... Synovitis of the early stage Synovitis of the late stage CHAPTER XXIV.— Affections of the Eyes Affections of the Bones of the Orbit . Affections of the Lachrymal Passages Affections of the Lachrymal Glanu Affections of the Eyelids . Syphilitic ulcerations Affections of the Conjunctiva Affections of the Cornea Affections of the Sclera Syphilitic Iritis .... Simple or plastic iritis Serous iritis .... Parenchymatous or suppurative iriti Infantile iritis .... Spongy iritis .... Affections of the Lens . Affections of the Ciliary Body . Choroiditis ..... Plastic choroiditis Serous choroiditis Parenchymatous choroiditis Retinitis ..... Affections of the Optic Nerve Affections of the Vitreous . Paralysis of the Nerves of the Eye Hereditary Syphilis of the Eye . CHAPTER XXV.— Affections OF THE Ear . External ear ...... Middle ear ...... Internal ear ...... Sudden Deafness prouuckd by Syphilis Deafness due to Syphilitic Affections of the Brain Diseases of the Ear in the Subjects of Congenital Syphilis B CONTENTS. CHAPTER XXVI.— Herkditakt Syphilis . The Duration and Progress of Hereditakt Syphilis The Process of Procreation . Influence of the father Influence of the mother Infection of the child at birth Infection by the semen of syphilitic men Invasion and Evolution of Hereditary Syphilis Eruptions of Hereditary Syphilis The erythematous sypbilide, or roseola The papular syphilide and condylomata lata The vesicular sypbilide The pustular syphilide Furuncular eruptions The bullous syphilide — Pemphigus The tubercular syphilide . Gummata and gummatous ulcers Affections of the Mucous Membranes Mucous patches of the mouth . Gummatous infiltrations . Affections of the Larynx Affections of the Lungs Affections of the Peritoneum Affections of the Alimentary Canal Affections of the Liver Affections of the Spleen Lesions of the Pancreas Affections of the Kidney Affections of the Supra-renal Capsules Affections of the Testicle Morbid anatomy Affections of the Synovial Sheaths Affections of the Nails — Onychia Affections of the Hair . Affections of the Thymus Gland . Affections of the Lymphatic Ganglia The Condition of the Blood . Lesions of the Umbilical Vein Affections of the Circulatory Organs Hemorrhagic Syphilis in New-born Children Affections of the Bones Osteo-chondritis Periostitis .... Dactylitis syphilitica Swellings of the metacarpal and metatarsal bon Affections of the Joints Affections of the Nervous System Treatment of Hereditary Syphilis CHAPTER XXVII. — Affections of the Placenta Macroscopic appearances .... Microscopic appearances . . . . Predisposing causes ..... CONTENTS. XIX PAGE CHAPTER XXVIII.— Treatment of Syphilis 787 Hygiene and Tonics .... 788 Meecdkials ...... 790 Fumigation .... 795 Inunction 798 Mercurial suppositories . 799 Hypodermic injections 799 Effects of Mercury .... 803 Duration of treatment 808 Iodine and its Compounds 810 Iodoform 816 Nitric Acid and Gold .... 817 Vegetable Decoctions and Infusions 817 Tayuya 818 Balneotherapia 818 Climatic Influences .... 820 Syphilization 820 LIST OF ILLUSTEATIONS FIG. 1. 2. 3. 4. 6. 6. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. Urethral syringe .... Urethral syringe, No. 1, A Hacker's urethral syringe " Peerless syringe" .... Urethral syringe with extra long pipe Otis's cold-water coil Urethral polypus .... Lacuna magna ..... Cupped sound ..... Griinfeld's endoscopic tubes Swab-holder ..... Blower and pencil for local applications Scissors for removal of polypi . Forceps for urethral polypi D^sormeaux's endoscope . The same modified by Denis Endoscope with gaslight attachment Prof. Auspitz's dilating urethroscope Dick's catheter-syringe Guyon's injector .... Bumstead's syringe for deep injections Tiemann's " universal sj'ringe". Gangrene of prepuce, with glans penis button-holed Nelaton's phimosis forceps Taylor's phimosis scissors and syringe Henry's phimosis forceps . Operation of circumcision Horteloup's forceps for the flaps Head of penis after first incision Method of introducing sutures . Paraphimosis ..... " Sub-preputial frill" Method of reducing .... Follicular abscess of urethra . Abscess on one side of friBnum Abscess divided by frrcnum into two lobes Abscess at peno-scrotal angle . Vertical section of testis and epididymis Miliano's compressive suspensory Morgan's suspender for varicocele . Weir's varicocele spring . Henry's scrotal clamp PAGE 48 49 40 49 50 75 81 82 88 88 88 88 89 89 90 91 93 94 94 94 99 108 109 110 110 111 112 112 114 115 116 121 122 122 123 140 150 ]t;5 1(16 168 LIST OF ILLUSTRATIONS. 48, 44. 45. 46. 47 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 69. 60. 61. 62. 63. 64. 65. 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. 76. 77. 78. 79. 80. 81. 82. 83. 84. 85. 86. 87. 88. 89. 90. 91. 92. 93. 94. 95. 96. 97. etc. , Sebaceous vulvitis Inflamed vulvo-vaginal gland Foster's vaginal douche . t Ophthalmic gonorrhoea . Collyrium-dropper . Bladder and urethra laid open Fossa navicularis with lacuna magna Vertical section of pelvis showing fasciie . Horizontal section of pelvis showing fascise Buck's fascia ...... Vertical section of bladder, penis and urethra Thompson's diagram showing seat of strictures Annular stricture Tortuous stricture Strictures near meatus Diagram showing curves of sounds, Charrifere-filiere Millimetre gauge Handerson's catheter gauge Compound male and female catheter Jaques's catheter Olis's prostatic guide Prostatic catheter Squire's vertebrated catheter . French flexible bougie and catheter Fine whalebone bougies . Acorn-pointed sounds Curved acorn-pointed sounds Acorn-pointed bougies Meatometer .... Pilfard's *' fossal bougies a boule" Otis's urethrometer . Weir's urethrometer ... First step in introducing catheter Second step in introducing catheter Thompson's instrument for over-distention Canulated staff. Filiform bougie with screw-head Bumstead's tine catheter with filiform Civiale's concealed bistoury Meatotome Dick's sonde-tourniquet . 1 Sections of the penis showing position of the urethra in the corpus spon- -bougie attachment giosum J Bumstead'e modification of Maisonneuve's urethrotome Voillemier's urethrotome . Otis's dilating urethrotome. No. 3 Otis's dilating urethrotome, No, 4 Civiale's urethrotome Holt'a rupture-instrument modified LIST OF ILLUSTRATIONS. FIO. 98. 99. 100. 101. 102. 103. 104. 105. 106. 107. 108. 109. 110. 111. 112. 113. 114. 115. 116. 117. 118. 119. 120. 121. 122. 128. 124. 125. 126. 127. 128. 129. 130. 131. 132. 133. 134. 135. 13G. 137. 138. Voillemier's rupture-instrument Syme's staflF ..... Mode of cutting on staff Grooved staflF with button-like end . Teale's probe-gorget Wheelhouse's operation . Tapping the urethra in the perinreum Otis's perineal tourniquet Thompson's "probe-pointed catheter" Dieulafoy's aspirator Potaia's aspirator .... >• Trocar and canula for puncture of the bladder Recto-vesical and supra-pubic puncture . Section of a chancroid ..... Skeene's urethroscope ..... Auspitz's diagram showing position of inguinal ganglia Phagedenic bubo .... Section of a chancre Section of an artery, vein, and a lymphatic in induration Similar sections showing obliteration of artery and vein Vegetating condylomata about the vulva Pharyngeal atomizer Sj'philitic affection of cerebral arteries Dactylitis of second toe . Dactylitis of finger Dactylitis of finger Dactylitis of finger . . Dactylitis of finger Gummata of head and face Syphilitic papule of conjunctiva |- "Hutchinson's teeth" . Gummy tumor of sclera . Section of the same t Case of dactylitis from hereditary taint Case of dactylitis from hereditary taint Case of dactylitis from hereditary taint Lee's latest lamp for fumigation Maury's apparatus for fumigation . PAGE 311 813 314 315 315 315 317 319 322 325 325 326 327 364 377 896 403 462 464 465 587 600 632 672 673 674 675 676 682 697 700 706 707 771 772 773 796 797 ERRATA. Pagfe 117, ]7tli line from top, /or " Badinet," read "Bardinet." " " 19lli Hue from top,/t>r "Foiirneaux," read "FurLieaux." " 16.J, ]-tth line from top, /or "ductor," read " dartos." " 2.58, 7th line from bottom, for " pubis," read '' pubes." " 306, llth line from top, /or "93," rertd "92." " 431, 12th line from top, /or "Pellizari," read "Pellizzari." " 567, loth line from top, /or " ultra," read " intra." " 743, foot-note, /or " Spath," read '' Spilth." " 75S, 8th line from bottom, /or " Rocliebonne," read " Eochebrune. " 763, 13th line from bottom, omit "areata" after " alopecia." " 764, 11th and 16th Hues from top,.A'r "Weisflag," read "Weisflog " " 11th Hue from top, /or "Wiederhofeu," read " Wiederhofer." YENEREAL DISEASES. INTRODUCTION. Yenekeal Diseases, so called from their most frequently originating in the pleasures of Venus, are the following : — I. GONORRIKEA. II. The Chaxcroid. III. Syphilis. Other affections may indeed be contracted in sexual intercourse, but those above mentioned, which depend more exclusively upon this mode of origin, and which are commonly recognized as The Venereal Diseases, will form the subject of the present work. The distinct nature of these three diseases, and especially of the latter two, has not always been admitted, and still finds opponents. Many volumes have been written and much bitter controversy indulged in by the advocates of either side. In the earlier editions of this work, this subject received considerable space and attention. Indeed, ours was the first comprehensive treatise upon Venereal diseases, published in any language, in which the distinct nature of the Chancroid and .Syphilis, so ably advocated by Bassereau, was made the basis of the work ; and we have reason to believe that to the satisfactory manner in wliich this new theory explained many facts before obscure, was to be attributed the favorable reception of our earlier efforts. In the present edition we do not intend to enlarge upon this question ; we shall on the contrary curtail or omit much that we have said before. "We must reserve our space for the many practical points which have been accumulating during the last ten or fifteen years, and which are now en- grossing tlie thouglits of those interested in Venereal. We claim that the distinct nature of the Chancroid and Syphilis is a question already settled in the affirmative, as recognized absolutely by the great majority of the )>rofession, and as recognized practically by all with a few rare exceptions. Dr. Frederick Zinsser,' in an admirable review of this subject, makes the ' The Doctrines of Unicism and Dualism of the Syphilitic Contagion, Am. J. Syph. and Derm., N. Y., vol. i, 1870, p. 238. 2 18 INTRODUCTION. f'ollowina; ti'iie remark : So simply and naturally the dovhle contagion ex- plains tJic different forms (of venereal disease), that even after the fall of dualism, should that event occur, clinically the differentiation would be perpetuated. Wishing to fill our book with living issues, we shall, for the most part, leave dead ones buried, contenting ourselves with a brief history of their lives for the benefit of our junior readers. There is only one point upon which we shall somewhat enlarge on account of its comparative novelty. We shall endeavor to establish the fact that not only is the chancroid distinct fi'om sy[)hilis, but that it possesses no specific virus of its own, and that it may arise independently of contagion, from the inoculation of the products of simple inflammation. We would thus make it a strict congener of gonorrhoea. History of Venereal Diseases. GoxoRRiKEA Gonorrhoea has existed among all nations, and from the earliest times of which we have any record. It is clearly referred to by Moses in the 15th chapter of Leviticus, where he lays down rules for the government of those who are affected witli "a I'unning issue out of the flesh." Among the Greeks and Romans, gonorrhoea appears to have been less common than among the Hebrews; still, unquestionable traces of it are found. Hippocrates describes five kinds of leucorrhoea, in addition to dis- charges dependent upon inflammation of the womb, which are mentioned separately. Herodotus states that "the Scythians made an irruption into Palestine and pillaged the temple of Venus Urania. The angry Goddess sent upon them and their posterity the woman's disease, which is charac- terized by a running from the penis. Those attacked by it are looked upon as accursed."' Celsus^ was also acquainted with balanitis and gonorrhoea; the latter dependent, as he supposed, upon an ulcer within the urethra ; and Cicero says that "incontinence gives rise to dysuria, in the same manner that hi";h living causes diarrhoea." At subsequent periods, this disease, and, in many instances, its compli- cations of swelled testicle and cystitis, were described with more or less detail by Mesne* in 904; by Haly Abbas,* one of the Persian magi, who followed the doctrines of Zoroaster and wi'ote in 980 ; by Rhazes,^ a learned Arabian physician, born in Chorosana in 852; by Albucasis,^ another Ara- bian of the eleventh century; by Constantine of Carthage;'' by Micliael Scott* in 1214; by Gariopontus of Salerno; by Rogerius, Jolin Gaddesden^ ' Clio, lib. i. 2 j)g Medicina, book vi, chap. 18. 3 Siimm. iii, part 4, sect. i. 4 De Virgse Passionibus, Causis eorum et Signis, book ix, chap. 28. 5 Rhazes, book x, chap. 3. 6 Theoric. nee non Practic, tract, xxi, fol. 92 et 93. 7 Constantinus Africaiius : De Morboruni Cognitione et Curatione, lib. v. 8 Michael Scott: De Procreat. Horn. Physion., cap. vi. s John Gadclesden : Rosa Anglica, Practica Medicinte, a Capite ad Pedes, lib. ii, c. xvii, fol. 107. HISTORY" OF VENEREAL DISEASES. 19 of" England (commencement of fourteeth century) ; John de Concoregio,^ John Arculanus, Guy de Chauliac,^ Valescus de Tarento, John Ardern,^ settled at London in 1371 ; and by many othei's. Since the close of the fifteenth century, when the study of venereal diseases received new impulse from the irruption of syphilis into Europe, it is hardly necessary to state that every medical writer has been familiar with the existence of gonorrhoea. The Chancroid A contagious ulcer of the genital organs, presenting all t]\e symptoms of, and undoubtedly identical with the ulcer now known as the chancroid, has also existed at all ages Avhose records have been pre- served. Ulcers of the genital organs and suppurating buboes are described by nearly all the Greek, Latin, and Arabian writers on medicine. Hippo- crates gives very minute directions for the treatment of abscesses in the groin, dependent upon ulcerations of the womb and of the genitals. Celsus is still more explicit, and clearly describes the simple, phagedenic, serpigi- nous, and gangrenous venereal ulcers, which are recognized at the present day. He also alludes to the danger of destruction of the prepuce when the ulcer is complicated with phimosis, and, under such circumstances, advises circumcision. Many other names might be quoted, but it is unnecessary to adduce farther evidence, since it is generally admitted that ulcers of the genital organs dependent upon contagion in sexual intercourse, have been known from a very remote antiquity. The only point in dispute relates to their nature. It is maintained by some authors, and especially by Cazenave, that these were instances of primary syphilis, and not chancroids, as here assumed; and they have been supposed to furnish evidence of the existence of syphilis in Europe prior to the close of the fifteenth century. This idea is inad- missible for several reasons. One argument against it is the frequency of suppurating buboes with which these ulcers are said to have been attended, since in the great majority of true chancres the inguinal ganglia which become indurated remain entirely passive; while the chancroid, on the contrary, is frequently accompanied by an inflammatory bubo terminating in suppuration. This consideration, however, will have no weight with those who do not allow, in cases of venereal sores, any prognostic value to suppuration of the inguinal ganglia; but we can Avell afford to waive it and base our argument upon the fact that there is no clear record in history of the existence of the general symptoms of syphilis prior to the year 1494; that the ulcer of the genitals known to the ancients was always a local affection, and never followed by manifestations at a distance from the point of contagion ; that rejjeated outbreaks of the disease when once apparently ' Practica nova Medicinje : Lucidur, tract, iv, fol. (J6. 2 Cyrurgia Guidonis de Cliauliaco, tract, vi, doct. ii. 3 Becket : Pliilosoidi. Trans., vol. xxx, p. 839. Most of tho above texts have been derived from a learned work written in the last century by Gruner, and entitled: Aidirodisiacus sive de Lue Venerea in duas Partes divisiis,*iuariim altera coutinet ejus Vestigia in Veterum Auctorum Monu- luentis obvia, altera tiuos Aloysius Luisiiius temere onusit Scriptores, Jena, ITSt). 20 INTRODUCTION. cured (lid not occur; that hereditary syphilis was unknown;' and finally, that the physicians who lived at the close of the fifteenth century, and who were perfectly familiar with the ulcers in question, were struck with horror and amazement at the appearance at this time of a disease which is now known to have been syphilis ; confessed that they had never seen its like before, and that they were ignorant of its nature and treatment ; and in their treatises upon venereal for nearly thirty years afterwards, described this and the former disease in separate and distinct chapters, thus showing that they did not entertain the least idea of their identity. Subsequent to the latter part of the fifteenth century, we must follow the history of the chancroid in connection with that of Syphilis According to the most reliable contemporary authors, syphilis was first known to European nations from its appearance in Italy in the latter part of the year 1-194, about the time that Charles YIIl., King of France, at the head of a large army, entered that country for the purpose of taking possession of the kingdom of Naples, to which he laid claim by right of inheritance. In this expedition, which was at first favored by the Neapolitans themselves, Charles left Home on his way to Naples Jan. 28, and was received in the latter city Feb. 21, 141)0."^ The Neapolitans soon became restive under the yoke of their new master, and, assisted by the forces of Ferdinand of Aragon, under the leadership of Gonsalvo of Cordova, the great captain, endeavored to expel the French from Italy. Now, although the new disease may have had no necessary connection with the events just mentioned, yet the latter doubtless favored the exten- sion and exacei'bation of tlie former through the license and debauch attend- ing large bodies of troops, and subsequently led to mutual recrimination between the natives and the invaders respecting the origin of the nudady; the French calling it "Mai de Naples," because it was to them unknown before the Neapolitan expedition, and the Italians ascribing its origin to the French, and calling it the "French disease." It is often asserted that the subsequent extension of syphilis was due to its conveyance to their homes alter the close of the war by the troops Avhich had been collected upon Italian soil. This could not, however, have been the sole, nor even the chief mode of its transmission ; since the French, on their return from Naples, fought the battle of Fornovo, July G, 1495,^ and a decree of Emperor Maximilian I., " Contra Blas[)liemos," promulgated at the Diet of Worms, August 7, of the same year, includes among the evils sent as a punishment against the prevailing vice of blas- phemy, " pnesertim novus ille et gravissimus hominum morbus, nostris dicbus exortus, quem vulgo Malum Francicum vocant, post hominum nie- moriam inauditus, sa^ve grassatur,"* thus showing that syphilis had already » Sypliilis in infants at tlie breast is first mentioned by Gasparcl Torello (1498). 2 Gl'K'Ciardim, lib. i, cap. iv. 3 Gi'icciahdixi, lib. ii, cap. iv. * GoLDAST. Const. Imp. ii, 110. HISTORY OF VENEREAL DISEASES. 21 spread so widely in Germany as to attract general attention about the time that the French left Italy. The testimony of other authors also concurs in showing that syphilis rapidly extended in the course of a few years over the gi*eater part of Europe, and pervaded every rank of society. As stated by John Lemaire, a poet of that period : — II n'espargnoit ne couronne ne crosse. A large amount of evidence is adduced by Bassereau^ and Chabalier^ in support of the fact already mentioned that syphilis was entirely un- known in Europe prior to 1494. Its connection with sexual intercourse was not at first recognized, and many attributed it to the evil influences of the stars ; and altliough a few endeavored to assimilate it to certain dis- eases of ancient times, as, for instance, to the " asaphati" of the Persians, the mentagra which prevailed at Rome under Tiberius, to psoriasis, ele- phantiasis, and lepra, yet the greater portion of the writers of that period declared that it was entirely new in the world's history, and all confessed that, so far as their own experience went, they had never seen anything like it. The contagious ulcers of the genitals which were known prior to the latter part of the fifteenth century, were called " caries," " caroli," and " taroli," and the first of these terms was afterwards applied to the new disease, which, however, was distinguished as the " caries gallica." Moreover, in the works of Marcellus Cumanus, Alexander Benedictus, Leonicenus, Gaspar Torella, John de Vigo, and other authors who wrote within thirty years after the appearance of syphilis, these two affections were described in separate chapters with many of the distinguishing feat- ures that are recognized at the present day. Thus John de Vigo mentions the induration of those ulcers which are followed by constitutional symp- toms : " Cum calositate eas circumdante ;" and none of the writers of this early period, when speaking of the French disease, make any allusion to suppurating buboes, which are described apart and referred to the "caries non gallica" known in ancient times. An exceedingly accurate descrip- tion is also given of the cutaneous eruptions, the nocturnal pains, the bony tumors, and otlier general symptoms of sy[)hilis ; and notice is taken of tlie fact that a cure is in most cases only temporary, and that the disease often returns. Moreover, the early writers on syphilis believed in the contagious- ness of general symptoms, and even of the blood of infected persons, whicli has recently been demonstrated by actual experiment. OuiGix OF Syphilis unknown None of the theories wiiicli have been julvanced to account for the appearance of sy[)hilis in Europe near tlie close of the fifteenth century, rest upon sufficient data to entitle them to absolute credence. We cannot suppose that it was of the nature of an ' AfTections do la poaii syniptdiiiatiqucs dc; la sypliilis, Paris. 1852. 2 Prouv(!S liistori(|uo.s do la plurality dos affoctious ditos veneriennes, Tlibse de Paris, 18(J0 (No. 52). 22 INTRODUCTION. epidemic and due to atmospheric influences, since it is expressly stated by those wlio witnessed its advent that it did not suddenly affect large num- bers of persons of all ages, but spread from one to another, chiefly attack- ing the middle-aged (the very class most exposed in sexual intercourse), and sparing old men and infants, and the inhabitants of cloisters, and that it advanced from Italy as a centre, and occupied several years in ex- tending to the more remote countries of Europe. Moreover our present knowledge of the disease enables us to state with confidence that it never appears except as the result of contagion. Supposed Aniericcm Origin — The theory which has met with the most favor, refers the origin of syphilis to America, whence Columbus returning from his first voyage, landed at Barcelona, in Spain, in 1493, only a year before the appearance of the disease in Italy. According to Chabalier, it was stated by John Baptist Fulgosus, Doge of Venice, as early as 1509, that a new disease, communicated only by coitus, and first affecting the genital organs, had broken out in Spain, and had thence been transported to Italy, and also that it came into Spain from Africa : " Qua? pestis primo ex Hispania in Italiam allata, ad Hispanos ex ^Ethiopia, brevi totum ter- rarum orbem comprehendit." The idea that syphilis was brought to Europe from America by the sailors under Columbus was first advanced by Leonard Schmans, in 1518, Ulrich von Hutten in 1519, and Fracas- tori in 1521. There can be no doubt that syphilis existed in the colony founded by Columbus during his second voyage, but whether indigenous to the West Indies, or brought there by the Spaniards, is unknown. Washington Irving, in his Life and Voyages of Columbus,^ says, when speaking of the colony at Isabella : " Many of the Spainards suffered also under the tor- ments of a disease hitherto unknown among them, the scourge, as was supposed, of their licentious intercourse with the Indian females ; but the origin of which, whether American or European, has been a subject of great dispute." Prof Joseph Jones'' has written an able and interesting article on syphi- lis among the Aborigines of this country, and endeavors to demonstrate its existence at that very early period by the skeletons found in the ancient burial ])laces in Georgia, Tennessee, Kentucky, Louisiana, and Mississippi. The marks of syphilis in the bones exhumed have been traced by Dr. Jones from the valley of the Cumberland to the Gulf of Mexico. The supposition had been advanced, tliat these bones presented merely " traces of periostitis," Avhich were not due to the action of the syphilitic poison, because " it is uncommon to find sliin-bones of adults belonging to races clad in skins and with the lower extremities exposed, in which there is not more or less roughness or hyperostosis along the tibial shafts." So far from these evidences of the action of syi)iiilis being mere " traces of periostitis, and constituting mere roughness or hyi)erostoses along the ' Vol. i, book vi, chap. xi. 2 N. Orl. M. and S. J., June, 1878. HISTORY OF VENEREAL DISEASES. 23 tibial shafts," the bones ave in many instances thoroughly diseased, en- larged, and thickened, with the medullary cavity completely obliterated by the effects of inflammatory action, and with the sui-faces eroded in many places. These erosions resemble in all respects those caused by syphilis and attended by ulceration of the skin and soft parts during life. Furthermore, the disease was not confined to the "tibial shafts ;" bones of the cranium, the fibula, the ulna, the radius, the clavicle, the sternum, and the bones of the face exhibited unmistakable traces of periostitis, ostitis, caries, sclerosis, and exostosis. That these diseases were not due to mechanical injury or to exposure to cold, is evident from the fact that they were almost universally sym- metrical. Thus, when one tibia was diseased, the other was similarly affected, both as to the position and nature of the disease. In like man- ner both fibnlfe presented similar evidences of periostitis, ostitis, and exos- tosis ; this was true also of the bones of the foi-earm (radius and ulna) and of the clavicle. "The diseased bones which I collected," says Dr. Jones, "from the stone graves of Tennessee and Kentucky, are probably the most ancient sypliilitic bones in the world." And he adds, " this discovery appears to be of great importance in the history of specific contagious diseases, in that it confirms the view held by some pathologists that syphilis originated in the Western hemisphere." It must be confessed that the investigations of Dr. Jones go far to favor the idea that syphilis existed among the early aborigines of America, and was conveyed by the crew and soldiers of Columbus to Elurope. Again, according to Captain Dabry,^ Consul de France en Chine, Chi- nese medical literature effords evidence of the existence of syphilis in that country and of its treatment by mercury, many centuries before the birth of Christ. In concluding this subject of the origin of syphilis, we can only express our firm belief that this disease was unknown in P^urope prior to the last decade of the fifteenth century, but we may add, in the words of Voltaire, " la verole est comme les beaux-arts, on ignore quel en a ete VinventeurJ'^ Age of Confusion in Venereal The views that were entertained by those who witnessed the first appearance of syphilis in Europe, and which in many respects coincided to a remarkable degree with those which luive been advanced in the middle of the nineteenth century, grad- ually lost tlieir hold upon succeeding generations, and were followed by th(! utmost confusion of ideas respecting this subject. A most admirable history of this " age of confusion in venereal," as it has been called, is given by Bassereau, which should be read by every one who would under- stand the origin of those errors from whicli the medical mind has cum- plet(>ly freed itself only within a very few years. "A tendency on the part of a very few authors, as Vella (A. D. 1508), ' La niedec'ine clu'2 U'S ohinois, Paris, 18G3. 24 INTRODUCTION. to confound together the various venereal diseases, became manifest in the early part of the sixteenth century, but the absolute confusion which ulti- mately reigned, was especially the work of those physicians, who had commenced the practice of their art subsequent to the year 1495, and who, therefore, were unable to compare the new disease with the venereal affections which had prevailed from time immemorial, before the close of the fifteenth century. In following the change which took place, we find that the first step was to make no distinction in their writings between the old and new ulcer, and to include in their descriptions of syphilis cer- tain complications Avhich belong almost exclusively to the ancient variety. Thus Nicholas Massa (1532), the author of a celebrated treatise on the French disease, includes among the unequivocal symptoms of this affec- tion, suppurating buboes, which accompany almost exclusively the ulcer of the ancients. " As the venereal ulcer of the ancients and its attendant suppurating bubo began to be included among the symptoms of syphilis, treatises on surgery ceased to contain those special chapters in which contagious ulcers of the genital organs and inguinal abscesses had heretofore been described. Discharges from the urethra were also included among the symptoms of syphilis, and still further modified the tableau. Finally, in the descrip- tions given of the French disease, not only were symptoms insei'ted which Avere completely foreign to syphilis, but the regular course of this affection was entirely forgotten. " This confusion was rendered complete by Anthony Musa Brassavolus. This physician, who was a laborious student rather than a sagacious ob- server, seems to have made it an object of his treatise upon the ' French Disease,' published in 1551, to collect together all the errors of the writers upon syphilis of this period, and to add others of his own invention. Not only did he include all venereal affections under the head of syphilis, but, as described by him, this affection lost its characteristic physiognomy, and was a mere collection of symptoms succeeding each other without order or regularity. According to this author, buboes may aj)pear before chan- cres ; syphilis may commence indifferently as an exostosis, an eruption u])on the skin, [)ains in the bones, or falling out of the hair and teeth. He goes so far as to admit eight primary symptoms, which he calls the simple forms of the disease, and which by their union in various ways may give rise to an infinite variety of combinations, which he terms the com[)ound forms of syphilis, and limits to two hundred and thirty-four in number. " The modifications of the doctrines professed by those who witnessed the first appearance of syphilis in Europe, could not fail to affect the treat- ment of venereal diseases. Before the year 1495, ulcers of the genital organs, the suppurating buboes dependent upon them, the various forms of vegetations and discharges fi'om the urethra, were considered as purely local affections, and treated by means of local remedies. As soon as the French disease appeared, the insufficiency of all topical ap|)lications in the treatment of the new disease was manifest ; but human ingenuity, never HISTORY OF VENEREAL DISEASES. 25 more fertile in resources than under circumstances of great necessity, soon discovered in mercury a powerful modifier of the new complaint. For several years this remedy was employed in the form of frictions, and only in case the patient had broken out with an eruption following a sore upon the genital organs ; but it soon became the custom to resort to mercurial inunction immediately after contagion and during the existence of the primary sore, with a view of preventing the appearance of general symp- toms. This practice was lii'st recommended by James Cataneus, who thought that the same remedy which cured the pustular eruption would also prevent it. ' Hfec enim onctio, absque dubio, tale destruit virus quod enim unam sanat segritudinem, ab eadem praeservat.' " This wise precept, to employ mercurial medication during the exist- ence of tlie primary sore for the purpose of preventing a general eruption, soon gave rise to the most serious errors ; for, about the time that it was given, physicians began to ignore the distinction between the two species of ulcers, and were consequently led to treat them all indiscriminately with mercury. This injurious, not to say barbarous practice, led to an exaggerated estimate of the powers of mercury, which, for tliree centu- ries, was given to a multitude of patients, Avho were supposed to be pre- served through its influence from symptoms of which they stood in no danger. " Hence Ave may explain the success of all those modes of treatment which charlatans have endeavored to substitute for mercury during the existence of supposed primary symptoms, as a prophylactic against sec- ondary manifestations ; since, if the same treatment, no matter what, be applied without distinction to patients with gonorrhoea, ulcerations, and buboes, there Avill always be a large proportion who will escape Hirther trouble, for the simple reason that their symptoms do not belong to the disease which first appeared in the fifteenth century, and are, therefore, incapable of infecting the general system." The Modern School of Venereal The above-mentioned confu- sion of ideas relative to venereal diseases, Avith the consequent indiscrimi- nate mode of treating them, continued unabated until towards the close of the last century, and did not wholly cease until after the first half of the present century had passed. Even as late as 1850 we find Vidal includ- ing under the name of syphilis catarrhal inflammation of tlie genital oi'- gans. As late at least as 18G0, the Professor of Surgery in one of the chief universities of this country was teaching his students that gonor- rha-a Avas liable to be followed by secondary symptoms, and should be treated Avith mercury ! The identity of gonorrhoea with syphilis Avas, however, denied even in the last century by Astruc,' Balfour,^ and Benjamin Bell.^ It was believed ' De morbi vcnereis, Paris, 1740. 2 Dissert, de gonorrlupa virulenta, Edinburgh, 17l)7. 3 Treatise on gon. virulentu, and lues venerea, Edinburgli, 1793. 26 INTRODUCTION. in by Hunter, but met with further opponents in Swediaur/ Hernandez,'^ and especially Ricord, who by the use of the speculum in venereal dis- eases, and his discovery of the chancre lan-e, refuted the chief arguments which had been adduced in its favor, and established the non-identity of the two diseases beyond dispute forever. This was the first step taken towards the formation of " The Modern School of Venereal." The idea that all venereal sores are due to a single virus, the virus of syphilis, had been the prevailing one for nearly three centuries prior to the year 1852. At the same time, it had not escaped the notice of many observers that the results of contagion were by no means identical ; that, in some cases, the persons infected showed no symptoms after the healing of their ulcers, while others developed a train of symptoms lasting through years, and even transmissible to their children. In the year 1852, Bassereau claimed a distinct cause or origin for each of these two classes of cases. He founded his claim, first, on the history of venereal sores, which we have already referred to, and which shows that although contagious ulcers of the genital organs, communicated in sexual intercourse, had been well known to the ancients, yet that the con- stitutional disease wliich we call syphilis made its first appeai'ance in Europe in the latter part of the fifteenth century. Bassereau's second argument was based upon the " confi-ontation" of persons atfected with venereal diseases, and he and others were able to prove, in several hundred cases, that when tlie disease was local in the giver it was also local in the recipient, and that when it was constitutional in the giver it was always constitutional in the recipient ; in other words, that the broad line of distinction separating a local disease on the one hand from a constitutional disease on the other, was constant in succes- sive generations without limit. It will be observed that this proof does not involve any differences real . or supposed in venereal ulcers themselves ; it may be said to rise above such consideration in tliat it ascends to the source and origin of such sores ; and we do not hesitate to say that much of tlie confusion and contradic- tion of opinion upon this subject has been due to the fact that observers have confined themselves to investigating certain symptoms of venereal ulcerations, which, though generally constant, may yet be poorly marked or even wanting, and wliich often require pi-actised eyes and fingers for their recognition. We maintain that this clinical proof adduced by Bassereau has never been shaken, for, althougli local ulcers have been produced by the inocu- lation of matter from syphilitic sores, yet this is susceptible of, and indeed requires, as we shall see hereafter, another explanation than an identity of poisons, and, on the other hand, there has never been a single authentic case in which syphilis has been produced by the inoculation of cJumcroidal matter from a person tvho has had only a chancroid and not syphilis. ' Traite coinplet dcs maladies v6iK'ri(3nnes, Paris, 1801. 2 Essai aiialytique siir la nou-identite des virus goiiorrheique et syphilitique, Toulon, 1812. ' HISTORY OF VENEREAL DISEASES. 27 Bassereau does not appear to have speculated on the cause of the differ- ence in venereal ulcers. We do not find in his work the words " Unity or Duality of Syphilis," nor any expression of opinion as to the existence of a specific virus for the local sore. He simply says that he is obliged to recognize a difi"erent cause {une cause differente) for the local and con- stitutional diseases. A school of dualists, however, soon sprang up, with Rollet, of Lyons, at its head, who departed from the simple faith of their founder in attach- ing undue importance to the characteristics of the sores themselves, and who claimed for the local sore a distinct, special virus of its own. One of the tenets of this school was that the secretion of syphilitic lesions could not be inoculated with success either upon the person bearing them or upon any other person affected with syphilis, and this tenet, in the theory of dualism, was looked upon as vital. It was not long, however, before it was successfully attacked and over- thrown. Clerc, of Paris, Melchior Robert, of Marseilles, and others, succeeded in inoculating the secretion of syphilitic sores upon the bearers, with the result of producing ulcers, without incubation, bearing all the characteristics of the chancroid, and inoculable in successive generations. Mr. Henry Lee, of London, and Kobner and Pick, in Germany, also found that a true chancre would become auto-inoculable, if it was irritated by the application to its surface of powdered savine, or by having a seton passed through its base, so as to render its secretion decidedly purulent. Again, Boeck and Bidenkap, in Christiania, in their later attempts at syphilization, took matter exclusively from true chancres, and obtained the same result as when they had inoculated chancroidal pus. In five cases reported by Bidenkap and Gjbr, of Christiania, matter was taken from ulcers obtained in the above manner, and inoculated by patients free from syphilis upon tliemselves, and in only one instance did any general symp- toms ascribable to syphilis follow, and these were of a doubtful character. These exjjeriments apjjarently proved the identity of the syphilitic poison with that of the local sore. By their means, it was supposed that the doctrine of duality was demolished, and the advocates of unity were triumphant. Wliether this conclusion was not too hasty, we shall presently take occasion to inquire. But these experiments actually did prove the absence of any distinct specific virus in the chancroid, incapable of genera- tion de novo; for here were chancroids artificially produced independently of any descent from chancroids. To defend tliemselves, the dualistic school took refuge in the "mixed chancre," a sore combining both the sy[)hilitic and chancroidal poisons, whicli, it was asserted, would satisfiictorily explain all these cases and still leave the tenets of dualism, as at that time understood, intact. This ex- })lanafion was for a wliile regarded as satisfactory, but it could no longer be upheld when such experiments had been multi[)lied indefinitely; when their number was so great that the chance of the commingling of two kinds of specific virus and their simultaneous inoculation was reduced to an absurdity; when an indurated syphilitic primary lesion could be taken 28 INTRODUCTION. at random, and, after due irritation, its secretion could be successfully inoculated with the effect of producing pustules and ulcers bearing every characteristic of the chancroid; and when the same result could even be obtained at will by the inoculation of the secretion from a purely secondary lesion, as, for instance, a syphilitic mucous patch ! If the chancroid was dependent upon a distinct specific virus, its presence in all these cases was simply impossible, and yet not a single shade of difference could be pointed out between the result produced and tliat from the most emblematic clian- croid ever met with in practice. Dualism was indeed henceforth dead, if by "dualism" be meant that each of the two kinds of venereal sore has a distinct, specific virus of its own. In the face of the experiments referred to, we cannot believe it possible to defend in future any such doctrine of duality. But the last word bad not been spoken in fixvor of a distinct origin of the chancroid from that of syphilis, nor the last experiment made and recorded wliich would decide this question. Let -us examine moi'e care- fully the experiments just referred to. What was the matter so successfully inoculated? The pure, unmixed virus of syphilis? By no means. It was a compound product, taken, to be sure, from a syphilitic lesion, but a lesion irritated commonly to suppuration by artificial means; containing possibly the germ of syphilis, but containing also, and in fact chiefly composed of, pus. Whicli of these two fjictors was responsible for the effect produced? The syphilitic virus? In that case this virus should have preserved its power of infecting the constitution, and matter taken from these ulcers, and inoculated upon healthy individuals, should invariably have produced syphilis, which has been shown not to be true. IMoreover, if it could be proved tliat pus alone, free from all suspicion of sy[)hilitic mixture, was capable of producing the same result, then p)is was the guilty factoi', and tliere Avas no such transformation as supj)osed by the unitists. Such i)roof we now have, as will be seen from the following cases: — In 18G5, Prof. Pick, at the suggestion of Prof. Zeissl, inoculated sim- ple, non-venereal matter of inflammatory origin upon syphilitic subjects. Taking the secretion of pemphigus, acne, scabies, and lupus, he inocu- lated it upon persons affected with sy[)liilis and produced pustules, not preceded by incubation, and the matter of which was further inoculable through several generations. Counter-inoculations upon the persons free from syphilis who were the bearers of these affections, were without effect. Tlie same result was attained by Kraus and Reder with the pus of scabies, and by Henry Lee witli pus from a non-syj)hilitic child. The late Mr. Morgan, of Dublin, also succeeded in producing pustides and ulcers, iden- tical in ap[)earance with the chancroid and capable of re-inoculation tlirough a number of generations, by inoculating syphilitic women witli their vaginal secretions. It would thus appear tliat the skin of sy[)hilitic individuals possesses a marked vulnerability, a peculiar aptitude to become inflamed when acted u[)on by irritants ; but this is nothing more than is seen in other and in non-syphilitic subjects, wdiose vital j)0wers are impaired by any cause HISTORY OF VENEREAL DISEASES. 29 wliatever. For instance, it is well known that amonn; medical students engaged in the dissecting-room, it is those who are run down by hard study and overwork, who are most likely to become inoculated by fluids from the dead body. Again, the idea which was entertained by some that there must be a syphilitic soil for such inoculations to succeed upon, has since been disproved by other experiments. The earliest of these experiments, so far as I am aware, have never been published, and were performed in the winter of 1867-8 by Dr. Ed- ward Wigglesworth, Jr., of Boston, upon himself, while pursuing his studies at Vienna. He has kindly furnished me witii the following his- tory: After stating the grounds which led him to the conclusion — origi- nal, it appears, with himself — that '■'■ jnis pure and simple might be the cause of the chancroid,^' Dr. W. says : — " I would state that I was free from all disease either hereditary or ac- quired ; that I had never had a sore of any kind or any local or constitutional lesion of the skin or mucous membranes, and that I was merely a little run down from overwork in the hospital. I took from an acne pustule upon myself, pus, which I inoculated upon myself in three places on the anterior radial aspect of my left forearm at the junction of the middle and upper thirds, first pricking open the apertures of hair follicles and then rubbing the pus into them. The result in the course of three or four days was three well-marked pustules. From each of these I inoculated one new spot upon the same arm nearer the wrist. The result was three ncAV well- marked pustules. From each of the three second series I again inoculated fresh spots still nearer the wrist, and again the result was positive. The second series was hardly as well marked as the first, and the third series was slightly inferior in vigor to the second ; still all were well marked, the nine sores being at the same time present upon my arm. On removal of the crusts, perceptible ulceration of the skin was found to exist. Zeissl, with whom I was studying at the time (18G7-8), happened to be lecturing upon dualism, and requested me to show my arm to the class to prove the production of ulceration from properly inoculated, simple, healthy pus. There were no buboes in my case, nor did the ulcerations require other treatment than exclusion from the air by means of a simple dressing, and cleanliness. The scars remain to the present day. I tluis convinced my- self and others — " I. That the products of inflammatory action, if properly introduced into the human integument, may cause local ulcers, closely resembling chancroids and re-inoculable in generations. " II. That this pus need not come from a syphilitic person or be inocu- lated upon a syi)hilitic person. If taken from, or inoculated upon, a per- soji debilitated by any disease as syphilis, the efiect woidd doubtless Ije the same though probably greater in intensity." Many years sul)se(iuent to these experiments of Dr. Wigglesworth, Kaposi' published the following statement : " ]\Iy own experiments have ' Die Syphilis der Haul, etc., p. 47. 30 INTRODUCTION. taught me that non-specific pus, sucli as that from acne and scabies-pustules, when inoculated upon tlie bearers as well as upon otlier non-syphilitic persons, will produce pustules whose pus proves to be continuously inocu- lable in generations ; that from these pustules losses of substance occur, which heal with the formation of scar-tissue ; and that as the number of pustules produced increases, the inoculability of the pus derived from them diminishes and finally ceases altogether." It is not necessary to dwell upon the exact correspondence of the result of such inoculations and that obtained by tlie inoculation of the so-called chancroidal virus. The following case, occurring in the practice of Dr. R. "W. Taylor and vouched for by him in all its details, is an instance of a chancroid origina- ting de novo. " C. P. C, aged 26, became syphilitic in 1869, presenting primary and secondary lesions. In March, 1870, he had a papular syphilide on the body, and on the 10th of that month he came to me with gonorrhoea in its acute stage. On the sixteenth he came with an inflamed group of unrup- tured herpetic vesicles, in every respect typical. He feared these Avere chancres, but said he had not had connection since the first of the month. At this time the gonorrhoea was still active. On the twenty-second he returned, feeling certain that he had chancres. I then found four typical oval cliancroids on the under portion of the prepuce over which the gonor- rhoeal pus had flowed, since he had failed to follow my advice to keep the vesicles properly protected. His gonorrhoea was then on the decline. On the twenty-sixth lie complained of pain in the right groin, and I found several enlarged painful glands. In spite of thorough cauterization at the jirevious consultation, the chancroids were still active. A few days later while intoxicated, he had intercourse witli his wife, and about March 31st he told me he feared that she had become infected. On the 5th of April, the wife came to me with five or six typical chancroids at the fourcliette and on the inner aspect of the labia minora. At this time the husband's chancroids were in process of repair, but he liad a typical cliancroidal bubo. Owing to neglect on the part of the wife her ulcers became very extensive and were followed by abscess in the groin, neither of which healed for more than a month. U[) to this time I have reason to believe that the wife had led an irreproachable life. She certainly liad never had syphilis. But, learning of her husband's infidelity, she became reckless, and two years afterwards contracted from another man a hard chancre on the left labium majus, for which, as well as for the subsequent secondary symp- toms, she was treated by myself. " To review the case briefly, a syphilitic man contracts a gonorrha'a and subsequently develops herpes vesicles, which in a few days are converted into typical chancroidal ulcers. I inoculated some of the discharge from the ulcers upon the patient's abdomen, and within a week a characteristic chancroid was developed. The experiment was, however, unnecessary, since additional proof was furnislied by the formation of several chancroids on his left thigh, in consequence of liis careless and uncleanly habits. HISTORY OF VENEREAL DISEASES. 31 Finally, intercourse with his wife resulted in her having chancroids and buboes." The idea that the products of inflammation are the source from which the chancroid springs, and that the simultaneous inoculation of these pro- ducts and of the germs of syphilis accounts for the varying degrees of ulceration and other phenomena met with in varieties of venereal sores, will strike many as novel, and it is easy to foresee the objections which will naturally arise. It will be asked : Can it be possible that the pus from acne, ectliyma, or scabies can give rise to a sore equal in duration and severity to that produced by matter from a typical chancroid ? Com- parative inoculations upon the same individual with these two agents may even be adduced to show that this is not the case. In replying to such objections, it must be frankly admitted that Ave do not as yet fully under- stand all the laws governing the inoculation of septic matter. We cannot, for instance, fully explain why one individual should be more susceptible than another, why ditferent parts of the integument, as that of the chest, the arms, and the thighs, should develop ulcers so varying in their destruc- tive tendency as is shown in the practice of syphilization ; why the secre- tion from purulent urethritis and purulent conjunctivitis should be inter- changeable, and yet have no effect upon the mucous membranes of the mouth, nose, or ear ; why a chancroid of the prepuce should inoculate other points of that membrane, and yet commonly spare the glans penis ; or why one upon the os uteri should allow the walls of the vagina in con- tact with it to escape ; and so with other instances that might be brought forward. That the effect produced is to a great extent proportionate to the ulcer- ative action of the source from which the matter is taken, is evident to any one who has performed auto-inoculation from indurated chancres. If the chancre consist of a simple erosion with a watery secretion, seated upon an indurated base, the first two or three, or even more, attempts at auto-inoculation will probably fail; but as the surface of the sore becomes irritated to suppuration by repeated pricks of the lancet, these attempts will succeed, first in producing minute pustules and ulcers, but subse- quently, as the suppuration increases, others larger and better developed. Taking these facts into consideration, it need not be wondered at if com- parative inoculations upon tlie same individual with matter from a simple skin affection and from a chancroid of the genitals, should show greater severity in the latter. But without entering further into this subject, we claim it to be sufficient to have shown that the inoculation of the products of inflammation will produce an effect identical in kind, even if not in degree, with that of matter from tlie most typical chancroid. The conclusions at which we have arrived may be summed up as fol- lows: — I. 7'he chancroid is entirely distinct from syphilis. II. The chancroid, however, does not depend vpon a specific virus of its oivn, incapable of being generated de novo. III. The chancroid, in most cases met with in practice, is derived from 32 INTRODUCTION. a chancroid, hut it may arise, especially in perso7is debilitated by any cause, from inoculation of tJie products of inflammation, either simple or syphilitic, and subsequently perpetuate itself from one individual, to an- other as a chancroid. lY. I'he simultaneous inoculation of the syphilitic virus and of the products of inflammation gives rise to the '•^ mixed chancre,^'' and explains the different degrees of ulceration which the initial lesion of syphilis is liable to assume. We hold that this view of the nature of the chancroid is most consistent with our present knowledge of pathology, and that it affords the only complete and satisfactory explanation of certain cases met with in practice and of the phenomena observ'ed in artificial inoculations. It has been adopted by Biiumler, who, in his recent able work on syphilis, after quoting experimental inoculations like those above given, says: "The necessary conclusion is, that the poison of the soft chancre may, under cer- tain circumstances, he produced de novo without the intervention of the syphilitic virus, Avhile the syphilitic poison propagates itself only in one continuous series. Hence the chancroidal poison, or whatever in these experiments produced the pustules resembling chancroids, cannot even be compared with the syphilitic poison, to say nothing of regarding them as identical." In the recent well-known debate upon syphilis before the Pathological Society of London, that accomplished surgeon, Mr. Hutchinson, came within one short step of the truth when he admitted the origin of the local venereal sore to be "the products of syphilitic inflammation, but not usually containing the germs of syphilis." If he had omitted the adjective, "syphilitic," before the word "inflammation," his expression would have been consistent with the facts at present in our possession, and he would have found it inconsistent with such facts to proclaim dualism as dead, since dualism is nothing more tlian a duality of poisons in the evolution of venereal sores. If the view here advocated be the correct one, it suggests an interesting analogy with the history of our belief as regards the nature of gonorrhoea, an afliection which in the last century was regarded as due to the sy[)hilitic virus. IJicord finally adduced convincing proof that it had nothing to do witli syphilis. It was afterwards supposed to depend upon a virus of its own, the gonorrheal virus. We now know that it may be caused by any simple irritant, but more especially by the pus from the urethral and other inflamed mucous membranes, whether originating or not in contagion. Such as the history of gonorrlujea has been, so, we predict, the history of the chancroid will be. In the preceding remarks, we have only casually alluded to the evidence in favor of a duality of poisons to be found in the symptoms presented by venereal sores themselves, and by the lymphatic ganglia in anatomical relation witli them. The value of this evidence must always depend upon the observer's knowledge, skill, and experience in venereal diseases. How often do we witness the grossest errors in the diagnosis of venereal ulcers DIVISION OF THE PRESENT WORK. 33 made by men who are deservedly eminent in general practice! Moreovei", instances not unfrequently occur in which the svmptoms are ill-defined, and in which the most experienced will wait for further developments before expressing an opinion. Hence, so long as the symptoms of the sores themselves were alone considered, the question of unity or duality remained undecided. And yet the evidence founded on these symptoms is not to be despised, for in the great majority of cases they are sufficient to enable us to distinguish the syphilitic from the local sore, and the obscurity of some cases is readily explicable on the ground of the simulta- neous inoculation of the products of inflammation and the germs of sy[)hilis, and the well-known immediate action of the one and the incubation of the other. DiA'ISION OF THE PRESENT WORK. Following the natural order suggested by the above considerations, we propose to divide the present work into three parts : the First treating of Gonorrhoea and its Complications ; the Second of the Local Contagious Ulcer of the Genitals, or Chancroid, and its Complications; and the Third of Syphilis. PART I. GONOERIKEA AND ITS COMPLICATIONS. CHAPTER I. URETHRAL G O X O R R H 03 A IN THE ]M A L E , Preliminary Considerations By far the most frequent disease originating in sexual intercourse, is an affection of certain mucous mem- branes, a prominent symptom of which is an increased secretion and dis- charge from the diseased surface. At various times and places, this disease has received different names founded on the prevailing ideas of the nature of the secretion referred to. At an early period in the history of Venereal, the discharge was supposed to consist of the semen, and hence the disease was called gonoiTlicjea, from yovri, sperm, and jjf«, to flow; a name whicli is still in use among American and English writers notwith- standing the incorrectness of the supposition in which it originated.^ The French call the same affection "blenorrhagie," or a flow of mucus, a name which is also erroneous, since the discharge does not consist of mucus alone, but of a mixture of mucus and pus. In popular language it is termed "cla[)"* by the English, and "•chaude-pisse" by the French. The chief mucous membranes subject to gonorrhoea are those lining the genital organs in the two sexes, and tlie conjimctiva oculi. Gonorrhoea of the anus, mouth, and nose are, indeed, mentioned by authors, but tlie existence of all of tliem is more or less doubtful. The symptoms and tlie treatment of gonorrluea vary according as the disease att'ects the male or female, and according also to the portion of mucous membrane attacked ; it will be convenient, therefore, to consider this affection under corresponding lieads. ' Cockburne (Tlio Syiuptoins, Nature, Cause, and Cure of Gonorrhoea, London, T757) first established the fact that goiiorrhcjua is not a How of semen. 2 Clip, clap, dippe, to embrace;, to fontUe. " CliX'pe wc in covenant, and nach of iis clip/>e other.'" — Piers Pluiif/hiiinn. " He kisselh her and clippe.th her lull oft." — Chaucrr ; Tim Merclmnt's Tale. " Oh, let me clip ye in arms as round as when I woo'd 1'" — Shakspeare: Coriolanus. " The lusty vine, not jealous of the ivy. Because she flips the elm '."' — Beaumont and Fletcher. "Old French, c/a/)/'ses, public shops kept by prostitutes. Iloblijn; — claj>iers, au old term fur houses of ill fame." 36 urethral gonorrhoea in the male. Urethral Gonoukikea in the Mai.k. Men are more liable to conti-act gonorrlioea than women ; and of a given number of cases of this disease in the former, in a large proportion it is the urethra which is affected. Cases of urethral discharge in the male outnumber all other forms of gonorrhoea in the two sexes combined. The explanation of this fjict will appear when we come to consider the causes and nature of gonorrhoea. Symptoms. — The symptoms of urethral gonorrhoea in the male first appear, as a general rule, between the second and fifth day after exposure; though, in exceptional cases, as late as the seventh, tenth, or fourteenth day; but their occurrence after this time, as alleged by some authors, is, I believe, to be explained on the ground that the earliest manifestations of the disease have been overlooked. At first, the symptoms are very slight, consisting only of an uneasy and tickling sensation at the mouth of the canal, which, on examination, is found more florid than natural, and moist- ened with a small quantity of colorless and viscid fluid, which glues the lips of the meatus together. This moisture of the canal gradually increases in amount, until on pressure a drop may be made to appear at the orifice ; at the same time it begins to lose its clear watery appearance, and assumes a milky hue. Examined under the microscope, it is found to consist of mucus with the addition of pus-globules; the number of the latter being proportioned to the depth of color of the discharge. ' Meanwhile, some smarting is felt by the patient in the anterior portion of the canal during the passage of the urine. Such are the symptoms of the early stage of gonorrha-a. The exciting cause of the disease has been applied to that portion of the canal w^hich lies near the orifice of the meatus and wliicli was chiefly exposed to conta- gion, and the ensuing inflammation is gradually lighted up in this part, and has not yet extended beyond that portion of the urethra known as the fossa navicularis. This early stage of gonorrhoea is often called " the stage of incubation," a name which is objectionable because the inflammatory process is doubtless set up at the time of the application of the exciting cause. Time is required for it to produce its full effect, and the earliest symi)toms are but slowly and gradually ushered in. A more ai)propriate name is tlie first or preparatory stage. The flrst stage of gonorrhoea usually lasts from two to four days. The symptoms gradually increase in intensity, until, in about a week after ex- posure, the second or inflammatory stage may be said to commence. If we examine the penis during this stage, we And the mucous membrane covering the glans reddened, and the whole extremity of tlie organ swol- len so that the pre])uce fits more tightly than natural. In some cases the latter is pufled out by ojdema in the cellular tissue, and phimosis may exist, rendering it imi)0ssible to uncover the glans. 'I'lie inflammatory blush is especially marked in the neighborhood of the meatus, the lips of which are swollen so as to contract the calibre of the orifice. The urethra SYMPTOMS. 37 is slightly more prominent tlian natural along the under surface of the penis, and is sensitive on pressui-e especially in the neighborhood of the fossa navicularis. The discharge has now become copious, so much so in some instances as to drop from the meatus as the patient stands before you. It is thick, of a yellowish cream color, and not unfrequently tinged with green. This greenish hue, as in the sputa of pneumonia, is due to the admixture of blood-corpuscles, which may be sufficiently numerous to produce the characteristic color of blood. The penis generally, and espe- cially upon the under surface over the course of the canal, is painful and tender on pressure. While passing his urine, the patient complains of intense pain which is now not confined to the anterior part of the canal, but is felt in all that ])ortion of the organ anterior to the scrotum, or is even more deeply seated. The severity of the suffering during the act is in some instances very great. The pain is compared to the sensation of a hot iron introduced within the canal ; and the popular name, cliaude-pisse, given to the disease by the French, is fully justified. This pain is excited in part by the irritation produced upon an abnormally sensitive membrane by the salts contained in the urine, but chiefly, I am inclined to think, by the distention of the contracted and sensitive canal by the passage of the stream. Hence, during the act, tlie patient involuntarily relaxes the abdominal walls, holds his breath, and keeps the diaphragm elevated, in order to diminish the pressure upon the bladder and lessen the size and force of the stream of urine. In consequence also of the urethra being contracted and more or less obstructed by the discharge, the stream is forked or otherwise irregular. Chordee — Another source of suffering in this stage of gonorrhoea is the nocturnal erections, which are apt to come on after the patient is warm in bed. The genital organs are in a highly sensitive condition, and are I'eadily excited by lascivious dreams, the contact of the bedclothes, or a distended bladder ; or, independently of such exciting cause, they assume a state of erection which even in health is more apt to occur during sleep. "When thus excited, it will often be found that the penis is bent in the form of an arc with its concavity downward. Tliis condition is known as chordee. Its explanation is very simple. The urethra, the chief seat of the inflammation, runs along the under surfiice of the penis. Plastic lymph is effused around the canal, gluing the tissues together and render- ing this portion of the penis less extensible than the remaining portion composed of the corpora cavernosa. Hence, in a state of erection, the corpus spongiosum surrounding the urethra, not being able to yield to the , extension, acts like the string of a bow, and chordee is produced. The stretching of tiie parts thus adhering together excitfjs pain, which is often very severe. The sufferer, awaking from sleep, instinctively grasps the penis in his hand, and bends it into a still smaller curve, so as to remove tlie strain from the under surface and thus ease the pain. I have been in the habit in my lectures of illustrating the mechanism of chordee by gluing 38 URETnRAL GONORRHtEA IN THE MALE. a piece of tape along the surface of an India-rubber condom, and then dis- tending it with air or water. The above ex|)lanation of the meclianism of chordee is tlie one usually received, though it is proper to state that it is rejected by Mr. Milton, who believes that chordee is due to spasm of the muscular fibres, which Kolliker and Mr. Hancock have shown to exist around the whole course of the urethra. Milton's explanation is opposed by the fact that bending the })enis so as to increase the curve of the arc affords partial ease to the pain of chordee ; and I am not convinced that the generally received opinion should thus be laid aside, though it is highly probable that spasmodic mus- cular action plays some part in the production of the frequent erections and chordee which take place in gonorrhrea. Hemorrhage In the congested state of the vessels of the urethral mucous membrane which obtains in acute gonorrhoea, it is not surprising that blood should sometimes be found mixed with the discharge, imparting to it a reddish or rusty hue. This is the ordinary extent of the hemor- rhage, although it may amount in a few rare cases to a decided flow of arterial blood, even when no special reason for its appearance, other than the gonorrhea, is known. It is, however, under sexual excitement that the hemorrhage is most likely to be free, and even alarming, especially to the patient and his friends. The occasion of it may be simply a violent erection. More com- monly it is prolonged sexual excitement, induced by the presence, even in the absence of fondling, of the fair individual to whom the trouble was originally due. Any excess in exercise — walking, standing, etc., or any attempt at coitus which may be made if a man is under the effects of li(juor, will evidently favor the same. Again, there is a practice in vogue among men of the town abroad, much more than in this country, of " breaking the cord," which consists in relieving themselves of the pain of cliordee by laying the erected and bent penis upon a flat surface and straightening it by a blow. This dangerous practice is often followed by a copious hemorrhage, which may subsequently return on slight excite- ment, the vessels having once been ruptured. I say " dangerous," chiefly on account of the liability to hemorrhage following. It is said that it may also produce stricture, which is not uidikely. At any rate the practice is barbarous. The amount of blood lost, under either of the aljove circumstances, varies of course in different cases. " A little blood goes a long way," so that the statements of patients should be received cum grano salt's; but competent observers have estimated it, in rare instances, as one or two pints. There are otiier discharges of blood, coming from the neck of the bladder, which take place in cases of gonorrh'cal cystitis. These will be mentioned hereafter. There are other important complications of the inflammatory stage of gonorrhoea, such as inflammation of the corpora cav(!ruosa, folliculitis, periurethral abscess, lymphangitis, adenitis, etc. etc., which are worthy of SYMPTOMS. 39 careful study, but wliicli will be best treated of in subsequent chapters, to which the reader is referred. The second stage of gonorrhoea, which we have now described, is vari- a1)le in its duration in different subjects. As a general rule, it lasts from one to tliree weeks, being influenced by the constitution of the individual, his mode of life, and the number of his previous attacks. It is succeeded by the third stage or stage of decline. This final stage of gonorrh. Foi'rxikii : De la contagion syphilitique, p. 111. Sir Henry Thompson : Stricture of the Uretlira, p. 120. Mr. Skey : London Medical Gazette, vol. xxiii (1838-39), i>. 439. Berkeley Hii,l : Syphilis and Local Con- tagious Disorders, p. 376. Guilland : Des manifestations du rlieuniatisrne sur Turethre et la vessie, 1876, p. 4. Otis : Clinical Lecture, Med. Record, N. Y., May 18, 1878. CAUSES AND NATURE OF GONORRH(EA. 43 overrated. In all such cases, the accused should receive the benefit of any doubt which may exist; and the physician who withholds it from her out of a morbid fear that he may be imposed upon, and thus runs the risk of convicting an innocent person, is unworthy of his calling. His province is to decide from the symptoms taken in connection with the known facts of the case, and unless these are sufficient to establish guilt beyond the shadow of a doubt, humanity demands at least a verdict of "not proven." Other causes, in addition to those already mentioned, may give rise to urethral gonorrhoea in the male. Thus, unquestionable instances are re- ported in which a gouty or rheumatic diathesis without exposure in sexual intercourse has occasioned a discharge from tlie urethra. Dr. Guilland has collected a number of such published cases, with the addition of others of his own. In two of them, the patients had never had intercourse with women, so that the urethral discharge following an attack of rheumatism could not be looked upon as a mere coincidence. In other patients, one of them an interne in the Paris hospitals, and all of them of a rheumatic diathesis, too long a time had elapsed since the last act of coitus to ascribe the urethritis to contagion. To finish Avith this subject of rheumatic gonorrhoea, I will here give Guilland's resume of its characteristic features, italicizing those which he appears to regard as of the most importance: " Discharge copious, appear- ing suddenly and attended with little pain ; disappears in most cases spon- taneously after a comparatively short duration ; general disturbance of the system frequent; coexistence of rheumatic symptoms, or at least his- tory of this diathesis. Above all, absence of any chance of contc(gion." Ricord relates a remarkable case of tubercular deposit in different por- tions of the urethra of a strumous subject with symptomatic urethral dis- charge;^ and a scrofulotis diathesis is generally a strong predisposing, if not an active cause of inflammation of the urethra as well as other mucous canals. ]Mr. Harrison rej)orts the case of a medical practitioner who suffered from a puriform discliarge, heat and pain along tlie course of the urethra, attended with frequent micturition, chordee, and sympathetic fever, after eating largely of asparagus.^ It is also claimed that arsenic, when producing a toxic effect either in consequence of the amount of the dose or tlie peculiar susceptibility of the patient, will act upon tlie urethral mucous membrane in a similar manner as it does upon the digestive tract and upon the skin, and cause urethritis. Two such cases are reported by M. Saint-Philippe.^ Among other causes of urethritis are free indulgence in fermented liquors, terebinthinate medicines, para|)legia inducing changes in the urine, the use of bougies, stricture, masturljation, prolonged excitement of the genitals, cancer of the womb, vegetations within the un.'thra, ascarides ' Bull. Acad, fie med., Par., vol. xv, p. ."iGS. * Lancet, London, Am. e(L, Jan., 1800. * Lend. M. Record, May 15, 1878, from tlie Gaz. m^d. de Bordeaux. 44 URETHRAL GONORRHCEA IN THE MALE. in the rectum, dentition, epidemic influences, etc. The internal use of cantharides is peculiarly liable to excite gonorrhoea, which, in this case, commences in the deeper portion of the canal. M. Latour, editor of the Union medicale, vouches for the truth of tlie following story : A physician, thirty years of age, had been continent for more than six weeks, when he passed an entire day in the presence of a woman whose virtue he vainly attempted to overcome, but who resisted all his approaches. From ten o'clock in the morning until seven in the evening, his genital organs were in a constant state of excitement. Three days afterwards he was seized with a very severe attack of gonorrlicea, which lasted for forty days. A chancre within the urethra is attended with more or less thin and often bloody discharge, which will be more particularly described in a subsequent portion of this work. Again, urethral discharges are sometimes due to changes in the mucous membrane lining the canal, induced by infection of the constitution with the syphilitic virus. In several instances I have observed a muco-purulent discharge coinciding with the first outbreak or a relapse of secondary symptoms, and so long after the last sexual act that it could not be attri- buted to the ordinary causes of gonorrhoea. Bassereau speaks of similar cases.^ There is no more frequent seat of early general manifestations than the mucous membranes in general ; and in the cases referred to changes probably take place in the urethral walls similar to the erythema, mucous patches, and superficial ulcerations which are found within the buccal and nas.il cavities. These cases are very rare, and can only be dis- tinguished from ordinary gonorrhcjea by the previous history and coexist- ing symptoms of the patient. For instance, if there has been no exposure for a long period, and especially if secondary symptoms have recently made their appearance upon other mucous membranes, the urethral discharge is probably symptomatic of the constitutional disease. Since the secretions of secondary lesions are now known to be contagious, the discharge in these cases is doubtless so, also ; it is not readily inoculated upon the person from whom it is derived nor upon any other affected with syphilis, but, if communicated to a healthy individual under the requisite conditions, it may give rise to a cliancre. Kicord's receipt for catching the clap may show how to avoid it : " Do you want to catch a dap? I will tell you how to do it. Select some woman of a pale lymphatic temperament — a blonde is better than a bru- nette — and the more 'whites' she has the better. Take her out to dine; order oysters first, and don't forget asparagus afterwards. Di'ink often and freely — white wines, champagne, coffee, liqueurs, they are all good. After dinner dance a while, and have your friend dance with you. Get well heated during the evening, and quench your thirst without stint with beer. At night play your part valiantly ; two or three times are not too much, but more would be better. The next morning do not forget to take ' Affections sjphilitiques de la in'au, p. 35G. CAUSES AND NATURE OF GONORRHCEA. 45 a prolonged hot bath ; moreover, do not omit to take an injection. This programme having been conscientiously followed out, if you don't have a clap some good Deity must have saved you." Fournier's statistics as to the class of women from whom gonorrhoea is most frequently derived are interesting: — Public prostitutes ........ 12 Clandestine prostitutes ....... 44 Kept womeu, actresses . . . . . . .138 Shop girls 126 Domestics ......... 41 Married women ......... 2fj 387 This table simply shows what daily observation corroborates, that there is not so much safety in what fast young men call '• a good thing" as they believe ; in other words, that more claps are caught in " nice little arrange- ments" than in brothels. The inferences from what has now been said of tlie etiology of gonor- rhoea relative to its nature, are so obvious that they require little more than mere mention. If in a large proportion of cases the disease can be tiaced to no other cause than leucorrhoea, the menstrual fluid, to excessive coitus, intercourse under circumstances of special excitement, inattention to cleanliness, the abuse of stimulants, etc., and if, when thus originating, it is undistinguishable, either by its symptoms, course, complications, or termination, from the same affection due to contagion, it is evident that it should be ranked among the ordinary catarrhal inflammations of mucous membranes, or, in otlier words, that it is a simple urethritis, the connection of which with sexual intercourse is a merely accidental, or at all events, not a necessary circumstance. But — it may be asserted — the possibility of contagion proves the pres- ence of a poison. Granted : but it does not follow that it is a specific poison, or one incapabhi of being produced by sim[)le inflammation. Such a, conclusion would be contrary to the facts adduced in the preceding pages, and, moreover, is not required by the analogy of inflammations of other mucous membranes ; since, in muco-purulent conjunctivitis — tlie true ana- logue of (jonorrhoea — we have precisely the same order of events, viz., inflammation origiiuiting in simple causes, and giving rise to a secretion which is contagious and capable of transmission through an indefinite series of individuals. The discharge from the two mucous surfaces just mentioned would even a[)pear to be transferable, since that from the urethra applied to the eye gives rise to purulent ophthalmia, the secretion of whicli, Pi' we may rely upon a few experiments by Thiry, of Brussels, will, wiien brought in contact with the lining membrane of tlie urethra, produce ure- thritis. Basee same at a more advanced stage, but involve the deeper parts of the passage, as the membranous and even prostatic portions. True ulcerations involving the whole thickness of the mucous membrane are not met with. The follicles opening into the urethra are often attacked as well as tlie glands themselves, and are found filled with pus. In old cases, the mucous membrane becomes thickened, and of greater density. The subjacent tissues do not escape, and the areoli of the s[)ongy tissue are filled up and effaced. With the lapse of time, the inflammation disappears from a great portion of the canal and limits itself to certain points, of which the most frequent is the bulbo-membranous I'egion. These present a granular sur- face or even fungous elevations, and in rare instances, sessile or pediculated veo-etations. The mucous membrane may be several times its normal thickness, firm, hard, and horny. Bands are sometimes found, stretching from one side to the other. The orifices of the glands may be obliterated or, in other cases, markedly dilated. To these changes should be added those which take place in the neighborhood of any stricture that may have formed, and which will be considered hei'eafter. Since granulations of the mucous membrane are one of the chief things souo'ht for in examinations with the endoscope, and since so much stress has been laid upon their presence, a fuller account of them is desirable. The following is from Desormeaux, '■* being the result of his endoscopic examinations: "We have seen that gonorrhoea, when passing into the chronic stage, limits itself to the bulbo-membranous portion of the urethra, and that the mucous membrane of this part, at first simply dei)rived of its lustre, soon becomes uneven. These inequalities increase, multiply, and finally form rounded hemispherical projections (granulations). Then the diseased portion j)resents a surface of a deep red color, uneven, scattei'cd over with round granulations, which are sometimes a little removed from each other and at other times closely opposed. The mucous membrane in the affected portion looks like a mulberry, both in its color and its granular surface. " The granulations vary in size from that of a mustard seed to a millet J M. Tiiiry's views have been published in a series of lectures in the Prcsse med. beige, Brux., aud are also advocated by Guyomar, These de Paris, 1858 (No. 282). 2 De I'eiidoscope, etc., 1865, j). 40. TREATMENT. 47 or even hemp seed. The smallest appear to be of newest formation. This lesion is a perfect resemblance of the granulations found on the uterine neck and on the ocular conjunctiva. The granulations are almost always of a more or less deep red, and often of a dregs-of-wine color ; but in some cases I have found in the midst of them other granulations, less numerous, small, and of a grayish color. "These granulations may occupy a greater or less extent of the canal, most frequently about an inch to an inch and a half. Sometimes they in- volve the whole of the posterior portion, from the end of the spongy urethra to the vesical neck. An almost constant character is that the lesion is unique; it does not spread; there is no interruption between its two ex- ti'emities ; we do not find isolated patches, separated by portions of sound membrane. There is only one patch, befoi-e and behind which there is some inflammatory redness gradually shading off into sound tissue." Desormeaux, Tarnowski, and others also describe herpetic patches in the canal, which are to be distinguished from the foregoing. "These patches of herpes correspond exactly to those observed on the skin, on the lips, and on the neck of the uterus. They are generally multiple and are found at different points of the canal. They have the same fugacious and mobile character as the ulcerations of the same nature met with in the mouth. A patch found to-day may be absent to-morrow, when others will be found in other places. Tliey again differ from granulations in that they occupy generally a much less extent. Finally, tl)eir aspect is quite different ; their surface is not granular, it is often merely deprived of its ordinary lustre {d'cpolU) like the aphthaj on the internal surfjxce of the cheeks, or like the [jatches denuded of epithelium that are frequently met with on the buccal mucous membrane of smokers. "We meet with still another form of herpetic urethritis, apparently of a deeper character. The ulcerations which it presents are less variable in their seat; they are uneven in their outline, and, were it not for accessory circumstances, one would be tempted, on superficial examination, to regard tliera as gonorrhoeal ulcerations in the reparative stage; but, with a little attention, we find, that instead of projections, the inequalities of the surface are due to depressions. Hence, while a granular surface may be compared to that of a mulberry, tlje former resembles the depressions on the skin of an orange or the head of a thimble. "Granular urethritis pursues an essentially clironic course and leads fatally to stricture. Herpetic urethritis is more under the influence of changes in the season, which control tlie evolution of rheumatic affections. The persistence of granuhitions on the one hand and the liability to her- petic eruptions on the other will explain why so many men have repeated attacks of gonorrhoea upon the slightest exposure." Trkatmext The treatment of gonorrhcjua must be a(hipted to the general condition of the patient, and especially to the stage of his disease. In the great majority of cases met with in practice, acute inflammatory symptoms have already set in at the time the patient first applies to the 48 URETHRAL GONORRIICEA IN THE MALE surgeon ; but in tliose exceptional cases Avhich are seen at an early period, and ill those only, we may often succeed in cutting short the disease by means of the treatment termed abortive. Abortive Treatment of the First Stage. — During the first few days after exposure, varying in number from one to five in ditierent cases, before the symptoms have become acute, when the discharge is but slight and chiefly mucous, and while as yet there is no severe scalding in passing water, we may resort to caustic injections with a view of exciting artificial inflam- mation wdiich will tend to subside in a few days, and supplanting the existing morbid action which is liable to continue for an indefinite period and is exposed to various complications. This is known as tlie " substi- tutive," or more commonly as the "abortive treatment" of gonorrhoea. This method has been inordinately praised and as violently attacked ; its true merit is probably to be found between these two extremes. It is certainly liable to be greatly abused, and, if so, is both unsuccessful and capable of producing the most unpleasant consequences ; but when limited to the early stage of gonorrhoea and used with ]iroper caution, it is a highly valuable method of treatment, unattended with danger, and unde- serving the censure sometimes cast upon it. In employing the abortive treatment, there are several points which it is important to recollect : 1. The disease, in the stage to which this treat- ment is ai)plicable, is limited to the anterior portion of the urethra, known as the fossa navicularis, or extends but a short distance beyond it ; it is not necessary, therefore, that the injection should reach the deeper por- tions of the canal. 2. For the treatment to be successful, the whole dis- eased surface should receive a thorough application of the injection, for if any portion remain untouched, it will secrete matter that will again light up the disease. 3. When once a sufficient degree of artificial inflammation is excited, the caustic has accomplished all that can be expected of it, and should be suspended. Since a solution of nitrate of silver, which is commonly used in the abortive treatment, is readily decomposed by contact with metallic sub- stances, metal syringes should be avoided. Glass syringes, if well made, answer every purpose ; but as found in the shops, they are apt to be un- equal in calibre in different parts of the cylinder, the wadding of the piston contracts in drying, and a portion of the fluid fails to be thrown out, as is seen by its overflow wlien the syringe is filled a second time. For these reasons, I never advise a patient to purchase an ordinary glass Fig. 1. syringe, knoAving that it will probably give him much annoyance, and perhaps prevent his deriving benefit from treatment. AVe have an excel- TREATMENT. 49 lent substitute in the hard-rubber syringes which can be obtained at the druggists. " No. 1" (Fig. 1) is tlie one generally sold when no special form is di- rected by the surgeon, but its nozzle is objectionable ; it is unnecessarily Fi-. 2. Fi |v 190 00 Vini Opii |j 30,00 Olei .Juniperi, « Olei Cubebai, aa 5ij 8 00 Copaibae 3iij 12 00 Spiritus Gaultheriae Ji 30,00 M. Dose. — A teaspoonful (5.00) three to four times a day. (Dr. Hollywood, of Detroit.) But in whatever way combined, many stomachs will not tolerate copaiba in a liquid form ; in which case we may prescribe the solidified mass, formed by the addition of magnesia, and known in the U. S. Dispensatory as Piluhe Copaibte. It requires some little tact to prepare this mass; or, rather, ditliculty is met with, unless the proper kind of copaiba be used. Two kinds of the balsam are found in commerce, one of which, the best, is solidifiable with magnesia, and the other not. The solidified mass should be divided into i)ills, each of which may contain five grains ; and it is desirable to coat them with sugar, both for the purpose of preventing their adhering together, and to render them more acceptable to the palate. This is to be accomplished in the following manner : Put the pills into a vessel with sufficient water to moisten them ; then turn them out upon a pan and sprinkle over them finely powdered sugar, at the same time rolling them about by shaking the pan, so that they may be entirely and equally coated. This process may be repeated after they are dry, as many times as is neces- sary to give them a thick coating of sugar. The dose is from four to eight COPAIBA AND CUBEBS. 67 pills three times a day. Thus prepared, they leave no taste in the mouth, and, being slowly dissolved in the stomach, are much less likely to excite nausea than the liquid. We have another anti-blennorrhagic, but little if at all inferior to copaiba, in the powdered berries of the Piper Cubeba. Cubebs possess the advan- tage over copaiba of being far less disagreeable to the taste, and less likely to excite nausea, eructations, vomiting, and diarrhcea ; and, on this account, are often to be preferred in the treatment of gonorrhoea. They cannot be relied upon, however, unless freshly powdered, and preserved in a glass vessel, since the essential oil which they contain is rapidly absorbed by any porous material. Cubebs are conveniently taken, mixed in sweetened water, in the proportion of one to two drachms of the powder to half a glassful of the liquid ; and this dose should be repeated three or four times a day. Cubebs are often advantageously combined with iron, especially for persons of weak habit, thus : — :^. Pulveris Cubebs 5ij 8100 Ferri Carbonatis 3ss 2100 M. To be taken three times a day. Cubebs and copaiba may be combined together in the same prescription. ^. Copaibfe .^ij 60 00 Pulveris Cubebse |j 30 00 Aluminis 3iss GJOO Magnesise q. s. ut fiat massa. To be divided into pills containing five grains each (0.32), of which from four to eight are to be taken three times a day. ;^. Pulveris Cubebfe Jiij 90 Copaibfle §iss 45 Aluminis ,^ij 8 Sacchari albi ^j 30 Magnesire 5iss 6 Olei Cubebse, Olei Gaultherise, aa gj 4 M. This mixture is known as " the Black Paste," and the patient may be directed to take a piece the size of a walnut, after each meal. The follow- ing prescription is particularly adapted to delicate stomachs : — ^. Copaibje.^ij 60 00 Magnesife 3j 4 00 Olei Menthjc Piperitje gtt. xx ... 1 30 Pulveris Cubeb.-e, liismutlii Subnitratis, ail §ij . . . . COJOO M. To be divided into pills of five grains each (0.32), and coated with sugar. I^. Copaiba; ^j 30 00 Magnesife 3ss 2 00 Pulveris Cubcb.T giss 4.') 00 Aiinnonia' Carbonatis 5i.i ^ *^t> Ferri Sulpbatis ^j ^ ^^ M. " (M<^ot.) To be divided into pills of five grains each (0.32); dose, three, three times a day. 68 URETHRAL GONORRHOEA IN THE MALE. Copaiba and cubebs may also be obtained enveloped in capsules of gelatine, and this is a popular form of administration. The capsules obviate the disagreeable taste of these drugs, but they do not always prevent nausea and eructations, when their contents are suddenly discharged into the stomach, by the solution of the envelope. In such cases, we may employ the French dragees which have been introduced witliin the last few years, and of which there are several varieties; some containing copaiba alone, some copaiba and tar, others cubebs, and others still both these drugs com- bined with iron ; I have found them all to be very reliable. The dose is from four to six, three times a day. Cullerier expresses the opinion, which is endorsed by Fournier, that it is sometimes advantageous to alternate doses of cubebs and copaiba. " Give, for instance, six capsules of copaiba in the morning, six of cubebs during the day, and six of copaiba at night; the next day, commence with the cubebs, and so on. This method of administering these drugs, simple as it may appear, is of great service, and I would recommend it whenever a case of clap does not yield to copaiba and cubebs given separately" (Cullerier). The "Matico Capsules," manufactured in New York, contain copaiba, oil of cubebs, the ethereal extract of cubebs, gallic acid, and morphine. In these, as in the "matico injection," the "matico" is represented only by gallic or tannic acid in small proportions, the active ingredients being those well known! Injections of an emulsion of copaiba into the rectum, when the drug is not borne by the stomach, have been recommended, especially by Velpeau. I have never tried this method of administering copaiba, and should have but little faith in its efficacy. It is acknowledged that a much large/ quantity must be used than when it is given by the mouth. A simple injection should first be employed to clear the rectum of fecal matter, when the followinn; mixture is to be thrown in : — ]^. Copaihffi 3v 20 Ovi Vitelli No. j. Extract! Opii gr. j Aqiije §vjss 195 M. 00 The nausea, eructations, and diarrha?a, which are often excited by copaiba, have already been referred to, and sometimes render it impossible to administer this remedy in any form to a delicate stomach. The diar- rhoea may often be controlled by the combination of alum or an opiate, but more frequently requires the drug to be suspended, and afterward resumed in smaller doses. Copaiba sometimes, also, gives rise to a cutaneous eruption, belonging to the class of exanthemata, as roseola, erythema, or urticaria. Such erup- tions should be carefully distinguished from those of secondary syphilis, as may readily be done by the absence of coexisting syphilitic symptoms, by the itching that usually, but not always, attends them, and by their disappearance in a few days after the copaiba is suspended. The adminis- COPAIBA AND CUBEBS. 69 tration of copaiba should not, as a rule, be continued, if it produce this effect, although Diday says that the eruption will disappear spontaneously all the same whether we go on with tlie copaiba or not. Another unpleasant symptom not unfrequently occasioned by copaiba, is pain in the region of the kidneys, dependent upon congestion of those organs. A few years ago, a patient was under my care for gonorrhoea, who had previously had several attacks of ha^maturia. Contrary to my advice, he took copaiba, which induced a return of the blood in his urine, and I afterwards learned that the administration of this drug had already produced a similar effect in a former attack of gonorrhoea. This and other similar instances may readily be explained on the probability that copaiba and cubebs produce a certain amount of hypera^mia of the kidneys. But a far more serious charge has been brought against these drugs, viz. : that of producing morbus Brightii. Now there is no evidence whatever that this charge is well founded. Zeissl states that in his large experience, he has found no proof of the same, and this is our own testimony and that of others well informed. The error has probably arisen from the fact that the urine of persons taking copaiba will, on the addition of nitric acid, deposit a sediment which has been mistaken for albumen. That it is not albumen is shown by its disappearance on boiling, or on addition of alcohol, potash or carbonate of ammonia. It is merely due to the copaibic acid contained in the urine. Cubebs may occasion, though much more rarely, any of the unpleasant symptoms just mentioned as likely to occur from copaiba. Both of these drugs, in large doses, will, in rare instances, excite severe headache, giddiness, and even more serious symptoms connected with the nervous centres. Ricord mentions a case of temporary hemiplegia, and another of violent convulsions, produced by copaiba ; in both instances, these serious symptoms were followed by the outbreak of a cutaneous eru[)tion, also dej)endent on the drug. The anti-blennorrhagics now mentioned, are of undoubted efficacy in the treatment of many cases of gonorrhoea, but in others they utterly fail ; nor have we any means of distinguishing these two classes of cases before- hand. As a general rule, if they are likely to prove successful, their good effect will be apparent in a fortnight or three weeks from their commence- ment, and if, by this time, the disease continue unabated, they should be omitted, and other means employed to effect a cure. When long continued, they ])roduce disorder of the digestive functions, impair the appetite, and induce general malaise and debility ; a condition of the sys- tem highly calculated to prolong the duration of gonorrhoea. Though often of marked btenefit, they are by no means indispensable in the treat- ment of every case of gonorrlnx^a. Preparations of the Gelsemium senipervii'ens are mucii employ(Ml at the South, given internally, in the treatment of gonorrluea, but in my hands have not proved of much benelit. This jdant acts primarily on the nerv- ous centres, and in full doses produces staggering in the gait, dimness of sight, and double vision. In one of my patients who was taking it, the 70 URETHRAL GONORRHCEA fN THE MALE. double vision was due to paralysis of the motor oculi of each eye, which passed off soon after the drug was suspended. The most convenient form for administration is the fluid extract, the dose of which is about fifteen drops three times a day, gradually increased until dimness of vision or staggering in the gait is perceived. The following formula is recommended by Prof. Wm. P. Seymour, of Troy :- R. Ext. Gelsemii fl. Sij 8100 Spiritus ^Etheris Nit. |ij .... 55 00 Tinct. Cubebfe gj 30|00 Spt. Lavaiidul?e Comp. §ss .... 15|00 Aquse q. s. ad §iv 120|00 M- 3J (4.00) every six or eight hours. The oil of yellow sandal wood is a very valuable internal remedy for gonorrhoea, which was first introduced to the notice of the profession in 1865, by Dr. Thomas B. Henderson, of Glasgow.^ I have found it quite as efficacious as copaiba, if not more so, and it is far more acceptable to the stomach. The dose is from fifteen to tliirty minims, three times a day, taken on lumps of cut sugar, in water, or in a mixture with alcohol and cinnamon — R. Olei Santali Flavi §j ...... 32100 Spiritus recti giij 90:00 Olei Cinnamomi f»\,xxiv l|CO M. et Sig. — From one to two teaspoonfuls (5.00-10.00) tlii-ee times a day. This oil is now put up in capsules ; from twelve to twenty are to be taken daily. I have known of a number of cures of gonorrhcea with the oil alone. Sometimes, like copaiba, it produces pain in the kidneys, and must be suspended.'^ I have tried the oil of erigeron as recommended by Dr. J. T. Pretty- man, but without favorable result.* Gurjun Balsam has recently been prescribed with success at some of the hospitals of Paris.* It is said to act more rapidly than copaiba, and to have no disagreeable effect on the breath. The following is Vidal's formula, as used at the Hopital St. Louis : — Gurjiin Balsam 4 grammes (1 drachm) ; Gum 4 grammes (1 drachm) ; Infusion of Star Anise 40 grammes (10 drachms). To be divided into two doses, and taken directly before meals. 1 can speak very favorably of Cannabis sativa as an internal remedy for gonorrhoea after the more acute symptoms have subsided. It is to be given in the form of the mother-tincture (one part of the fresh plant to ' Glasgow Medical Journal, 1865. 2 See articles by M. Panas, Union nied., Paris, Sept. 23, 1805; and by Dr. H. H. A. Beach, Bost. Med. and Surg. Journ., Nov. 5, 1808. * Am. Journ. Med. Sci., July, 1860. « Bull. gen. de tlierap., Paris, Feb. 28, 1878. EXPECTANT TREATxMENT. 71 two parts of alcohol, by weight), in doses often to fifteen drops, in water, three or four times a day. During the administration of copaiba, cubebs, or any other drugs which act by their presence in the urine, the patient should drink but little fluid, so that the urine may be undiluted and as fully charged as possible with the remedy. Expectant Treatment In a work like the present, which is intended to give the views of other authors as well as our own, it would be unjust to the reader to omit saying that the treatment above recommended is in several respects at variance with that advised by some authorities of the highest eminence. I refer to the present teachings of the French school, and especially to those of Fournier and Diday. The treatment adopted by these surgeons is, to a great extent, an ex- pectant treatment, and may be stated as follows : In the first place they do not believe in the efficacy of copaiba and cubebs, nor in urethral in- jections during the acute stage of the disease, or even Avhile any decidedly puriform discharge remains. They believe that these means may repress the discharge for the time being, but that the latter will return in full force as soon as the former are stopped ; moreover that their use at this time so habituates the stomach and urethra to them, that they can be used to much less advantage at a later period, when their action would other- wise be speedily effectual. Hence, Diday lays down the following rule : " Tell every patient who comes to you at a time when the acute stage of clap is established, that he must wait a month or six weeks before it is possible to give him specific remedies with advantage."^ Meanwhile, while waiting for the clap to become " ripe" enough, as Diday expresses it (to be plucked ?), these surgeons prescribe attention to hygiene, " a full bath every third day," ** several local baths of cold water daily," "avoidance of beer, white wines, and Vermouth;" "pure wine, coffee, liqueurs, pork, and spiced dishes only in moderation," together with " a glass of water, four or five times a day, either sweetened with syrup or orgeat, or with a pinch of the following powder : — I^. Sacch. albi, Pulv. Acacire, ail §ij 60 " Glycyrrliiz?e, " Potass. Nitrat. aa giss .... G M." If in spite of this treatment the inflammation should increase, without, however, attaining its maximum intensity, " Order five or six glasses a day of a ptisan of couch-grass (^chiendent), and strawberry root (racine de Jraisier), sweetened with syrup of liquorice. Every second day, before going to bed, take a bath and remain in it for an hour and a half. Two or three times a day, bathe the penis with a warm infusion of marshmallow. S{)rinkle the inside of the suspensory bandage worn with powdered cam- phor, " etc. etc. etc. ' Th6rapeutic|uo dos mal. ven,, 1876, p. 12. 12 URETHRAL GONORRH(EA IN THE MALE. When the inflammation has reached its height, " ap])ly eight leeches to the perinajum. Kemain in bed or at any rate in your room. When walking keep the penis elevated. Drink two or three pints daily of flax- seed tea, or a ptisan of the white water-lily. Take a full bath every day, lasting from two to three hours. Frequent local baths of an infusion of marslmiallow. Pass water with the penis immersed in warm water. Avoid every occasion, physical and moral, for erections. Keep your hoioels open. " A clap must not be considered ripe, simply because such time has passed as is regarded as the ordinary term by the patient, influenced by theoretical considerations, prejudices or his own convenience. Each clap has its own course ; and although we may usually reckon on five or six weeks for it to attain maturity, this period is sometimes shorter, and very often longer; frequently it amounts to two months and a half or three months, and in one case under my care it was eleven months ! How shall we ascertain that a clap is ripe ? It is ripe when there is little or no pain in passing water and in erections, Avhen the meatus is no longer red nor tume- fied ; when the discharge has much diminislied, and, instead of being yellow or green, is white and somewhat sticky. This last feature is characteristic, and, since it cannot appear without the other signs of maturity existing, it, of itself, is a resume of all the signs, in a diagnostic point of view ; so much so that, in any case of claj), if the discharge, collected a sufficiently long time after an erection and held between two fingers, xvill stretch be- tween them as they are separated to the extent of four-tenths of an inch (metre 0.01), we are authorized to pronounce that clap ripe" (Diday, loc. cit.). The clap having been found or supposed to be "ripe," copaiba and cubebs, aided or not by urethral injections, are to be used vigorously for a week or a fortnight. If, after the lapse of this time the patient is not well or his discharge nearly gone, " stop the treatment at once, its continuance would be a mistake ; the reason it did not succeed was that it was premature ; make up your mind then to wait ; return for a time to demulcent drinks ; then try again suppressive medication, as soon as it shall appear to be in- dicated" (Fournier). Copaiba and cubebs would appear to be more relied upon by these surgeons and others of the French school than ure- thral injections. The statements of patients are always to be taken cum grano salis; hence I cannot fully rely upon the word of a recent patient returning from Paris who said an eminent French surgeon told him that urethral injections were nearly obsolete in France. As said in commencing, the above treatment recommended by Fournier and Diday is in the main expectant. Aside from rest and hygiene, the means recommended while waiting for the claps to become "ripe" can have little if any efiect. I will not say but their course is the best. The cases, which everybody meets with, of a clap hanging on month after month under ordinary treatment, are enough to lead us to try anything which promises better success. But 1 have never been able to tborougldy test their treatment, simply because patients will not submit to such temporiz- OBSTACLES TO SUCCESS. 73 ing. I Avould not myself if I had the disease, nor would you, virtuous reader, if you should chance to "contract a clap from a water-closet" (or otherwise). At the same time, the experience of these surgeons may in- duce us to inquire in many cases whether medication has not been carried too far. Obstacles to Success — A mistake, generally committed by patients who treat themselves for gonorrhoea, and by some physicians, especially in the early years of their practice, is over-medication and a neglect of the gene- ral health. Nothing is more common than to meet with a patient, suffer- ing with gonorrhoea of several months' standing, who has been kept on low diet, and been taking various preparations of copaiba and cubebs, using a variety of injections often exceedingly irritant in their composition or strength, and who is now run down, weak in body, and despairing in mind. His digestion is impaired, his appetite gone, and his clap as bad as ever. Let such a man lay aside his capsules, pills, powders, mixtures, and irri- tant injections ; give him substantial food, and a tonic, as quinine or iron ; and his disease will probably begin to improve at once, and subside en- tirely in the course of a few days or Aveeks. Under any circumstances, you will have removed one great obstacle to a cure, and if the discharge do not entirely disappear, it is probably kept up by some local complication, which can now be attacked with a prospect of success. Independently of debility, the chief causes of the continuance of a gonor- rhoea! discharge are the existence of stricture and irritation of the neck of the bladder. It is desirable in every obstinate case to ascertain if the former be present by the passage of bulbous sounds, and if any obstruction be met with, appropriate treatment should at once be adopted; but even in the absence of stricture, the introduction of an instrument into the bladder two or three times a week has a most beneficial effect upon old cases of clap.^ It sometimes happens that a case of gonorrhoea has been going on well for a week or ten days under the use of the anti-blennorrhagics and injec- tions — the discharge has almost entirely ceased, and the patient considers himself nearly well, when suddenly a relapse takes place ; the discharge is once more thick and purulent ; the scalding in making water returns ; the injection, which has scarcely been felt for a number of days, excites considerable pain, and at the same time the patient has a frequent desire to pass his urine, and suffers from an uneasy sensation in the perineal re- gion. The latter symptoms dtuiote that the disease has extended to the deeper portion of the urethra, and that there is ii'ritation or inflammation of the neck of the bladder. Under these circumstances, the case requires to be veuv carefully watched and judiciously treated. Unless great care be used, the infiannnation may extend through the vas deferens to the scrotal organs, and swelled testicle ensue ; or the prostate gland may become in- volved. If irritant injections now be used, they will prove inefficient and will aggravate the symptoms. It is best to suspend the use of injections ■ See chapter on Gleet. 74 URETHRAL GONORRH(EA IN THE MALE. altogether, and to resort to the exhibition of alkalies and sedatives, as recommended in the inflammatory stage, until the subsidence of the symp- toms shall enable us to resume direct treatment ; the patient should also be particularly careful with regard to exercise. Canada turpentine, the product of the Abies baJsamea, will also be found of essential service in these cases. It may be made into pills containing five grains each, of which from six to twelve should be taken daily. I have also been much pleased with the effect of tincture of ergot, administered in drachm doses three times a day. Treatment of Special Symptoms — It remains to speak of the treatment of certain special symptoms which may attend a case of gonorrhoea, and one of the most annoying of these is chordee. Various sedatives are em- ployed for its relief, among which camphor holds the first rank. This may be given in the form of a pill, combined with extract of lettuce or opium, as in the following formuhe : — I^. Lactucarii, Pulveris Campliorae, aa ^ij .... 2]60 M. ft. \V\\. XX. Dose. — Two at bedtime. (Ricord.) I^. Pnlveris Camplior?e ^iss 2|00 Pulveris Opii gr. x |65 M. ft. pil. No. X. Dose. — One or two. (Ricord.) AVe have also used with good result the monobromide of camphor in doses of three grains (gramme 0.20), either made into a pill with the ex- tract of hyoscyamus or dissolved in the tincture of the same. Mr. Milton prefers camphor in a liquid form in large doses. He directs the patient to take one drachm of the tincture in water on going to bed, and eveiy time he wakes up with chordee, to repeat the dose. He states that after the continuance of this treatment for two or three nights all tendency to chordee disappears. Dr. Ed. R. Mayer^ says " full doses of gelsemium at bedtime are the most certain preventive of chordee." Lupuline is another remedy of undoubted power in allaying the excita- bility of the genital organs, and possesses the advantage over opium that it does not constipate the bowels. It may be given in doses of fifteen grains, triturated in a mortar with sugar. This quantity is to be taken before going to bed, and may be repeated one or more times in the night if required. Of the above means of relieving chordee, I regard Mr. Milton's method of giving camphor, if it do not disagree with the stomach, and the admin- istration of lupuline, as the best ; yet none of the remedies mentioned can be relied upon with certainty of producing the desired effect, for they all fail in many instances. Much may be accomplished by directing the patient to avoid eating or drinking for some hours before going to bed, to • "Specific Medication," a paper read before the Luzerne County Medical Soc, at Pittston, Pa., Sept. 13, 1876. TREATMENT OF HEMORRHAGE. 75 be careful to empty his bladder and rectum, and to sleep on a hard mat- tress, with but few bed-clothes over him. The position in bed is also of importance, since erections are much less likely to take place when lying upon the side than upon tlie back. Suppositories of the extracts of opium or hyoscyamus and belladonna introduced into the rectum may often be found of service. Another means of relief wliich I have found highly successful is bath- ing the genital organs in very hot water directly before going to bed. The reaction after the application of heat has a sedative effect, and in this respect has exactly an opposite influence to that of the cold lotions Avhich are sometimes advised. Many French surgeons recommend leeches to the perinjeum. I have never tried them, believing the remedy Avorse than the disease. Treatment of Hemorrhage — A slight hemorrhage from the urethra in gonorrhoea is often a blessing rather than a curse, since it relieves the con- gested condition of the vessels. Even when so great, though still moder- ate in amount, as to require precautionary measures, it will usually be sufficient to put the patient into bed with his hips elevated, and apply ice or cloths dipped at short intervals in ice-cold water to the genitals. If at hand, the ingenious " cold-water coil" of Dr. Otis, represented in Fig. 6, may here be employed. Fiof. 6. Otis'g cold-water coil. In severe cases we are obliged to resort to urethral injections of very cold water, or of water with the addition of some strong astringent as the perchloride or jjersulphate of iron. These means will rarely fail, but we may be led to try the effect of a full-sized sound, or a piece of a flexible catheter introduced into the canal and a comi)ressive bandage around the penis. A compress firmly applied by a bandage to the perinaaum or Otis's perineal tourniquet will take the place of this when the blood comes 76 URETHRAL GONORRHCEA IN THE MALE. from the deep uretlira. Hoemostatics, especially ipecac or ergot given internally, will do no harm. As an attack of" gonorrhoea is passing off, it not unfrequently happens that the discharge assumes an intermittent character, entirely disappearing for a few days, and then, without apparent cause, reappearing for a day or two. This may occur several times in succession, and in some cases that I have witnessed, it has assumed great regularity. The surgeon should, of course, assure himself that the return of the symptoms is not due to im- prudence, and, if satisfied of this, is generally safe in telling the })atient that his disease will soon cease entirely to annoy him. It is important to continue treatment for some days after all traces of the disease have passed away, since relapses are very readily induced. They are usually brought on by the patient's neglecting the rules with regard to exercise, diet, etc., already laid down, or by his indulging in sexual intercourse. He should be particularly cautioned on these points, and should be directed to continue his medication, both external and inter- nal, in decreasing doses, for at least ten days after the lips of the meatus have ceased to be glued together in the morning. Until every symptom of gonorrhoea has disappeared for this length ol' time, the patient cannot consider himself as securely well, and should still be cautious in his habits for a fortnight longer. After the entire cessation of the discharge, patients sometimes complain of abnormal sensations in the genital organs, which they describe under the names of "tickling," "crawling," and sometimes "lancinating," and which may be nearly constant or intermittent at intervals of several hours or several days. These sensations in most cases are not dependent upon inflammation or organic changes in the part, but are of a strictly neu- ralgic character. They are best relieved by the passage of a full-sized sound every few days ; and they are much less felt when once the mind is set at rest with regard to any danger of a return of the gonorrhoea. The reader may be interested to know what is the average duration of treatment required in the hands of the best surgeons for the cure of gonor- rhoea, laying aside those cases which are seen in the first stage, and which are speedily cured by the abortive method. This may be estimated at four to six weeks. Greater success, on the average, is probably not attain- able by any means with wliich we are at present acquainted. Although I have been led in the preceding pages to criticize the ex- pectant treatment as recommended by some French surgeons, yet I cannot close this chapter without a quotation from Fournier, which contains much sound common sense. He says: "We meet with cases of gonorrhrjea Avhich defy all treatment. Shall we in these cases persist and struggle on, piling one remedy and one injection upon another? I believe that this l)ractice will more frequently aggravate the disease than cure it. In my opinion it is better to desist, to stop all medication, to encourage the patient and leave to time what art has not been able to accomplish. I am not afraid to say that there are many patients, who, after exhausting all the resouixes of therapeutics, get well through time alone. Moreover, in INCURABLE GONORRH(EA. 77 most instances, the disease subsides into a mere inoffensive oozing from the canal. It is better to put up with a small evil than to expose one's self to a worse one by seeking a cure which remains uncertain. Now there can be no question but that medication continued for a long time, and incessant irritation of the urethra, may result in serious accidents and in grave complications. In the face of this danger springing from the treatment, the physician must know when to stop in time. Unable to cure in every case, he should at least not make the case worse." 78 GLEET. CHAPTER II. GLEET. AVhat is the difference between chronic gonorrha'a and that affection known as " blennorrhoea" or "gleet"? If half a dozen snrgeons be asked this question, it is not probable that the answers of any two of them will exactly correspond, and this because a gleet is, in most cases, preceded by a gonorrhoea, the latter terminating in the former, without any broad line of demarcation between them. Yet if gleet be worthy of a separate name, it must possess some distinctive features, and these we will endeavor to describe. Let us understand then by gleet a chronic discharge from the urethra, unattended by pain, or other symptoms of inflammation, and containing only a very small quantity of pus, of a milky or opaline color, so scanty as to be seen only when a very long time has elapsed since passing water, as in the morning on rising, when the lips of the meatus may be found glued together, and, possibly, a small drop of the fluid may be pressed from the canal. At other times the fluid is absent or is only detected by the presence of long shreds, looking like vermicelli, floating in the urine. This fluid deposited upon the linen, leaves a diffused grayish patch, slightly darker (possibly faintly yellow) at the centre. Another characteristic of gleet is that, unlike chronic gonorrhoea, it is not readily lighted up into an acute stage of inflammation by excesses in diet or coitus, although it is not entirely free from this risk.^ In addition to gleet, we might admit with Diday, still another chronic discharge from the urethra, which is characterized by its entire freedom from pus or muco-pus and which consists merely of a transparent, viscous fluid, that can be stretched to some distance between the fingers. Its appear- ance is not constant in the morning as is the discharge of gleet, nor does it depend upon the time passed since urinating. It shows itself from time to time, independently of erections, and especially on straining at stool, etc., and the lips of the meatus are more moist than they used to be (or than the patient supposes them to have been). In short, such cases should properly be included under tlie head of " prostatorrhtea," in which mental treatment is of quite as much importance as physical, not to say more so. ' When a patient lias exposed himself in coitus and has observed an aggravation of an old discharge, the question often comes up, whether he has simi)ly revived the acute stage in consequence of his imprudence or has contracted a fresh clap. The former is probably the case if the aggravation of the symptoms appeared the next morning after exposure ; the latter, if the aggravation has been delayed a few days (Diday). DIAGNOSIS. T9 The recognition, however, of these three chronic urethral discharges, viz., chronic gonorrlioea, gleet, and chronic urethral moisture in excess, is of such importance that we will present their diagnostic symptoms in a tabulated form : — Chronic Goxorkhcea. Objective Si/mptoms. — If urine lias not been passed for three or four hours, a whitish or yellow drop may be pressed from the urethra. Meatus slightly reddened. Subjective Sijmptoms. — Slight pain in passing urine and in erections. Liabilities. — The dis- charge and pain aggra- vated temporarily by ex- cess in diet, coitus or other imprudence. Danger of contagion great. Gleet. Objective Symptoms. — Dis- charge, seen only in the morning, is of a milky or opaline white color, never decidedly yellow. Some- times merely glues the lips of the meatus together or is observed only as fila- ments in the urine. Subjective Symptoms. — Pain absent ; possibly sen- sation of tickling or of "cold," occurring irregu- larly and of short dura- tion. Liabilities. — Excess of any kind much less likely to aggravate symptoms. Danger of contagion slight. Chronic Urethral Moisture. Objective Symptoms — Not constant in the morning nor after many hours' re- tention of urine. Consists simply of a drop of trans- parent iluid, appearing especially on straining, which can be stretched between the points of the fingers from an inch and a half to two inches. Subjective Symptoms. — None. Liabilities. — Not affected unless by extraordinary imprudence. No danger of contagion. Thus it will appear that, although gleet has certain claims to be con- sidered as an affection distinct from chronic gonorrhoea, yet the two have no broad line of distinction between them, and the latter may gradually merge into the former. Much in the way of treatment is also ap[)licable to the two affections, and I have therefore deferred speaking of certain means adapted to chronic gonorrhoea until tlie present chapter. Gleet generally follows without interval an attack of gonorrhoea, as a consequence of the neglect or unsuccessful treatment of the latter. In many cases, however, gonorrha-a runs tlirough its successive stages and is ajjparently cured ; then after an interval of several weeks or even months the patient returns with the report that he has recently noticed in the morniug on rising that the lips of his meatus adhere together, and, on sep- arating them, that the urethra contains a small amount of matter ; he suf- fers no pain or inconvenience, but is still anxious about his discharge and desires to be free from it. In such instances, it is probable that the cure of the preceding urethritis was only apparent, and that a slight degree of inflammation was left in the deeper portions of the canal, not manifesting 80 ■ GLEET. itself externally until aggravated by some exciting cause, as coitus, alco- holic stimulants, latigue, etc. Or, again, it is not improbable that there is a stricture of the urethra, which is the most frequent cause of the continu- ance of a gleety discharge following an acute attack of gonorrhoea. Other organic changes may exist within the canal and be productive of gleet, as a granular condition of the mucous membrane, vegetations similar to those met with upon the internal surface of the prepuce, and, in rare instances, polypoid growths. Idiopathic gleet, or gleet not preceded by acute urethritis, may be de- pendent upon various affections of the prostate, and especially upon the hypertrophy of this gland so common in old men. It may also arise from disorder of the digestive function, and from disease of the bladder or kid- neys, whereby the urine is rendered abnormally irritating. Gleet is often maintained by a state of general debility, or by a strumous, rheumatic, or gouty diathesis. That general debility is a fruitful source of the persistence of gleet, is evident from the frequency of this disease in ])ersons of broken-down constitutions, and from the beneficial influence of tonics and general hygienic measures in its treatment. Again, gleet is peculiarly frequent and obstinate in persons of a strumous diathesis who are subject to chronic inflammation of other mucous membranes, and under such circumstances it is benefited by the administration of anti-strumous remedies. The influence of rheumatism and gout in the production of dis- charges from the urethra has already been mentioned in connection with gonorrhoea. Symptoms In many cases of gleet, the discharge is the only symp- tom. There is, as before mentioned, an entire absence of pain in the part, of redness and tumefaction of the lips of the meatus, and of scalding in passing water. In some instances, however, the patient expei'iences a feeling of uneasiness in the penis or perinfeum, or an itching about the glans or in the deeper portions of the canal, which may either be constant or attendant only upon the passage of the urine. Again, at the first act of micturition in the morning, the obstruction offered to the exit of the stream by the matter which has dried around the meatus and glued its lips to- gether often gives rise to forcible distention of the canal, and a sharp momentary pain in the urethra, wliich may be avoided by previously sep- arating the lips of the orifice. The discharge in gleet varies in its character, quantity, and in the time of its appearance. In some cases it is evidently purulent, especially when the gleet has followed a recent attack of gonorrhoea. In other instances, it is perfectly transi)arent, and, examined under the microscope, is found to consist of a clear fluid, containing epitlielial cells and free nuclei, either with or without a few pus-globules. Again, coagulated masses, like the white of an egg, are sometimes forced from the canal. In some cases, the discharge is constant, and sufficiently copious to stain the linen ; but in the majority it is perceptible only in the morning on rising. When de- PATHOLOGY. 81 pendent upon inflammation of the deeper portions of the canal, or of the prostate, it may only appear during the efforts of the patient at stool, or be mingled with the last drops of urine in micturition. The small amount of the discharge in most cases of gleet, and the frequency of this disease among soldiers, has given rise to the name "goutte militaire," employed by the French. Hunter, in his work on Venereal, states that "a gleet is perfectly inno- cent with respect to infection," and that in the relapses which sometimes occur, "the virus," in his opinion, "does not return." This statement, although often refuted, still iinds place in many elementary works, which are in the hands of medical students. A doctrine more dangerous to the peace of families could scarcr^iy be promulgated. It is, indeed, true, that men are occasionally met witii who have for years suffered from gleet, and who have yet had frequent connection Avith their wives with impunity, but where contagion ceases and immunity begins/ no one can tell ; and even if we were able to pronounce a discharge of a certain degree of purity innocuous, we could not foresee the effect upon it of a few hours' sexual indulgence. It may at the pi'esent moment be wholly mucous, and entirely innocent of contagious properties, and yet a short time hence be purulent, and in the highest degree dangerous. The fact is, no one can pronounce sexual congress safe, so long as a urethral discharge exists, and in replying to the frequent questions of patients on this point, the surgeon should not only avoid incurring the responsibility of allowing it, but do all in his power to dissuade from it. Pathology The pathological changes in gleet are the same as those met with in chronic inflammation of other mucous surfaces, as the con- junctiva, tear passages, the external meatus auditorius, etc. This fact had already been regarded as probable from a few post-mortem examinations made by Rokitansky,^ Mr. Thompson,^ and others, but has been placed in a much clearer light since the introduction of the endoscope. The changes revealed by this instrument as occurring in chronic gonorrhoea have been described in the previous chapter, and the same may be found in gleet. More es{)e- cially some remains of a granulating surface, a slight stricture, or recurrent attacks of herpes within the canal, will account for the persistency of a discharge. The presence of polypoid growths is not common, but they are occasionally met with, and the accompanying wood-cut represents one, of the actual size, whicli was removed by ' " •' I- rethral polvpus. Griinfeld through the tube of the endoscope. The con- tinuance of the inflammation within the ducts opening into the urethra, after the canal itself is free from disease, will also explain many cases of ' Pathologicc-),! Anatomy, Sydenliaiii Society's Translation, vol. ii, p. 233. ^ Stricture of the Urethra, 2d etl., lS58, p. 74. 6 82 GLEET. gleet. The lacuna magna (Fig. 8) upon the superior wall of the fossa navicularis is peculiarly exposed from its situation to participate in tlie in- flammation of gonorrlioia, and its internal surface is not readily accessible to injections. Dr. Phillips^ states that he has succeeded in curing four obstinate cases of gleet by introducing a director along the upper surface of the urethra until its extremity entered the lacuna magna, and slitting up the wall of the follicle with a narrow bistoury. TREATMENT Ricord used to " Gentlemen, if I am to go to say to the students at his lectui-es — - well, the bad place, I know what my punishment will be. I shall have a lot of fellows with the gleet standing round me, with their lamentations, their importunities, and their prayers to me to make them well." This mauiKiis mot but faintly indicates the annoy- ance which a case of gleet often gives both to patient and surgeon ! The treatment of gleet should be addressed to the general condition of the patient as well as to the local disease. It may be laid down as a rule to which there are but few exceptions, that in gleet the tone of the general health is more or less reduced. Not that all patients with gleet are necessarily weak and emaciated ; on the contrary, many appear to be robust and hearty; but it is almost always the case that they are not capable of the same amount ©f exertion as formerly; they are sensible that they have lost a portion of their animal vigor ; and the benefit of general hygienic measures and tonics in their treatment is unmistakable. The diet should be plain but substantial, con- sisting of fresh meat, vegetables, eggs, etc., to the exclusion of salt meats, cheese, and highly-seasoned articles ; and secretion from the skin should be promoted by means of frequent sponging or bathing. "With regard to exercise, although a long walk or ride, especially when carried to fotigue, » This experienco of Dr. Phillips was given in the first edition of this work, 1861, p. 87. The "Dr. riiillips" referred to was Dr. Clias. Phillips, Traits des mal. des voies urinaires, Paris, 18(iO, p. 34. With singular coincidence of the name of Phillips and the number of reported cases (4), Prof. Otis (Stricture of the Male Urethra, N. Y., 1878, p. 9) says: "Dr. Benjamin Phillips, in his treatise on 'Diseases of the Urethra,' states that he has found the continuance of a chronic gonorrhoea to depend upon the engagement of the lacutia marjna in the disease, and cites four cases of cure by slitting up the inferior wall of that sulcus on a director." Mr. Milton, "On Gonorrhea," 4th ed., p. 312, says he has "sought in vain for the work referred to by Dr. Otis, of which no date nor page is given," and my own efforts have been equally unsuccessful. Further information of Dr. Benjamin Phillips and his work on "Diseases of the Urethra" is evidently called for ! A. Superior surface of urethra. B. Fossa navicularis. G. Probe inserted in D, the lacuna magna. (After Gm'-rin, Elements de chir. ojieratoire, 185.5, p. 526.) TREATMENT. 83 will be found to aggravate the discharge, yet when commenced with mode- ration, and gradually and steadily increased in proportion to the strength, it is found to be highly beneficial. Healthy exercise of the mind is no less important than that of the body, and the attention of the patient should be distracted as much as possible from his disease, and all books and associa- tions calculated to excite the passions be avoided. The bowels should be opened daily, if possible by selecting such articles of food as are laxative, and by regularity in the hour of going to the closet, or if required, by the administration of medicine. One of the following pills, taken at bedtime, will usually insure a free stool in the morning. I^. Strychnise gr. ss 103 Pil. Colocvntli. Comp. 3ss .... 2| M. Divide into thirty pills. In the tincture of the chloride of iron, we have a most valuable combi- nation of a tonic and an astringent ; Avhich, in most cases of disease of the generative organs in the male and female, is unequalled by any of the more modern and elegant preparations of this mineral. It may be given in doses of from five to twenty drops, largely diluted with water, three times a day, directly after meals. If the dose be properly graduated, it less frequently excites headache in the male than the female; should this unpleasant symptom occur, iron reduced by hydrogen may be substituted for it, in doses of three grains, three times a day. "Where the constitutional debility is marked, the union of quinine with iron may be desii'able, as in the fol- lowing : — I^. Ferri et Quiniae Citratis 3J-iiJ • • • 4 — 12 Aqu?e §1 30 Syrupi Limonis §iij 120] M. A teaspoonful (5.00) after each meal. ^.. Tincturse Cantharidis 5j 4 Quiniae Sulpliatis 5"^s 2 Tincturse Ferri Cliloridi 5ij .... 8 Acidi Sulpliurici diluti gtt. xxx . . 2 Aquae destillatje §viij 250 M. One ounce (30.00) three times a day. (Cliilds.) . Other salts of iron, as the tartrate of iron and potassa, or the pyrophos- phate of iron, may be substituted for the citrate, in the first of the above prescriptions. Witli patients of a strumous diathesis, cod-liver oil, the syrup of tlie phosphates, or Blancard's pills of iodide of iron, may often be used with advantage. I have found that the iodide of potassium has a tendency to increase the discharge from the urethra, as it often does the secretion from other mucous membranes, and I do not therefore administer it. Tliis eHect of the iodide may frequently be observed, when we are giving it for tertiary S3q)hilis to patients, who, at the same time, are affected with gleet. From what has already been said of copaiba and cubebs, it is evident that but little good can be expected from their administration in cases of 84 GLEET. chronic urethral discharge. Moreover, most patients whose disease has arrived at this stage, have already taken them ad nauseam for the pre- ceding gonorrhoea ; hence, we are rarely called upon to administer them in pure gleet. In those cases, however, in which the gleet has relapsed into a clap, they may be given with benefit, especially when combined with a tonic, as in the drag^es of copaiba, cubebs, and citrate of iron ; in Meot's pills, the formula for which has already been given; and as in the following prescription : — I^. Copaibae §ss 151 Tinctiirse Caiitharidis ,^ss . . . ^ . . 15 Tincture Ferri Chloridi §j 30 1 M. Dose. — Thirty drops (2.00) three times a day. The reader will observe that the tincture of cantharides is an ingredient of several of the above prescriptions. Experience has shown that this drug exerts a decidedly curative action in many cases of gleet, and in gonorrhoea also, in the chronic stage. It is a favorite remedy with the homoeopaths, in doses of a fraction of a drop of the tincture every few hours, in the acute stage of clap, and is considered by them to be indicated by scalding in micturition, chordee, and a greenish or bloody discharge. I have used it, however, only in the chronic stage. The tincture may be given in doses of three or five drops three times a day, or it may be com- bined with iron, as follows : — I^. Tinctur?e Cantliaridis 5ij 8j Tincturse Ferri Chloridi gvj .... 24| M. Ten drops (0.65) in water, three times a day. In some cases of gleet there is considerable irritability of the neck of the bladder, as shown by a frequent desire to pass the urine and unpleasant sensations in the perinasum. In these cases benefit will be derived from the administration of the salts of potash, combined with hyoscyamus, or from the oil of yellow sandal wood or copaiba. Bougies In all cases of gleet, the uretlira should be carefully examined with proper instruments, in order to detect the presence of stricture ; and if the slightest contraction be discovered, it should at once receive appro- ))riate treatment, since upon its removal Avill probably depend the cure of the discharge. Of late years, my friend. Dr. F. N. Otis, has especially insisted upon the dependence of gleet on a narrow meatus or on a slight stricture, " stricture of large caliber," within the canal ; indeed, excluding cases of polypoid growths and inflammation of urethral sinuses, he believes that gleet is always symptomatic of stricture, as the following quotations from his writ- ings will show : " Chronic urethral discharge means stricture. " "When there is discharge, there will, in every case, be found, if the examination is efficiently made, a iceU-dcJined and unmistakable point of stricture. BOUGIES. 85 " The complete division of stricture has, in my experience, resulted uni- formly in its complete disappearance witliin a period varying from three months to one year, and the cure of gleet has, as a rule, followed the com- jilete divisio7i of stricture ivithin a period varying from tioentyfour hours to four weeks after the final operation."^ While believing with Dr. Otis that every undoubted stricture of the urethra should be removed, and that without its removal no case of gleet can be per7nanently cured, I have yet seen quite a number of cases in which after the most thorough operation for the stricture and when no traces of the same remained, the discharge still continued for months and even years ; I cannot, therefore, agree with him, that always " chronic urethral discharge means stricture," or that the removal of all strictures invariably cures gleet. The removal of the stricture is in all cases required, but may not be sufficient to stop the discharge. Dr. Otis has done great service by calling attention to the influence of strictures of large caliber, both immediate and reflex, which had been generally ignored, and his urethrometer to determine the size of the urethra and the presence of coarctations, is a great advance in our means of diag- )iosis. For a full account of this instrument, as well as of his " dilating urethrotome," the very best devised for division of strictures of large cali- ber, the reader is referred to the chapter on stricture. Acorn- or olive-pointed sounds, first proposed by Charles Bell, are also essential for the diagnosis of slight strictures. As frequently made, the shaft is unnecessarily long, for with a straight stem they are only adapted to detect strictures in the straight portion of the canal. If you want to explore the urethra beyond the bulbous portion, use a flexible bougie a boule, or, better still, a stiff acorn-pointed steel sound bent in the proper curve. P]ven then look out that you do not mistake the con- traction at the triangular ligament or at the neck of the bladder for a stricture. This mistake has often been made not only by novices, but by those who ought to have known better. We have already remarked that the tendency of gonorrhoea in its last stages is to limit itself to cei'tain points of the canal, and these points may often be discovered on passing an olive-pointed sound. If we find on repeated introductions tliat the patient always complains of sensitiveness at the same spot, we have reason to believe tiiat tliis is the seat of abnor- mal changes. If granulations exist, there may be a flow of a few drops of blood or the bulb on withdrawal be found smeared with the same. Pus may also be withdrawn in the same manner from the urethral pouch just behind a stricture, even when the urethra might be su[)[)Osed to have been cleansed by tlie passage of urine a short time previous. The frequent passage and retention of bougies is one of the best means known for the treatment of gleet, even when no stricture can be discovered. The manner in which bougies eflect a cure of chronic urethral discliarges ' Am. Clinical Lectures, edited by Seguin, vol. i, no. x. The italics are in tlie orisinal. 86 GLEET. is somewhat obscure, but is probably to be explained on the ground that they distend the canal, expose lacunar in which matter would otherwise lodge, and separate for a time the diseased surfaces : or, again, they may serve to stimulate the vessels of the part, and thus change their action. Bougies tapering towards the extremity and terminating in an olive- shaped point, are well adapted for the purpose. They are introduced easily and with little inconvenience to the patient, and the contraction near their point facilitates the introduction of medicated ointments into the deeper portions of the canal. The instrument should be large enough fully to distend the canal but not to stretch it, and is best smeared with vaseline. The bladder should previously be emptied and the patient placed in the recumbent posture. However gently it may be introduced, the first passage of a bougie usually excites a more or less disagreeable sensa- tion, which sometimes gives rise to syncope, and which generally renders it advisable to withdraw the instrument in a few minutes ; but after two or three insertions it ceases to give annoyance, and may be retained for half an hour or an hour. It sometimes happens that the bougie aggravates the discharge, and re- vives the acute inflammation which has for a time disappeared. In such cases it is best to suspend the treatment and resort to injections, which w^ill often effect a permanent cure. This aggravation of the symptoms however, according to my experience, takes place in a minority of cases only. With this exception, the passage of the bougie may be repeated every second or third day at first, and afterwards every day, or in some instances as often as twice a day. Bougies may be medicated in various ways. Calomel rubbed up with sufficient glycerine or oil to cover it, forms a very cleanly and excellent mixture with which to anoint the bougie, and I think materially assists the curative action. Mercurial ointment may also be used either alone or combined with extract of belladonna, the latter being added in case the urethra is irritable. I^. Unguenti Hydrargyrl §ss 15] Extract! Belladoiinse 5ss 2| M. For the purpose of stimulating the mucous membrane, we may employ the diluted ointment of red oxide of mercury, or an ointment containing a few grains of nitrate of silver, but such applications should not be con- tinued for any length of time, lest they keep up tlie discharge. ^. Ung. Hydrarg. Oxidi Riiliri 5.i . . • 41 Adipis ^iij 12| M. ^^. Argenti Nitratis gr. v-x . . 130 — [60 Adipis §j SOJ M. In old cases of gleet I have used the following mixture with very satis- factory results. A full-sized sound should be thoroughly smeared with the THE ENDOSCOPE. 87 tenacious mass, then oiled and be passed as far as the membranous portion of the urethra, and allowed to remain for three minutes. The first effect is to increase the discharge, which, however, subsides in the course of a few days to a less quantity than before the application, when the process is to be repeated at intervals until a cure is effected. IJl. Cupri Sulphatis ^iss 6] Cerse Albse ^j 30 Adipis 5iss • . . . 61 M. Any ordinary sound will answer for the application, although one may be made especially adapted for the purpose with a number of cup-shaped depressions to hold the ointment, as represented in Fig. 9. Fie:. 9. Cupped sound. Another most excellent application is a mixture of tannin and glycerine in such proportions that, when cold, it will form a solid mass. The cups are filled with the mass, which is liquefied by the heat of the body. T/te Endoscope. — It is a good rule to follow in learning the use of the Endoscope, as it is of the microscope, for the beginner to commence with the simplest instruments and afterwards add to his stock as his wants and his own experience dictate. All that is wanted for the examination of the Fiff. 10. The upper figure represents the metalUc endoscopic tube which is blackened on the inside; the lower figure its conductor and handle to facilitate its introduction, made of hard rubber. urethra is a number of straight urethral tubes adapted to different sizes of the canal, and the necessary means of illumination. The tubes proposed by many ilifferent authors are all about tlie same and e(iually serviceable. Fig. 10 represents those of Grlinfeld, one of the latest and most advanced writers on endoscopy. Cuts of the desirable accessory instruments, a swab-holder for removing blood and mucus, a pencil for the api)lication of caustics or astringents, a j)owder-blower for the same purpose, forcei)S and scissors for the removal of urethral polypi, a larger bent tube with a glass 88 GLEET. window at the bend for the examination of the deeper parts of the canal and the bladder, are also given. These are enough and more than enough for the requirements of any one but a specialist. Fis. 11. FORD C.H.&C2 Swab-hulder for removing blood and urethral discharges. Fig. 12. Blower for medkatod powders, and pencil for application of caustic and astringent solutions. Fig. 1.3. Scissors for removal of polypi. Fig. 14. FORD C, H. X C2 Forceps for removal of polypi. ^ T^nr illumination, sunlight, when obtainable better than artificial light, is thrown in through the tube by means of the ordinary frontal mirror. In the absence of sunlight, an argand burner or Tobold's condenser. Such instruments and such mode of illumination are all that are in general use at the present day. They are indeed in some respects superior to the older and more cumbrous ones, since they enable the observer to control the direction of the light and detect lights and shadows marking not only pathological changes but the openings of the ducts of urethral follicles, observed in this way for the first time by Griinfeld, whose valuable papers are recommended to the reader.^ Desormeaux's original instrument, represented in Fig. 15, is expensive ' Der Harnrohren-Spiegel, seine Anweiiduiig ; Wiener Klinik, Felirnar-Milrz, 1877. See also Wiener med. Presse, No. 11 and 12, 1874; Die Endoscopie bei Strictnren der Urethra, Wiener med. Wochensclirift, No. 39, Sej^t. 2.5, 1875 ; Auto- endoscopie der Urethra, Wiener med. Ztg. No. 36, 1875. THE ENDOSCOPE. 89 and not easily handled. The same may be said of Cruise's, which affords rather a better light. Fi-. 15. D^sormeaux's endoscope. The lower tube, -nitli a glass window at the commeacement of the bent extremity, is intended for exploration of the bladder. In the absence of sunlight a modification of Desormeaux's instrument by Denis is excellent, Fig. 1 G. It is much cheaper than Desormeaux's and handled more readily and with less discomfort to the patient. Desormeaux's endoscope modified hy Denis. Mr. Cruise uses as a burning fluid a solution of camphor in kerosene, ten grains "or more" to the ounce. I use in Denis's instrument one part of the best sperm-oil and six parts of Pratt's Astral oil, which, by the way, is an excellent compound to burn in the German students' lamp. Fig. 17 represents an endoscope adapted to ordinary gaslight. 90 GLEET, Just as this edition is going to press, a new dilating urethroscope has been presented to the profession by Auspitz' (Fig. 18). The name of its Fitr. 17. eminent inventor is sufficient to lead us to anticipate from it the advantages Avhich he claims it possesses. Success in the use of the endoscope requires dexterity on the part of the surgeon, which can only be attained by practice. The patient's urethra should also be habituated to the use of instruments by the passage of sounds before an endoscopic examination is attempted, and this may require several preliminary sessions. The best position to place him in is the horizontal with the knees strongly flexed, and the tube should be introduced into the membranous or prostatic portion of the canal before the plug is withdrawn. Other portions are brought into view as the tube is drawn out. It will readily be seen that for the purposes of diagnosis, the endoscope ' Vrtljschr. f. Dermat., Wien., 1870, s. 3. INJECTIONS. 91 proves itself to be an invaluable instrument in many cases, as, for instance, in those of urethral polypi, or venereal ulcers which might otherwise es- cape detection. It reveals also the presence and the exact seat of patches of granulations, spots of herpes, etc., and as applications can be made Fig. 18. through the tube, it enables us to reach these parts directly. Granulations can be touched by the solid nitrate of silver, with a solution of the same salt, or by any astringent in powder, as the sulphate of zinc, either pure or diluted. In herpes of the canal Desormeaux recommends the application of the Oil of Cade, which looks a little as if he were governed by precon- ceived notions as to the nature of the affection. There is every reason to believe that the ui-ethroscope, as now improved, will be found of great value in the treatment of chronic urethral affections, but hitherto it has not supplanted other means of diagnosis and treatment, and cases of gleet still make their oft-repeated visits at the cliniques of Desormeaux and other experts in the use of the endoscope. Injections — Injections have been so fully discussed in the preceding chai)ter, that little remains at present to be said of their composition, or the ordinary mode of their administration. In gleet as in gonorrhcea, weak solutions of the acetate or sulphate of zinc (containing from two to three grains to the ounce of water) are in most instances to be preferred; and the injection should be made to per- meate the urethra as deeply as possible, in order that it may be applied to the whole extent of the affected surface, but care should be taken not to distend the canal with too much force, the sensations of the patient being the best indication when a sufRcient amount has been employed. So far as inflammation of the testicle and prostate have any connection with the use of injections, I believe they are more frequently due to violent manipu- lation than to the irritant character or strength of tlie solution. Hence, injections should always be used with gentleness, while at the same time the canal should be entirely filled, that none of the folds into which the 92 GLEET. urethral walls are naturally thrown except during the passage of the urine may escape coming in contact with the astringent fluid. With this pre- caution, a weak injection may be employed after every passage of the urine, a degree of frequency which will often prove successful when a less degree has failed. In addition to the formuLt for injections given in the chapter upon gon- orrhoea, the following may be added : — I^. Hydrargyri Bicliloridi gr. j . 106 AqujB §viij-xij 250j — 375| M. ^. Gall?e ^j 4| Aluminis9ij 2 GO Aqu£e §viij 250| M. I^. Acidi Nitrici gtt. xvj-xl . . 11 — 2\G0 Aquie 5viij 250| M. I^. Liq. Ferri Persiilphatis (Squibb) 5ss 2] Aquae ^vj 180 M. Tiie strength of the above solution may, in some instances, be increased. Dr. Lordly,^ of N. Y., recommends warm medicated injections, about three pints, made daily by the surgeon himself by means of a fountain- syringe, and a catheter introduced into the prostatic urethra. The water is medicated by some astringent, as the sulpho-carbolate of zinc, not more than three grains to the ounce. The injection is to be followed by the insufflation of some astringent powder. Ricord advises solutions containing iodine in scrofulous subjects, and, altliough the injection of this mineral into the urethra cannot be supposed to affect the constitutional diathesis, yet it may exert a beneficial action upon the mucous membrane as when applied to the fauces. R. Tiiict. lodinii gtt. viij 150 Aquae §viij 250J M. (Ricord.) I^. Ferri lodidi gr. viij 150 Aquae §viij 250| * M. (Rioord.) I will here repeat a suggestion previously given, that the use of any medicated injection, and especially one containing insoluble ingredients, will prevent even a sound urethra from exhibiting its normal dryness. Without due caution, therefore, a patient may go on injecting long after his disease is cured. Hence, after the discharge has for some time been reduced to a very minute quantity, and especially if it appear to consist of little more than the insolu])le de])osit of the solution, the injection should be omitted for a few days, in order that the exact condition of the urethra may be determined ; or again, it may be administered only once in the twenty-four hours, selecting for the purpose the early part of the day, and 1 Hospital Gaz., Fob. 15, 1878. DEEP URETHRAL INJECTIONS. 93 J. the appearance of tlie meatus the following morning Fig. 19. will indicate what progress has been made towards a cure. Deep Urethral Injections. — In the ordinary method of injecting the male urethra, it is difficult to make the fluid pass through the whole extent of the canal into the bladder. After a certain portion (about half an ounce) of the contents of the syringe has been injected, the remainder escapes above the piston, or, however tightly the glans may be compressed around the point of the instrument, flows from the meatus. The obstruc- tion to the entrance of the fluid is due to the contraction of muscular fibres (the compressor urethi'aj muscle) which surround the membranous portion and serve as a sphincter to the urinary canal ;^ and this is the pos- terior limit of the application of the fluid to the ure- thral walls by the more common method of injecting. In order to reach the deeper portions of the canal which are involved in many cases of gleet, it becomes necessary to resort to injections through a catheter, or by means of the " urethral syringe with extra long pipe," manufactured by the American Hard Rubber Company, or with Tiemann's " universal syringe," which is pro- vided with a catheter extremity. ^ Mr. Dick and Mr. Erichsen recommended a catheter syringe. Fig. 19, for deep urethral injections ; the piston consists of a sponge which will absorb about a quarter of a drachm of fluid, and this is expelled through minute openings whenever the stylet is thrust down. Still better for use in the deeper parts of the canal is Guyon's injector (Fig. 20). It consists simply of an ordi- nary bougie a bottle, perforated by ? minute canal which terminates near the point in several flne openings. The injection is made through it by means of a common hy- podermic syringe, provided with such a nozzle as will fit the bougie. The only objection to this instrument is the difficulty, in some cases, in introducing a flexible bulbous bougie beyond the triangular ligament. Tliis objection is obviated in my own instrument. Fig. 21, which I have found to be well adapted for old cases of gleet, sfjermatorrhcea, etc. The length of the urethra may be measured by introducing a catheter and marking the point in contact with the meatus wlien the urine first Dick's catheter syringe. • Seethe section on tlie Anatomy of the Uretlira in the chapter on Stricture. 2 This instrument will be found very iiseful in tlie treatment of venereal dis- eases, for instance in deep urethral injections, in injections into the nostrils and pharynx, etc. 94 GLEET. commences to flow ; upon witlulrawing the instrument the distance between its eje and the mark upon the stem will be the measurement required. Fig. 20. Guyon's injector. On introducing the catheter-syringe for the purpose of injecting (the pa- tient having first passed his water), it is an easy matter to carry its point Fig. 21. Author's syringe for deep urethral injections. within half an inch of the vesical neck without entering the bladder, when the fluid may be throAvn in as the instrument is slowly withdrawn. If the Fig. 22. <5t n? ^TT oLvia h h K A * Tieinann's " universal syringe." instrument be sufficiently large to moderately distend the canal, none of the injection will escape from the meatus so long as the eye is in the pros- tatic or membranous portion of the urethra, since the contraction of the same muscle which prevents the entrance of fluid from without, also pre- vents its exit from within, and obliges it to flow backwards towards the bladder ; hence we may, if we choose, limit the application of the injected fluid to the deeper portions of the canal exclusively, and the pain excited will be found to be less than when a solution of the same strength is thrown BLISTERS. 95 into the external portion, since the urethra, like other mucous passages, is most sensitive near its outlet. The chief disagreeable sensation following an injection thus confined to the portion of the urethra lying between the compressor urethras muscle and the neck of the bladder, is an urgent desire to pass water, which, however, should be resisted as long as possible, that the fluid may have time to act upon the urethral walls before it is washed away or neutralized by the urine. During the succeeding twenty-four hours, micturition is somewhat more frequent than usual, but is not par- ticularly painful ; and the discharge is often slightly increased for a day or two. The efficacy and safety of these injections in affections of the deeper- seated portions of the uretlira is attested by MM. Diday' and Bonnet, of Lyons, Mr. Langston Parker,^ of Birmingham, and my own experience. The same formulaj may be employed that have been recommended for in- jections by the more common method, and the application may be repeated once or twice a week. Blisters Blisters were long ago recommended for the cure of obstinate cases of gleet, but had almost fallen into disuse, when they were revived by Mr. Milton, in his work on the treatment of gonorrhoea. This author speaks of them in the folloAving terms : " I have seen two blisters, with a mild injection or two, at once cure a clap which had defied the most ener- getic treatment ; and as I never found a case which resisted blistering and injections together, that was not complicated with stricture or affection of the testicle, I am slowly arriving at the conviction, that every case of clap or gleet, hoicever obstinate, may, if u7icomplicated, be cured by blistering, singly or combined.'''^ It is to be feared, however, that this remedy has proved less successful in the hands of other surgeons than in Mr. Milton's. Recent writers who have spoken favorably of it appear to have done so chiefly on Mr. Milton's authority ; others, as Mr. Langston Parker, have given their testimony decidedly against it, and in my own practice it has not been attended with such success as to lead me to prefer it to other and less disagreeable modes of treatment. Still it may be worthy of a trial in obstinate cases which have resisted the use of bougies and injec- tions. The manner of applying blisters to this region is of considerable import- ance. The hair should be shortened around the root of the penis, and a piece of paper be wrapped around the organ, and cut in such a manner as to form a pattern of its surface from the pubis to within half an inch of its extremity. The blister, corresponding in shape and size to the pattern, ' Des injections circonscrites a, la partie profonde de I'urethre, de leur mode d'ex^cution, et de leur efficacite curative ; Annuaire de la syphilis, annee 1858, p. 61. Diday's method of employing deep urethral injections has been followed in the above description. * Syphilitic diseases, p. 82. Air. Parker injects the fluid into the bladder, lets it remain for a few minutes, and desires the patient to force it out. This ixiethod is not so good as the one above recommended. 3 Milton on Gonorrhoea. The Italics are in the original. 96 GLEET. should be applied to the penis, and tied or fastened in its place, that it may not slip, and, coming in contact with the scrotum, produce a trouble- some sore. It should not be retained longer than two hours, during which the patient must remain quiet. The morning is the best time for its ap- plication, since, if applied at night, it is likely to prevent sleep. On removing it, the surface is found to be reddened, but not vesicated, unless, perh.aps, at a few points ; and the penis should now be covered with a rag spread with simple cerate, and be ■[protected from friction by an external layer of cotton wadding. On examining the parts after a few hours, it will be found that numerous bullfe have formed on the surface, wliich at hrst appeared to be only red- dened. These may be pricked, and the serum which they contain evacuated, but the epidermis should be carefully preserved. I have sometimes found the extremity of the prepuce beyond the site of the blister, puffed out Avith an effusion into its cellular tissue, which may be left to take care of itself, or, if excessive, be evacuated by a few punctures with a lancet. Cantharidal collodion is a more convenient application than the un- guentum lytta?, but its effect cannot be limited like that of the latter, which should therefore be preferred. When applied for a few hours only, I can confirm Mr, Milton's statement, that blisters do not excite severe pain, nor produce a troublesome sore. The first effect of their application is to in- crease the urethral discharge, which can only be expected to be benefited in the course of five or six days. The blister may be repeated at the end of a week, if any discharge still remain, Tiie perinasum may be Vdistered in a similar manner, but this will require the patient to be kept in bed until the vesicated surface has healed. Separation of the Affected Surfaces Contact of the diseased surfaces doubtless assists in keeping up the discharge in gleet, as it is well known to do in balanitis. Hence it has been proposed, by means of a probe and a gum-elastic bougie open at the extremity, to introduce a strip of lint, either dry or soaked in some astringent fluid, Avithin the urethra, and thus maintain its walls apart, renewing tlie application after each passage of the urine. This method, in whicli I have had no experience, has been suc- cessful in some instances, but is very troublesome and inconvenient, iind would appear to be attended with danger of the lint slipping entirely into the urethra, and entering the bladder, Civiale mentions a case in which this accident occurred, but does not give the ultimate result.^ Mr, Milton^ states that it has happened to him in several instances, and that the lint has always found its way out, but the danger of its retention is too great to be incurred. Separation of the affected surfjxces is partially effected by certain forms of injections, as those containing bismuth, calamine, and other insoluble ingredients. Finally, in obstinate cases of gleet in which the discharge appears to come from the anterior portion of the urethra, laying open the lacuna magna, as recommended by Dr. Phillips, is worthy of a trial,^ ' Maladies des organes genito-urinaires, vol. i, p. 444, 2 On Gonorrhrea, p, 31. ^ See page 82, CAUSES. 97 CHAPTER III. BALANITIS. Ik the prepuce be retracted, a mucous surface of considerable extent is exposed, a portion of which covers the gkins penis, and the remainder consists of the internal retiection of the prepuce. This surface may be the seat of inflammation, similar to that wliich has been described as affecting the urethra. If the disease be confined, as it sometimes is, to the mem- brane covering the ghins, it should, strictly speaking, be called balanitis; if to the internal surface of the prepuce, posthitis, and if it involve both, balano-posthitis ; all these varieties, however, for the sake of convenience, are commonly included under the one name, balanitis. Gonorrhoea spuria, balano-preputial gonorrhoea, and external blennorrhagia are other terms by which it is sometimes known. Causes Men in wliom the prepuce is long, or who are affected witli congenital phimosis, are peculiarly exposed to balanitis, since the mucous membrane covering the glans and lining tlie prepuce, is maintained in so sensitive a condition, from its want of exposure to the air and friction, that inflammation is readily set up by the least cause of irritation. Such a cause is at hand in the natural secretion which exudes from the very numerous sebaceous follicles that exist on the internal surface of the pre- puce and the furrow at the base of the glans. If from inattention to, or the impossibility of cleanliness, as in cases of phimosis, this cheesy secre- tion be not frequently removed, it becomes decomposed and is changed into an ammoniacal, foul-smelling, emulsion-like fluid, which acts strongly as an irritant ujjon the delicate mucous membrane with wliich it comes in contaet. When phimosis is present, it will readily be understood how this fluid, coming from a small j)reputial orifice, may be mistaken for urethral gonorrhoea. I once had a patient come to me from the western coast of South America, simply to consult me tor a supposed clap, for which he had been taking copaiba and using urethral injections for many months. A careful examination showed that the discharge came only from the balano-preputial fold in a penis aflected with congenital phimosis, and cir- cumcision speedily relieved him of his trouble. The diagnosis in such cases is readily made, by exposing and wiping the meatus, and then noting whether upon pressure the matter comes from the urethra or from beneatli the foreskin. ^Moreover, the pain in micturition in cases of urethritis extends along the course of the canal, while in balanitis it is confined to the excoriated surfaces of the extremity of the penis. 7 . 98 BALANITIS. It will be evident that the stagnation and decomposition of any secre- tion, other than that just nientiontMl, may have the same eii'ect. Thus the purulent discharge from chancroids situated on or near the glans, the more or less watery secretion from a true chancre, mucous patches or other secondary lesion, the acrid exudation from vegetations, a gonorrlioeal dis- charge gaining entrance from the meatus, — all these are fr(M]uently the cause of balanitis. The pressure exercised by a mass of vegetations or by the exuberant development of the indurated base of a chancre are also worthy of mention. Thus far we have said nothing about contagion as a cause of balanitis. If this were a frequent cause, the inimber of cases of this atlection would be even greater than those of gonorrhoea, considering how much more than the urethra the glans penis is exposed in sexual intercourse, whereas the contrary is the fact, Sigmund reckoning one case of balanitis to seventeen of gonorrhoea, and Fournier one to twenty-four. Still to this cause — con- tagion — some instances of inflammation of the balano-preputial fold may doubtless be ascribed. Benjamin Bell relates a story of two young men, each of whom introduced beneath his prepuce a pledget of lint soaked in gonorrheal matter and kept it in place for twenty-four hours. This was followed in one of them by a very severe attack of balanitis attended by paraphimosis. The other had a slight external intiammation, but, the matter having entered the urethra, he was attacked on the second day by a violent urethritis. To tlie above causes of balanitis we may add excessive coitus, masturba- tion, and leucorrhoeal discharges in women with whom the sexual act has been accomplished. It appears from the above that balanitis in the great majority of cases is not due to contagion and is not, strictly speaking, a venereal disease; according to Fournier's statistics it is venereal in only one-fifth of the cases met Avith. Symptoms In its mildest form lialanitis is a very trivial affair. The patient complains of tenderness and an itching or tickling sensation at the head of the penis, and perliaps scalding during micturition if the urine comes in contact with the inflamed surface. On examination we find the glans sensitive to pressure, reddened, smeared with a thin, whitish or slightly yellowish, offensive fluid, and perhaps here and there deprived of its epithelium in patches. In a more advanced stage the. glans api)ears to be swollen, its redness is intensified, the prepuce is somewhat tumefied, the discharge is more copi- ous and purulent, the parts more painful and sensitive on contact with the clothes. The patches denuded of epithelium are now more marked, and are quite characteristic of this affection. They consist of exulcerations, of a bright red color, sharply defined, but irregular in their outline, iso- lated at first, but gradually becoming confluent. They are due simply to the epithelium having been macerated and detached ; and they form a strong contrast in color with other portions of the surface on which the COMPLICATIONS. 99 Fijr. 23. latter is only partially detached, but Avbitened by constant soaking. Sometimes they cover the whole surface of the glans, leaving no trace whatever of its normal outer layer. The above symptoms may be still further aggravated. The prepuce becomes of a dull red color, and its oedematous swelling so great as to give to the virile organ the shape of an Indian club ; sometimes it is twisted in the form of a corkscrew in front of the glans. The discharge is in- creased in quantity, is of a greenish color, and streaked with blood. Erec- tions are frequent and very painful. The passage of the urine is impeded, amounting in some cases to retention, and, when accomplished, is attended with intense scalding as the fluid passes over the fissured orifice. Gangrene of the prepuce is not an uncommon occurrence. It is usually [»artial, in fact, just sufficient to relieve the tension and allow the glans penis to protrude through the opening formed by the slough. In this way arise the oddest deformi- ties, amusing to any one but the patient, as is shown in the accompanying wood-cut. One attack of balanitis predisposes to another. Men with a long prepuce or congenital phimosis are often met with, who have lived thirty or forty years without suffering inconvenience from their malformation, but who, after one attack of balanitis, are constantly subject to others, following inter- course with healthy women or even mere impru- dence in diet. In consequence of a succession of such attacks, the foreskin is changed in its tex- ture, resembles in its feel leather or parchment, and can only be peeled off the glans with some difficulty. Its orifice and internal surface and the surface of the glans are uneven, dry, and beset with fissures which readily bleed. In one case which came under my care the patient, a bell-hanger, had suflTei'ed in this way constantly for eight years, during most of which time he had been in the hands of quacks, who told him he had syphilis and treated him for such. Frequent attacks of balanitis, especially in the subacute form, favor the development of vegetations Avithin the balano-preputial fold. Adhesions may also take place between the o[)[)Osed surfaces, especially in the furrow at the base of the glans. They are usually limited in their extent, but in rare cases become general. Without having actually grown together, the two surfaces may be adherent to each other, as if glued together, and may readily be separated by the nail. Gangrene of prepuce with glans penis button-holed. Complications Phimosis and paraphimosis which frequently com- jtlicate balanitis will form the subject of the next two chapters. Lymphitis Inflammation of one or more of the lymphatic vessels running along the dorsum or sides of the penis is not an uncommon com- plication of acute balanitis. They may be felt like hard, sensitive cords 100 BALANITIS. niiniing from the base of the ghins towards, and sometimes extending to, the pubes. Tiieir course may be visible to the eye by a reddish line upon the skin covering them. They very rarely suppurate unless a chancroid exist beneath the prepuce. Adenitis The glands in the groin occasionally swell and become slightly tender and painful, but rarely, if ever, su])purate. Penitis General inflammation of the penis is said sometimes to occur, marked by " erysipelatous redness and considerable tumefaction of the whole organ ; inflammatory oedema of the prepuce extending to the sheath of tlie penis, which is painful and sensitive to the slightest contact ; an abundant phlegmonous discharge ; lymphitis and swelling of the inguinal glands. Formidable as it appears, this condition most frequently termi- nates in resolution, though sometimes the inflammation extends to the cellular tissue and produces superficial abscesses and even gangrene." (Fournier.) Diagnosis. — The presence of balanitis is easily recognized. The diag- nosis of the cause on which it depends is not always quite so easy. We Avill consider first those cases in which the glans can be uncovered and the Avhole balano-pi-eputial fold exposed to view, and next those more diflftcult cases in which phimosis conceals the parts. In the former an inexperienced observer might mistake the redness sur- rounding a patch of herpes for simple balanitis, but the characteristics of herpes, as will be shown in another cliapter, are sufficient to avoid this error. One or more chancroids situated near the furrow at the base of the glans will be obvious enough, and the same may be said of a true chancre with an ulcerated surface and an indurated base, the diagnosis being confirmed by the induration of the glands in the groin. More dif- ficulty may be experienced in the diagnosis of a superficial chancre, which will often closely resemble one of the exulcerated patches mentioned as occurring in herpes. It is generally, however, isolated, causes little in- flammation of the surrounding parts, has a thin layer of parchment indu- ration beneath it, and is attended by induration of the inguinal ganglia. Secondary eruptions and especially mucous patches often appear on the glans near the furrow in the early stages of secondary syphilis. Tliey are generally multiple, of smaller size than the exulcerations of balanitis, more regular and rounded in their outline, of a less vivid red color, and are accompanied by other secondary symptoms elsewliere. When phimosis is present and the balano-pre|)utial fold cannot be ex- posed, we have to distinguish between a discharge coming from the urethra and the discharge of balanitis. Tiie diagnostic signs have been given incidentally on jtage 07. The presence of chancroids beneath the prepuce may be difficult to de- termine. It is almost invariably the case, however, that in such instances the pus from these ulcers inoculates the fissures at tlie preputial orifice; hence chancroids of the pre[)utial ring, which may easily be seen on partly retracting the prepuce, afford a presumption of their existence within the TREATMENT. 101 balano-preputial fold. Auto-inoculation of the pus may be practised as a test, but this will rarely be done unless the question of an operation comes up. True chancres may often be recognized by the mass of induration around them, which can be felt by the fingers externally. Induration of the glands in the groin will remove all doubt, and this will serve also to indicate the presence of superficial chancres which might otherwise pass unnoticed. Treatment — When the prepuce can be retracted, the treatment of balanitis is exceedingly simple. All that is necessary, in most cases, is to free the parts from any collection of matter by gently washing them with tepid water, and then to cut a piece of lint or soft linen into pieces about an inch square, and laying them upon the glans with their upper margins well up in the furrow behind the corona, to draw the prepuce over them. In this manner the inflamed surfaces are isolated from each other, and speedily take on a more healthy action. The frequency with which this application should be repeated depends upon the copiousness of the dis- charge ; generally from two to four times in the twenty-four hours is suffi- cient, and a cure is usually attained in a few days or a week. In severe cases, however, other measures than those mentioned may be desirable. If the surface be excoriated, it is well to pencil it over lightly with a crayon of nitrate of silver, or to apply a solution of this salt, of the strength of twenty or thirty grains to the ounce of water. I decidedly prefer to use the lint dry, because it thus better absorbs the matter exuded. Many surgeons, however, moisten it with some lotion like the following: — I^. Liquoris Plnmbi Diacctatis 5ij • . . 81 Aquffi 3ij 60| M. ^. Acidi Tannici 5.1 41 Glycerinae §j 38J M. IJ;. Liquoris Sodte Clilorinat.-e ,^iij ... 121 Aqme §v 150! M. ^. Extracti Opii 9j 1 25 Ziiici Sulphatis gr. vj -40 Glyci'riiKB §j 38 Aquae §iij 90 M. As a local application to the inflamed surface (after washing and before the introduction of lint), iodoform has been recommended. This may be dissolved in ether, one drachm to the ounce, and be painted on with a brush. On the evaporation of the ether, which causes but little pain, a thin film of iodoform is left. The ether j)artially removes the bad smell of the iodoform. Salves beneath the prepuce are to be avoided; so also poultices, which favor oedema. Cliancroids should receive their appropriate treatment and true chancres 102 BALANITIS can best be treated and their induration removed by the internal use of niercurj. When phimosis, either congenital or acquired, exists, the parts are less accessible to treatment. We may sometimes succeed in enlarging the preputial orifice and thus be enabled to uncover the glans, by the insertion of a few small pieces of compressed sponge, which swell under the moisture of the discharge and distend the ring. If this procedure fail, we must resort to injections between the prepuce and glans. For this purpose any urethral syringe with a long nozzle may be made to answer, but by far the best is one devised by Dr. Robt. W. Tay- lor^ (Fig- ^5). It consists of an india-rubber syringe, to which is attached a nozzle which is three inches long and nearly flat, having a diameter of less than an eighth of an inch. Near the end of it and situated on the edge are five minute holes, two on each side and one on the extreme end. This nozzle can be introduced very easily and without pain as far back as the fossa glandis. The syringe should be inserted in different directions and plain water at first be thrown in until the prepuce is thoroughly washed out, as may be known from the returning fluid being clear. This done, a medicated solution should be thrown in and Dr. Taylor prefers a solution of carbolic acid, two drachms to the half [)int of water. These injections should be repeated five or six times a day. For the further treatment of supervening phimosis, see the next chapter. If the balanitis be attended by much infiltration into the cellular tissue of the prepuce, the fluid should be evacuated by several punctures with a lancet. If the patient can keep his bed, the penis may also be enveloped in a single thickness of linen, ^y^it with cold water or diluted Goulard's extract, and exposed to the air. If, however, he continues his daily oc- cupation, no benefit can be expected from such applications, which, when confined by the clothes, act like poultices, and favor rather than prevent oedema. In all cases the cure of balanitis will be accelerated, if the patient be kept quiet and the parts elevated. With persons who have repeated attacks of balanitis it becomes an important object to take measures to prevent them. To accomplish this the strictest cleanliness should be enjoined. The parts sliould twice a day be cleansed of all accumulation of their natural secretion, and afterwards moistened with an astringent lotion, as a mixture of equal parts of brandy and water with the addition of alum, a solution of tannin, or any of the astringent washes already mentioned. A good formula is the following : — I^. Acidi Tannic! 5ij 8 Aluminis ^\v 16 Glyceriiiffi t^iij 15 Aqure §viij 250 M. This maybe used as a wash or it may be put up in a wide-mouthed phial and the penis be immersed in it. I Am. J. Syph. & Derm., N. Y., Oct., 1872. TREATMENT. 103 It is also desirable to attend to the digestive functions, and to regulate the diet. The influence of a long prepuce in producing relapses of this disease has already been referred to. 1 have sometimes succeeded in remedying this malformation by directing the patient to keep his prepuce constantly reti-acted by means of a narrow bandage applied around the penis, posterior to the glans. If this be worn for a few weeks, the prepuce will often remain retracted without further assistance, and the mucous surface of the glans becomes hardened by exposure and friction. If this attempt prove unsuccessful, the superfluous integument should be removed by circumcision. 104 PHIMOSIS. CHAPTER IV. PHIMOSIS. The term Phimosis is applied to that condition of tlie penis in which it is impossible to retract the prepuce behind the glans. It may be either congenital or accidental. Congenital Phimosis In the majority of cases phimosis is a con- genital malformation due to unnatural narrowness of the preputial orifice, and may be associated with adhesions varying in position and extent between the glans and its covering. A remarkable instance of this kind is recorded in the Surgical Register of the N. Y. Hospital: Joseph Smith, of Prussia, aged 49, was admitted into this institution Oct. 19, 1832, with congenital phimosis. Dr. Stevens removed the free portion of the prepuce, which was found to be attached to the margin of the meatus instead of the base of the glans, and formed a tubular prolongation of the urethra nearly an inch in length. Congenital phimosis is a source not only of great inconvenience to the subject of it, but of increased exposure to venereal diseases in promiscuous intercourse, and is sometimes the cause of serious disturbance in the genito-urinary and nervous systems. Mr. Jonathan Hutchinson' has shown by statistics that syphilis is much less common among Jews than among Christians, probably on account of the practice of circumcision among the former. At the Metropolitan Free Hospital, situated in the Jews' quarter, London, in 1854, the proportion of Jews to Christians among the out-patients was nearly one to three ; yet the ratio of cases of sy{)liilis in the former to those in the latter was ooly one to fifteen ; and that this difference was not due to their superior chastity- was evident from the fact that the Jews furnished nearly half the cases of gonorrhoea that were treated during the same period. Mr. Hutchinson's observations also lead him to believe that hereditary syphilis is much rarer among the children of Jews than Christians ; and the experience of most surgeons will confirm the fact tliat persons with a long prepuce, and espe- cially those affected with congenital phimosis, are peculiarly subject to venereal diseases. The size of the preputial orifice in congenital phimosis varies in dif- ferent cases. In some, it is large enough to permit of the partial exposure of the glans and the removal of the natural secretion of the part, at least with the assistance of a syringe and injections of warm water ; while in ' Mod. Tiiiios and Gaz., Lond., Dec. 1, 1855. CONGENITAL PHIMOSIS. 105 Others, it is so contracted that it is difficult or even impossible to uncover the meatus ; whence it happens that the entrance of the urine at each act of mictLirition beneath the prepuce, and the collection of sebaceous mat- ter, maintain a constant state of irritation and even chronic inflammation, to which most of the adhesions met with between the opposed surfaces are undoubtedly attributable. Daily observation proves that congenital phimosis is not inconsistent with a state of perfect health ; and yet when we reflect upon the sympathy existing between different portions of the genito-urinary apparatus, and between the latter and other organs, we might reasonably expect to meet with at least occasional instances in which irritation of the head of the penis due to this cause gives rise to disturbance in other parts of the body. These anticipations are realized in practice ; but, according to Fleury,' who has ably investigated this subject, such disturbance is to be attributed more to the extreme sensitiveness of the balano-preputial membrane con- stantly protected from friction and exposure to the air, than to the irrita- tion of collections of sebaceous matter ; since it is often present even when the condition of the parts admits of the most perfect cleanliness. Among the ill effects ascribed to congenital phimosis are : balanitis, constant itching and even pain at the head of the penis, inordinate ex- citability of the genital organs, frequent erections, erotic dreams, seminal emissions, imperfect development of the penis and testicles, incomplete and painful ejaculation of the sperm, vesical tenesmus, incontinence of urine, gastralgia, neuralgia, and genei-al lassitude and prostration. Prob- ably no one will be disposed to call in question the occasional connection between the milder of the above affections and phimosis. Thus no one can doubt that boys with congenital phimosis are peculiarly prone to suffer from nocturnal incontinence of urine, of wdiich they are cured by circum- cision ; that at a more advanced age the penis does not attain its full development ; that they are more apt to practise masturbation and to have seminal emissions ; that in married life they do not have the full enjoy- ment of the sexual act, the usual complaint being of too speedy ejacula- tion ; and that during life they are subject to disagreeable sensations and to attacks of balanitis, which are even aggravated in old age when the integument generally becomes loose and flabby. The same is equally true of persons witli a long prepuce, even if no actual phimosis be present. With regard to the more remote effects of congenital phimosis, some doubts might be legitimately entertained, were it not for the circumstan- tial report of the symptoms, and the fact that simple excision of the elon- gated prepuce has in many cases brought complete and permanent relief.^ Witiiin tiie last few years additional cases of the remote effects of con- ' Gaz. tl. h6p., Paris, Oct. 30, 18.51. " Fleuky's observations have been fully confirmed by Borelli {Maladies genito- risicalcs, Gaz. d. /i6p., Paris, Dec. 1851) ; Anagnostaxls relates a cure of ambly- opia by the excision of the prepuce {Rev. de (h^rap. m^d.-chir., No. 4, IS.'iO). See also an article by John II. Packard, M.D., "On Congenital Phimosis" (Am. Jour. Med. Sci., Oct., 1870) 106 PHIMOSIS. genital phimosis and of a small meatus urinarius have been reported by Drs. Sayre, Moses, Otis, Green, Bro\vn-8equard, and others. These cases have been ably summed np, and others added, in a report from the Surgical Section to the New York Academy of IMedicine, by Dr. Yale,' who says : " The forms of nervous disturbance observed in these cases, so far as I have ascertained, have been, notably, incoordination of muscular movements, including those necessary to speech, less commonly spasm or spastic contraction, and paresis, generally of the lower extremities. I find no case of paralysis of sensation, but hypera:sthesia is often men- tioned. Several cases of amblyopia have been published. A mental con- dition resembling hysteria or hypochondriasis is a frequent element in the clinical histories." Verneuil reports a very interesting case in which careful microscopical examination of the excised prepuce showed that the terminal plexus of nerves had become hypertrophied, and in which the nervous symptoms were thus fully accounted for.^ Accidental Phimosis. — Accidental phimosis may depend upon any cause enlarging the glans penis to such an extunt that it will not pass through the preputial orifice, or occasioning such an amount of tliickening or contraction of the prepuce that it cannot be retracted ; in other words, the seat of the difficulty may be either in the glans or its covering. In some cases the obstruction is simply mechanical, as from vegetations within the balano-preputial fold, the induration surrounding a chancre, or the cicatrization of any ulcer situated upon tiie margin of the prepuce. More frequently it originates in inflammatory action, as idiopathic balanitis or posthitis, or the same affections excited by the presence of ulcers, secondary eru|)tions, vegetations, etc., either of which may occa- sion swelling of the glans or infiltration in tlie lax cellular tissue of the prepuce. M. Bourgade (Progres med., Paris, Sept. 2, 1876) has observed four cases of phimosis due to the irritating action of the saccliarine urine of diabetes upon the meatus, glans, and prepuce, and states that a surgical operation is useless so long as the cause persists. M. Verneuil and M. Comillon, of Vichy, have observed similar cases. The former says a confrere of his has lost two patients on whom he imprudently operated for diabetic phimosis. There is still another cause of phimosis which, strictly speaking, cannot be included among those just mentioned ; I refer to a peculiar thickening of the mucous membrane and submucous tissue, observed both in men and women after tlie cicatrization of a chancroid or chancre, and which consists neither in specific induration nor oedema, but in liypertro|)liy of the normal tissues of the organ. Gosselin believes that this effect is i)ecu- liar to venei'eal ulcers. It is most frequently found in the labia minora in ' See N. York M. J., Aug., 1877. 2 Arch. gen. de iu6d., Paris, Nov., 18G1. TREATMENT. 107 women, and in the prepuce in men. In the latter the envelope of tlie glans may become so thickened that its retraction may be very difficult and give rise to iissures of the preputial orifice, or may be quite impos- sible. Treatment In congenital phimosis attended by any of the unpleas- ant effects alluded to at the commencement of this chapter, circumcision is the only sure means of relief. I would go even farther than this, and say, that every case of congenital phimosis, if persistent on the approach to, or after puberty, demands the ablation of the prepuce, whether any unpleasant consequences have ever manifested themselves or not. It would be well for the future comfort and health of tlie individual, if fathers would inquire into and attend to this matter as their sons approach adult age. If, from any cause, an operation be impracticable, the subject of congenital phimosis should be directed at each act of micturition to expose the meatus as fully as possible in order to prevent the entrance of the urine beneath the prepuce, and intra-preputial injections should be re- sorted to if sebaceous matter accumulates or any signs of inflammation appear. The best syringe for this purpose is one with a broad, flattened nozzle, to facilitate its introduction between the prepuce and glans, as proposed by Dr. R. W. Taylor. (See Fig. 2.5.) In accidental phimosis, the rule commonly accepted is to avoid an operation if possible, unless congenital phimosis has previously existed ; but when due to vegetations beneath the prepuce, or to contraction of the preputial orifice from the cicatrix of a chancroid which has entirely healed, an operation may be necessary to gain access to the abnormal growths or to restore the opening of the prepuce to its original size. Phimosis dependent upon a large mass of specific induration disappears under the internal administration of mercurials. An operation should, if possible, be avoided or deferred when the phi- mosis is due to acute inflammation, which may in most cases be subdued by rest in the horizontal posture, low diet, cathartics, leeches to the groin or perin;\3um (not upon the prepuce), a lead and opium wash, and, if it be certain that no chancroid is present, by scarifications. The orifice of the prepuce may sometimes be dilated so as to permit retraction of the latter by inserting between it and the glans a number of pieces of compressed sponge, or Nelaton's phimosis forceps may (Fig. 24) be employed. In some instances we are certain that an ulcer is concealed between the prepuce and glans, where it may have been seen either by the patient or surgeon before the phimosis supei'vened ; in others, its existence is highly probable, from the fact that the patient has been exposed in promiscuous intercourse. Now the mere suspicion of an ulcer within the hidden folds of mucous membrane is sufficient to induce caution in resorting to an operation which may be followed by inoculation of the edges of the wound. It is indeed true that if the sore be a chancre, auto-inoculation will not be likely to take place ; but it may be of the mixed variety, or there may be both a true chancre and a chancroid ; hence the fact that a mass of 108 PHIMOSIS. induration can be felt beneath the prepuce is not sufficient of itself to justify an operation. A case in point has fallen under my own observa- tion : A medical friend was called to treat a case of phimosis dependent upon an ulcer, surrounded by a cartilaginous mass of induration which Fijr. 24. Nt'laton's Phimosis Forceps. could be felt beneath the prepuce. Relying upon the fact that a chancre cannot readily be inoculated upon the person bearing it, he resorted to an operation ; but in a few days the edges of the wound assumed tlie appear- ance of a chancroid. In doubtful cases the nature of the secretion may be tested by auto-inoculation before resorting to circumcision. Under some circumstances, however, and especially with gangrene threatening, an operation cannot be avoided. The question then comes up in what manner it shall be jierformed. In the inflamed condition of the parts, with the prepuce infiltrated, thickened, brawny, and perhaps threatening gangrene, circumcision is for obvious reasons not to be thought of. The immediate object to be attained is to relieve tension and to expose the balano-preputial fold so as to admit of local applications and attention to cleanliness. The method commonly adopted under these circumstances has been to slit up the prepuce along the dorsum by means of a curved bistoury guided by a director, which has first been introduced from the orifice to the angle of reflexion. Tiie objections to this method are two : In the first place, if there is much thickening of the prepuce it does not fully expose the parts ; the flaps on either side are too unyielding and too sensitive to en- able us to bend them back and reach, for instance, chancroids situated in the sulcus near the frnsnum. In the next place, the ultimate result of the operation is undesirable. Two " dog's ears" are left which are anything but elegant or useful in this situation, and which require a subsequent bloody operation for their removal. For these reasons I prefer the procedure recommended by Dr. R. W. Taylor, in his paper on phimosis, already referred to. This consists in making two incisions, one on either side, exactly in tlie middle of the lateral portion of the prepuce, either by means of a bistoury, or, prefera- bly, with a pair of strong scissors (Fig. 25), such as those devised by Dr. Taylor for this purpose. TREATMENT. 109 The result of this operation is that the prepuce is converted into two flaps — an upper and a lower — with the glans penis between them, and the upper flap can be elevated and the lower one depressed with the greatest ease, so as to expose the whole surface. Then, after the acute disease has Fi£r. 25. Taylor's Phimosis Scissors. Taylor's Syringe for sub-preputial injections. subsided and the edges of the incisions have healed, these flaps may be snipped off without confining the patient to the house or taking him away from business. But, it will be objected, you thus have double the amount of raw surface exposed to contagion. Very true, but the advantage gained is more than a counterbalance, and, moreover, if the incision be properly cauterized and dressed, contagion will in most cases be avoided. The caustic pre- ferred by Dr. Taylor is pure carbolic acid, rendered fluid by a small quan- tity of water. Four pieces of lint are to be cut — tw^o to fit the glans, the one above and the otlier below — and two strips to place between the cut sur- faces. These pieces of lint are soaked in the acid and put in their places; the flaps are then brought together and a bandage wound round the penis, allowing the meatus to be free. The whole should be kept wet with cold water, and the dressing repeated daily until the parts are healed. The thickening of the substance of the prepuce, already described as a sequela of venereal ulcers, is rarely so great as to produce complete phi- mosis ; but the difficulty attending the exposure of the glans and the fre- quent rents which tlie act occasions, often justify the removal of the hy- pertrophied tissues. Befoi'c describing this operation, let me remind the student that the prepuce is composed of two layers, separated by a cellular tissue of such lax texture as to admit of an almost indefinite amount of motion between them. The internal or mucous layer is firmly attaciied to the penis pos- terior to the corona glandis, and hence is incapable of being drawn forwards to any ^reat extent in front of the glans. Tlie external or integumental layer, on the contrary, is continuous with the flaccid skin of the body of the penis, and may be greatly elongated ; its anterior portion doubling in 110 PHIMOSIS. upon itself as the posterior is drawn forwards. It follows from this ana- tomical arrangement that a section of the prepuce in front of the glans can only include the integumental together with an insignificant portion of the mucous layer. Of the various methods of performing circumcision recommended by dilFerent authors, I prefer the following : — The patient should be upon the bed where he is to lie until cicatrization is accomplished, in order after the operation to avoid unnecessary motion and hemorrhage, which would interfere with speedy union ; and it is de- cidedly best that he should be etherized. The requisite instruments are a pair of long-bladed forceps, a sharp-pointed bistoury, blunt-pointed scissors, and sutures of very fine silk. Henry's forceps, represented in Fig. 26, are the best on this occasion, although any long forceps will answer. Fig. 26. Henry's Phimosis Forceps. A tape may be tied around the base of the penis near the pubes to re- strain the hemorrhage. Allow the penis to hang without traction in its Fig. 27. natural condition, and, if your eye is not a sufficiently accurate guide, trace with a pen and ink a line upon the skin corresponding to the corona TREATMENT. HI glandis, to serve as a guide for the incision. Next draw the prepuce for- wards, until this line is in front of the glans, and grasp it from above downwards between the long blades of the forceps, which should be in- trusted to an assistant ; the external part is now to be excised in front of, and close to the blades of the forceps, having first been put upon the stretch by the left hand of the operator. Any attempt to cut from either margin of the fold will be attended Avitli some difficulty, since the several layers of the skin and mucous membrane oppose an amount of resistance to the knife that is not readily overcome ; hence, it is better to transfix the centre of the flap (the blade of the knite parallel to, in front of, and in contact with the forceps), cut downwards, and complete the section by turning the knife, and cutting upwards (Fig. 27). The assistant ^should now remove the forceps, when the integument will retract, carrying its cut edge back to the base of the glans, and exposing the raw external surface of the mucous membrane which still covers the glans (Fig. 29). If the mucous membrane be in a healthy condition it may be divided with scissors along the dorsum, and turned back to be united to the integument ; but if thickened by chronic inflammation, vege- tations, or the cicatrix of an ulcer, the flap (E, B, B) on either side should be excised. Indeed the latter course is always best, with this important proviso, however : don't cut off the whole of the flap quite down to the line of its insertion, if you do you will find the introduction and removal of your sutures difficult, and union by first intention is less likely to be attained ; hence, make your cuts on either side so as to leave about half an inch of the mucous membrane behind. This ablation of the flaps may be done by successive cuts with ordinary curved scissors, on a line parallel with the corona glandis ; or further accu- racy may be secured by the assistance of Horteloup's phimosis forceps^ Fig. 28 Horteloup's I'liimosis Forceps (2 actual size). (P^'ig. 28), which, placed astraddle on the penis, are made to grasp the flap, and the redundant membrane is then excised by one stroke of a bistoury. If tlie frienum is short, divide it. Several little arteries may spirt in your face, quiet them with a good twist of the torsion forcieps, and keep the bleeding surface exposed to the air for a few minutes until you are sure all bleeding has ceased, unless you wish to be called from your bed the coming night. Tliere is still a little cut desirable, which I have for a long tinitt employed, and which has rec(Mitly been mentioned by Dr. Keyes ' Bull. gun. dv th(5rap., etc, I'aris, 1878, p. 559. 112 PHIMOSIS. (Van Buren and Keyes, p. 11). This cut is made with scissors in the retracted integument along the dorsum to a point (A) about one-quarter of an inch behind the free margin, and the edges of the incision ((7, C) are to be rounded off. Its object is to insure perfect freedom from con- striction at the line of division, without which both cicatrization will be delayed and the ultimate condition of the parts be less satisfactory. Fijr. 29. Fio;. 30. > - For the purpose of uniting the edges of the wound some surgeons em- ploy serres-fines, and others silver sutures. The foi'mer are likely to be detached by the movements of the patient before he recovers from the ether, and the latter are too stiff to be removed without unnecessary pain. If very fine silk be used — such as is employed by oculists in operations upon the eye — it will be found to possess all the advantages of metallic sutures, and may be left in for a week without causing suppuration. More- over, instead of using interrupted sutures, as is usually done, if we employ the continuous suture commencing at the fraiuum, it will be found that this part of the operation ran be finished in one-quarter of the time and the edges will be much better adapted to each other, as seen in Fig. 30. Simple exposure to the air, and ])rotection by means of a cradle from contact with the bedclothes, is all tliat is retpiired for tlie first twelve hours, after which a water-dressing may be applied. The patient should remain in bed until the parts have nearly healed, and, if contact of the urine with the wound cannot be otherwise prevented, should micturate with his penis immersed in a basin of tej)id water. In favorable cases, confinement to the house for three to five days is sufl[icient. It would hardly seem necessary to caution the surgeon not to excise too large a portion of the integument, were it not for the following case re- ported by Nelaton :^ A patient appeared at the clinique who had been operated upon for phimosis eleven days before by the usual method. The physician, forgetting that the integument of the penis is very lax and extensible, had, before making the incision, drawn it forwards to its utmost limits ; the consequence was thiit, aft(M- tlie o[)eration, the penis was de- ' Pathologie chiiurgi(^ale, t. v. p. 663. TREATMENT. 113 nuded nearly to the abdominal wall. An extensive suppurating surface had remained, which was torn and made to bleed by frequent erections. The case does not appear to have been followed to its termination, but Nelaton remarks upon the rigidity and malformation of the organ, pro- vided cicatrization should take place, and adds that " this case shows the importance of marking the limits of the incision before the operation." The American editor of Erichsen's Surgery states that the favorite operation for phimosis at the Pennsylvania Hospital, Philadelphia, consists in simple division of the mucous layer of the prepuce, by means of fine scissors, one blade of which is sharp, and the other probe-pointed. The former is made to penetrate between the two layers of the prepuce along the dorsum of the organ, while the latter passes between the glans and its envelope, and thus the internal layer may be divided as far as the corona glandis. The prepuce should be retracted several times each day, espe- cially during micturition, both in order to prevent contact of the urine with the wound, and also immediate union, which would tliwart the pur- pose of the operation. Faure accomplishes the division of the mucous layer in a simpler man- ner, as follows : The skin of the penis is forcibly drawn towards the abdo- men, when an incision is made with blunt-pointed scissors upon the dorsum of the retracted preputial orifice, implicating the mucous membrane, but sparing the integument. This allows of a still further retraction of the pi'epuce, bringing into view an additional portion of mucous membrane, which, by a succession of the above procedures, may be divided to the base of the glans. Dr. Hue,^ of Rouen, instead of dividing the prepuce with a cutting instrument, passes a needle through its dorsal surface close to the base of the glans, and ties the portion of skin in front of the puncture with an elastic ligature, which is said to cut its way through in three or four days. Dr. H. states that he has operated with satisfactory results by this method in eighty cases, comprising both adults and children. Jobert (de Lamballe) makes an incision from the pi-eputial orifice on each side of the fra^num as far as the corona glandis ; then cuts off the fraanum, which is now included in a small triangular flap ; and finally unites the skin and mucous membrane by the interrupted suture, thus leaving the greater portion of the prepuce intact and merely enlarging its orifice beneath.^ Tiiese methods, unattended by any loss of substance, may suffice when it is desired sim^Jy to relieve uncomplicated phimosis; but when the mucous membrane is in a diseased condition, as is genei'ally the case when an operation is required, circumcision should be preferred. ' Doctor, bond., Nov. 1, 1878, p. 235. ^ Uaz. d. hdp., Paris, 27 Aug., 1861. 114 PARArHIMOSIS. CHAPTER V. PARAPHIINIOSIS. The term Paraphimosis implies exactly the opposite of phimosis, viz., the retracted prepuce cannot again be drawn forward so as to envelop the glans. This condition is often met with in boys with a tight prepuce, as the result of their first attempt to expose the glans ; again it may follow coitus with a woman whose vulvar orifice is small, or it is often produced by patients themselves by retraction of the prepuce for the purpose of in- specting or dressing some venereal affection with which they are afflicted. Having thus exposed the glans and ignorant of the danger of thus leaving it for any lengtli of time, they allow the prepuce to stay back and soon find it impossible to bring it forward again. The tight preputial orifice has Fiff. 31. ,..«-.^^j^j:^« Paraphimosis. (After JuUien.) acted like a ring constricting the penis ; the glans has in consequence be- come congested and swollen, and in any attempt at reduction the preputial ring meets with obstruction from the abrupt base of the corona, such as the knuckle offers to a tight ring on the finger. The swelling goes on increas- ing; the submucous and sub-integumental cellular tissue becomes infiltrated with serum, and the parts present the appearance represented in Fig. 31. Now it is to be observed that the constricting ring, the preputial orifice, PARAPHIMOSIS. 115 is buried in the first furrow seen as we proceed from tlie base of the glans backwards ; the swollen fold between it and the glans is the preputial mucous membrane retracted; the folds back of it are folds of the integument of the prepuce and body of the penis ; the greatest amount of the ojdema is found in the lax cellular tissue below in the neighborhood of the frse- num ; the glans itself is swollen and tilted backwards so that the meatus looks somewhat upwards. If the case be left to itself, nature's course (we can hardly call it cure) is as follows : — the constricting ring, in its portion upon the dorsum of the penis, is attacked by ulceration and gangrene, first involving only the skin and subjacent cellular tissue, and appearing as a series of antero-posterior fissures wliich soon unite and form a transverse open ulcer Avith irregular borders. The ulcerative process deepens until it has eaten through the fibrous ring beneath, when the constriction is relieved, the patient's suffer- ing is at an end and the ccdema soon disappears. All cases, however, do not terminate thus fortunately. The ulcerative process may result in gangrene, involving a large portion of the integument and the glans, and even opening into the urethra. Venot^ reports a case in which one-third of the glans was lost. Auger^ relates a case, in which the ui'ethra was opened to the extent of one centimetre (four-tenths of an Fig. 32. " Sub-preputial frill." (After JuUien.) inch). Through erosion of a vein or artery, copious hemorrhage may occur. .Suppurative inflammation may invade the cellular tissue and destroy the integument of the penis to a greater or less extent. Erysipelas, i)hlebitis, and lymphangitis are still other dangers, to which patients with paraphi- mosis are exposed. ' .1. de met!, et cliir. prat., Paris, 1836, p. 347. « Union med., P.iris, 1872, p. 91. ]1B PARAPHIMOSIS. In all or nearly all cases, which are not early treated, adhesions form between the skin and the upper surface of the corpora cavernosa, rendering any later attempt at reduction impossible. Moreover, after the patient has been relieved by the destruction of the ring and the ulceration has healed, these adhesions remain. A depressed cicatrix is left by the ulcer, and the lower portion of the prepuce, which is now redundant, continues swollen and thickened. The appearance of the organ is well represented in Fig. 32. Under these circumstances, a subsequent operation is evidently required to restore to the organ its pristine elegance and usefulness. The above symptoms are those of the inflammatory form of paraphimosis, which is the most common. There is another indolent form, in which there is scarcely more than mere oedema of the prepuce without inflamma- tory action, and in which reduction is easily effected. Treatment When called to a case of paraphimosis, it may not be advisable to attempt reduction until the cedema has first been diminished by rest in the horizontal posture, elevation of the penis, and a saline cathar- tic, assisted in some instances by scarification of the swollen tissues in front of the stricture, the application of ice or a stream of cold water directed upon the part. Attempts at reduction are extremely painful and it is hence desirable to put the patient under the influence of ether. Chloroform should not be used in this nor in other minor operations, if ever. The difficulty of re- duction is frequently increased by the vicious manner in which the attempt is made. The swollen glans and mucous layer of the prepuce are to be passed through a narrow preputial orifice. Mere pressure from before backwards will increase their transverse diameter and augment the diffi- culty of reduction ; this can be best accomplished by compressing, and, if necessary, elongating them, and drawing;, the constricting ring and integumental layer over them. ^Multiple punctures with a lancet should be made in tlie swollen tissues in front of the constriction, and these parts, after having been well com[)ressed and kneaded between the fingers, so as to evacuate as mucli of the infiltrated serum as possible, had better be oiled. The surgeon then encircles the body of the penis with the thumb and forefinger of the left hand in the manner represented in Fig. 33, and thus secures a base of support. With the fingers of his right hand, he now still further compresses the glans in its trans- verse diameters for several minutes, and then endeavors to insert the nail of his Fig. 33. TREATMENT. 117 thumb or index finger beneath the constricting ring on its dorsal aspect, at the same time tucking under the hitter the fold of mucous membrane in front. As soon as he succeeds in this attempt and can feel the ring riding up on his nail, he knows that no firm adhesions have formed, and he has an inclined plane on which to complete the reduction. His efforts, however, should not be for a moment relaxed until the whole is completed, or, otherwise, the parts will slip back into their former position. M. Bardinet^ employs a hair-pin in a similar manner to the above. He describes his method as follows : — " I bend the glans on its anterior (lower) aspect and gently draw the skin of the penis forwards from behind the constriction. I then attempt to insert the bend of a hair-pin between the preputial ring and the body of the penis. This done, I have two levers in the branches of the pin, wiiich I move back and forth for a triple purpose, to depress the prominence of the base of the glans, to elevate the preputial ring and to secure an inclined plane upon which it may gently be made to glide." Before Badinet, however, the late Abraham CoUes, Prof, of Surgery at the Royal College of Surgeons in Ireland, succeeded, after other means had failed, in relieving two severe cases of paraphimosis, by passing a di- rector beneath the stricture from before backwards, and elevating it upon the point of the instrument, while the stem was made to compress the swelling in front, and gradually force it back beneath the stricture. This process was repeated on each side of the penis, after which reduction w^as quite easy.^ After reduction has been accomplished, the parts should be kept ele- vated and covered with some cooling application until the swelling has disappeared. The above methods are recommended as the most worthy of adoption. Among the many others proposed, we may mention the following : In one proposed by M. Garcia Teresa, the centre of a piece of tape is placed upon the dorsum of the corona glandis, the opposite ends passed round the sides of the glans, crossed beneath the frisnum, and wound around the little finger of each hand; the glans is then compressed by flex- ing the middle and ring fingers, and exercising traction in opposite direc- tions, wliile the other fingers remain free to draw the prepuce forwards, and accomplish its reduction.* Dr. Van Dommelin effects compression of the glans by winding around it a strip of adhesive plaster half a yard long, and about a quarter of an inch wide, commencing at its base, and terminating near the orifice of the urethra.* M. Seutin, of Brussels, has invented a pair of forceps with spoon-shaped extremities, to maintain compression of tlie glans until the constricting ring can be drawn over them. ' Nouveau proc6(le dc reduction A'as at one time abandoned and indeed tliought to be injurious, but has since been recommended by Baizeau,^ RoUet,^ and Fournier,^ The last-named author says that copaiba sometimes calms the erethism of the vesical neck in a marvellous manner in a few hours, but adds that it often fails completely. Sir Henry Thompson* also speaks well of copaiba in some cases of chronic inflammation of the bladder, but says that the doses should be small, as five minims, and be given in mucilage three or four times a day. In place of the ice above recommended in the acute stage, some authori- ties recommend poultices or hot fomentations over the hypogastrium, and hot baths. If the latter be employed, immersion of the whole body is pre- ferable to sitz-baths. If there be general febrile disturbance, aconite should be given internally. After the more acute symptoms have subsided, benefit will be derived from the internal use of cantharides, but it must be given in very minute doses, as, for instance, one drop of tlie tincture to an ounce of water, of which the patient is to take a teaspoonful three times a day. Stronger doses will only aggravate the trouble. A few drops of a tincture of chima- phila umbellata, administered in the same manner, has also been highly recommended. ' De la cystite hem. dii col complicaut I'urethrite et de son traitement par les balsamiqiies. Gaz. d. h8p., Paris, 1861, p. 457. 2 Traite des mal. ven., Paris, 1861, p. 314. 3 Nouveau diet, de med. et de clii. prat., t. v, p. 180. * Diseases of the Urinary Organs, 3d ed., 1873, p. 199. 182 INFLAMMATION OF THE VESICULyE SEMINALES. CHAPTER XVI. GONORRHCEAL INFLAMMATION OF THE V E S I C U L .E S E Ikl I N A L E S . GoNORRHCEAL INFLAMMATION of tlie seminal vesicles has been de- scribed by several authors, as Cruveilhier, Andral, Mercier, Velpeau, Lallemand, Gosselin, and Prof. V. Pitha,^ upon whom I must chiefly rely for its description. It is unnecessary to dwell upon the mode of its occurrence, since this is so readily explained by extension of the inflammation from the urethra through the ejaculatory ducts. It may also be caused by any mechanical or other iri-itation of tlie prostatic portion of the urethra. The symp- toms noticed by the patient are much the same as those of prostatitis. A constant dull, pressing pain is felt in the rectum, shooting from the neck of the bladder to the sacrum. This pain is increased by the passage of the feces, especially if tliey are hard ; also by micturition, by erection of the penis, and above all by any attempt at coitus. The calls to defecation and micturition are frequent, and the latter is attended with dysuria. Erec- tions of the penis are frequent and may amount to constant priapism. Involuntary emissions occur from time to time, which are excruciatingly painful, and the semen is found to be reddened with blood or of a yellowish color due to the admixture of pus. Even between the emissions a slimy secretion mixed with blood and pus may be discharged from the urethra, and, under the microscope, be found to contain spermatozoa. "Bloody semen" is not an uncommon occurrence in men who have for some time suifered with a chronic gonorrhoea, or gleet. They usually dis- cover it by the stains on their bedclothes after a wet dream, or by the color of tlie semen in a condom which they have worn iii cottu, and they are naturally frightened by it. It does not always indicate that the vesi- cular seminales are involved, but shows that some inflammation still re- mains in the prostatic urethra or ejaculatory ducts. It is not serious, and often disappears spontaneously. Its appropriate treatment, if any be re- quired, is a deep urethral injection of a few drops of a solution of nitrate of silver, either by the autlior's deep urethral syringe or by Guyon's method. Physical examination is somewhat diflicult; but with a long finger and some adroitness the vesiculae seminales may be reached through the rectum. They lie dii-ectly above the prostate, not more than a finger's breadth apart, ' Haii(ll)ucli der speciellen Pathologie und Therapie, redig. von Virchow, 6 Band, 2 Abtheilung, p. 132. INFLAMMATION OF THE VESICUL^ SEMINALES. 1S3 and one or both of them when inflamed may be felt as an oval, sensitive, hard or fluctuating tumor, which, with care, need not be mistaken for an abscess of the prostate. Pressure upon them excites a dull pain. In some cases, this affection is said to be of short duration and to leave no traces behind it. In others, the cavity of the vesicula becomes enlarged, even to twice its normal size, and is transformed into a puriform sac, which may either break in the perinieum, giving rise to infiltration of the neighboring tissues and the formntion of a fistula, or it may empty itself through the urethra. Again the walls of the vesicula may become ulcer- ated and the sac itself obliterated, in which case, according to Gosselin, the vas deferens and even the epididymis share the same fate. When the acute inflammation terminates in a chronic form, we may have thickening and induration of the walls of the sac, with chalky deposits, or, especially in scrofulous subjects, deposits of true tubercle. Usually such tuberculosis accompanies a general affection of this character, but occa- sionally it is limited to the vesiculie seminales, or at least to the urinary organs, especially the kidneys, in addition to the seminal vesicles. Prof. Y. Pitha reports a case in which the left kidney and the left vesi- cula were infiltrated with numerous coarse masses of tubercle, partly pulpy in the centre, and a portion of the prostate gland and the membranous part of the urethra were the seat of large tuberculous ulcers. The patient was a day-laborer, aged 50. A'elpeau observed a case in which vesiculitis terminated in an abscess, followed by peritonitis which proved fatal. (Tarnowsky, op. cit., p. 330.) In spite of tlie nearness to each oiher of the two openings of the ejacu- latory ducts, both vesiculie are rarely attacked at the same time. If both are involved, resulting in such changes as those described, impotency must necessarily folIal inflammation from the vagina. It may also be pri- marily attacked, as is readily explained by the fact that this is the part of the female genital organs against which the glans penis most impinges in the sexual act, and consequently the part where, in chronic gonorrhoea especially, a drop of contagious matter issuing from the meatus of the male, is very likely to be alone deposited. I have seen repeated instances in which the mucous membrane covering the cervix and the upper part of the vagina was the seat of acute inflammation, while the lower and outer portions of the genitals were intact. On examination with the speculum, we find the usual symptoms of in- flammation of a mucous membrane, congestion, redness, varying in intensity, development of the papillae, and at. first a thin and afterwards a purulent discharge. As the acute inflammation subsides, we often see superficial ulcerations of the cervix, seated especially upon the posterior lip. When the muciparous follicles are involved, they appear in the form of granulations, varying in size from a millet-seed to a pea, and capable either of undergoing resolution or of breaking of the follicular abscesses, leaving behind small, roundish ulcerations. Since the cervix is almost devoid of sensibility, gonorrhoea confined to this part occasions but little pain, but may give rise to general malaise, reflex neuralgias, disturbance of digestion, and irregularity in menstruation. ' Uterine Therapeutics, 4th ed., 1878, p. 353. ^ Native Diseases of the Gulf of India, London, 1849. GONORRHOEA OF THE URETHRA. 19T Gonorrliocal infllaniniation may also involve the cavity of the cervix, in which case we find a peculiar gelatinous secretion, resembling in appear- ance the white of an egg, projecting from the os, and so tenacious that it is with difficulty removed even by a swab. It is sometimes detached spontaneously in lumps, falling into the vagina, where it excites no little irritation, and is finally discharged through the vulva upon the patient's linen. The alkaline reaction of this secretion in contrast to the acidity of the vaginal discharge has already been mentioned. In describing this secretion, we should not fail to observe that it is by no means to be considered as characteristic of gonorrhceal contagion, since it may depend upon many other affections incident to women. A proba- bility of its gonorrhceal origin would be afforded by the fact that it had been preceded by acute vaginitis, or that it had coexisted for a consider- able time witii chronic, subacute inflammation of the upper portion of the vagina. Here, as in urethral discharges from the male, an accurate diag- nosis is often impossible, for the simple reason that there is nothing specific in the disease. This discharge from the os uteri is often innocuous, especially in married life and in persons of cleanly habits, but under the (usually) oft-repeated intercourse between the unmarried or when attention to cleanliness is not observed, it is liable to occasion gonorrhoea in the male. Still further upwards may the inflammation of gonorrhoea extend, in- volving the lining membrane of the cavity of the uterus itself. We do not propose to enter fully into the category of symptoms which may be thus produced, and which belong rather to the domain of gynaecology. We will merely enumerate some of them, as various disturbances of menstrua- tion and especially an irregular and profuse monthly flow; gradual dilata- tion of the uterine cavity from the collection and decomposition of the secretion from its walls, and hence so-called physometra; abnormal flexions of the uterus; and, finally, the disturbances of the digestion and general health of the patient which these conditions are sure sooner or later to entail (Zeissl). Gonorrhoea of the urethra usually coexists with that of the vulva, or vagina, and sometimes with that of the uterus alone. Cases, however, are reported in which this was the only part of the genital organs aftected. Gibert met with three such instances,^ Kicord with two,^ and Cullerier with one ;^ and in several of them, it was noticed that the stains of the discharge upon the woman's linen were small and circular, instead of being large and irregular as in cases of vulvar and vaginal gonorrhoea. The shortness of the urethra in women and the oblique position of the canal, which favors the spontaneous flow of matter, renchn* tiie diagnosis of the urethritis less easy than in the male. The discharge in cases of ' Gibert's first caso was published in th« Rev. med., Paris, t. i, 1834. He has also (riven two other cases in his Manuel sur les maladies sypliilitiques, p. 284. 2 Mem. Acad. roy. de med., t. 2e, p. l.'JO, Paris, 1833. 3 N. Diet, de m6d. et de cliir. prat., Paris, t. 4e, p. 253. 198 GONORRHCEA IN WOMEN. vulvitis, also, being seen, as might easily happen, in the vicinity of the meatus, may be erroneously supposed to come from that orifice. Again, tiie passage of urine causes all traces of ui-ethritis to disappear for a time. An examination, in order to be conclusive, should be made at least an hour or two after an evacuation of the bladder, and any discharge around the meatus should first be removed. The finger may then be passed into the vagina, and pressure be made against the pubic arch, in the course of the canal, from behind forwards ; when, if urethritis be present, one or more drops of purulent matter will appear at the meatus, the lips of which will be found swollen and inflamed ; and the introduction of a sound into the canal is attended with considerable pain. Scalding during micturition may easily be a deceptive symptom, since it may be produced to a still greater degree by the contact of the urine with the excoriated nuicous membrane of the vulva, when the latter is involved. If no vulvitis be present, it is a symptom of value. A few drops of blood are sometimes mixed with the discharge, but hemorrhages are never soco))ious as in ure- thritis in the male. Gonorrhoea of the urethra, occurring in women other- wise healthy, does not show the same tendency to run into a gleet as in men. It almost always disappears before the accom[)anying vaginitis or vulvitis, and is tlierefore to be regarded as of secondary importance.* In broken- down constitutions, however, and in women who have borne many chil- dren, or who are suffering from congestion of the abdominal viscera, it may assume a chronic form, and prove exceedingly obstinate. A thickening takes place throughout the whole canal, which can be traced as a firm cord behind the })ubes, and may be seen standing out in relief at the upper part of the entrance of the vulva, when the nymi)hi>3 are separated. This con- dition is attended with uncomfortable sensations in the part, and a frequent desire to pass water, aggravated by motion, by coitus, and the return of the menstrual period, and relieved by rest and the recumbent posture.^ The shortness of the urethra in women also favors the extension of the inflammation to the neck of the bladder, in which case the dysuria is very distressing. Vegetations often spring up around the meatus, partially or almost wholly closing the orifice, and interfering with the i)assage of the urin3. The value of urethritis as indicating contagion has been noticed by many authors. In the majority of cases in which it is present, patients acknow- ledge that they have been exposed to impure intercourse. Eveiy physi- cian knows how common it is for the vulva and vagina to become inflamed from causes other than contagion, but he will find it difficult to recall a single case of like character, in which the urethra was inflamed and gave forth a purulent secretion ; hence purulent urethritis in women is strong presumptive proof of contagion. 1 DuKAND Fardkl, Memoiro sur la blennorhagie chez la feinrno, et ses rlivorses complications. J. d. conn, nied.-cliir., Paris, juillet, aout, et Septembre, 1840. 2 West, Lectures on the Diseases of Women, 2d ed. p. (jl8. COMPLICATIONS. 199 Complications Bubo is a less frequent complication of gonorrhaa in women than in men, and Ricord states that it very rarely occurs unless the urethra is affected.^ Durand Fardel reports the case of a woman who had a rape committed upon her by several men, and in whom a bubo formed and terminated in suppuration.^ An examination showed that she had acute inflammation of the vulva and vagina, and that there was no laceration or ulceration of the mucous membrane, yet the violent origin of the disease would excite suspicion as to the bubo being due entirely to the gonorrhoea. No mention is made of the condition of the urethra. Vegetations, mucous patches or tubercles, chancroids and chancres, are frequently found to coexist with gonorrhoea of different portions of the female genital organs, and especially with vulvitis. Their presence is a constant source of irritation, and their removal is essential to a cure of the primary disease. Vegetations should be destroyed by the knife or caus- tics ; mucous patches are a symptom of syphilis, and require general as well as local treatment ; and chancres and chancroids are to be treated according to rules to be laid down hei'eafter. Inflammation of the Fallopian tubes sometimes occurs as a consequence of the extension of the disease from the uterine cavity. At the post- mortem examination of a case of this character, M. Mercier^ found one tube obliterated by a deposit of lymph upon its fimbriated extremity, and the peritoneal surface inflamed to a considerable extent around it. In a case reported by Bernutz and Goupil, small abscesses were found upon the walls of the tubes on one side, while on the other side there was a puru- lent collection within the peritoneal cavity, possibly due to the passage of matter from the tube. The obstruction and obliteration of the Fallopian tubes in this manner will doubtless account for the well-known barrenness of prostitutes in some cases. Ovaritis has been mentioned by a number of authors as another com- plication ; among others by Ricord,* who considers it analogous to gonor- rhoea! epididymitis in the male. Ricord describes his case as follows : TJie patient, aged thirty-two, an inmate of the Hopital da Midi, was suffering from acute gonorrhoea of the uterus and external genital organs, when a swelling suddenly appeared in the left iliac fossa. The part was very sensitive to the touch and its temperature increased. Tliere was considerable febrile excitement and nausea. The patient lay on her back, inclined a little to the left, with the thighs flexed. The discharge from the urethra and vagina had almost entirely disappeared. Pressure upon the neck of the uterus, with the finger introduced within the vagina, was not painful ; but when the womb was pressed toward the right side, pain and a sense of tension were felt in the left broad ligament. Pressure toward the left side, tried for the sake of comparison, caused scarcely any ' Not<'S to Hunter, BurasteacL's translation, 2d ed., Phil., 1850, p. 107. 2 Op. cit. 3 Meinoire sur la peritoiiite consitlereo commo cause de sterility cliez les femmes, Gaz. Tiicil. de I'aris, 1838, p. 577 ; also Gaz. de hop., Paris, 1846, p. 43li. * Notes to Hunter, 2d ed., p. lOU. 200 GONORRIICEA IN WOMEN. inconvenience. The passage of the feces and urine, and all motion of the abdominal walls were painful. Under the use of antiphlogistic remedies, these symptoms gradually diminished and disappeared in about twelve days, and at the same time the discharge increased in quantity. The patient, however, was shortly afterwards seized with a second attack on the opposite side, with the same sym[)toms and the same suspension of the discharge.' The late Mr. De ]\Ieric also reported three cases of gonorrhocal ovaritis in the London Lancet, June 14, 1862, which were followed by two cases, by Mr. John Taylor, in the same journal for July 12, 18G2. It is doubtful, however, whether the ovaries can be affected in the same isolated manner as the epididymis in man. Their inflammation in these cases is probably part and parcel of the gonorrhocal pelvi-peritonitis already alluded to, and which was first thoroughly studied in the admira- ble work of Bernutz and Goupil.^ These authors observed this affection at Lourcine Hospital, in Paris, in an extraordinary proportion of cases, since out of ninety-three women who entered with gonorrhcea, twenty- eight had pelvi-peritonitis, or nearly one in three ! This proportion can- not, of course, be taken as the general rule, for it was doubtless the occurrence of this severe complication which led many of them to come to the hospital, while hundreds of uncomi)licated cases of gonorrhcea stayed away. In the cases seen by Bernutz and Goupil there was no instance of the occurrence of the peritoneal affection before the eighth day. It was rare before the fourteenth, but frequent towards the end of a month, that is, about at the menstrual period. De Meric, on the contrary, states that in his cases the ovary became affected at the most acute point of the disease. The immediate causes may be regarded as the recurrence of the menses, fatigue, and excessive sexual indulgence. There follows an almost com- plete cessation of the vaginal discharge. For the symptoms I must refer the reader to works on the diseases of women, as gonorrhoeal pelvi-perito- nitis does not differ from that due to other causes. Diagnosis Before the application of the speculum to the study of venereal diseases, the diagnosis of gonorrlujea in women was often difficult and sometimes impossible ; and the discharges of vaginitis and of various syphilitic lesions within the vulva were confounded together. To a sur- geon of the present day, acquainted with modern methods of investigation, such mistakes are not likely to occur. With the recognition of the dis- ease, however, our power, so far as diagnosis is concerned, ceases. It is impossible to go farther and determine its origin. Many authors have attempted to give diagnostic signs Jis between gonorrhoea originating in contagion and that produced by other causes, but they have all most sig- nally failed to produce any which are at all satisfactory, simply for the 1 Notes to Hunter, p. 107. 2 Clinique med. sur les mal. d. femmes, Paris, 1862, t. ii, p. 140. TREATMENT. 201 reason that none such exist. " The microscope fails to furnish us with a means of distinguishing between gonorrhoeal and simple vaginitis, and no symptom or combination of symptoms is absolutely conclusive on this point.'" Acute inflammation and the presence of urethritis may render impure intercourse probable, but cannot be regarded as decisive ; and what is wanting in the physical diagnosis must be sought for in the history of the case. Treatment. — The treatment of the different forms of gonorrhoea in women varies but little in the acute stage of the disease. It is chiefly during the chronic stage that any variation is required to meet special in- dications, presented by inflammation of particular portions of the mucous membrane. Moreover, nature does not always, nor indeed in most in- stances, follow the classification which we have found it convenient to adopt ; several of the genito-urinary organs are generally involved together • — more commonly the vagina and vulva — and the treatment of this most numerous class of cases will first claim our attention. The chief remedies adapted to the acute stage are rest, cathartics, hot baths, lotions, and a general antiphlogistic regimen. Zeissl recommends cold applications over the genitals, which should be changed as soon as they become warm. It is of the first importance that the patient should abstain from exercise of all kinds, and, if possible, be confined to her bed; indeed, in most cases her own sensations demand this, without the order of the surgeon. Meats and stimulants should be forbidden, and the diet restricted to weak tea, toast, a decoction of flaxseed, rice- or barley- water, gruel, etc., unless the symptoms are subacute from the first, or the patient debilitated. In selecting a cathartic at the outset of the disease, preference should be given to a mercurial, for the purpose of unloading the abdominal and pelvic vessels, and the bowels should afterwards be freely opened every day, by small doses of Epsom salts, citrate of mag- nesia, and other salines. Aloes, and the numerous preparations which contain it, should be avoided, on account of its tendency to produce con- gestion of the ha^morrhoidal vessels. Blood-letting Bleeding from the arm and even the application of leeches in the neighborhood of the genital organs, may be said to be things of the past ; although the latter may possibly be required in rare instances. If used, they should be applied to the groins, where their bites will not be smeared with the discharge. Baths and Lotions A hot bath, repeated once or twice a day during the acute stage, is very grateful to the feelings of the patient, and bene- ficial in equalizing the circulation and relieving the local inflammation ; and immersion of the whole body is to be preferred to hip-baths. Meanwhile, the external genital organs should be frequently bathed with some emollient lotion, and a piece of lint soaked in the same be in- sei'ted between the labia, in order to separate the inflamed surfaces and ' West, op. cit., p. 628. 202 GOXORRHffiA IN WOMEN. absorb the discharge. The following is an excellent formula for this purpose : — R. Dt'cocti Papavoris 3 pts. Liqiioiis Plumbi Siibacetat. dilut. 1 pt. M. Diday recommends the introduction at night of pledgets of cotton, smeared with the followins; ointment : — I^. Cucumber Ointment §j 30 Alum 3j 4 Tannin J^ij 2 M. 60 These should be removed in the morning, and the following wash be applied or injected : — ^.. Decoction of White Oak Bark Oj . . 5001 Borax §ss 15| M. Sedatives, of which Dover's powder is perhaps the best, should be ad- ministered at night to induce sleep, and also at intervals during the day, if the pain is severe, or the patient nervous and irritable. Injections The above measures are the only ones admissible during the acute stage of the disease, especially if the vulva is involved ; in which case the insertion of an enema tube is too painful to admit of injections. When, however, the inflammation is chiefly confined to the vagina, the lotion just mentioned may be injected into this canal every few hours, and in many cases of a subacute type, injections may be used from the very commencement. As soon as the sensibility of the parts will permit, it is also desirable to introduce a speculum, and ascertain if any ulcer be present. The kind of syringe used, and the mode of injecting, are matters of no little importance. The small metallic or glass instruments in common use are entirely inadequate for the removal of the discharge. The as- tringent ingredients of the first portion of fluid injected are spent in coagulating the purulent matter collected in the vagina. To wash away the coagula thus formed, and exert a medicinal effect upon the mucous membrane, the quantity of the injection should not be less than a pint ; indeed, it is better to precede any medicated injection by a copious one of plain water, so as to cleanse the vaginal walls as freely as possible. A pump-syringe, or better still, one of Davidson's or Mattson's syringes, made of India rubber, and provided with metallic valves, will enable the patient to inject any desired quantity with one introduction of the tube. "While using the injection, the patient should lie on her back, with the pelvis elevated ; if she merely stoop down, the fluid escapes as fast as it is injected, and fails to reach the deeper portions of the canal. With a bed- y)an under her the wetting of the floor and clothes will be avoided. Farther, I must not forget to mention the excellent vaginal douche, de- picted below, the invention of Dr. Frank P. Foster, of this city. The well-known " fountain syringe" may also be employed. TREATMENT. 203 As a general rule, injections of greater strength may be used for women than for men, and for the sake of cheapness and convenience, they are commonly made more simple in their composition. The patient may be supplied with the solid ingredients, and allowed to mix them as required, Fig. 45. Foster's vaginal douche and in order to avoid the expense of having them put up by the druggist in divided portions ready for use, it is desirable, among the ])Oor, to supply tliem in bulk. A little instruction from the surgeon will enable the patient to measure them out with sufficient accuracy. A heaping teaspoonful, or, in other words, as much as can possibly be taken up by a teas[)Oon, of the more common ingredients of injections, is nearly as follows : — Almii 5'.i ^ Sul2)liat(! of zinc 5'j 8 Acetate of zinc 5'*^^ 6 Subacetate of h;ad 3iij 12 Tannin 5ss 2 From one to two drachms of either of these salts to the pint of water, is th. 288. GONORRn(EA OF THE RECTUM, MOUTH, NOSE, ETC. 213 recently reported the case of a young man who confessed having exposed himself in this manner. On the following day he had pain in the lips and gums. On the fourth day the mucous membrane of the lips and buccal cavity became intensely red; motion of the mouth was painful; the gums were spongy, inclined to bleed, and a little receding from the teeth, and the buccal secretion was increased in quantity. Other authors speak of a copious puriform secretion and aphthous exudations. Potrasie's case is said to have been cured in a week by means of an alum gargle. Gonorrhoea of the Nose. A case of this kind is reported by Mr. Edwards.^ Holder (op. cit., p. 288) also speaks of it. It is said that it may arise either from the matter of gonorrhceal ophthalmia flowing down upon the nares or from the use of a napkin, or the fingers soiled with the same; that generally only one nostril is affected; that the symptoms are about the same as a very severe " cold in the head ;" that there is but little pain ; and that it is readily cured by cold applications, snuffing up cold water, pencillings with a solu- tion of nitrate of silver and afterwards the use of an alum or borax lotion. Umbilical Gonorrhcea. A young man, aged 10, was found by Morrison^ to have urethral gonor- rhoea and at the same time a similar discharge from the umbilicus, which was relieved by solutions of acetate of lead and sulphate of zinc. ' London Lancet, Am. reprint, June, 1857. 2 Bull. med. du Nord, Lisle. No. 10, 1874. 214 GONORRH(EAL OPHTHALMIA. CHAPTER XX. GONORRHCEAL OPHTHALMIA. GoNORRH, p. 482. 5 Not^s to Hunter, 2d ed. Phila., 1859, p. 275. 8 Traitedes maladies articulaires. Paris, 1853, t. i, \>. 37(). 1 Quelques considerations pourservir ^ I'histoire de I'artlirite l)lenn(jrrhagiqiie ; in 8vo., pp. 45. Bordeaux, 1846. 8 Arch. gen. de med., Sept., 1854. s Annuaire de la syphilis ; ann^e 1858, Lyon. '0 Union med., Paris, Nos. 9 and 10, 1867 ; also N. Dict.de med. et de chir. prat.', Paris, tome v, p. 224. 223 GONORRIIGEAL RHEUMATISM. [latient siiflfering from gonorrluca should suddenly be seized with inflamma- tion of tlie joints; but should tliis same patient, after entirely recovering from both affections, and after several years of perfect health, again con- tract gonorrhoea, and again be seized with articular rheumatism, the occur- rence would be sufficiently remarkable to excite r. suspicion in the mind of the most careless observer that there was some connection between the two. Let this second attack be followed by a third, fourth, and fifth, and the suspicion would be converted into a very strong probability. Suppose that numerous other patients were met with in whom these two affections thus repeatedly coexisted, an attack of gonorrha^a in each of them being followed by one of rheumatism, with such certainty that the latter might be predicted immediately on the api)earance of the former, and a manifest relation between the two diseases could no longer be doubted. Now, this repetition of these two diseases in the same person is not merely hypo- thetical — it is a reality; and it is observed in subjects entirely free from any rheumatic diathesis, who have inflammation of the joints at no other time than when they have gonorrhoea. Among the many cases which mi'i'ht be cited, none perhaps will better illustrate this [)oint than the fol- lowing, which I quote from the lectui-es of Sir Astley Cooper: — "I wull give you," says this distinguished surgeon, "the history of the first case 1 ever met with; it made a strong impression on my mind. An American gentleman came to me with a gonorrhoea, and after he had told me his story, I smiled, and said : do so and so (particularizing the treat- ment), and that he would soon be better; but the gentleman stopped me, and said, 'Not so fast, sir; a gonorrhoea with me is not to be made so lirrht of — it is no trifle; for, in a short time you will find me with inflam- mation of the eyes, and in a few days, I shall have rheumatism in the joints; I do not say this from the experience of one gonorrhoea only, but from that of two, and on each occasion I was affected in the same manner.' I be""""ed him to be careful to prevent any gonorrhoeal matter coming in con- tact with the eyes, which he said he would. Three days after this I called on him, and he said, ' Now you may observe what I told you a day or two a"0 is true.' He had a green shade on and had ophthalmia in each eye ; I desired him to keep in a dark room, to take active aperients, and a]»ply leeches to the temples. In three days more he sent for me, rather earlier than usual, for a pain in one of his knees; it was stiflT and inflamed ; I ordered some applications, and soon after the other knee became inflamcHl in a similar manner. The ophthalmia was with great difficulty cured, and the rheumatism continued many weeks afterwards." Similar cases are related by nearly every author who has written on this affection, and, further on, many are given in a table of the diseases of the eye which accompany gonorrhoeal rheumatism. M. Rollet relates in detail five such instances occurring in his own |)ractice, and this repetition took place in eight of thirty-four cases reported by Brandes, of Copenhagen, and in three of eight cases observed by M. Diday. According to Rollet's researches, this repetition has been noted in nearly one-quarter of the total number of cases of gonorrhoeal rheumatism which have been published. CAUSES. 229 The frequency of eases like these can leave no doubt in the mind that a close relation exists between these two affections, and additional evidence is found in tiie fact that the rheumatism attendant upon gonorrhoea pre- sents certain peculiarities, which, in general, are sufficient to distinguish it from the oi'dinary forms of rheumatism. Causes In comparison with the great frequency of gonorrhoea, gonor- rhoea! rheumatism is exceedingly rare. Very little is known of the causes which occasion it in the few, while the many affected with gonorrhoea es- cape. Its occurrence might naturally be attributed to a rheumatic dia- thesis, especially as the fact is well established that persons subject to rheumatism are particularly prone to contract gonorrhoea ; and it is dis- tinctly asserted by several writers that a constitutional tendency to rheu- matism is a predisposing cause of inflammation of the joints during an attack of gonorrhoea. There is reason to believe, however, that the plau- sibility of this ojjinion, founded on a priori reasoning, has given it greater weigiit than it deserves. Those who have expressed it, have failed to produce any evidence in its support ; and if we examine the published cases of tiiis disease, we frecpiently tind it noted that the jiatient never suffered from rheumatism excej)t when he had gonorrhcea. M. Rollet has made this jjoint a special subject of inquiry, and states that in the great majority of cases of gonorrhoeal rheumatism which have come under his observation, there was no rheumatic diathesis either in the | atients or in their parents. He also states tiiat he has had under treatment many pa tients with gonorrhoea who were predisposed to rheumatism, and yet in them, urethritis has not been attended by any inflammation of the joints ; and this fact derives additional weight from the frequency with which gonorrlneal rheumatism, after having once occurred, is re-excited by a subsequent clap. These statements of M. Rollet go far to s1k»w that a rheumatic diathesis has no part in tlie production of gonorrliu'al rheuma- tism ; and the contrary opinion is now generally abandoned.^ In earlier times, when gonorriura was regarded as identical with syphi- lis, an evident explanation of tiie occurrence of rheumatism in the course of a urethritis was readily found, but the same is untenable with our present knowledge. The same is true of the "gonorrhoeal diathesis," which some authors have maintained to exist, since gonorrhoea is a local disease, and docs not attect tlie system at large. It should be observed thjit this form of rheumatism does not accompany inflammation of all portions of the genital organs, but only that of (he urethra. No attack of balanitis in the male, or of vulvitis or vaginitis in ' \r. Kollct woaki'iis his position by aasHrting an antagonism between a rheu- matic diathesis and gonorrlm'a, in virtue of which, he believes that a clap some- times cures a patient of a tendal rheumatism ! The phenomena of gonorrhoeal rheumatism are also inconsistent Avith the idea of a metastasis from the urethra to the joints, since in most eases there is an exacerbation of the urethral discharge preceding the articular inflammation. This is especially noticeable in chronic cases of gleet, in which gonorrhoeal rheumatism supervenes. Gonorrhoeal rheumatism is comparatively rare in women, indeed, its existence in this sex was formerly denied. Further observation has, how- ever, shown that women are not exem[)t from it, and no small number of cases liave been reported by various authors, as Ili(;ord, Vidal, Cullerier, de Meric,' Mr. Hardy ,'^ Dr. Angelo Scarenzio,^ Langlebert,* and Four- nier. The last named author saw^ seven cases in women within about two years' time. Frequency This is a rare affection if compared with the frequency of gonorrhoea. Thus Fournier states that in 1912 cases of gonorrhoRa which have come under his observation, he has met with 31 cases of rheu- matism, or about one in 62 cases; but, as Fournier remarks, this propor- tion must be above the truth, when we consider what a large number of cases of gonorrhtea are neglected or treated by the patients themselves without surgical advice. 1 British Med. Journ., 1867, vol. ii, p. 33.5. 2 Dublin Quart. Journ., vol. xlvi, p. 241. 3 Giornale Italiano, Miiiano, 1874, vol. ii, p. 129. < Gaz. m6d. de Lyon, 1805, p. 484. SEAT. 231 Seat None of the joints are exempt from an attack of gonorrha'ul rheumatism, but this disease affects the knee far more frequently than any- other joint. The following table exhibits the order of frequency with which the various joints were affected in 81 cases observed by MM. Fou- cart, Brandes, and RoUet : — Articulation of the knee " " ankle hips fingers and toes . shoulder wrist . elbow . sternum and clavicle tarsal bones sacrum and ilium lower jaw . tibia and fibula . Fournier gives the following table of his observations : — Synovial membranes of the joints .... " " " tendons .... Muscles ......... The bursje ......... The sciatic nerv^e ....... 64 30 15 15 10 10 8 3 2 2 1 1 161 51 10 10 6 5 And nine cases in which it was impossible to determine the exact seat of the pain complained of by the patients. Besides the joints, gonoiThfeal rheumatism frequently affects the ocular tunics; also the bursas connected with the muscular tendons, especially the tendo-Achillis ; and sometimes the sheaths of the muscles, as in muscular rheumatism. Again, liicord states that he has met with several patients who suffered from severe pain in the plantar region, apparently seated in the fascia?. Dr. Lieberinann^ rejwrts a case of suj)|)osed gonorrhoeal rheu- matic inflammation of the crico-arytenoid joint of the larynx. The knee-joint, therefore, is the favorite seat of gonorrhoeal rheumatism, though all the joints of the body are liable to its attacks. This disease, however, is less prone to cliange its seat from one joint to another than ordinary artictdar rheumatism. This fact is evident from an exainination of the above table, which shows that there were but IGl joints atiected in 81 cases; an average of about two joints to each case. I know of no similar table exhibiting the number of articulations affecftnl in a given number of cases of ordinary rlieumatism, but the proportion is undoubtedly much greater. Again, in 10 of tiie 11) cases in the above table, furnished by M. Foucart, only one joint was affected ; of the 34 cases of jM. Brandes's, the rheumatism was mono-articular in 5, and also in 10 of the 28 cases > Med.-Chir. Centralblatt, No. 41, 1874, as quoted in the N. Y. Med. Jour. Sept., 1878, p. 327. 232 GONORRHffiAL RHEUMATISM. collected by M. Rollet. These facts, therefore, would give us a ratio of about one-third, in which gonorrhoeal rheumatism attacks but a single joint, but more extended statistics are required before this proportion is received as accurate. Even when gonorrhrcal rheumatism does not remain confined to one joint, but extends to others, the articulation first affected does not recover its normal condition, as it often does in ordinary articular rheumatism, but generally continues in a state of inflammation after the disease is lighted up in other joints. In this respect, gonorrhocal rheumatism again differs from acute rheumatism, but approximates to the character of rheu- matic gout. There can be no question, I think, that gonorrhfjeal rheumatism some- times attacks the heart, but it is equally certain that this complication is much less fretiuently met with than in ordinary acute articular rheuma- tism.^ Ricord states that in several clearly marked cases of gonorrhocal rheumatism, he has observed symptoms of endocarditis, and also of effusion within the pericardium, but it is to be regretted that he has not given these cases in detail. The rarity of any mention of heart disease, how- ever, in the reported cases of gonorrhceal rheumatism, proves the correct- ness of the above assertion that this disease is usually free from such complication. The following case is reported by Mr. Brandes : — A man, 50 years of age, had had five attacks of gonorrhoea within ten years ; each attack being attended with disease of the joints. In a sixth attack he was seized with violent pain and swelling of several joints, espe- cially the knee. A few days after, inflammation of the eye and pericardium ensued. The friction sound was well marked; and the pulsations of the heart were irregular. There was dulness on percussion over a considerable space, with palpitation and pain in the precordial region. The symptoms improved under venesection and mercurials. Meanwhile the iris became inflamed in the right eye, and a week after this eye recovered, the left was attacked. The patient finally recovered, but suffered from weakness of the lower extremities for a long time, so that he was obliged to walk with crutches for several months. Dr. Marty re|)orts a case of gonorrha3a in a niivn 22 years of age, which was comi)licated by acute endocarditis located at the aortic valves. There was no rheumatism or metastatic articular afl'ection. He has collected jiine other cases in which a disease of the heart or pericardium developed itself four or five weeks after the commencement of a gonorrhoea. Of the ten (including the above), seven were endocarditis and three pericarditis. In eight of the cases the cardiac affliction was preceded by gonorrhfjeal rheumatism ; in the other two, there was none. The urethral discharge was re-established when the acute symptoms disappeared. Dr. Marty concludes that any serous membrane maybe attacked during the existence ' "I am induced to think that, under ordinary circumstances, some heart affec tion arises in about half of all cases of acute rheumatism." {Fuller on RheumiUism.) SYMPTOMS. 233 of gonorrhoea, and that this inflammation is due to the disease of the urethra. {Med. Record. Aug. 11, 1877, from the Archives gen.) M. Desnos^ read a case of tliis atfection before the Paris Hospital Society. At the antoj)sy a small ulcer was found on the mitral valve, together witli a considerable vegetant endocarditis of the aortic valves and the whole of the interior of the heart. Ricord is the only authority, so far as I am aware, who has seen any affection of the nervous centres in gonorrhceal rheumatism. This surgeon states that he has met with symptoms of compression of the spinal marrow and of the brain, such as paraplegia and hemiplegia, which appeared to be produced by increased effusion Avitliin the serous membranes of the brain and spine, and which followed the same course as the affection of the joints. No affection of the lungs or pleura has ever been observed in gonor- rhceal rheumatism. Gonorrhceal rheumatism is essentially an hydrarthrosis, and in many instances the inflammation is confined to the synovial membrane of the joint during the whole course of the affection. The predilection of this disease for serous membranes is shown by its attacking the bursa? con- nected with the tendons, especially about the wrist and ankle. Rollet states that he has seen one case in which the seat of the disease appeared to be a bursa accidentally develo|)ed over the acromion process, and CuUe- rier has met with the same in the bursa in front of the patella. Symptoms In describing the symptoms of gonorrhceal rheumatism, it is desirable to take those of ordinary articular rheumatism as a standard of comparison. Proceeding in this manner, we find that gonorrha-al rheuma- tism is generally ushered in with less febrile disturbance than its more frequent congener. In some cases there is an entire absence of premoni- tory symptoms, and the patient's attention is not attracted to the joints until effusion has taken place and motion has thereby been rendered pain- ful and difficult. In other instances, a slight chill and wandering pains have been experienced, before the morbid action has become settled in any one joint ; and those cases are exceptional in which the inflammatory symptoms at the outset are comparable in violence to those of acute rheu- matism. AVlien the articular disease is fairly established, the pain is increased and is often severe ; but here, also, we And the symptoms less acute, as a general rule, than in ordinary rheumatism. Even in those cases in which the local pain is great, there is much less general febrile excitement; and an examination of the blood drawn in five cases by M. Kollet and in one by M". Foucart, faih^d to show that bufled and cupped condition of the clot which is so frequently met with in acute rheumatism. Sweating, which is so abundant in ordinary rheumatism, is absent in the form of the disease accompanying gonorrhoea. ' Gaz. licbd , Paris, Nov. IG, 1877, quoted in the Monthly Abstract of Med. Sei., vol. V, p. 23. 234 GONORRHCEAL RHEUMATISM. The integument covering the affected joint generally retains its normal color though it sometimes puts on the blush of inflammation. When the knee-joint is the seat of the disease, as is frequently the case, the symp- toms of a serous effusion within the capsule are readily detected. The patella is elevated above the femur and is freely movable; the joint has the form of a cube, the usual depression on either side of the patella being replaced by swellings, and fluctuation can be detected witliout dilliculty. It is evident that the inflammatory process is conflned to the synovial membrane, and that the fibrous and osseous tissues are unaffected. Tlie collection of serum necessarily impairs the mobility of the joint, and pain is excited by pressure or by any attempt at motion. If the disease do not yield readily to treatment, other tissues about the joint become involved, and we may then find redness of the skin, together with fulness of tlie ves- sels and a corresponding increase of the pain and general febrile disturb- ance, assimilating the case to one of acute rlieumatism. Those cases of gonorrhoeal rheumatism which commence with the most decided inflammatory symptoms are generally tlie most amenable to treat- ment; those, on the contrary, in which the febrile action is but slight, and in which there is but little moi-e than a passive effusion into the synovial sac, are more obstinate. Recovery, in any case of this disease, can rarely be expected in less than a month or six weeks, and is often delayed for several months or even years, especially when the patient is debilitated and when the affection of the urethra is allowed to run on or does not yield to treatment. Fourniei-' has called attention to an interesting and comparatively rare symptom of gonorrhoeal rheumatism, viz., sciatica. He states tliat he has observed seven instances, and that an eighth is reported by Tixier.'' It is unnecessary to describe the symptoms of the cardiac affection which sometimes complicates a case of gonorrhuoal rheumatism, since these do not differ from those of endocarditis and pericarditis attendant upon ordi- nary acute rheumatism. The inflammation of the eye which frequently precedes or accompanies — or sometimes alternates with the disease of the joints, and which is evidently dependent upon the same condition of the general system, will presently receive special mention. Most cases of gonorrhfcal rheumatism terminate sooner or later incom- plete resolution, although they may render the patient a cripple for a long period. Suppuration within the bursa very rarely occurs. It is admitted by Ricord, who says, however, that it is always due to some accessory cause of inflammation ; and Vidal mentions one case occurring under liis charge in which it was necessary to open the joint and evacuate tiie puru- lent collection. Zeissl mentions an interesting case communicated to him by Dr. Eisenmann in which death ensued. Again Dr. Prichard^ reports two cases, in one of which an abscess communicating with the joint formed ' Note pour servir a I'liistoire du rhumatisme urethral, Paris, 1866. * Thfese, considerations sur les accidents a forme rhuinatismale de la blennor- rhagie. Paris, 1866. 3 British Medical Jour., Apr. 6, 1867. SYMPTOMS. 235 on the thigh just above the knee, and another in the popliteal space. Am- putation of the thigh was resorted to, and an examination of the joint showed extensive ulceration of the cartilages, with marked increase of vas- cularity of the neighboring parts. Anchylosis, especially of the smaller joints, is a more frequent termination of gonorrha^al rheumatism, and in scrofulous subjects, this disease has not unfrequently been followed by that strumous affection of the joints known as '• Avhite swelling;" here, as in other well-known instances, a constitutional cachexia selects the weakest part of the body as the seat of its manifestation. Dr. Holscher^ reports a case in wliich death is said to have occurred from gonorrhccal rheumatism. An abscess formed in the affected joint, and purulent infection ensued, terminating fatally. The period at which rheumatism makes its appearance in the course of gonorrhoea appears to be more variable than that of epididymitis. Some cases are met with in which the affection of the joints occurs during the acute stage, or first week or two of the duration of the clap ; indeed it may occur coincidenfally with, or even before the appearance of any dis- charge from the urethia, and it is worthy of notice that such eaily cases are generally more acute in their character than later ones. Yet in the majority of cases we find that the rheumatism manifests itself at a later period, when the urethral discharge has passed its climax. Generally, we find that the running has been more copious for a few days preceding the outbreak of the rheumatism, and this is especially noticeable in long- standing cases of clap which have been accompanied by several repetitions of the articular aff^ection, each of which has followed an exacerbation of the discharge. Cases in which the running suddenly diminishes or entirely dries up before the rheumatism appears, must be regarded — in spite of the opposite opinion so frequently expressed — as rare and excep- tional, and not sufficient for the basis oi" a theory of metastasis. In de- ciding this point — to which much importance has been attached — it should be recollected that if the rheumatism occurs several weeks after contagion, the discharge will jorobably have somewhat diminished, following the course which it usually pursues in cases entirely free from any comjdica- tion. After the disease of the joints is established, the running sensibly decreases in most cases, as a conse(iuence of revulsive action. In other instances — estimated by Rollet at abo\it one-tliird — it remains without mucli change. It rarely disappears entirely, except as the result of treat- ment. Gonorrhccal rheumatism, unlike acute rheumatism, but lik(i rlieumatic gout, fre(iuently attacks the eye.'^ The ocular affection in these cases, is ' A.nialos de Holschor, 1844. 2 " In true rheumatism, tlit) (»yo seldom suffers ; so seldom, that I find no record of any aflfection of that organ in more tlian 4 f>nt of the 379 cases of acute and sub- acntc! rheumatism admitted into St. George's Hospital, during the time I ludd the office of Medical Registrar. Hut in rheumatic gout, the eye is not unfrequently implicated. It was inflamed in 11 out of the 130 cases of rheumatic gout admitted during the same period ; and it has sufTered more or less sevctrely in five out of 75 cases, which liave fallen under my own care at the hospital." (Fuller.) 23G GONORRHCEAL RHEUMATISM. tliat form of " 2;onorrliersons who had for some time had intercourse with the opposite sex affected in the same manner. He also quotes Dr. Lindwurm, of Munich, as having successfully inoculated vegetations. Yet Zeissl does not believe that there is any- thing specific in these excrescences. VEGETATIONS. 243 ground that the acrid secretion from vegetations, when applied to neio-h- boring parts, and possibly, when transferred to another individual, acts in the manner already explained, and gives rise to others. The very fact that their supposed contagion takes place upon the person affected, is suffi- cient to prove that they are not dependent upon the virus of true syphilis, the lesions of which are not auto-inoculable ; and there is no reason what- ever for ascribing them to tlie poison of the chancroid. Moreover, they present the same aspect, follow the same course, and are amenable to the same treatment, when occurring in young cliildren and pregnant women who are otherwise healthy, as in persons affected with venereal diseases. Several varieties of vegetations have been admitted, especially by the French, founded upon their resemblance to various objects in nature. Thus, Alibert, who believed that vegetations were syphilitic, admitted them as one of tliree principal forms of the syphilodermata ; and divided tliem into six varieties : " La syphilis vegetante framboisee ;" " en choux fieurs ;" " en cretes ;" " en poireaux ;" and " en vermes ;" to wliich he added the truly syphilitic lesion, mucous patches, under the head of " condylomes." No useful purpose, however, is attained by this classification, which serves only to confuse the mind ; since the form of vegetations is solely dependent upon accidental circumstances, as their position and the pres- sure of neighboring parts. It is sufficient to know that they are sometimes flat and but little elevated above the surface ; while at others they are attached by means of a pedicle of variable diameter : and that they are chiefly developed in whatever direction they meet with the least resistance. When exposed to the air they are often dry and hard ; when protected by an opposed surface, they are soft and smeared with a highly offensive secretion. Their microscopical appearances are thus described by Lebert : "A feeble power shows their internal vascular structure and numerous seba- ceous follicles about their base. With a high power, the pa[)illa3 appear to be composed of an outer rind consisting of concentric layers, and of an internal substance ; the two differ from each other only in density ; for, besides their vascular element, they consist only of epidermic cells. In the outer layers, these cells are more densely packed and present a longer and narrower outline, which, at first sight, gives tliem a fibrous appearance. The internal portion is also composed of epidermic cells in close juxtaposition, but round and finely dotted on their surface. Vegeta- tions are nothing else tlian a development of the papillie of tlie cutis, and, in tlieir anatomical composition, do not differ mucli from certain papilli- form warts." Vegetations are most frequently met witli upon tlie internal surface of the prei)uce directly back of the furrow at the base of tlie glans ; they are also found upon the margin of the meatus, or within this orifice upon the walls of the fossa navicularis ; upon the vulva in women, and especially in the neighborhood of the carunculaj myrtiformes; and, in both sexes, around the anus, upon the tongue, velum palati, and even within the larynx. 244 VEGETATIONS. Treatment The treatment of vegetations consists simply in their removal by the knife, scissors, Wolkmann's spoon, caustic, or ligature, and the destruction of the base from wliich they spring. With the vegetations upon the internal surface of the prepuce, I have found it most convenient to touch them with glacial acetic acid or with fuming nitric acid, and re- peat the application upon the fall of the eschar as often as may be neces- sary; or, when prominent and pedunculated, they may be snipped off with scissors, and their base thoroughly cauterized, although, when cutting instruments are used, the hemorrhage is sometimes a little troublesome ; hence, when practicable, a ligature is to be preferred. A small AVolk- mann's spoon with a cutting edge is also useful in the removal of vegeta- tions whether prominent or flat, and has the advantage of not being formi- dable to the patient. It, however, removes only the outgrowth and does not attack the root, which will still require the application of caustic. As soon as the tenderness produced by the application of caustic has subsided, it is desirable to keep the glans uncovered in order to harden the internal layer of the prepuce by exposure to the air and friction ; and, unless the preputial orifice is very narrow, this may generally be accomplished by wearing for a few days a narrow bandage round the penis posterior to the glans. Special attention should also be paid to removing any collection of the smegma prceputii, and keeping the parts perfectly clean. The above acids act so ftxvorably, that I have seldom resorted to other caustics, with the exception of chromic acid, which has come into favor within a few years. ^ A solution of this acid (one hundred grains to the ounce of water) is a powerful escharotic, and is especially useful in those obstinate cases in which the vegetation repeatedly returns after removal ; but it should be applied with caution, simply moistening the surface of the morbid growth and sparing the healthy tissues in the neighborhood, or otherwise it is apt to induce severe pain and inflammation. Again, a solution of corrosive sublimate in collodion (3J ad sj) may be applied over the whole surface of the growth. In vegetations of considerable size, it has been suggested to inject into the substance of the tumor by means of a hypodermic syringe from half a drop to several drops of strong acetic acid. The perchloride or peri^ulpliate of iron is often of service. It is sufiicient in many cases to give the patient a prescription for the liquor fei-ri per- sulphatis and direct him to apply it once or twice a day to the growtli, wliich soon shrivels up and falls ot^', when a few further a[)plications to the base will prevent its return. The tincture of tliuja occidentalis as a local application has been recom- mended especially by Dr. J. 11. Leaming, of New York. The homoeo- paths administer the same internally in doses of one drop while using it locally. ' See Dublin Quarterly Journal of Mod. Science, vol. xiii, p. 250; Eanking's Abstract, vol. xxv, p. 149 ; New Orleans Med. News, Nov. 1857. TREATMENT. 245 For the removal of flat, horny vegetations Zeissl advises an ointment of arsenious acid or of the iodide of arsenic, as in the following formulae : — K.. Acidi Arseniosi gr. ij 112 Unguenti Hydrarg. gj 4] M. R. Arsenici loiiidi gr. ij 112 Unguenti Hydrarg. 5j 4| M. The same author confirms the statement made by Dr. Peters, of Prague, that vegetations which have resisted all forms of cauterization and even excision will sometimes disappear under the simple application of cold poultices. Vegetations about the vulva may be treated in the same way as those upon the prepuce. When situated around the margin of the anus, they are generally of considerable size, and require to be snipped off with scis- sors before the application of acid to the base. Vegetations during pregnancy may appear at quite an early period; they grow very rapidly, and often attain an immense size. I have seen a mass as large as a man's arm, extending from the mons veneris to the sacrum, and surrounding the vulva and anus. During gestation no opera- tive procedure is admissible; but the pain, itching, and offensive odor may be palliated by careful attention to cleanliness and lotions of diluted La- barraque's solution, followed by the application of calomel or of some astringent powder, as equal parts of savin and burnt alum. After delivery, they often disappear spontaneously, or may be removed by the knife or caustic ; but when the mass is very large, only a portion should be attacked at a time.' Vegetations situated upon a chancre or mucous patch cannot always be distinguished from those upon the .sound integument ; but the history of the case, and especially the coexisting symptoms, Avill determine when mercury is required to combat syphilitic infection of the general system. ' A resume of the articles wliich have appeared upon vegetations in pregnant women may be found in tlie Gaz. liebd. do med., Paris, Feb. 8, 18G1. 246 HERPES PROGENITALIS. CHAPTER XXIII. HERPES PROGENITALIS. We apply the term herpes progenitalis to an inflammatory vesicular affection, which occurs upon various portions of the genitals of" both sexes, and which has incorrectly been called herpes preputialis. In the male it occurs most commonly on the inner layer of the prepuce, and less frequently on the glans and on the integument of the penis. In tlie female, the inner surface of the labia majora, both surfaces of the labia minora and the in- tegument around the vulva are its favoi'ite seats. The number of vesicles varies ; frequently there is but one, and again they are quite numerous and grou[)ed together often in a circle or arc of a circle. The eruption may or may not be attended by any unpleasant sen- sation ; usually, however, a slight burning heat and itching are felt at the outset. A small, red, inflamed spot appears, upon which the vesicles rapidly form. In some cases there is a marked inflammatory areola, which in other instances, is a mere rim of redness. The vesicles vary in size from a pin's head to half a pea. When unruptured, we find a rounded, trans- lucent vesicle containing clear serum. Usually, however, owing to the thinness of the epidermal covering and the moist condition of the membrane, rupture takes place very early. Exceptionally, and especially when seated on the integument, the vesicles remain for sevei'al days, and their contents, gradually becoming turbid and drying, form a small brownish scab. Rup- ture of the vesicle leaves a shallow exulceration, corresponding in size to the vesicle. Its floor is at first of a deep rosy red, with a finely uneven surface. Its edges are sharply cut as if punched out, and sometimes a little undermined, but never to the same extent as seen in the chancroid. There is usually no tendency of the ulceration to progress, nor do the sores fuse together. In exceptional instances, however, the contrary is true, and more or less troublesome ulcerations occur. This is not unfrequently seen in the early stage of syphilis, when the exulcerations of herpes may take on all the cliaractei'istics of chancroids and run a similar coarse. They may even be found to be auto-inoculable, and also give rise to a bul)o. AVhen they are seated upon an inflamed prepuce and when irritated by contact with gonorrhoeal pus, more or less destructive tendency is also apt to show itself. The amount of inflammation accompanying these vesicles varies ; in some cases there is but little heat, redness, and swelling, while in others these are well marked. We have sometimes observed the vesicles to be pre- ceded and accompanied by severe pain, limited sharply to their area. HERPES PROGENITALIS. 247 Again, we have found the exulcerations covered with a very thin, yellowish- white film, which remains for a considerable time in an indolent condition, interfering with healing. The duration of herpes varies from a few days to two weeks. Under the name of neuralgic herpes, Mauriac^ has described an affection of considerable gravity, in which, besides the herpetic eruption, there is an accompanying neuralgia of various branches of the sacral plexus of nerves. In one case related by this author, a patient, who for eleven days previously had felt a slight sensation of heat in the prepuce, was suddenly attacked by a severe prickling and intense itching in the part. Mere pressure of the clothes became insupportable, and the patient could not sleep at night, so great was the suffering. Four or five days later he was attacked by darting pains down the leg, and in the perina^um, buttocks, and scrotum. There was perversion of sensibility in the same parts, anaesthesia passing into hypera?sthesia and the reverse, which was almost unbearable. Two years later the patient had another attack, only one vesicle being present. He, at this time suffered from boring pains, neuralgia of the urethra, and disturbances of sensibility. In a second case observed by Mauriac, there were, for forty-eight hours before the appearance of a single vesicle, paroxysmal pains radiating through the penis and perina?um, and subsequently darting up and down the leg. A short time after, a vesicle appeared at the orifice of the meatus, accom panied by liyperaeslhesia of the urethra, painful micturition, and pain in the bladder. We have also seen several cases of vesicles on either lip of the meatus, attended by neuralgia of the bladder and urethra. The canal itself was of a deep red color, was somewhat swollen and bathed with a copious mucous secretion in which no pus-cells could be detected. The affection lasted about a week and was for the first few days very painful. The following is a well-marked case of neuralgic herpes, occurring in our own practice : — The patient was a man 35 years old, thin and i)ale, but of average general healtli. His father and his sisters had for years been subject to sciatica and other forms of neuralgia. When 15 years old our patient was attacked with sciatica, which has returned as often as four times a year for the last twenty years. The attacks are sometimes preceded by gastric disturbance. The pain begins just above tlie knee and extends upwards to the gluteal region. Genei'ally about the fourth day, he has a sensation of heat and burning on the side of the penis corresponding to the sciatica, and very soon a group of vesicles appears which is quite painful. He also suffers from burning in the urethra, and mild strangury and pain on the same side of the ^scrotum as tlie sciatica. Tiie herpes coexists with the sciatica in seven out of ten of the attacks. Herpes progenitalis is very prone to relapse at longer or shorter inter- vals, sometimes with distinct periodicity. It is usually unattended by any ' LeQoiis sur I'lierpe.s nevralgif|ue des organes genitaux, Paris, 1878. 248 HERPES TROGENITALIS. cliange in the inguinal ganglia, but in some severe cases the latter are slightly swollen and painful for a few days. In a few instances, when the vesicles become ulcerated, suppurating buboes occur. We have seen these several times, especially in syphilitic subjects, and we think that most authors are too positive as to the immunity of these glands in herpes progenitalis. This affection must be regarded as neurotic in its nature, and its excit- ing cause peripheral irritation of the nerves of the penis. Thus it is often developed for the first time after the cure of a chancroid, and some think especially in those cases which have been treated by active cauterization. A long prepuce and the low grade of balanitis, which so often accompanies that condition, are quite common causes, while frequent sexual inter- course, excessive alcoholic indulgence and rich food are known to produce relapses. The vaginal secretion of some women has been known to cause outbreaks of this eruption. "VVe can recall the case of a gentleman, who, prior to his marriage, had had intercourse with many women with im- punity, but who was attacked by herpes after each act of coitus with his wife. We know little of the influence of a rheumatic or gouty diathesis as causes of this eruption, although they are recognized by some physicians as such. The neuralgic form of herpes is luidoubtedly of central origin and merely an accompaniment of the neuralgia occurring in persons of a neurotic tendency. The diagnosis of herpes in most cases is readily made, yet the exulcer- ated vesicles sometimes closely resemble either a chancroid or chancre. In general, the burning and itching sensation attending the invasion of herpes, the superficial character of the ulcer, its less profuse secretion and less undermined edges will establish the diagnosis, while, in many cases, the history of frequent relapses will point directly to it. The syphilitic chancre may resemble exulcerated herpes very closely, not only in its solitary but multiple form. Fournier very aptly says that herpes will rarely be mistaken for a chancre, but that the latter may be mistaken for herpes, and we are convinced that this is frequently the case. The chancrous erosion is an exulceration, but its color is of a deeper and duller red, sometimes even coppery; its surface is smooth and shining without any unevenness or granulations. There is no undermining of its edges, and the surrounding areola is very slight and of a deep, dull-red color ; in short, there is a characteristic absence of inflammation. Although in chancre there may be but slight oedema of the base for a few days re- sembling herpes, distinct induration is soon felt. Any subjacent hardness of herpes disappears day by day, while that of the chancre increases. Then too in syphilis we soon have induration of the inguinal ganglia. The heat and burning felt either prior to or during the evolution of her- petic vesicles is also a valuable diagnostic sigu. As its name denotes, the " multiple herpetiform chancre" presents fea- tures resembling those of exulcerated hi'rpes in groups. The distinguish- ing signs of the two will be given in the chapter on chancre. TREATMENT. 249 Treatment The first indication is to remove any periplieral irrita- tion which may exist. Hence, in cases of a long and tight prepuce cir- cumcision is necessary, and we have often seen a permanent cure from this operation. Even in the absence of a long and tight prepuce, there may be such an abundant irritating secretion in the balano-preputial fold as to require careful attention to cleanliness, and the interposition of lint either dry, which we prefer, or wet with a mildly astringent wash. When herpes follows sexual intercourse, immediate ablution and immersion of the penis in an astringent liquid will be of service. In all cases of a gouty and rheumatic tendency, and in cases of dyspepsia, appropriate remedies should be used. For the local treatment of the exulcerations we would recommend the interposition of dry lint or the application of dry calomel or some other absorbent powder. As washes we sometimes use the follow- insr : — M M Ai'genti Nitrat. Aciuc-e 5j . . 130 301 Ziiici Snlpliat. gr. vj . . Spt. Lavandulae Comp. 5ss Aqufe §ij 136 2 601 Acifli Carbolici gtt. xx 1|30 Glyceriiije ,:^iij 12 Aquam ad ^ij 60| 250 STRICTURE OF THE URETHRA. CHAPTER XXIV. STRICTURE OF THE URETHRA. Haying considered the complications of gonorrhcca, it remains to speak of one of the most frequent and important results of the same disease, urethral stricture. Anatomical Considerations. An acquaintance with the anatomy of the urethra — including the character of its lining membrane, the fibrous, muscular, elastic, and erec- tile tissues which surround it, its dimensions and direction — is essential to a proper appreciation of the pathology of stricture and the skilful exe- tion of operative procedures requisite in its treatment. The male urethra is naturally divided into three portions, viz., the pros- tatic, membranous, and spongy. The prostatic urethra is the portion included in the prostate gland, and generally, but not always, traverses this body at the union of its middle and upper thirds. Its length in the adult is about one inch and a quarter; its posterior boundary is a prominence of the mucous membrane, called the ^iinila vesica ; its cavity is fusiform, largest in the centre, and some- what contracted towards either extremity. Upon its floor, a short dis- tance in front of the uvula is an abrupt elevation of the mucous membrane and subjacent tissue, which forms a ridge three-fourths of an inch in length, and which gradually subsides as it approaches the membranous lu'ethra. This prominence is known as the vera montanum, crista urethrcB, or caput gaUinaginis. It contains erectile tissue, connected with that of the corpus spongiosum, and is adapted to assist in the closure of the urethra at this point, and prevent the passage backwards of the semen during coitus. Directly in front of the summit of the veru montanum, is a small sac or pouch, three or four lines in depth, which is called the " sinus pocu- laris," and also, from its probable homology to the womb, the " uterus masculinus."^ Tlie ejaculatory ducts traverse the walls of this cavity and open upon its margin. On each side of the veru is a depression called the " prostatic sinus," in which are found the orifices of the prostatic ducts from twenty to thirty in number. The memhranous urethra extends from the ai)ex of the i)rostate to the ' The most recent philosophical anatomists confirm tlie homology between the prostatic vesicle and the uterus. For an able resume of this subject, see Simpson, Obstetric Memoirs and Contributions, vol. ii, p. 294. Philadelphia, 1856. ANATOMICAL CONSIDERATIONS. 251 Fig. 49. Couptl's GUni, bulb, and is nearly or wholly included within the two layers of the deep perineal fascia. It is about three-fourths of an inch in length on its upper, but is shorter on its lower surface, owing to the encroachment of the bulb upon the latter. It is narrower than any other part of the urethra, except the meatus, and in consequence of the greater development and number of muscular tissues surrounding it, pos- sesses in a higher degree the power of contraction. This characteristic has led some authors to give it the name of the " muscular region" of the urethra. The spongy iirethra, inclosed in the erectile tissue of the corpus spongio- sum, varies in lenjith according to the degree of turgescence of the penis ; in a state of relaxation, it usually mea- sures about live inches ; during erec- tion it may attain seven or eight. The posterior portion of this region is somewhat dilated, especially on its inferior aspect, and has received the name of " the sinus of the bidb." The term " bulbous portion" is also applied to the posterior inch of the spongy urethra. The ducts of Cowper's glands open near its centre. Besides being somewhat dilated, the sinus of the bulb is extremely dilatable. This may be shown by two casts of the urethra in fusible metal, the one taken while the canal is simply filled, the other while it is forcibly distended by the metal. The difference in the size of tlie part corresponding to the bulb Avill exhibit the dilatability of which it is susceptible. Anterior to its sinus, the spongy portion maintains a nearly uniform diameter until within about an inch of the meatus, where it again enlarges and forms the "fossa navicu- larig." Lastly, the external orifice or " meatus" is a narrow vertical slit, which is generally the most contracted part of the wliole canal. In some instances, however, the smallest diameter is found about a quarter of an inch within the meatus, where it can of course be seen. The mucous membrane lining these various regions is continuous poste- riorly with that of the bladder, and anteriorly with the covering of the Ortfice!' ./ ^ucU. The bladder and urethra laid open. Scea from above. (After Gray.) 252 STRICTURE OF THE URETHRA. Lacunii magna. glans penis. It is very delicate in its structure, and abundantly supplied with bloodvessels and nerves, Avhich render it highly vascular and sensi- tive. Numerous glands ("glands of Littre") racemose in their structure,^ are found in the spongy and membranous, and mucous follicles in the prostatic region, the secretion from all of which constantly lubricates the passage. Fossae or lacunar of the mucous membrane, apparently destitute of glandular structure, are also found upon the upper, and more nu- merously upon the lower surface of the urethra. They may sometimes be traced for nearly half an inch beneath the lining membrane, and their mouths are commonly directed forwards. One, lai'gor than the rest, and called the "lacuna magna," is situated on the upper aspect of the canal, from half an inch to an inch posterior to the meatus. These lacunjB, especially when dilated by long-continued in- flammation, may obstruct the passage of a sound and lead to the formation of false pas- sages. The urethral mucous membrane is covered with the cylindrical form of epithelium. Except in the prostatic region, this membrane is arranged in longitudinal folds, which are gene- rally in contact and close the canal, the latter appearing on a transverse section of the penis as a mere star or split. According to Mr. Thompson, the rugae of the mucous membrane " ap- pear to be connected with the existence of numerous long and slender bands of fibrous tissue, which are seen lying immediately beneath the mucous membrane, for the most part in a longitudinal direction. In the bulbous and membranous portions they are extremely delicate, constitut- ing these the weakest parts of the urethral wall, a fact worthy of remem- brance in connection with the use of instruments." In the bulbous region the danger of doing violence is increased by the dilatability of the passage, and by the presence of the firm anterior layer of perineal fascia just be- yond it. The dimensions and direction of the urethra, taken as a whole, will be better appreciated after considering other tissues which surround it. The urethra is invested by " unstriped, organic or involuntary" muscular fibres, which vary very much in their abundance and their arrangement in different parts of the canal. These fibres in the prostatic urethra are both longitudinal and circular, the latter layer being nearly half an inch thick near the neck of the bladder, and gradually diminishing towards the apex of the prostate. It has been called by Ilenle the sphincter vesicce ' KoLLiKER, Manual of Human Histology, published by the Sydenham Soc, vol. ii, p. 236. DEEP PERINEAL FASCIA. 253 intermis. External to this layer is another, called the sphincter vesicce externus, which is most developed near the apex of the prostate, where it is continuous with the compressor ui-ethra; muscle. In the membranous urethra is found a layer of unstriped fibres arranged circularly, and this portion of the canal is also invested by the striated fibres of the compressor urethrte muscle. In the spongy urethra, there are no circular fibres except in the poste- rior portion of the bulb. There are a few unstriped longitudinal fibres, which are either scattered or which form only a broken layer. It thus appears, on anatomical grounds, that spasmodic stricture cannot exist an- teriorly to the deepest portion of the bulb. The corpus sponffiosum is dilated at its posterior extremity where it forms the bulb. It terminates anteriorly in an expansion, called the •' glans penis ;" while a thin layer of erectile tissue is continued back- wards around the membranous portion of the urethra and extends into the veru montanum of the prostate. The coi-pus spongiosum consists of a vast number of venous sinuses, communicating with each other in all dii'ections. Its great vascularity explains the hemorrhage which is liable to ensue, when the spongy portion of the urethra is divided by the knife of the surgeon or accidentally wounded. This occurrence, however, is less likely to take place, when an incision is confined to the mesial line and made in an upward direction, since the amount of vascular tissue is much less above than below the urethra. This will be shown by diagrammatic sections of the penis, when we come to speak of internal urethrotomy. The corpora cavernosa are tAvo in number. Arising in front of the tuber ischii, and intimately united to the periosteum covering the rami of the ischium and pubis, the two unite in front of the symphysis, to which they are connected by the suspensory ligament cxnd are continued forwards as far as the corona glandis, wliere their common extremity is capped by the expansion of the corpus spongiosum forming the glans. The vascular connection between these bodies is free, though little, if any, exists between them and the corpus spongiosum, which lies in a groove upon their under surface. Deep Perineal Fascia — The triangular space, seen in the bony pelvis to intervene between the pubic and ischiatic rami, is occupied by a tense, fibrous septum, constituting one of the chief supports of the pelvic viscera above, and known by the various names of " deep perineal fascia," " tri- angular ligament of the urethra," " Camper's ligament," '' middle perineal fascia," " ano-pubic aponeurosis," etc. This septum is composed of two layers, an inferior and a superior, separated by an interval in which are found the membranous portion of the urethra, which necessarily passes through the deep perineal fascia to arrive at the surface, the compressor urethrie muscle, Cowper's glands and ducts, the arteries of the bulb, and the dorsal vein, nerve, and artery of the penis. We might familiarly liken his septum to a double window, through which n funnel, representing the 254 STRICTURE OF THE URETHRA. urethra, passes ; in which case the portion of the funnel contained between the sashes would correspond to the meml)ranous region. Fig. 51. Vertical antero-posterior section in the inedian line, showing fascise. (After Tillanx.) a, ante- rior or i.ubio-vesicalcal-de-sac of the peritoneum 6, urachus. c, posterior, or recto-vesical cul- de-sac of the peritoneum, d, pubio-prostatic ligament. ^ suspensory ligament of the poms. /, r'ecto-vesical cul-de-sac of the peritoneum, i^, point at which the peritoneum is reflected ou the posterior face of the rectum, q, summit of the bladder. At their apex, the two layers of the deep perineal fascia are thin and firmly attached to the sub-pubic ligament and pubic bones, they tlien pass downwards and backwards, and are stretched between the pubic and ischiatic rami. The space between them containing the important parts already mentioned, is from half to three-fourths of an inch in depth. The vena dorsalis penis pierces the fascia half an inch, and the uretlira usually SUPERFICIAL PERINEAL FASCIA. 255 at about three-fourths of an inch below the symphysis ; but, according to measurements made by Mr. Thompson, the latter distance may vary from seven-eighths to an inch and a quarter; a difference of some importance as affecting the sub-pubic curve of the urethra. The superior (or deeper) layer of the triangular ligament is continuous with the aponeurosis underlying the prostate gland (the prostato-perineal fascia). The inferior (or more external) layer, winding round the poste- rior edge of the superficial transversus perintei muscle, advances forwards and becomes continuous with the superficial perineal fascia (Buck's fascia), which invests the penis. Ficr. 52. Diagram represpnting a horizontal section of the perinajum, designed especially to show the arrangement of the deep perineal fascia. (After Tillaux.) a. corpus cavernosum. h, inferior layer of deep perineal fascia, c, deep transverse perineal or Guthrie's muscle. (<, section of urethra, e. Cowper's glands. /, superior layer of deep perineal fascia, ^r, internal pudic artery, ft, internal pudic nerve, i, descending branch of the ischium, y, superficial fascia, t, erector penis orischio-caveruosus muscle. I, bulb of the urethra. ??(, accelerator urinie or bulbo-caver- nosus muscle, n, superficial fascia, o, superficial perineal arieiy. p, superficial perineal nerve. q, skin. Siipe^-jicial Perineal Fascia. — Strictly speaking, there are two layers of this fascia, the superficial and deep. The former consists of cellulo- adipose tissue, belonging to the general integument of the body. Tlie latter is aponeurotic in its structure, and is chiefly important in its relation to the present subject. In accordance with frequent usage, it alone is in- tended by the term " superficial fascia of the perina;um." This fibrous structure corresponds in its general direction with the deep perineal fascia just described, but is situated upon a more external plane ; behind the trans- versus perinaji muscle it is reflected upon itself and, as already stated, be- comes continuous with the anterior layer of the triangular ligament. This reflection of the fascia, corresponding to the bi-ischiatic line, forms a line of demarcation between the anal portion of the perinaium behind and the urethral portion in front. Purulent collections generally respect this limit, so that, in the absence of other data, we may know with great cer- tainty wliether a perineal fistula i)roceeds from one or the otlier of the.se portions. Anal and rectal fistulie are situated behind the line and uretliral fistula) in front. (Tillaux.) 256 STRICTURE OF THE URETHRA. At the sides the superficial perineal fascia is attached to tlie rami of the pubic and ischiatic bones. In front it is continued on to the penis and sending off a layer which separates the corpora cavernosa from the corpus spongiosum completely surrounds this organ up to the base of the glans. Buck's fascia. (After Buck.) A. The corpus cavernosum, enucleated from the sheath. B. The sheath, split up to the suspensory ligament, of whose anterior layer it is a coutiauation. G. The relations of the sheath to the corpus spongiosum urethrse, one layer of the fascia passing above it, and the other below it. D. Its relations to the glans penis, to which the sheath adheres insep- arably by its outer surface, while by its inner surface it caps the corpus cavernosum. E. The dorsal arteries, veins, and nerves, raised with the sheath. These relations of the superficial fascia to the penis were first fully de- scribed in the first volume of the Transactions of the American Medical Association, by the late Dr. Gurdon Buck of New York. As this paper is not generally accessible, and deserves to be preserved in memory of the distinguished sui-geon who wrote it, I shall quote the greater part of it: — " The anatomical structure in question consists of a distinct membra- nous sheath investing the penis in the manner to be described, and forming a continuation of the suspensory ligament above, and of the perineal fascia below, and will be best understood by a description of the mode of dissect- ing it. "The penis and scrotum are to be circumscribed by an incision at the distance of three fingers' breadth all around, and crossing the perinauim at the anterior margin of the sphincter. SUPERFICIAL PERINEAL FASCIA. 257 "The dissection of the skin and subjacent cellular and adipose tissues is to be made towards the penis, on the level of the fascia lata laterally, and of the perineal fascia posteriorly, and carefully continued to the body of the penis, as far as the corona glandis. By this means, the penis, as well as the suspensory ligament, is denuded of its loose movable investments. "An incision is then to be made along the dorsum of the penis exactly in the median line, splitting through the suspensory ligament, and extend- ing forward to the corona, between the dorsal vessels and nerves that run parallel on either side. The adhesions of the sheath along the dorsum are tirm, and require careful dissection ; the bloodvessels and nerves being raised with it, serve as a guide to show tlie line of adhesion, " The dissection being prosecuted laterally as well as inferiorly and at the extremity, the entire corpus cavernosum is enucleated, the muscles of the perinanmi being raised with the sheath. It is now clearly seen that the suspensory ligament from above, and the perineal fascia from below and laterally, form one continuous membrane with the sheath, inclosing the corpus cavernosum in its cavity, and embracing the corpus spongiosum urethni3 between two layers, one of which passes above and the other below it. The excavated base of the glans adheres inseparably to the outer sur- face of the sheath, while by means of its inner surface, it caps the summit of the corpus cavernosum. "Its adhesions are most firm at the extremity of the corpus cavernosum, along its dorsal surface, and at the insertions of the erector and accelerator muscles. It is thickest around the corona, along the dorsal surface, and where it forms the suspensory ligament. Zones of vessels run at regular intervals in the direction of the circumference of the penis, from the dorsal trunks to the corpus spongiosum, between the layers of the slieatli. The cavity formed by the sheath, and occupied by the corpus cavernosum, is limited posteriorly by the triangular ligament (deep perineal fascia). " That portion which covers the perineal muscles, and has been described by authors under the names of the superficial fascia of the perineum, in- ferior fascia and ano-penic fascia, arises laterally from the ascending rami of the ischium, and descending of the pubis, as far forward as the inferior edge of the symphysis, where the two layers meet and form the suspensory ligament. Postei'iorly, it is continued over the transverse muscle, and iolding around its edges is prolonged upwards into the ischio-rectal fossa. " It also sends off from its upper surface membranous septa between the accelerator muscles in the middle, and the erectors on either side, to join the triangular ligament, and thus forms the three distinct and independent sheaths that are confounded anteriorly with the common sheath investing th^ corpus cavernosum." M. Jarjavay afterwards confirmed Dr. Buck's observations, and gave full credit to the " Chirurgien de TAmerique" for the originality of his discovery.^ ' Jarjavay, Traite d'auatomie cliirurgicale, Paris, 1854, t. ii, p. 57l). 17 258 STRICTURE OP THE URETHRA. Richet,^ while agreeing with Dr. Buck in the main, differs from him in some particulars. He states that the posterior portion of this fascia is quite loose and areolar upon the dorsum, where it cannot be distinguished from that covering the pubes; and that thus a communication is opened by which inliltrations of urine may gain the sub-integumental cellular tissue of the penis and abdomen without perforating the fascia. Pelvic Fascia The pelvic fascia is, in reality, the superior aponeurosis of the elevator ani muscle — a muscle which is lined with an aponeurosis on either side of it. This fascia is lost on the sides of tlie pelvis with the fascia of the obturator internus ; within, it is attached to the rectum and the lateral fascia of the prostate. Although thin in structure, it is generally sufficient to prevent purulent collections formed above it from pointing in the perina^um and vice versa. (Tillaux.) A knowledge of these fascire, which may be facilitated by a study of the accompanying figures from Tillaux,^ is essential to every surgeon who ope- rates upon the genito-urinary organs. Their practical bearing is so clearly set forth by Tillaux, that I shall give it in his own words : — The three fasciai above described, the superficial and deep perineal fascia and the pelvic fascia, circumscribe between them two chambers or reservoirs, viz., one inferior and the other superior. The first contains the spongy portion of the urethra and the corpora cavernosa, the second the membra- nous and prostatic portions of the canal. Inferior Penile Chamber This chamber is bounded by the super- ficial fascia of the perinaaum below and the deep fascia above. We have seen that these two fasciaj are continuous with each other at the posterior edo-e of the transverse muscle. Its shape has been compared to that of a pistol, the but-end of which is below at the bulb. This cliamber contains the bulb of the urethra, Cowper's glands, the spongy portion of the urethra, and the corpora cavernosa. It is covered by the skin, the superficial fascia, and the subcutaneous layer of cellulo- fatty tissue. It is generally in this compartment that ruptures of the urethra take place in consequence of strictures ; hence the infiltration does not extend, in the direction of the rectum, into the ischio-rectal fossa. It first invades the penis, but does not remain confined there for a long time ; it extends to the scrotum, escapes from the chamber on a level with the suspensory ligament, and reaches the pubis and the walls of the abdomen, which are sometimes undermined in their totality. In this compartment, also, urinary tumors and urinary abscesses are developed, which are so often the consequence of strictures of the urethra. This accident should be carefully distinguished from infiltration of urine. The latter takes place suddenly in consequence of rupture of the urethra ; the urine immediately invades the inferior chamber without any obstacle • RiCHET, Traite d'anatomie medico-chirurgicale, 2e ed., Paris, 18(j0. 2 Traite d'anatomie topograph ique, etc., Paris, 1877. SUPERIOR OR PROSTATIC CHAMBER. 259 to its passage, passes beyond its limits, extends to a distance, and causes mortification of the tissues wherever it extends. Urinary abscesses and tumors occur in quite a different way. The in- flammation of the urethra, which always exists behind a stricture, extends slowly to the neighboring tissues. There is thus gradually formed on the inferior wall of the canal, a nodule, varying in size (possibly as large as a large hen's egg), and of extreme hardness. This is a urinary tumor. These tumors are also immovable, and in case they fill the space between the two ischia, no line of demarcation separates them from the osseous walls. They occupy exactly the median line, which serves to distinguish them from chronic inflammation of one of Cowper's glands. If the urethra breaks after this preparatory work has taken place, the urine finds before it an insurmountable barrier and cannot become infiltrated ; then we have a urinary abscess. If pus forms within this indurated mass, its envelope is so thick and resistent, that we can never feel fluctuation at the outset. These abscesses should be opened early, for fear that the envelope may become perforated and urinary infiltration follow. It is often necessary to cut through several centimetres of indurated tissue before reaching the cavity. Superior or Prostatic Chamber. — The prostate is circumscribed by a series of aponeurotic planes which isolate it on all sides. They are above and in front, the pubio-vesical ligaments or tendons of the vesical muscle, which run into the pelvic fascia ; behind and below, the prostato- peritoneal fascia and the superior layer of the triangular ligament ; on the sides, the lateral aponeurosis of the prostate. The jnibio-vesical liyaments are very resistent, but they do not form a continuous plane. Between their fibres exist spaces traversed by large veins coming from the penis; the urine may follow the same- road, and infiltration is then the more easy, since, in front of the ligaments, exists a layer of lax pre-vesical cellular tissue. The prosta to-peritoneal aponeurosis (Fig. 51, n) extends from the cul-de- sac of tlie peritona3um to the posterior edge of the triangular ligament. It is continuous below with the superior layer of this ligament, just as the superficial fascia is continuous with the inferior. Its adherence with the peritonaeum prevents this membrane fi-om ascending into the pelvic cavity as the bladder becomes distended, and, on the contrary, makes it form a very deep cul-de-sac. It covers all the posterior surface of the prostate, which it thus se})arates from the rectum. But this layer, composed almost exclusively of smooth muscular fibres, generally presents only feeble resist- ance. It is easily destroyed and perforated by pus, as, for instance, in suppurative prostatitis, and thus a urethro-rectal fistida may form. It is evident that, if the posterior Avail of the prostatic chamber gives way, before any barrier has been formed against infiltration, the urine at once extends into tlie anal portion of the perinanun, invades the ischio- rectal fossa, completely isolates the rectum, and extends upwards into tlie pelvic cavity. The penis, the scrotum, and the abdominal wall are abso- 260 STRICTURE OF THE URETHRA. lately intact. This dangerous form of infiltration is insidious, and at the outset often recognized with difficulty. It is happily rare, and follows most frequently false passages in the prostatic urethra in persons with a middle lobe so enlarged as to obstruct the entrance of a catheter. The lateral aponeurosis completes the prostatic chamber. It is a fibrous plane nearly quadrilateral, placed directly on each side of the prostate in such a manner as to present an internal and an external face, a superior and an inferior border. It extends from before backwards, from the pubis, where it is continuous with the pubio-prostatic ligaments and the trian- gular ligament, to the rectum, to the lateral walls of which it is attached, whence the name of pubio-rectal, which has been given it. From above downwards, it occupies the space comprised between the superior perineal fascia and the prostato-peritoneal aponeurosis, to which it is attached. Besides the prostate, the prostatic chamber contains Wilson's muscle, and especially a large number of veins. It is very exceptional to find that the lateral aponeuroses of the prostate o-ive way in consequence of organic lesions of the urethra, or the violent use of a catheter; but they are readily cut in the operation of lithotomy, especially in the lateral operation. This condition is fiivorable to infiltra- tion of urine, which then takes place in the anal portion of the perina^um; and the sub-peritoneal cellular tissue is likewise invaded. The perina3um, as we have said, is divided into two distinct portions ; one anterior, the genito-urinary ; the other posterior, the recto-anal. This division is justified by the course of infiltrations of urine. Two great forms of infiltration may occur ; one has for its starting point the portion of the urethra included in the penile or inferior chamber, when the urine invades the penis, the scrotum, and, if not arrested in time, the abdominal wall; the other proceeds from the part of the canal inclosed in the superior or prostatic chamber ; the urine extends into the rectal portion of the peri- na^um, fills the ischio-rectal fossa, gains the pelvic and often the abdominal cavity. This is in accordance with fact and with our knowledge of anatomy. Dimensions, Mobility, and Direction of the Urethra — Having considered the separate portions of the urethra and the various tissues which surround it, we may now regard it as a unit ; and more especially with reference to the size and form of instruments retjuired in tlie treatment of stricture. The statements of authors relative to the length of tlie male urethra repre- sent it to be from five and a half to twelve inches. This discrepancy may be accounted for by the different methods employed in taking measurements; whether upon tlie living or dead subject ; by the amount of traction exer- cised upon the parts ; and, also, to a certain extent, by an actual variation in different persons. The size of the penis appears to have no influence upon the length of the urethra ; the latter, as shown by Sappey's observa- tions,^ often being in an inverse ratio to the former. The greatest source of variation is found n\ the length of the anterior or ascending portion of 1 RechercTies siir la conformation exterieure et la structure de I'uietre de rhomme, Paris, 1854. DIMENSIONS AND MOBILITY OF THE UREXIIRA. 261 the subpubic curvature, AVithout seeking for any absolute standard, it is desirable to obtain an average which may assist in determining the situa- tion of strictures, and afford useful information in their treatment ; and after all that has been said by authors of the variable length of the urethra in different individuals, the results of measurements are found to be nearly identical, provided the method of making them be always the same. The length of the urethra may be estimated during life by means of a graduated catheter, the flow of urine indicating when the eye near its point has reached the vesical extremity of the canal, and care being taken that the penis is not stretched upon the instrument. After death, the urethra and bladder may be removed from the body, slit open superiorly, gently extended upon some smooth surface, allowed to contract by their own elasticity, and then measured with a tape. Attempts have also been made to ascertain the length of the urethra by casts of the canal in fusible metal ; but the two methods just mentioned are far more reliable. According to the careful and minute observations of Mr. Tliompson and Mr. Briggs, the results of measurements thus taken during life and after death are not identical ; by the former, the avei'age length is found to be seven and one-half inches ;' by the latter, eight and one-half. This differ- ence is constant, and may readily be accounted for by the different condi- tions nnder which the measurements are taken. It is worthy of remem- brance, " since all accurate researches into the pathological anatomy of stricture are, of necessity, confined to an observation of the parts after death, while, in relation to treatment, the measurement during life is that which alone must be remembered."'^ The urethra cannot be said to have any fixed and absolute diameter, since its walls admit of greater or less expansion according to the amount offeree exerted upon them. A No. 12 catheter or sound of the English scale rarely fails to pass with ease, if the pa,rts be healthy ; and not unfre- quently No. lo will pass without difficulty. It is more important to be familiar witli the relative than witli the actual diameters of the different portions of the canal. The external orifice or meatus is almost invariably the most contracted part; so that whatever instrument fairly enters the urethra will pass tlirough it, if no obstruction exists. Another im[)ortant inference from this fact is, that to restore to its original calibre by dilatation one of the deeper portions of the urethra contracted by stricture, the meatus must be enlarged, which can generally be effected only by incision. The next narrowest point of the canal is at the junction of the bulbous and membranous regions ; while tlie middle of the jtrostatic portion, and the sinus of the bulb are the widest. Xhe degree of mobility of different portions of the in-ethra is chiefly in- fluenced by the attachments of the neighboring fasciie. The anterior part ' Leroy d'Etiollcs oV)taiu(Hl an average of (?iglit inclies from one. hundred niea- suroments during life, by nx-ans of a graduated gum-elastic souml. {Dca rilri- cissomcut lie Vnritre, etc., Paris, p. 5.) 2 TiioMi'Sox, op. cit., p. 4. 262 STRICTURE OF THE URETHRA, of the penis is free, and capable, in a flaccid condition, of assuming almost any position ; in its posterior third, however, this organ is connected with the symphysis, by means of the suspensory ligament ; with the ischiatic and pubic rami, by the crura of the corpora cavernosa, and with the anterior layer of the deep perineal fascia, by means of the bulb ; the spongy urethra may, therefore, be said to be fixed in proportion as it approaches the mem- branous region. The membranous region is the least movable of all, owing to its firm connection with the pelvis by means of the two layers of deep perineal fascia. The prostatic urethra is susceptible of some slight change of position, dependent upon the action of the anterior fibres of the levator ani, and the amount of urine in the bladder. In a flaccid condition of the penis, the urethra has two curves : the first confined to the anterior, the second to the deeper portion of the canal. The former is simply due to the dependent position of the anterior part of the organ, and is effaced in a state of erection or when the penis is ele- vated to an angle of about 60^ with the body. The latter may be called Fig. 54. Prep !**« A'ertical section of bladder, penis, and urethra. (Alter Gray.) the sul)-pubic curve, from its position beneath the symphysis. Unless some degree of force be used to straighten the canal, this curve is permanent, and a knowledge of its direction is essential in determining the proper form of instruments and the manner of their introduction. STRICTURES. 263 The sub-pubic curve commences an inch and a half anterior to the bulb, attains its lowest point, when the body is in the upriglit position, nearly opposite the anterior layer of the deep perineal fascia, and finally ascends through the membranous and prostatic regions. According to the obser- vations of Mr. Thompson and Mr. Briggs, it " forms an arc of a circle three inches and a quarter in diameter ; the chord of the arc being two inches and three-quarters, or rather less than one-third of the circum- ference." Mr. Thompson states that he has often found it more acute in spare men ; and in the corpulent, more obtuse ; that traction of the abdomi- nal muscles exercised through the suspensory ligament may also render it more abrupt, whence the advantage of raising the shoulders when perform- ing catheterization upon patients in the recumbent posture. The elevation of the bladder above the pubes in children, and the enlargement of the prostate so common in old men, also effect a change in the direction of the sub-pubic curve from its usual adult standard, and require therefore a corresponding variation in the form of instruments. Swellings and ab- scesses about the lower extremity of the rectum, large hemorrhoidal tumors, and various other circumstances may also operate in a greater or less degree to cause some change in the direction of this curve. Strictures. Strictures may be briefly classified as Spasmodic and Permaxext or Organic. Spasmodic Stricture — The chief element of a spasmodic stricture is muscular spasm, with which is usually associated more or less congestion. Either of these may exist alone; commonly both are combined. Many of the older writers on venereal diseases, as Charles Bell, denied the influence of spasm, except perhaps in the membranous region, to which their knowledge of any muscular tissue surrounding the urethra was mainly confined. The subsequent discov.ery by Kolliker and Hancock of organic muscular fibres about the canal has shown the possibility, and, reasoning from analogy, the probability, that spasmodic contraction may take place in any {(art of the uretlira, where these fibres are circular; in otlier words, witliin the limits already defined. (See page 253.) The exciting cause of spasm is some impression upon the sentient nerves, transmitted to a nervous centre, and returned through motor fibres, tex*mi- nating in either voluntary or involuntary muscles. In the urethra, spasmo- dic ai;tion, sulUcient to produce stricture, may take place in the submucous layer of organic fibres ; or, in the membranous region, in the striped fibres of , the compressor urethraj ; iinA, perhajis, to a less extent, in those of the acceleratores in the spongy region. While [)erforming catheterization upon irritable su1)jects, it has occasion- ally been observed by nearly every surgeon, that the instrument is grasped and temporarily held by the urethral walls, even when the canal is free from permanent obstruction. In this case, the sound, or catheter, acts as 264 STRICTURE or THE URETHRA. a foreign body, and the irritation which it produces is followed by con- traction in accordance with the familiar laws of reflex action. In other cases, the eccentric irritation is caused by laceration, abrasion, or a wound of the lining membrane, such as may ensue from the rough use of a catheter, or other surgical instrument. This, of itself, may excite spasm; or the same may be induced by contact of urine with the raw surface. Striking examples of spasmodic stricture are also met with as the result of irritation about the rectum, excited by the presence of a tapeworm, ascai'ides, htemon-hoids, fissure of the anus, fecal accumulation ; or by operations upon this part, especially the ligature of piles. Sir Benjamin Brodie^ met with a case of spasmodic stricture, in which the spasm was intermittent, recurring every twenty-four or forty-eight hours, and which was finally cured by quinine after the failure of other means. Among other causes of spasm, are the presence of a stone in the bladder, or urethra ; organic stricture of this canal ; immoderate sexual intercourse ; the free use of alcoholic stimulants ; long retention of tlie urine ; horse- back exercise; digestive derangements; exposure to sudden changes of temperature, and mental emotion. A spasmodic stricture is characterized by its short duration. It appears suddenly in persons of delicate habit, especially in those who have com- mitted some imprudence in diet, and as suddenly disappears. Explora- tion of the canal by means of a sound after the s[)asm has passed, and frequently during its continuance, shows that there is no organic obstruc- tion. Mr. Smith^ details a case in which a patient, who had suffered from a violent attack of retention a short time before, suddenly died; and, at the post-mortem examination, not the slightest contraction was found. Prof. Otis believes that a spasmodic stricture due to reflex irritation may exist continuously for years, even fifteen or twenty years, during which time it is nearly or wholly impassable to any instrument, although at any moment it may be made to entirely disappear by the removal of the source of irritation. He says : " Deep organic uretliral stricture is often simulated by muscular spasm, the result of irritation caused by slight anterior strictures, even by a slight contraction of the meatus urinarius alone. The great proportion of cases treated by (jradnal dilatation are treated for deep stricture lohich does not exist."'^ (The italics are in the original.) So far as I know, such long-continued spasm is never met with in other muscular tissues. Moreover, I believe that any spasmodic stric- ture can be passed with patience and suitable instruments, and until I meet with a case of the kind described by Dr. Otis, as I never yet have done, I cannot admit of spasm lasting through years. I shall presently have occasion, when speaking of the seat of strictures, to mention Verneuil's views regarding spasmodic stricture at the bulbo- ' Lond. M. Gaz., vol. i, p. 507. 2 Henky Smith, Stricture of the Urethra, London, 1857, p. 23. 3 Stricture of the Male Urethra, 1878, p. 301. PERMANENT OR ORGANIC STRICTURE, 265 membranous junction, which are of interest in this connection, and are quite similar to those recently set forth by Dr. Otis. In the great majority of cases which come under the observation of the surgeon, inflammation and spasm are combined, and to these is added some degree of permanent contraction. A patient has an organic stricture which has given him but little annoyance, and offered no serious obstacle to the complete evacuation of the bladder ; suddenly, after freely indulging in spirits, or coitus, and retaining his urine for several hours, he finds himself utterly unable to pass water. The urethra, partially con- tracted by organized deposit in and around its walls, is entirely closed by the supervention of congestion and spasm, and complete retention is the result. Under appropriate treatment, the congestion and spasm may be subdued, though the organic stricture remains after their disappearance. Permanent or Organic Stricture The albuminous fluid which infiltrates the tissues in acute urethritis, and which may contribute to the formation of congestive stricture, is, in most cases, eventually absorbed, and the canal recovers its normal calibre. But under other circumstances, and especially as a consequence of chronic inflammation, products of a more plastic nature are thrown out, which become organized, exhibit the same tendency to contract as adventitious deposits in other parts of the body, and give rise to permanent contractions of the canal. According to the more recent views of pathologists, stricture is due to a proliferation of the elements of the submucous cellular tissue and not to the organization of any effused fluid. It is evident that the diminution in the calibre of the urethra is but one of the bad effects of stricture ; the normal elasticity of the canal is lost, and the exei'cise of its function seriously in- terfered with. Organic stricture may be due to traumatism, as a fall upon the perini^um, in which case it is peculiarly obstinate and not generally amenable to treat- ment by dilatation. In the anterior portion of the canal, it may also have arisen from the cicatrization of a chancroid, or from the specific induration surrounding a chancre. Masturbation has also been enumerated among the causes of stricture, but, as it appears tome, without sufficient evidence.^ Seat. — There are several sources of error which should be avoided in attempts to determine the anatomical seat of strictures during life. These are the mobility of the stricture itself, which may often be thrust back to a considerable distance on the point of an instrument ; the liability of the penis to be elongated by traction at the time of taking the measurement ; and the actual elongation which often ensues as a consequence of the frequent handling which this organ receives from persons suflTering under stricture. Th(? great discrepancy in the stat(;ments of authors as to the most fre(iuent seat of this com[)laint shows that these, and i)erliaps other sources of error have not been sufficiently guarded against; and the tendency has almost ' See a paper by Dr. Samuel W. Gross, On sexual debility and impotence, with special reference to masturbation as an exciting cause of stricture, Med. and Surg. Reporter, Pliila., May 5, 1877. 266 STRICTURE or THE URETHRA. invariably been, as shown by recent investigations, to assign to stricture a seat posterior to its true situation. Fig. 55. The spongy portion. Tliu meml)ranons portion. The prostatic portion. Region No. III. Region No. II. Region No. I. " A healthy nrelhra, eight inches and a half in length, slit up from the upper part, accurately reduced on scale from a drawing made from the oriijinal while fresh, to half the natural size. On the left-hand side arc indicated the anatomical divisions of tlie urethra, and on the right the boundaries of the regions refeiTi-d to in relation to the locality of stricture." (After Thompson.) Sir Henry Thompson made a careful and laborious examination of over three hundred preparations of stricture contained in the chief museums of Paris, London, and Edinburgh, and arrived at the following conclusions as to its site. He premises by dividing the urethra for the sake of con- venience into these three regions : — I. The Sub-pubic Curvature, which comprises an inch of the canal before, and three-quarters of an inch behind, the junction between the spongy and membranous regions, tlius including the whole of the mem- branous portion. SEAT. 2fiT II. The Centre of the Spongy Portion, a region extending from the anterior limit of the preceding, to within two inches and a half of the external meatus, and measuring therefore about two and a half to three inches in length. III. The External Orifice, including a distance of two inches AND A HALF BEHIND IT. Of 270 preparations, embracing 320 distinct strictures, Mr. Thompson found In region I . . . 216 or 67 per cent. " " II . . . ol " 16 " " " " III . . . 54 " 17 " " 320 According to this eminent authority, the largest number of strictures are therefore situated at the sub-pubic curvature ; and he would still further limit the most frequent locality to the anterior portion of this region, since he says " that part of the urethra which is most frequently affected with stricture is tlie portion comprised in the inch anterior to the junction, that is, the posterior or bulbous part of the spongy portion. The liability of this part to stricture appears to diminish as it approaches the junction, where it is less common ; while behind, it is very rare. Most rarely is a stricture found so far. back as the posterior part of the membranous por- tion."' The next most frequent situation of stricture is stated to be the external two and a half inches, and the least frequent the middle portion of tlie spongy region, although the difference between the two is not very great ; while botli are of but small importance compared with the anterior portion of the bulb. Mr. Walsh'^ and M. Mercier^ arrived at results very similar to the above. On the otlier hand, in 1866, M. Verneuil read a paper before the Ana- tomical Society of Paris,* in which he denied the frequency of organic stricture at the bulb and at the commencement of the membranous portion ; or rather he maintained that in cases of stricture a ^iroHS contraction is almost always met with at about two and one-half inches from the meatus, and tliat beyond this, at the depth of five inches, i. e., at the bulbo mem- branous junction, there is constantly a second contraction, but only spas- modic and symptomatic of the former. "Whenever there is irritation of the anterior portion of the urethra, the membranous portion contracts and arrests a sound." " Wlienever a patient shows symptoms of urethral stric- ture, one contraction exists in the spongy portion, a second in tlie mem- branous portion. The first alone is fibrous ; the second spasmodic and ' Op. cit., p. 83. •^ Mod. Press, Dubl., Jan. 23, 1856, p. 51. 3 Rochorchos sur le traitement d. mal. d. voies urinaires, 1850, p. 377. Also Bull. Soc. anat. de I'aris, 1858, p. 441. * Bull. Soc. anat. de Paris, avril, 18(JG, p. 170. 268 STRICTURE OF THE URETHRA. symptomntic of the first." Verneuirs views are still furthei- developed in an able article by M. H. Folet/ in which an extensive bibliography of the opinions of dilTerent authors on the seat of stricture is given and the fol- lowing conclusions ai-e arrived at : — 1. Fibrous, organic stricture is frequent in the spongy portion of the urethra, where it is often overlooked. 2. Organic stricture of the bulbo-membranous region, although said to be frequent, is rare. 3. In all cases of stricture of the spongy urethra, there exists a second obstruction five inches from the meatus, at the commencement of the membranous region. This obstruction is due to muscular spasm, and is only a symptom of the penile stricture. Tlie latter (penile) is often slight and incapable in itself of notably impeding micturition. The secondary spasm is the efficient cause of the dysuria, and constitutes a serious and sometimes invincible obstacle to catheterization. 4. The calibre of the penile stricture is constant, and can be only slowly and regularly dilated. That of the spasmodic stricture is subject to the most sudden and capricious variations ; it may perhaps be easily passed in the morning, and in the evening, under the influence of some irritation, be completely impassable. .5. In those rare cases in which the organic stricture is seated at the bulb, a secondary spasmodic stricture exists none the less, immediately behind it. Dr. Otis,^ whose views on spasmodic stricture have already been referred to, is also a firm believer in the greater frequency of organic strictures in the spongy portion of the urethra. He states that out of 258 strictures under his care, 52 were in the first quarter inch of the urethra ; G3 in the following inch, viz., from :^ to 1^ ; 48 from 1^ to 2\ ; 48 from 2;^ to 3^ ; 19 from ^ to 4^ ; 14 from 4| to 5^ ; 8 from 5^ to ^ ; 6 from G^ to 7^. These discrepancies may, perhaps, be explained, when we consider the two methods by which the results have been obtained : Sir Henry Thomp- son and others founding their observations upon post-mortem specimens, and enumerating only such cases of stricture as are apparent after death ; Verneuil and Dr. Otis making their examinations during life, and count- ing in a large number of slight contractions, even of the meatus, which their opponents would not admit to be strictures at all. Further and un- biased investigation is, however, necessary before this question can be regarded as settled. Stricture never occurs in the prostatic region of the urethra, at least no unquestionable instance of the same is to be found recorded. Number. — Thompson states that in most cases there is only one stric- ture in the same subject. Of 267 preparations examined by him, the stricture was single in 226. Others have reported several distinct con- tractions. Hunter^ met with six ; Colot with eight ; and Ducamp with • Arch. gen. de med., Paris, avril, 1857, p. 401. * Op. cit., i>. 97. ^ Kicord and Hunter, op. cit., p. 1G8. FORM. 269 Fi°:. 56. Fiff. 57. Fig. .16. Annular stricture. Fig. 07. Irregular, or tortuou.s stricture. Posterior to the stricture in each figure are seen pouches of the mucous membrane, formed by dilatation of the lacuna; aud ducts, and capable of entangling the point of an instrument. (After Thompson.) five ; but Boyer never found more than three, and Mr. Thompson' never more than " three, or at the most four." Civiale^ says that when there are several, one of them is almost always situated in the sub-pubic curve, and the Fig. 58. others between it and the meatus. Here again Otis, with a different method of examination, is at variance with other authorities, regarding multiple strictures in the same person as the rule and not an exception. He reports one case in which he found fourteen.^ Form The form of stricture neces- sarily varies with the amount and situa- tion of the fibrinous deposit which pro- duces it. This may consist of a few fibres, which encircle the whole or a ])art of the urethral circumference, like a thread, or may form a band, varying in extent and thickness. Tliis is the " linear stric- ture" of Mr. Thompson and others ; the " bridle stricture" of Cliarles Bell ; and the " valvular stricture " of French writers. Strictures near the orifice of the urethra. (After Thompson.) ' Op. cit., p. 54. 2 Op. cit., vol. i, p. 157. 3 Op. cit., p. 68. 270 STRICTURE OF THE URETHRA. Where the fibrinous deposit is more extensive, the stricture covers a larger portion of the urethral walls. In some instances, it is abrupt on either side, like the last-mentioned form, but wider ; as if a whip-cord were tied externally to the mucous membrane ; this is called an "annular stricture." If the induration be more diffused around its base, a section of the canal will resemble an hour-glass, and the contraction receives the name of "indurated annular stricture." Again, stricture may involve the canal to the extent of half an inch or several inches ; when the passage is often more or less deviated from its normal direction, and the stricture is said to be " irregular or tortuous." Degree of Contraction The plastic material of stricture exhibits a constant tendency to contract, and become harder and firmer with time ; it is consequently true, as a general rule, that the longer a stricture lias existed, the more callous it is, and the less susceptible of dilatation. Ex- ceptions to this law, however, sometimes exist; and strictures of long duration are met with which yield readily, while others, recent in their origin, prove very obstinate. Complete obliteration of the urethra may take place as a consequence of a wound of the canal, sometimes from within, but more frequently from without. In strictures other than those of traumatic origin, the urethral w^alls are probably never completely fused together; although cases are reported in which fistulous passages had for a long time turned tlie urine from its normal channel, and in which, on post-mortem examination, it was impossible to introduce the finest probe througli the contraction, even after the external portion of the penis had been slit up.^ Instances of this kind, however, are rare; in most cases, liowever great the narrowing, urine will still find its way out, though it may be only by a few drops at a time. There has been no little discussion of the question, whether the urethra, when permeable to urine, is always permeable to instruments. The late Mr. Syme, of Edinburgh, and also Mr. Lister, asserted, in the earlier years of their practice, that whenever any urine comes out a catheter may with patience and perseverance be got in sooner or later, but they were both of tliem repeatedly foiled at a later period of their lives, and it is safe to say that no surgeon of any considerable experience will maintain that he has never met with a case of "impassable stricture." Pathology op Stricture. In mild cases of stricture, the canal in front of the contraction preserves its normal dimensions and character ; but in severe and chronic cases, when the flow of urine has been much obstructed, and tlic anterior portion of the urethra, through continuity of tissue, has particijjated in the inflam- mation which chiefly affects the part behind the stricture, it is contracted; another condition, difficult of explanation, is one of dilatation, which, in ' Thompson, op. cit., p. GO-Gl. PATHOLOGY OF STRICTURE. 2T1 a case described and figured by Charles Bell, was very considerable. In- stances in which the urethra was ulcerated in front of the stricture, are also given by the same author. Posterior to the stricture, the urethra is generally enlarged, as a natural consequence of the impediment to the free evacuation of the bladder. The canal ultimately loses its elasticity and becomes dilated so as readily to admit the finger, or even form a pouch which may appear as a fluctuating tumor in the perinteum. The lacunar of the mucous membrane and the orifices of the prostatic and ejaculatory ducts frequently participate in this enlargement; and the septa between the pouches thus formed constitute a network, chiefly confined to the floor and sides of the canal, wliich is well adapted to obstruct the passage of an instrument unless the point be well elevated towards the pubes. The mucous membrane behind the stricture is the seat of chronic in- flammation ; it is sometimes contracted and puckered; sometimes thin and minutely injected with bloodvessels; the surface is generally covered with a layer of pasty exudation, and it is from this source that the gleety discharge, which is so constant an attendant upon stricture, is derived. Ulceration frequently takes place, which may be superficial, or which may extend to the deeper tissues, producing large and ragged excavations of the urethral walls, or, in rare instances, it may even occasion destruction of the contracted portion of the canal. Abscess and Fistula A still more serious consequence of stricture is the development of abscesses and fistulte in the neighborhood of the urethra. In most cases the urethral mucous membrane is impaired or destroyed at one or more points by ulceration; during the sti-aining of micturition, urine, perhaps in a very minute quantity, escapes into the cellular tissue ; an abscess is formed which burrows in various directions, or which opens and establishes a fistulous communication between the external surface and the urethra. In other cases abscesses are developed without rupture of the urethral walls or infiltration of urine ; and they may occur even when the obstruction to the evacuation of the bladder is far from complete. In most cases, however, a communication is subsequently established by the ulcerative process. When a urethral opening exists, it is generally behind the contracted part, but sometimes in front of it. Tlie coui'se taken by urinary fistula; is often veiy erratic ; they may open into the rectum, upon the perina^um, upon the surface of the scrotum, upon the abdomen, even as high as the umbilicus, or upon the thighs or nates. These abnormal passages rarely have more tlian one opening into the urethra, but very frequently a number upon the external surface : in one ca^e, seen by Civiale, the latter amounted to no less than fifty-two.^ Their internal surface becomes lined with adventitious tissue, which bears a very close resemblance to mucous membrane, but is destitute of glands and follicles; it is organized, well supplied with nerves and bloodvessels, and constantly secretes a muco-jjurulent fluid. Calculous matter is deposited • Op. cit., vol. i, p. 539. 272 STRICTURE OF THE URETHRA. in fine particles or in larger masses, resembling mortar, upon the walls, and more particularly near the orifices or in some blind pouch opening into the passage. Deposition of similar matter often takes place in the dilated sinuses of the prostate, and this gland may become infiamed, and abscesses form in its substance. Bladder The vesical walls become hypertrophied, as a consequence of the obstruction to the flow of urine and the additional force requisite for its expulsion induced by stricture. This hypertrophy chiefly affects the muscular layer, but does not wholly spare the areolar tissue, which is somewhat thickened and increased in density. The walls of the bladder may attain five or six times their normal thickness, and measure from half an inch to an inch in thickness. The developed fasciculi of muscular fibres form prominent ridges upon the mucous surface, and have been aptly compared to the columnar carnete of the heart's cavities. Frequent and violent expulsory efforts cause protrusion of the mucous membrane between these columns, and pouches are formed, which, small at first, may gradually increase in size until they equal or excel the dimensions of the bladder itself. On post-mortem examination the mucous membrane of the bladder is found to be thickened, soft and pvdpy, and much congested in patches ; its color is heightened and generally of a dark-red hue, its surface is smeared with slimy mucus, which, when mingled with the urine, may obstruct the narrow orifice of the stricture ; scattered over it is a quantity of fine calculous matter, or it is covered with lymph, sometimes in small patches, at others, in layers of considerable extent. The irritability of the bladder excites to frequent acts of micturition, and the capacity of this viscus is eventually much diminished. Instances are recorded in which it would not contain more than an ounce, or even half an ounce, of fluid. Ureters and Kidneys As a stricture obstructs the exit of urine from the bladder, so it cannot but impede the passage of fluid into it ; conse- quently we find changes similar to those already described in the ureters and kidneys. The former are often so dilated tliat they will admit the finger or thumb, and in some instances, have been mistaken for a portion of the small intestine ; their parietes are thickened, and lymphy deposits, and other evidences of chronic inflammation are found upon their internal surface. The kidneys may participate in these lesions ; the pelvis, infun- dibvda, and calices, are distended ; the medullary tissue of the organ is atrophied under the pressure to which it is subjected, and enormous reser- voirs may be formed, capable of containing five, ten, and in one instance, observed by Sir Henry Thompson, twenty ounces. Genital Organs Stricture is not unfrequently attended with hyper- trophy and induration of the penis, and tumefaction and ajdema of the prepuce. The ejaculatory ducts may be dilated ; their walls, and those of the vesicular seminales, inflamed and thickened ; and their cavities contain SYMPTOMS OF STRICTURE. 273 pus, and other products of inflammation. There is often considerable irritability of the testicle, and attacks of epididymitis sometimes occur, especially after the use of instruments within the urethra. It is evident from a consideration of the organic lesions which stricture induces in the bladder, ureters, and kidneys, that the secretion of urine must be seriously interfered with, and the perfect elimination of eflPete matter consequently prevented ; and it is also probable that more or less noxious material is absorbed from the partially decomposed urine which collects in the bladder and elsewhere. The inevitable eflfect of this upon the system at large, and especially upon the nervous centres, is too well known to require explanation. Symptoms of Stricture. One of the earliest symptoms of organic stricture is generally a gleety discharge from the urethra. If the contraction of the canal has imme- diately succeeded an attack of gonorrhoea, the urethra may never have recovered its normal condition since the acute symptoms were present ; but in some instances all traces of muco-purulent matter had entirely dis- appeared, when suddenly, perhaps after some excess, the linen is found again stained, or the lips of the meatus adherent. This discharge is not a constant symptom of stricture, but is present in the great majority of cases. It is chiefly derived from the contracted portion of the canal, and the parts lying directly behind it. Another early symptom, and sometimes the first which attracts the notice of the patient, is a gradual diminution of the power over his bladder. He is not able to retain his water as long as usual, and a desire to urinate calls him up several times during the night. The stream, moreover, is diminished in fulness, is projected with less force than natural, and may be variously distorted ; sometimes it is flattened, at other times spiral like a corkscrew, forked, or divided into two or more portions which di- verge from the meatus ; or, at the same time that a small stream issues from the canal, a portion falls in drops at his feet ; he is obliged to take special care to avoid soiling his shoes and clothes ; and finally, when he supposes the act fully accomplished, a few drops dribble away, and wet his person and his clothing. The above symptoms cannot, however, be re- garded as pathognomonic of organic stricture, since they may be produced by otiier causes, as the presence of inspissated mucus in the canal, spas- modic contraction, calculi, irregular action of the bladder, etc. At the same time, each passage of the urine may be attended with pain and disagreeable sensations, varying in intensity, position, and character. Most frequently there is a sense of dull aching in the perineum, back, and loins, or in the glans penis ; often pain of a sharper character is felt in the course of the urethra or at the neck of the bladder, or follows the course of the spermatic cord, and is most severe in the groins and testicles, wliile sometimes it shoots down the thighs. Another frequent seat of pain is 18 274 STRICTURE OF THE URETHRA. behind the pubes, where it is probably due to some degree of inflammation of the bladder. As the disease progresses, all the above symptoms are aggravated ; and the urgency of micturition, especially, is much increased. Frequently, the patient is almost wholly deprived of sleep by repeated calls to urinate, and the length of time which this act requires. In aggravated cases, the urine dribbles away in small quantities, while the patient is asleep, or with- out his consciousness during the day. This has sometimes been mistaken for incontinence of urine; whereas it is almost invariably due to disten- tion of the contracted bladder and overflow of its contents. The urine also undergoes certain changes in consequence of its retention and partial decomposition, and the vesical inflammation which is thereby excited. These have already been mentioned in the chapter on cystitis. Hcematuria, which, however, is seldom excessive, sometimes occurs in connection with stricture, and is most frequently met with in old and aggravated cases in which the mucous membrane of the urethra and bladder is much congested. The genital functions may be variously interfered with. In consequence of the irritation of the parts, frequent erections may take place, or noc- turnal emissions occui". In other cases, erection is never perfect, owing to the rigidity of the urethra, or an obstruction to the entrance of blood into the corpora cavei'nosa ; pain may be felt in sexual intercourse, and the semen, instead of being at once ejaculated, slowly dribbles away, or passes backward through the dilated urethra into the bladder ; hence, persons with stricture are frequently impotent. Haemorrhoids, prolapsus ani, and irritation about the rectum, which is occasionally severe, are often produced by the repeated and violent strain- ing required in emptying the bladder. In a similar manner, hernia is liable to occur, especially in old men. Retention of urine sometimes supervenes in the early stages of organic stricture, in consequence of congestion and spasm ; it may indeed, in rare instances, afford the flrst indication to the patient that he is the subject of stricture ; but in most cases it appears at a later period, when the obstruc- tion to the passage of urine is already very great. It generally follows exposure to wet or cold, a long ride or drive, and, most frequently, a hearty meal, at which alcoholic stimulants have been freely indulged in. Distention of the bladder, in such cases, may even produce rupture of the vesical walls. If the peritonseum be involved in the rent, the urine gains entrance to the abdominal cavity ; the vesical tumor disappears, but the abdomen is tense and swollen, and death soon occurs from peritonitis. More commonly the contents of the bladder are at first effused into the sub-serous cellular tissue, where they may cause extensive gangrene of the surrounding parts, or whence they may afterwards escape into the ab- dominal cavity by ulceration. In no case of rupture of the bladder from retention, has the patient been known to recover.^ ' Thompson, op. cit. CAUSES OF STRICTURE. 275 Still more frequently, the distention of the bladder produces rupture ot the urethra behind the stricture, where its walls are weakened by chronic inflammation and ulceration. In the sudden and extensive infiltration of urine which ensues, no time is given for adhesive inflammation to erect barriers to its progress, as often happens in the slower formation of urinary abscesses, and thus the urine, forced on by the contractile power of the bladder, permeates the loose cellular tissue, wherever it is not limited by the fasciae. When the rupture takes place anteriorly to the triangular ligament, the effusion, after breaking through Buck's fascia, extends for- wards and upwards into the scrotum and over the abdomen ; its extent may generally be defined by the swelling and discoloration of the integu- ment, and an emphysematous crackling on pressure, which is due to the mixture of gases with the fluid ; the vascular connection between the superficial and deeper tissues is cut oiF or impeded, and, unless free inci- sions be made, gangrene of extensive portions of the skin may ensue. Thus, cases are recorded in which the effusion perforated the superficial perineal fascia and extended down upon the thighs, and in which the greater part of the integument from the knee to the umbilicus, including the coverings of the penis and scrotum, sloughed away, and left the tes- ticles entirely exposed and suspended only by the spermatic cords and ves- sels ; yet, even under these circumstances, recovery has been witnessed. A symptom, which is to be regarded as of serious import, is the appear- ance of a dark spot upon the glans penis, which indicates that the in- filtration has gained access to the corpus spongiosum urethras, and that "ansrene has alreadv commenced. "Wlien rupture takes place posteriorly to the triangular ligament, the symptoms may for a time be obscure : as when occurring elsewhere, the patient often has the sensation of something giving way, and experiences temporary relief from his sufferings ; if the rent be large enough to allow of the free escape of urine, the vesical tumor subsides, and, tlie tension of the parts being relieved, the patient may be able to pass water, but the quantity thus evacuated or drawn off is found to be small; soon deep throb- bing pain is felt in the periuiXium, and symptoms of general depression set in ; and the urine, after burrowing in various directions, may approach the surface. Causes of Stricture. A knowledge of the causes of stricture, and the relative frequency ot their action, may best be attained from an analysis of a large number of cases, siicli as is furnished in the following table prepared by Mr. Thomp- son.' It should be observed that 143 of these 220 cases were collated from the records of University College Hospital, London, and 49 from reports by different surgeons in medical journals ; occurring for the most part in hospital practice, they represent the worst class of urethral con- ti'actions. 216 STRICTURE OF THE URETHRA. ANTECEDENTS, OR SUPPOSED CAUSES OF 220 CASES OF STRICTURE.' Gonorrheal Ii[flam)iiafion in . . . . • • • • • .164 Injury to Perimcuin ........... 28 Cicatrization of C/iancres or Cliancroids ........ 3 Ditto, following Phaijechena .......... 1 Congenital, including cases in which the urethra may have been small from malformation, and those in which marked irritability of the urinary organs existed from childhood, accompanied by an unusually small stream ......••••••• 6 Poisoning by Niti-ate of Potash,^ Lithotritij, 3Iastnrbation,^ o{ ench one . . 3 True Inflammatory Stricture, including temporary stricture and retention from sudden acute inflammation, usually caused by some excess, and disap- pearing by resolution .......... 8 T;ue 5jj«S7/wx/ic kSVrtrtdre, caused by irritation about the rectum ... 2 " " " no cause assignable ...... 2 " " '•' caused by undue acidity or alkalinity of the urine 3 220 Of the 1G4 cases attributable to gonorrhoea — In 90 the disease is reported to have been chronic or neglected. " 3 it was attributed by the patients to strong injections. " 6 the discharge is stated to have ceased entirely and rapidly under treatment ; but in five of these stricture appeared almost immedi- ately after. " 4 other cases the stricture appeared to be almost simultaneous with the gonorrhcea. In the remaining 61 there is no report of chronicity, etc. Of the 164 cases attributable to gonorrhoea — 10 appeared immediately after, or during the attack ; 71 " within 1 year of its occurrence ; 41 " " 3 or 4 years ; 22 " " 7 or 8 years ; 20 are reported at periods between 8 and 20 to 25 years. It appears from the above table that gonorrlicea holds the first, and in- juries of the perina?um the second rank in tlie etiology of stricture. Urethral contractions are favored by the long continuance, rather than the severity, of urethritis. If we omit the Gl cases of the above table in which there is no report of the duration of the preceding gonorrhoea, we find that, in nearly nine-tenths of the remainder, the urethral inflamma- tion, to which the stricture was attributable, was either chronic, or ne<'-lected. Inquiries addressed to patients laboring under stricture show that, in the great majority, the urethral contraction has been preceded by several attacks of gonorrhoea ; but, whether by one or more, that the last was prolonged for many weeks or months, and terminated in a gleet. We may hence infer that whatever, either in tiie patient's mode of life or in liis constitutional tendencies, prolongs the duration of a gonorrhoea, tends to produce stricture. 1 Thompson, op. cit. p. 124. 2 Medi(-al Times, Lond., June 22, 1844. 3 Lallemaxi), Cliniijue Medico-Chirurgicale, Ire part, p. 109. DIAGNOSIS. 277 Laceration ot the urethral walls during chordee, and wounds from the imprudent use of sounds, catheters, etc., require a passing notice. The former may occur spontaneously, or arise from the hahit, more prevalent among Frenchmen than Americans, of relieving chordee by forcibly ex- tending the penis ; or, as is said, " breaking the chord." Wounds of the urethra by instruments from within evidently have the same effect as from without ; in the process of cicatrization which ensues, the natural coaptation of the parts must frequently be lost, and fibro-plastic material endowed with contractile properties be deposited. A distinction, however, is to be made between transverse and longitudinal wounds of the urethra from witliin. The former only may be said to be likely to produce stric- tures. Such results do not follow longitudinal incision, made, for instance, in internal urethrotomy. Much influence in the production of stricture has been attributed to tlie use of injections. I feel obliged to dissent in toto from this opinion, whicli appears to me to be based upon reasoning post hoc ergo propter hoc. When made very strong, or used at an improper stage of the disease, or with excessive force, injections may doubtless act as escharotics, or aggra- vate the inflammatory action, and thus favor urethral contraction, but this effect pertains only to their abuse. A chancre or chancroid, like any other ulcer, destroys a certain portion of the tissues upon which it is situated, and this loss of substance is not restored in the process of cicatrization, but the gap is filled with fibro- plastic deposit, in the form of granulations, which gradually contracts and approximates the edges of the original sore, or which forms a hard un- yielding cicatrix between them. In this manner venereal ulcers situated upon any portion of the urethral mucous membrane may lay the founda- tion of stricture. Examples of this kind are most frequently seen in sores upon the margin of the meatus, or in the fossa navicularis. Diagnosis. The general symptoms alone might be considered suflficient to indicate a case of stricture, but in many instances are very deceitful. There are other affections of the urinary organs, the symptoms of which closely re- semble those of stricture, and which have often been mistaken for it. Experience, therefore, would show that the greatest care should always be employed in forming a diagnosis. Tiie diseases which are most likely to be confounded with organic stricture, are subacute iuHaiiiniation of the prostate, and urethral neuralgia and hyperaisthesia, S,ubacute inflammation of the ])rostate may be attended by nearly every symptom which has been described as belonging to stricture, viz., by fre- (juency and difficulty of micturition, gleety discharge, and pain in the perinaium, above the pubes, and elsewhere. This identity in the symp- toms may readily lead to a mistake in diagnosis, which may even be con- firmed by a superficial exploration of the un-thra ; for the prostatic portion of the canal, in this affection, is exceedingly sensitive and the introduction 278 STRICTURE OF THE URETHRA. of a catheter attended with sevei-e pain ; if, then, the surgeon yields to the feelings of the patient and fails to malie a thorough examination, or, if he employs a tine sound or bougie, the point of which is liable to be obstructed by catching in some lacuna of the mucous membrane, the erroneous con- clusions already drawn from the history of the case may apparently be confirmed. The same mistake may also occur in cases of urethral hypersesthesia, either when occasioned by sympathetic irritation from stone in the blad- der, affections of the rectum, etc., or when, in the absence of any apparent cause, tlie exalted sensibility can be attributed only to nervous derange- ment. Tlie diagnosis of a suspected case of stricture can, therefore, be founded only upon a careful and thorough exploration of the urethra, and the instruments required in such examination, and tlie manner of using them, will now claim our attention. Exploration of the Urethra — The instruments requisite for phy- sical exploration of the urethra, and the diagnosis of stricture, most of which are also useful in treatment, are a set of sounds, solid and flexible catheters, and bougies of various forms. I propose to describe those only which I have I'ound most useful in practice. Shape and Size of Metallic Instruments. — Tlie degi-ee of curvature of unyielding instruments used in urethral exploration is a matter of no small importance. It would seem desirable that the curve should correspond to the natural curvature of the least movable portion of the urethra itself, which is that portion underlying the symphysis [mbis. Mr. Thompson has adopted this principle in the construction of catheters and sounds, and his example has of late been very generally followed, since it has been found that experience confirms the deductions from theory, and that urethral instruments with such a curvature are most readily introduced. The sub- pubic curve is an arc of a circle three and a (juarter inches in diameter, or, in other words, of a circle described by a radius one and five-eighths of an inch in length, the chord of the arc measuring two inches and three- quarters. The accompanying figure exhibits a catheter and sound so bent as to corresj)ond to this curve. In order that the precise direction of the point of the instrument may be indicated by the direction of its shaft, it is desirable that a constant relationship should exist between the two. According to the principle of construction here recommended, this is a right angle in the catheter, and in the sound, a somewhat shorter instrument, an angle of 120^^, or a right angle and a third. Another form of sound, known as Benique's, is a very desirable one in some cases. It has a double curve corresponding nearly to the two curves of the urethra when the penis is not elevated against the pubes, and hence is of the sam(^ shape that a flexible bougie assumes when introduced into the bladder and abandoned to itself. When properly made, it will be found on examination, as shown in the diagram, that its extremity follows EXPLORATION OF THE URETHRA. 279 the same curve as that above described, but that it includes, a larger arc ot the circle. Its point is likewise at aright angle with its shaft. As to the choice between these two forms of sound, it may be said : in practised hands they are generally equally easy of introduction, although Fis:. 59. A B represents an arc of a circle three and a quarter inches in diameter (radius \% in.) ; a B b, a catheter with Thompson's curve ; f B e, a sound, with the same curve, but shorter; c b d, a large Bunique's sound, its extremity following the same curve, hut including a larger arc of the circle. I have met with cases in which the one entered more readily tlian the other. For many years, I have been in the habit of using the short sound with Thompson's curve for the dilatation of stricture, — when, of course, there would be no object in reaching the deepest portion of the canal, — and of using a long sound with IJeniqiie's curve in the treatment of cases of irritability of the neck of the bladder or whenever it is desirable to have the instrument enter this viscus and be retained for a time. The greatest confusion formerly prevailed, and still prevails to a con- siderable extent, concerning the numbering of catheters and sounds. We hear of an " PiUglish scale," but there is no such thing as a constant Eng- lish scale, since the numbers of no two English makers exactly correspond, although they do approximately, and we cannot as yet dispense witli the term, however inaccin-ate. The French, on the contrary, have a definite standard, and if you Ijuy half a dozen fih'eres of as many different instru- ment makers in France, you will find them all to agree. Besides this 280 STRICTUttE OF THE URETHRA. recommendation of uniformity, the French scale has also this advantage, that the steps of its gradation are shorter than the English, which is often very desirable in dilating strictures. The French scale, often known as the Charriere-jiirere, progresses by steps of one-third of a millimetre in diameter, that is to say: No.l repre- sents an instrument one-third of a millimetre in diameter, No. 2 two-thirds, No. 3 three-thirds or one millimetre. Given the number of the instru- ment, and you know its diameter in as many thirds of a millimetre. I have italicized the word diameter, because in the previous edition of this book I made the stupid mistake of saying that the number of each instrument represented its circumference in millimetres, and other writers have followed my bad example. If the circumference of a circle were exactly three times its diameter, my statement would have been true, but, of course, it is not. The diameter is to the circumference as 1 is to 3.14159, and although this fraction beyond the three might be ignored in estimating the circumference of the smaller numbers of sounds, yet its multiplication in the higher numbers makes no little difference. The following table exhibits the diameters and the circumferences of sounds from numbers one to forty inclusive according to the French scale: — c o d « C (p - 1 No. j 5 * s <£■- No. 11 e3 No. sS No. 'Z 2 e£ t S Sz: ga E Z^ ga E z: ga 5"^^ *•- o"" 1 0.33 1.0.5 11 3.67 11.52 21 7.00 21.99 1 31 10.33 32.46 2 0.67 2.09 12 4.00 12.57 22 7.33 23.04 32 10.67 33.51 3 1.00 3.14 13 4.33 13.61 23 7.67 24.08 33 11.00 34.56 4 1.33 4.19 14 4.67 14.66 2A 8.00 25.13 34 11.33 35.60 5 1.67 5.24 15 5.00 15.71 25 8.33 26.18 35 11.67 36.65 6 2.00 6.28 16 5.33 16.76 26 8 67 27.23 36 12.00 37.70 7 2.33 7.33 17 5.67 17.80 27 9.00 28.27 37 12.33 38.75 8 2.67 8.38 18 6.00 18.85 28 9.33 29.32 38 12.67 39.79 9 3.00 9.42 19 6.33 19.90 29 9.67 30.37 39 13.00 40.84 10 3.33 10.47 20 6.67 20.94 30 10.00 31.42 40 13.33 41.89 It will thus be seen that when Dr. X, who bases his " French" scale on circumferences, tells us that he has divided a stricture up to 30, he has really divided it to less than 20 of the true French scale, and that when he says 40, he should say a little over 38, etc. etc. Drs. Van Buren and Keyes have proposed a scale, which they liave christened " The American ( ?) scale," and which is intrinsically better than the French scale, since it progresses by half millimetres in diameter and thus avoids the thirds of millimetres of tlie French scale, evidently an undesirable departure from the metric system. I must, however, object to the introduction of any new scale, when one already exists that is known and used iis a standard by so many surgeons in every civilized country. To depart from tliis standard on one's own responsibility is merely to in- EXPLORATION OF THE URETHRA. 281 troduce inextricable confusion. Fig. 60 represents the Charriere-filiere, with the numbers (expressing thirds of millimetres in diameter) above the Fig. 60. 20 21 22 23 24 25 26 27 28 15 15 16 16 15 14 13 D O O OOQ OO O Q O o o 11 10 10 9 9 G .TIEM4NN- CO. 7 6 s^^aaai openings. For the sake of comparison, I have added below the openings the corresponding numbers of the English scale with as great accuracy as I have been able to estimate them. Fig. 61. FiK. 62. £ n -^ ■ " tjs| I r 2 H 1 1 {:{: ^H'll^ 1 1 nil III! -=3:3 mmunui^Rn JE am\uau C.TI£MAWM.».CC.^ It should be observed, that in the present work Avhenever the size of urethral instruments is men- tioned, the number of the French scale is intended. .For measuring the diameter of a given instrument, supposing the same to be unknown, we may employ the gauge represented in Fig. Gl. A still more convenient gauge, however, has been invented by Dr. H. Ji. Ilanderson, of New York, and is shown in Fig. 02. The catlieter, sound, etc., to be 1 1 2 2 3 T 1 * 4 \ 5 ^ 5 7 8 6 9~ 7 10 II 1 '^ > q 13 n 10 14- 15 H 16 17 n 12 \& > 13 19 z 20 i '■* 21 M 1 15 1 ^ o ■ — 23 > 16 24 17 25 26 \a 27 19 28 20 — 2_9_J 30 21 31 32 2Z 33 7^ 34. 35 24 36 ?S 37 38 26 39 40 282 STRICTURE OF THE URETHRA. measured, is simply to be inserted in the base of the opening and slid towards the apex as far as it will go, when the parallel lines on either side will indicate its size according to both the French and the Van Buren- Keyes scale. Catheters are conveniently made somewhat longer than the canal they are designed to traverse, and usually measure about eleven inches. The handle of the catheter is provided with a firm oval ring attached to each side, in order that the least twisting of the instrument on its axis during its introduction may be at once manifest to the operator, and also to permit of its being retained as a permanent catheter. The vesical extremity of the instrument has two eyes for the entrance of urine, one situated half an FiK. 63. Compound male aud female catheter. inch, and the opposite one an inch from the extremity. They are often made too large, and allow of tlie protrusion of folds of the lining membrane of the canal, obstructing the passage of the catheter, and exciting unneces- sary pain. Their edges should be bevelled off with nicety. Instead of these two lateral eyes, the end of the catheter is sometimes piei'ced with Fi-'. 64. 'liemann's V(4vet-eye catheter. numerous small apertures, which are objectionable on account of their liability to become clogged with blood or mucus. Fijr. 65. Otis's prostatic guide. A " complete set" of catheters is entirely unnecessary. As they are used only for evacuating the bladder, a large and a small one (Nos. 8 and CATHETERS. Fio-. 66. 283 284 STRICTURE OF THE URETHRA. 20 French), besides a probe-pointetl, a prostatic, and a female catheter, fulfil every purpose. The " compound male and female catheter" (Fig. 63) is, however, a requisite for every pocket-case of instruments. Of gum-elastic catheters, those made by the French, with a conical end and a bulbous point (see Fig. 68) are often of value, on account of the ease and safety of their introduction. They are admirably fitted for a patient's own use, since their flexibility i*enders it almost impossible for him to do himself harm. In cases of enlarged prostate, however, there is nothing equal to the Nelaton catheter, of pure rubber, which is now made in Eng- land of superior stability and outside finish and which is commonly known as Jaque's catheter. It is also made in this country by Geo. Tiemann & Co., who claim to have improved the eye of the instrument so that it cannot excite irritation in its passage (Fig. 64). In some instances it is desirable to impart to this instrument increased firmness witliout impairing its elasticity, in which case the stylet or guide of Prof. Otis, consisting of a light steel rod (a) eight inches in length, upon which is screwed a spiral riband (b) five inches in length, will be found of value (Fig. 65). A silver prostatic catheter, with more than the usual curve and a long beak, should always be at hand. Fig. 66 represents the size and shape ot one which has never yet failed me in cases of retention of urine from enlargement of the prostate. Squire's vertebral catheter (Fig. 67) is also highly esteemed by many of our best authorities in cases of prostatic obstruction, but many accidents Squire's vertebral catheter. have occurred from the separation and detachment of its links, owing to imperfect construction, and it may well be supplanted by the Jaque's catheter, with or without a stylet, already mentioned. Sounds Tlie best sounds are made of " Stubb's steel," and are either highly " polished in oil," or, more frequently at the present day, nickel- plated, both to avoid rust and to present a smooth surface to the urethral walls. For reasons already given, I prefer to have in my office two full sets, one of Tliompson's, the other of Benique's, curve. The former, how- ever, may be made to answer every purpose, and are (juite sufficient for a case of instruments to take to an operation or for the use of a general prac- titioner. They should range in size from number 12 to 36, or even 40. In cases of stricture so tight as not to admit No. 12, it is better to employ bou- gies, since the stiffness of a small metallic instrument exposes to the danger BOUGIES. 285 Fiff. 68. n of making a false passage. Their handles should be broad and roughened, so as to afford a secure hold to the hand and indicate any deviation in the direction of the point. It is well to have the points gradually tapering to two sizes smaller than the shaft, and the same arrangement enables us in making up an out-door case of urethral instruments to economize space by dispensing with every other number of the scale. Bougies. — Bougies are made of wax, gum elastic, whalebone, and other materials, and are furnished with variously shaped points. The English mahogany-colored bougies, which on account of their dura- bility are so commonly found in surgical cases in hospitals and private offices, are objectionable, except in certain cases of prostatic obstruction in which considerable stiffness of the instrument is called for, because of their not readily following the natural curve of the urethra. They are the source of much of the pain and even injury so often inflicted upon patients in catheterization. No other bougies can equal those made by the French, which are black in color, highly flexible, conical towards the extremity, and furnished with an olive- shaped point, which prevents their catching in the lacunje of the canal. " Filiform bougies" of the same material are indispensable in the treatment of tight strictures, and should be in the hands of every surgeon who attempts to treat such cases. If their value were better known, we should hear of fewer instances of "impassable" strictures. Fine whalebone bougies (Fig. (39), some with straight and others with eccentric and twisted points, are also of value in cases of tight strictures in the anterior portion of the uretlira, but on account of their stiflfness they are less adapted to strictures in tlie sub-pubic curvature. The desired shape and stiffness may be imj)arted to the points of fine flexible bougies by first soaking them in hot water, then twisting tliem as required, and finally plunging them into cold water. Or, again, tlie twisted points may be covered with several coats of collodion, which will retain tlieir form even wlien exposed to the secretions of the urethra and the urine. The employment of gum-elastic and whalebone fili- form bougies as guides in internal urethrotomy and in the rupture of strictures, will be mentioned here- after. All bougies should be carefully examined from time to time, and if found impaired in the slightest degree should at once be destroyed, lest they be incautiously used and a portion break oft' in the canal. Bougies of elastic gum become rough with use, whereby they irritate the mucous mem- brane, and should in this case also be discarded. After using them, they should be wiped quite dry and free from oil, which acts on the rubber, and Frencli flexi- ble bougie and catheter. Fisr. 69. nF.Fono ^\ ■^v. Fine whalobonobougies twisted points. 286 STRICTURE OF THE URETHRA. then be dusted ovei* with powdered soapstone, and be kept, in warm weather, in a cool place, as in an ice-chest. But no rubber material can be long kept in our climate, hence it is desirable for the surgeon to replenish his drawers sparingly at any one time. Whalebone bougies must be oiled occasionally, or they become brittle and unsafe. The question has arisen, which is the less painful to the patient, the introduction of a metallic or flexible instrument ? My own preference, except in somewhat tight strictures, is decidedly in favor of the former, and this preference is founded on the statements of my patients when I have had occasion to use both. I would certainly, liowever, recommend one who was not in the habit of using instruments, to employ the latter (flexible), but as my friend Dr. Ashhurst* justly remarks, " the practi- tioner will do wisely not blindly to follow one exclusive method, but to vary his remedies according to the exigencies of each particular case." Acorn- (^-^ bulbous") pointed Sou7ids and Bovgies — We are indebted for the original conception of these instruments to Chas. Bell,'^ who, as early as 1807, described them under the name of "ball-probes," and claimed for them all the advantages which they have since been proved to possess. Bell's instruments, as the name he gave them indicates, were ball-shaped or spherical at their extremity ; they were made of metal, both ball and shaft. The ball-shaped head was afterwards changed to one of an olive form. This was no improvement, since a sphere will better detect a sliglit contraction than any bulb of an olive-shape. An actual gain was acquired in making the terminal bulb like an acorn with a somewhat abrupt shoulder, thereby facilitating the introduction of the instrument and at the same time increasing its accuracy of diagnosis upon withdrawal. Leroy d'EtioUes'* recommended the same instruments made of flexible material. As now chiefly used, made of metal and with acorn-shaped bulbs, they were described in the first edition of this work (p. 275), pub- Fi-. 70. Acoru-poiutPd sounds. lished in 18G1, when they had long been in common use. It is desirable to have them in sets, like sounds ranging in size from 12 upwards, nickel-plated, their shafts straight and about six and a half inches long, ' The Principles and Practice of Surgery, 2d ed., 1878, p. 913. " Chas. Bell, Operative Surgery, Am. reprint, Phil., 1812, vol. i, p. 72. 3 Traite d. angusties d. Turetre, Paris, 1845, p. 122. BOUGIES. 281 with a disk upon the distal end upon which the number is marked (Fio-. 68). This form is the most generally useful, but it should be distinctly under- stood that it is adapted only for exploration of that portion of tlie urethra anterior to the triangular ligament. If it be desired to explore beyond this point, we must either use a similar instrument which I have had constructed curved like an ordinary sound (Fig. 71), or employ the acorn- Fig 71. Curved acorn-pointed sound. pointed bougie, made of flexible material (Fig. 72). In practice, how- ever, bulbous sounds or bougies are rarely resorted to for exploration of the deeper portion of the canal. Fig. 72. OS Acorn-pointed bougies. The advantages offered by these instruments are the following: They enable us to detect and locate points of tenderness in the canal, where a chronic gonorrhoea or gleet very likely has its seat. They are a valuable means for determining the presence of slight contractions or the so-called " strictures of large calibre." It is commonly said that they enable us to determine the length of strictures, but this is evidently impossible, unless the stricture terminate abruptly at each extremity, wliich is rarely the case. A stricture is usually shaped like an hour-glass, and more or less contraction exists before the obstruction is encountered by any sound that can be made to pass through it. The presence of a slight stricture is better detected on the withdrawal than on the insertion of tlie sound, since the abrupt base of the bulb then impinges more decidedly against it. If a second stricture exist beyond the first and tighter than the latter, it may be detected by the acorn-pointed sound. The size of the meatus is conveniently measured by meatometers, such as recently figured and described by Prof. Henry G. Pifiiird.^ The accom- panying cut (Fig. 73) will explain itself. It is desirable to have two on liand, so as to include the whole scale of sizes to which the meatus is liable, each being marked with the numbers corresponding to its divisions. If tiie surgeon wishes to multiply liis instruments in this direction, lie may do so with short bougies a boule (Fig. 74). This refinement, however, is hardly necessary to those not over-blest pecuniarily. ' Physician and Phannac, N. Y., Jan. 1, 1879. 288 STRICTURE OF THE URETHRA. Fig. 73. Fig. 75. Otls's urethrometer Piffiird's " fossal bouaries a boule." Urethrometer. — Since the meatus is usually the small- est part of the urethra and varies very much in its calibre, it may not allow the introduction of any of the instruments thus far mentioned of sufficient size to thoroughly explore the canal and especially to detect slight contractions. An instrument which could be inserted through a narrow me- atus and then be dilated within the urethra, with an index at its distal extremity showing the amount of its dilatation, was therefore a desideratum. This want has been supplied by the ingeniously contrived urethrometer of Prof. Otis (Fig. 75), who describes it as follows : — ^ " It consists of a small, straight canula, size No. 8, French, terminating in^ a series of short metallic arms, hinged upon the canula and upon each other. At the dis- tal extremity where they unite, a fine rod, running through the canula, is inserted. This rod (which is worked by a stationary screw at the handle of the instrument), when retracted, expands the arms into a bulb-like shape, 10 millimetres in circumference when closed, and capable of expansion up to 40 millimetres. A thin rubber stall (C) drawn over the end of the closed instrument, pro- tects the urethra from injury and prevents the access of the urethral secretions to the interior of the instru- ment. When introduced into the urethra and expanded up to a point which is recognized by the patient as filling it completely — and yet easily moving back and forth — the index at the handle then shows the normal circumference of the urethra under examination. In withdrawing the instrument, contractions at any point may be exactly measured, and any want of correspondence between the calibre of the canal and the external orifice be readily aj)preciated. Among the advantages claimed for this instrument are : I. Its capacity to measure the size of the urethra and to ascertain the locality and size of any ' Stricture of the Male Urethra, N. Y., 1868, p. 77. URETHROMETER. 289 strictures present, without reference to the size Fig. 76. of the meatus. II. It enables the sui^eon to complete the examination of several strictures by a single introduction of the instrument." While admitting the great advance made by Dr. Otis in enabling us to determine more accu- rately the size of the urethra at its various points, yet his instrument possesses this defect : its ex- tremity is of an elongated olive shape, and hence is less capable of indicating a slight contraction than if it were of an acorn form — the same ob- jection that is made to Bell's original ball- probes, only still greater. This defect is reme- died in B. AVills Richardson's urethrometer,^ and also in one invented by Prof. Robt. F. Weir, of New York (Fig. 76). Dr. Otis believes that a constant relative pro- portion exists between the calibre of the urethra and the size of the penis, as follows : When the flaccid penis, about three-fourths of an inch back of the corona glandis, measures 3 inches in cir- cumference, the size of the urethra is 30 milli- metres in circumference, or more.* When it is 3^^ inches, it is 32 or more ; 3^ inches, 34 ; 3| inches, oG ; 4 inches, 38 ; 4^ to A^ inches, 40 or more millimetres. The constancy of this rela- tionship is denied by Dr. R. F. Weir,^ but seems to have been received generally asat least approxi- matively correct, and hence of considerable prac- tical value. The urethrometer is commonly introduced as far as the bulbous portion of the inx'thra, that is to say, about 4^ to o inches, before being dilated. Upon witlidravving it, it will usually be found ' , •/ 1 .> o Ml- .- Dr. Weir's nrethroiiictor.— necessary to screw it down 2 or 3 millimetres The rings uu the shaft i-.c^te when it arrives at 3^ or 3 inches from the meatus "'^ points of arrest, ami per- ,. ,, , ,., ., ,ri, 1. . niit subsoqueiit accurate iiiea- even in penectly healthy uretiira?. lluisdimin- suremeut. ished in size, it ought, according to the state- ment of its inventor, to traverse the remainder of the canal to the meatus without liindrance, unless some abnormal contraction be present. But here comes up a question : Is a normal, liealthy urethra always uniform in its calibre in its spongy [)ortion, and must every irregularity which can be detected by the urethrometer be regarded as an evidence of ' Dublin Q. J. M. Sc, Nov. 1873. 2 Dr. Otis's scale in millimetres of circumference differs somewhat froiii the Charriire-fiUhre, or French scale. (See p. 280) 3 New York M. J., April, 1876. 19 290 STRICTURE OF THE URETHRA, disease, or are constrictions (or obstructions) in this jjortion of the canal to some extent independent of disease and consistent with a state ot" health, or, in a word, normal'? My own opinion is most decidedly in favor of the latter view. Those who maintain the contrary are logically forced to the conclusion — which they readily admit — that every obstruction that can be detected by the urethrometer, even in the absence of present inconve- nience, requires internal urethrotomy, for fear of some eventual ill effect. Such is not my opinion. The two sides of this question were well pre- sented in a discussion before the New York County Medical Society, Jan. 2Jr, liSTG, and at its subsequent meeting, by Dr. Otis on the one hand, and Drs. Sands and Weir on the other. A report of the same may be found in the columns of the New York Med. Journ. for April, 1876. Dr. Weir, a most able and conscientious observer, formulates his conclu- sions, in which I fully concur, as follows: 1. The spongy portion of the urethra is the smallest (except the meatus) and least dilatable portion of the canal. 2. Normal constrictions (or obstructions) ai-e to be met with in this por- tion of the canal as small certainly as No. 29, and the means at present re- sorted to are insufficient for the differentiation of such from " strictures ot large calibre." 3. The healthy urethra in this portion can generally be readily and safely dilated up to an average size of 32 millimetres. 4. Tlie normal size of the meatus is from No. 21 to 28. 5. Tlie urethral canal is, in the words of .Jarjavay,' " narrow at the meatus, dilated in the glans, and very slightly narrowed at tiie termination of the fossa navicularis ; then it formsia cylinder nearly uniform to the pre- pubian angle, where a coarctation is found. It enlarges then to the bulb," etc. It may be remarked that somewhat more pain and uneasiness are occa- sioned by the urethrometer than by the use of an ordinary sound or bougie a loide, and a few drops of blood are likely to follow the withdrawal of the instrument. Introduction of the Catheter. — A catheter may be introduced while the patient is in the standing or sitting posture, but the recumbent position is on many accounts the best ; the patient lying s(iuare on the back, with the shoulders elevated, the knees di-awn up and somewhat separated, the geni- tal organs entirely exposed, and the surgeon standing or sitting on hisleft.^ The operator now raises the penis to an angle of about sixty degrees with the body, thereby effacing the anterior curve of the urethra, by means of the ring and middle finger of the left hand, its [)alm looking upwards; the • Recherches aiiatomiqiies sur 1' niethre, 185(3, p. 208. 2 Tliis is the position usually recommenrled, but much depends upon the liabit of each surgeon. For myself, I prefer to be on the patient's right, and to introduce the instrument as far as the bnlb with its convexity facing the pubes, when by rotating the shaft round towards the abdomen, the point readily slips into the membranous jjortion. This method, called the " tour de maitre,^' has been said to be " dangerous," but on what grounds, I have yet to learu. INTRODUCTION OF THE CATHETER 291 thumb and forefinjrer are thus left free to retract the prepuce and separate the lips of the meatus. The catheter, previously warmed and oiled/ is held tightly between the thumb and fore and middle fingers of the right- hand, "like a pen," its shaft corresponding to the fold between the abdo- men- and the left thigh. The introduction of the instrument should be slow and with the exercise of little force; its own weight is almost sufficient to effect its passage if properly directed; if any obstruction be met with, the instrument should be withdrawn for a short distance and again advanced with the direction of its point slightly varied, or if the obstacle be due to spasmodic contraction of tlie urethra, it may generally be overcome by Fig. 77. First stt'p in intioduciug a ciUlieter. {Voilleinier.) gentle pressure continued for a moment or two; while i)assing throuo-h the first two inclies of tlie uretlira the point of the instrument is inclined to tiie lower surface in order to avoid tiie lacuna magna ; beyond this it should be ' Vaseline, with tlu; ailditicm of ten grains of carholic acid to eaeh ounce, is one of the host and most convenient hihricants for this and other urethral instruments. 292 STRICTURE OF THE URETHRA. directed rather to the upper surface to escape the sinus of the bulb ; when it has penetrated beneath the pubes, the shaft is brought round to the median line of the body, and parallel to the surface of the abdomen ; the handle is now to be elevated to a perpendicular and, pressure being made with the disengaged hand upon the mons veneris and the root of the penis for the purpose of stretching the suspensory ligament, be gently depressed between the thighs, not foi'getting meanwhile to maintain a certain amount of progressive motion in the instrument,^ when the point will usually glide into the bladder; if any difficulty is met with at this stage of the proceed- ing, it is probably because the point has caught in the extensible tissue of the bulb, and the instrument should be again raised to a perpendicular and slightly withdrawn, and the penis elongated by traction before the manoeu- vre is repeated; fui-ther assistance may be obtained, if necessary, during the latter part of the introduction, by gently pressing against the convexity of the instrument just back of the scrotum, or by introducing a finger into the rectum, ascertaining the exact position of the point and guiding it for- wards and upwards against the posterior surface of the symphysis; the passage of the extremity over the uvula vesicte is often indicated by nausea or a slight tremor on the part of the patient, and its entrance into the bladder by a flow of urine. Fig. 78. Second step iu introduciii!,' a catheter. (Voillemier. Let us review these several steps, and notice the chief natural obstacles which are to be avoided. The first is the lacuna magna situated upon the upper surface of the urethra ; this is to be shunned by directing the ' "The great art in passing a sound consists in properly combining the motion of reversion with tliat of progression imparted to the instrument." (Voillemier.) INTRODUCTION OF THE CATHETER. 293 point of the instrumerit towards the lower surface during the first two inches of its passage. The second is the symphysis pubis, against which the extremity will imi)inge, if the abdomen be distended and the handle be held in the median line ; hence the direction to hold the shaft parallel to the fold of the thigh, and not to bring it to the median line or ele%'ate it until the point has penetrated beneath the symphysis. The third is the sinus of the bulb ; the urethral wall is here very extensible, and is readily thrown into a fold upon which the point of the instrument catches instead of passing through the opening in the triangular ligament into the mem- branous portion ; this is less likely to happen if the tissues be stretched by traction upon the penis; and, if it occur, the point is to be disengaged by slightly withdrawing it, and afterwards advanced in a direction moi'e to- wards the upper surface of the canal. It is to be observed that this is the only stage of the process in which traction upon the penis is desirable; after the point has entered the membranous portion, it is positively inju- rious. Again, hypertrophy of the prostate or abnormal development of the uvula vesicae may oppose an instrument in the last part of its passage ; this is to be avoided by depressing the handle and thus elevating the point towards the symphysis : in these cases a prostatic catheter is often required. In using a flexible filiform bougie, the fact that it has passed the stric- ture and entered the bladder may be known by our ability to insert it up to the handle, and to give it a to-and-fro motion Avith perfect freedom. It is a golden rule in every case of suspected stricture to make the first examination with an instrument suflUciently large to distend the urethra, whatever history of his previous symptoms may be furnished by the patient ; in this manner many sources of error already indicated will be ' avoided. The difference in the impression conveyed to the hand of the operator by mere spasmodic contraction of the urethra and an organic stricture, is very marked, but can be better felt than described. In the former case, the tissues against which the point of the instrument impinges evidently preserve their natural suppleness, and the obstruction yields to gentle and continued pressure ; while in the latter, a firm resilient obstacle is felt, which can be thrust backwards, im|)arting more or less motion to all the surrounding parts ; and if, after a trial of one or more smaller in- struments, one be found which can be successfully introduced witliin the stricture, it is grasped or " held" by it in a very characteristic manner. This can be only very imperfectly simuhited by any contraction of tlie voluntary and involuntary muscles surrounding the membranous portion of the urethra which are sometimes called into action, especially in irri- table subjects, by the presence of a foreign body, and it requires but little practice to make the distinction. Moreover, in spasmodic contraction, a full-sized sound can be introduced witli a little gentle coaxing, and, if allowed to remain a short time, is found to be freely moval)le. Strictures of the urethra anterior to tlie scrotum are sometimes appre- ciable from the surface in consequence of the amount of firm deposit which surrounds them ; and external as well as internal examination is always 294 STRICTURE OF THE URETHRA. desirable in order to ascertain the presence of any sinus or abscess in the neighborhood of the canal. However simple the introduction of a sound or catheter may appear to be, and however simple it really is in most instances to a practised hand, yet cases now and then occur in which the most able surgeons meet with diffi- culty or are completely foiled on the first trial. The evident rule in such cases is to be sure to do no harm and, if necessary, jjutieiitly to wait. Treatment. Constitutional Means The constitutional management of stricture must of course vary in different cases. It is sufficient, in most cases, to prescribe such measures as will best promote the health, and place the system in the most favorable general condition. An indication of the highest importance is to lighten the duty imposed upon the kidneys, and render the urine bland and unirritating to the infiamed suifaces over which it passes; and this is to be chiefly accomplished by regulating the character and quantity of the food, and favoring depuration of th(! blood through other channels, as the skin, bowels, and lungs. The diet should be simple but sufficiently nourishing ; stimulants, and especially effervescing stimulants, as champagne and beer, highly seasoned food, cheese, cabbage, salt meats, strong coffee, and all articles which tend to load the urine should be avoided ; the bowels should be opened daily, if necessary, by gentle laxatives, but violent purges are to be avoided. The skin should be stimulated by frequent bathing and friction ; when there is much irritability of the urethra, the hot hip-bath will be found very beneficial ; no more exercise should be taken than is sufficient to maintain the appetite and strength ; and in general the patient should lead a quiet and regular life. When the urine is alkaline, or contains an undue quantity of lateritious deposit, great benefit wmU be derived from the compounds of potash and soda with the vegetable acids, as the citrate and acetate of potash, and tartrate of soda and potash, etc. Sir Henry Thompson recommends benzoic acid in these cases. Probably no class of affections has more thoroughly taxed the ingenuity of surgeons to discover some speedy and effectual method of cure, than have strictures ; and a volume might be filled with the different operative procedures which have been proposed for this purpose ; but the limits of this chapter require that I should confine myself to the strictly prac- tical, and speak of those methods only which have stood the test of ex- perience. Dilatation Numerous explanations have been given of the mode of action of dilatation, but the one now generally received, and which is probably correct, is, that, so far as it effects any permanently good result, it acts by promoting absorption. The presence of a bougie Avithin a stric- ture may mechanically dilate its w^alls, but sooner or later after the with- drawal of the instrument, the plastic matei'ial again contracts; and all the phenomena attendant upon dilatation show that it accomplishes something DILATATION. 295 more than tins, and that, like pressure elsewhere, it possesses the power of producing absorption of inflammatory deposits. At an early period of the existence of stricture, before its constituent elements have become firmly organized, there is reason to believe tliat they may be entirely removed by the treatment now under consideration ; at a later stage, a portion only can be thus dissijiated, and it is in these cases especially that we are forced to be content with palliating the evil by mechanically enlarging the canal from time to time, or to resort to rupture or urethrotomy. With regard to the instruments employed in dilatation we are in many instances limited to fine flexible bougies, because these alone can be made to pass the obstruction, and, as previously stated, flexible instruments are advisable in all cases wliich will not admit a sound as large as No. 12 (Frencli). In less contracted cases, the unyielding material of metallic instruments gives them the advantage of not being indented by tlie firm walls of indurated strictures; and being inflexible they are entirely under the control of the operator and can be guided with precision in any desired direction ; in all cases complicated with false passages they should un- doubtedly be preferred. On the other hand, although no instrument can be made to glide into the bladder moi-e gently and safely than a well- polished or nickeled steel sound, yet when used by persons of little experi- ence in urethral exploration, it may occasion much suffering and inflict serious injury; such persons, whether incompetent surgeons, or patients practising upon themselves, without previous instruction, should only make use of the flexible, bulbous-pointed, French bougies previously described. The same method should be followed in performing dilatation as in ordi- nary catheterism. If the first instrument employed will not enter the obstruction, a second and smaller one must be tried; the dimensions of the stream of urine indicating by approximation the actual size required. All attempts to penetrate the narrowed ciiannel should be made with the utmost gentleness, and any sudden thrusting of the instrument avoided; force is only admissible when the point is felt to be "held," thereby indi- cating that it is already engaged in the passage, and even then pressure must be steady, only very gradually increased, and always moderate. False passages are usually found below or at the sides of the urethra; hence, if tliere be any reason to suspect their presence, the extremity of the instru- mcmt should be carefully guided along the ui)per surface. It often hap|)ens, however, that the orifice of the stricture is eccentric, being above or below, or to one side of the centre of the canal; if therefore previous attempts have proved unsuccessful, the direction of the instrument may be varied; or, if a bougie be used, it may be turned on its axis at the same time that it is gently pressed forwards. Assistance is sometimes afforded, especially in strictures of tlie spongy and bulbous portions, by passing the disengaged hand down externally to the seat of the obstruction and exercising a cer- tain degree of pressure. In cases of extreme dilHculty, Sir Henry Thomp- son recommends that the urethra should first be freely injected with olive oil, which is to be retained by compression of the meatus while a small instrument is passed; he believes that thus the strictui-e is not only 296 STRICTURE OF THE URETHRA. thoroughly hibricated, but also somewhat dilated by the mechanical pres- sure of the Huid, and states that this metiiod has proved of very decided advantage in his hands. A tight stricture may foil our efforts on tlu; first trial, in which case the attempt should not be renewed for at least three or four days, or until all inflannnatory reaction has ceased. With patience and perseverance, success may often be obtained after a number of sessions, even five or six. The endoscope may afford valuable assistance, as in several cases reported by Prof. R. F. Weir.' The endoscopic tube is to be crowded down firmly upon the surface of the stricture; then on making traction, by grasping the penis tight enough to prevent the tube from slipping, a funnel-shaped depression is formed, into the bottom of which a filiform bougie is passed and there held while the endoscopic tube is withdrawn. The bougie, being thus supported by the urethral walls, can now, in many cases, be readily passed on into the bladder. In cases of tight stricture, accompanied by hypera^sthesia or spasm, an ana3sthetic is desirable. The length of time that an instrument should be retained will depend somewhat upon the sensitiveness of the canal. Mr. Thompson recommends that it should be immediately withdrawn. I am in the habit of leaving it in for from two to five minutes. The phenomena following the passage of an instrument tlirough a stricture have been carefully studied by Sir Henry Thom|)Son, and are both highly interesting and instructive. At the first succeeding act of micturition, the stream of urine is found to be increased in size: in the course of a few hours it diminishes, and is even smaller than before the introduction of the instrument; finally, after a day or two, it is permanently enlarged. Thompson attributes the first-mentioned effect to mechanical dilatation; the second to reactive congestion and spasm; and the third to the subsidence of the latter, and to the removal by absorption of a portion of the organic deposit. Tiie practical deductions from these observations are: that an instrument should not be inserted with such force, nor retained so long, as to excite decided inflammatory action ; and that cathcterism should not be re[)eated until the irritation produced by previous a[)j)lications has disappeared. An interval of from two to five days between the applications is usually sufficient. At the second visit, tlie instrument first employed may be introduced for a moment, then withdrawn, and the next larger size inserted. Tiius by a gradual advance, the stricture may be enlarged to a calibre corresi)onding with that of the external meatus, but not to the original size of the constricted portion of the canal, unless the unyielding ring of the meatus be slit up. This should be done, unless the meatus is unusually patent, and the dilatation then be continued until an instrument equal in size to the normal calibre of the urethra, as measured by the urethrometer, can be freely [)assed ; in short, dilatation to the fullest extent is to be recommended. Under no circumstances should cathcterism be at once ' Am. J. Syph. & Derm., N. Y., 1870, vol. i, p. 34. CONTINUOUS DILATATION. 297 abandoned so soon as the stricture is dilated to the desired extent, what- ever tliat may be ; but the patient should be taught how to pass instruments himself and be directed to use them once a week for several months and at gradually increasing intervals for the remainder of his life. Any future tendency to contraction, as evinced by trial, should warn him that the subsequent treatment has not been faithfully carried out. Conthmous Dilatation} — A more expeditious mode of dilating stricture is by the method known as " continuous dilatation," in which a catheter, if it can be introduced, is retained for a considerable length of time, gene- rally for several days in succession. In the course of twenty -four or forty- eight hours, a purulent discharge appears, proceeding from the seat of the obstruction, and the [)assage is rapidly enlarged ; other instruments gradu- ally increasing in size are then successively introduced, until the desired amount of dilatation be attained. Xo one instrument should be left in for more than forty-eight hours, lest it become incrusted with calculous deposit or cause deep ulceration of the urethral walls. This practice is not to be recommended, unless when from any cause, as for instance the presence of false passages, the difficulty already experi- enced in introducing a catheter has rendered it probable that it cannot be reinserted if once withdrawn. Continuous dilatation is likely to be attended with untoward symptoms and is always followed by a strong tendency to recon traction. I never resort to it except to the slight extent of enlarging the canal sufficiently to enable me to pass the shaft of some instrument intended for internal urethrotomy or rupture. Witliin the last few years, several attempts have been made to revive continuous dilatation, and have acquired some temporary notoriety; one by ]\I. Le Fort,^ and another by M. Corradi,^ of Florence. Althougii the names ap[)lied by these authors to their methods would lead one to suppose them to be new, the process is essentially the same as that already mentioned, and is to be judged as such. An interesting paper on Corradi's method is to be found in the thesis of M. Bos.* ^'Over Distention" — Mr. Thompson applies this name to a method which does not differ from that heretofore known as "rapid dilatation," except that the instrument employed by him permits distention to be car- ried beyond the size which the meatus of the urethra will admit. The action of this instrument will be readily understood from Fig. 79. Mr. Thompson describes as follows the manner of using it : — " The method of applying the power by this instrument differs materially from that in others, in being made slowly (better, therefore, under the influence of chloroform), so that from seven to ten minutes are occupied « * "Dilatation perinan<»nte" of the French. * Malgaioxk, M6i1. operat., edit. Lk Fokt, 187.'), p. 507. 3 See Bkoca, Rapport sur la prix d'Argenteuil, Bull, do I'Acad. de med., Paris, t. xxxiv, p. 1215. * De la dilatation rapide des r^trecissements de ruretlire, Tlie.se inaugurale, Paris, 1876. 298 STRICTURE OF THE URETHRA. in slowly reaching the maximum point of distention ; the ohject being to overstretch the morbid tissues as much, and to rupture them as little, as possible, in order to destroy, or, at all events, to greatly Fig. "0. impair, the natural tendency of the sti'icture to contract. Before operating, the distance of the stricture from the external meatus is measured by passing a full-sized bougie down to the stricture ; the slide is then placed upon the figure which denotes that distance. The instrument is passed until the slide aiTives at the meatus ; when the maximum distention is reached, the screw is turned back a little, so as not to close the blades ; the instrument is withdrawn ; a full-sized gum catheter is passed, and allowed to remain twenty-four hours. On the third day after the operation, a large metallic sound is passed, and subsequently at longer intervals. If it is preferred to rupture instead of to distend to the same degree, the handle must be turned rapidly, and in a few seconds the full size named can be obtained." I find it difficult to reconcile Mr. Thompson's com- mendation of this practice with what he says in the next sentence when speaking of " rapid dilatation :" " Tliis term and the practice it describes may now lapse into oblivion. The proceeding by rupture, whatever else it may do, must of necessity render wholly unneces- sary any resort to the violent measures employed as rapid dilatation!" I have reason to believe that this instrument is rarely used at the present time, even by its inventor. In concluding the remarks upon this method of treatment I desire to say that gradual dilatation should be selected as the safest and best method of treatment for the majority of strictures, especially when seated at a greater depth than four inches from the meatus. As we shall see presently, it is not as well adai)ted for strictures of the pendulous portion of the penis; but even here the general practitioner, wlio is not familiar with urethral surgery, should not hastily abandon this method of treatment in favor of the more dangerous ones which we have yet to describe. Internal Incision and Rupture — There are certain considerations connected with these two methods of treatment which, in order to avoid repetition, it may be well to take up at the outset. The nearer a stricture is situated to the external meatus, the less the dano-er, as a general rule, from operative interference. Strictures witliin INTERNAL INCISION AND RUPTURE. 299 Fijr. 80. three inches of the external orifice, and especially those at the meatus, are so unyielding, and reoontract so readily, that incision becomes desirable. In the subpubic curvature the vascularity of the tissues would seem to call for rupture in preference to internal urethrotomy, and in practice, the former will, as a rule, be found to be the safer operation. There was formerly a radical defect in most instruments intended to operate upon urethral strictures from within the canal. I refer to the large size of the shaft of the instrument, which rendered it impossible to employ them in very tight strictures, and hence these instruments were open to the grave objection that a quarter or more of the treatment must first be accom- plished by dilatation before they could be used. Two inventions obviate this difficulty in an admirable manner, and enable us to make use of either rupture or internal incision in any case of stricture through tvhich any bougie, hotoever small, can be passed. In one of these, original with that eminent surgeon. Prof. AVm. H. Van Buren, M.D., the extremity of the urethral instrument is per- forated like a canula for a short distance, say the eighth of an inch, from its tip, with a groove extending further up the shaft, so tliat the instrument may be introduced threaded, as it were, upon a fine bougie previously in- serted (Fig. 80). This invention, while commending itself by its simplicity, is only adapted to whalebone bougies ; gum bougies are too flexible to serve as the guide ; and since the latter can often be I)assed through strictures in the subpubic por- tion of the canal, when the former cannot, the use of this device is, I think, limited. In tiie other plan, a flexible bougie is pro- vided with a metallic cap which screws on to the extremity of the instrument (Fig. 81). The bougie may be of any degree of fineness; if its point can be introduced through the stric- ture and retained for a short time, the main pd/tion of the stem will soon follow ; the metallic shaft is then screwed upon tlie bougie and passed into the bladder, when the stricture is completely under the control of the operator. In my own practice I have extended the use of this plan by providing my urethral case of instruments with a dozen or more flexible gum bougies of various degrees of fineness all of them armed 300 STRICTURE OF THE URETHRA. with metallic screws, any one of which will fit the extremity of either of the instruments I most frequently employ for the purpose of rupture or internal incision, and which may also serve as a guide for a catheter to draw off the urine. This plan is only objectionable because it requires a Fig. 81. IIEMANN-CO-NV degree of nicety in the adjustment of the screw-tips which few instrument- makers will give unless carefully watched and driven up to the mark ; but it is, I believe, the best, and is of extended application. These devices, and especially the latter, enable us to seize the oppor- tunity foi- an operation. Strictures are not at all times equally i)ermeable. We may "get through" one day and not another. If a special day and hour be appointed for the operation, unexpected difficulties will often be met with. When a difficult case of stricture presents itself and the first trial fails to pass the contraction, time and patience are the first requisites. Haste is almost sure to do harm. Let the exploration be repeated at proper intervals, always with flexible bougies armed with screws available when the opportunity offi^rs ; then when, thanks to skill and chance, the contraction is passed, the choice of the operation, whether rupture or in- cision, is left to the operator. AVhichever instrument he prefers may be attached to the bougie, which is coiled up in the bladder as the shaft is made to advance, and the patient is relieved of his distress upon the spot by a rupturing tube or incising blade. Tliere are certain considerations pertaining to the treatment before and after the operation, whether by rupture or incision, which may as well be mentioned here. No one should think of operating upon a stricture, unless in case of special emergency, while the patient is depressed from any cause. I find that many patients from the South and West are suffering with symptoms referrible to malarial influence, aggravated probably by their urethral trouble, and this condition should first be removed by quinine and tonics. A still more important point is to examine into the condition of the kidneys. It should be an invariable rule before operating in any case of stricture, to make one or more thorough examinations of the urine, and to note its amount in the twenty-four hours, its specific gravity, the presence of albumen, casts, etc. Tlie importance of a continued low specific gravity as indicative of renal trouble, even if casts cannot be found, should not be Ibrgotten. It is almost needless to say that any evidence of kidney dis- ease makes the prognosis a grave one, and should lead us to avoid an ope- ration if possible. If an operation be decided upon it is best to keep the patient quiet for a few days beforehand, and to take measures to have the rectum empty. At the time of the operation the size of the meatus should be carefully examined, and, if necessary, .be enlarged, by the method presently to be INTERNAL INCISION AND RUPTURE. 301 described, to a size corresponding to the supposed Fig. 82. calibre of the urethra, as estimated by Otis's rule already given (see p. 289). Supposing the incision or rupture to have been made, the surgeon is naturally inclined to explore the canal by means of bougies a boule or otherwise, in order to ascertain if the desired result has been fully attained, and that no band of stricture remains. In operating upon the first three or four inches of the canal, this exploration may be made within reason- able limits with impunity, and, indeed, the operation may be repeated on the spot if found necessary. In cases, however, of tight stricture at the depth of from four to five and a half inches, T am satisfied that much harm is often done by such subsequent exi)loration over the raw surface. In these deep- seated strictures it is far better to remain satisfied, for the time being, with the fact that the divulsing tube or the incising blade has been successfully passed, and leave further exploration to a subsequent period. In short, it is one of those instances in which the old proverb /(?«, p. 7!K). 2 Med. Rec, N. V., Aug., 1874, p. 438. TREATMENT OF RETENTION OF URINE. 325 in hot water ; when all the ether is vaporized, the rubber tube is to be adjusted and tlie trocar-needle inserted into the cavity to be evacuated. Fig. 107. Dieulafoy's aspirator. As already stated, the use of the aspii-ator appears to be devoid of danger, even if tlie trocar passes through a fold of the peritonaeum. It would appear also that its frequent repetition is equally harm- less, since, as believed, there is no authentic case on re- cord in which mischief has been done. In one instance, Guy on* performed tvventy- three aspirations upon the same patient in eigiit days, and "the most simple cathe- terization could not have been more harmless." It need only be added tliat this operation is almost free from pain, and does not require the use of an an;esthetic agent. Tlie use of the aspirator has almost if not quite super- seded the old methods of punctit.-ing the bladder. The latter, however, may receive t>„,,;„- • . ' ' J v.v^. . <^ lotains aspirator. ' DiKULAFOY, Pneumatic Aspiration of Morbid Fluid.s, London, 1873, p. 102. 326 STRICTURE OF THE URETHRA. a few words of explanation, in case they should be called for in the absence of the proper means for aspiration. Puncture by the Rectain This operation is inadmissible in case the prostate is much enlarged from iiy|)ertrophy or the presence of a tumor, on account of the danger of wounding this body ; also if the bladder be greatly contracted, since the trocar may perforate its anterior as well as posterior wall. It may be performed with an ordinary curved trocar and canula, about eight inches in length, but it is an advantage to have the former grooved, so as to indicate with certainty by the flow of urine wlicn the point has entered the bladder. Fis. 109. Fiff. 110. Fig. 109. Side view ofcamila and trocar. 1. Eye iu the former c )ni)iiuiiieatiug with the groove in the latter. 2. Rings for the purpose of attachment. 3 Channel lor the escape of urine. Fig. 11(1. Trocar seen on its convex aspect, and showing the groove, which is converted into a tube by insertion iu the cauula. (.\ftor Phillips.) The patient is to be placed as in the operation of lithotomy, with an assistant supporting each extremity. The lower bowel having been emptied hy an enema, the surgeon introduces his left forefinger, well oiled, into the rectum, and feels for the recto-vesical wall just back of the posterior margin of the prostate. A tap upon the hypogastric region with the opposite hand should communicate an impulse to tlie point of the finger in the rectum, and this is to be regarded as indis[)ensable before proceeding with the o[)eiation. The canula and trocar are now to be introduced along the TREATMENT OF RETENTION OF URINE. 327 finger as a guide, and, while an assistant compresses with l)Oth hands tlie lower part of the abdomen, the point is directed forwards exactly in the median line, and, by depressing the handle, made to penetrate into the bladder, the accomplishment of which may be known by its freedom in this cavity and the fiow of urine. The canula, carefully kept in place during the withdrawal of the trocar, is to be fastened by a T bandage, and may be retained until the permeability of the urethra is re-established. Fijr. 111. Recto-vesical and supni-pubic puncture. (After Phillips.) The risks of this operation are: wounding the peritomeum or vesicular seminales; consequent peritonitis, or infiammation of the appendages and substance of the testicle; persistence of the opening; and abscess between the rectum and bladder. In practice, however, these results rarely follow. The peritonaeum is too high up to be much exposed, and the vesicuhe .semi- nales may be avoided by adhering closely to the mcMlian line. The recto- vesical puncture has been known to remain fistulous for life, but generally exhibits a strong tendency to close ; and the formation of abscess is rare. Pu/icture (ibore the Pahes Tiiis o[)eration, performed with an ordinary trocar, was a favorite with Abernethy, anut no matter how the solution of continuity has been produced, nor how larger or minute its size — it may be a rent or tear, or the su[)erficlal ulceration underlying a herpetic vesicle ; it may be a chancre, the initial lesion of syphilis, or a secondary symptom like a mucous patch — it affords a door of entrance sufficient tor successful inocu- lation. , But the (piestion naturally arises whether this law is absolute. Is it ' Ann. univ. di mcd., Milano. 344 CHANCROID. reasonable to suppose that in all of t lie numerous cases of simple chancre, some solution of continuity must have existed, without which contagion could not have taken place ? Is it not possible that in some instances, at least, the virus may have permeated the external layer of the skin or mucous membrane, without any denudation of the epidermic or epithelial layers? I am not disposed to answer tliis (piestion positively in the negative ; it is one which physiologists are better entitled to solve ; yet several considerations would lead me to believe that there is no necessity of explaining on the theory of endosmosis, certain cases of contagion in which "no solution of conti- nuity can be discovered. The epithelial layer of the mucous membranes is much thinner and much more readily removed than the epidermis of the external integument. Continued moisture, as is seen in cases of an elongated prepuce, is alone sufficient to produce a superficially excoriated surftxce ; the effect is hastened if the moisture be combined with purulent matter, with the natural sebaceous secretion of the ))art, or with filth. The door of entrance may be merely microscopic, not visible to the naked eye ; if it is (?nly large enough to admit a single pus globule, it will serve the purpose of contagion. It would, therefore, seem suflicient to sujjpose, with Ricord, in cases of inoculation without ap[)arent solution of conti- nuity, that the virulent pus has at first acted like a common irritant, until the surface had become denuded at some minute point, which would enable it to exercise its power. If it has gained entrance within the open mouth of a follicle, the same eiFect will be accomplished the more readily. Instances of mediate contagion with tlie chancroidal are less common than with the sy})hilitic virus. Patients occasionally transfer the matter from one part of the body to another upon their fingers. A boy at present under mv care with chancroids on the penis, has produced a similar ulcer on his leg by scratcliing a pimple in that situation. After tlie operation for })himosis in our venereal hospitals, the wound is not unfrerpiently inoculated by the use of cutting instruments, serres-fines, sponges or towels, smeared with chancroidal pus. Fournier states that one of his patients contracted a chancroid upon his finger by washing his hands in water which had been v.sed a few moments before by a friend for the purpose of cleansing his j)enis which was affected with chancroids. The seats of Avater-closets may unquestionably serve as the medium of contagion, althougli not to the extent that is alleged by patients, the frequency of whose assertion to this effect has led to the remai'k that " only clergymen contract venereal diseases in that way." It has occasionally been noticed that a man would contract a chancroid from a woman, who, upon examination, was found to have nothing the matter with her, but who was discovered to have had intercourse a short time previously witli sonu; man who had this disease ; and the question has arisen whether (;liancroidal pus might not be deposited by one man in the vagina, to be picked up by another without the woman herself being affected; her genital organs thus serving merely as the medium of con- tagion. Thus Ricord rejmrts a case in which a married pair invited a friend, an officer, to dinner. Everything went on in an unexceptionable COXTAGIOX. 345 manner till near the close of the repast, when it was discovered that there was no cheese in the house, and the husband w.ent out to purchase some. The officer took advantage of" his absence and abused the rights of hospi- tality. A few days after the husband broke out with a chancroid, and applied to Ricord for advice. Ricord examined the wife and found her free from disease, but obtained a confession of her exposure with the officer, who liappened at the same time to be under Ricord's treatment for chan- croids. To test tlie possibility of such an occurrence, M. Cullerier instituted the following experiment: — Louise Yaudet entered the Lourcine Hospital Oct. 10, 1848, to be treated for an ulcer of grayish aspect and witli shar|)ly cut edges in each groin, whicli had already persisted without treatment for a month. There was considerable surrounding inflammation, which was subdued by rest and poultices, when the genital organs and anus were carefully examined and found to be free from ulceration. The vagina was reddened and smeared with an abundant muco-purulent secretion, but its mucous sur- face was intact and the os uteri healthy. The inguinal ulcers were dressed with charpie moistened in aromatic wine, and vaginal injections of a solution of alum ordered; under which treatment the sores and vaginitis rapidly improved. Nov. 2o, after finding on a second examination that the mucous mem- brane of the vulva and vagina was, as befoi-e, intact, and after inoculating without success the vaginal secretion, M. Cullerier collected upon a spatula a consideiable quantity of pus from the ulcers in the groins and deposited it in the vagina. The patient was then directed to walk about under sur- veillance lest she should touch the parts, and at the end of thirty-five minutes was again placed upon the bed, and some of the fiuid found in the vagina was inoculated upon her thigh. The vagina and vulva were then freely washed with water, dried, and waslied a second time with a solution of alum. Two days after, the inoculation had produced the characteristic pustule of a chancroid, which was left another twenty-four hours to confirm the diagnosis, and then destroyed with Vienna paste. Repeated subse- quent examination showed that no ulceration had been caused in the vagina, whicii was not even more infiamed than before. In two months the patient left the hospital cured of both her vaginitis and inguinal ulcers. In a second case in which this experiment was performed, the pus was allowed to remain in the vagina for nearly an iiour and did not take f'ffect.' Tarnowski'^ has repeated these experiments in a numl)er of instances with the same result. It would thus ajjpear that in rare instances the .sound vagina may play the part of a niere niedium of contagion, and the same may possibly be true of the genital organ of the male. According to Auspitz,"' who cites iiis autliorities, mediate contagion was ' Quclques points do hi contagion mediate M6n\. Soc. de chir. do I'iiris, ciuoted in Lemons sur le diancre, p. 255. « Voitrii<,'e, p. 55. ' Die Lehren vora syph. Cojitagium, p. 89. 346 CHANCROID. known to Widemann, Vella, Fernel, Thierry de Hery jind Ambrosius Pare, de Blegny, Astrue and Swediaur. Frequency of the Chancroid — Of the three venereal diseases, gonorrhtjea is undoubtedly by far the most frequent, as shown by the expe- rience of every surgeon, and numerous cases of this disease are treated by l)atients themselves who never appear for advice or consultation. The frequency of the chancroid as compared with that of the true cliancre is not so readily determined ; indeed we have reason to believe that it has varied at different periods, and we know that it varies in different classes of society. At the time when a distinction between the cliancroid and chancre first began to be recognized, it was the universal testimony that the former was much more frequently met vvith tlian the latter. Bassereau's notes of patients presenting themselves at M. Ricord's clin- ique in 1837 and 1838 would even show the immense disproportion of thirty chancroids to one true chancre, which is almost incredible, but the former must at any rate have been greatly in the majority.' M. Puche prepared a table of all the venereal ulcers resulting directly from contagion which entered the H6i)ital du Midi during ten years (1840 -1850) and formed a total of 10,300, of which 804o were chancroids and 195;") chancres;'* in other words, the ratio of the former to the latter was nearly as 4 to 1. The statistics of other observers represented the ratio as somewhat less, as, for instance, 3 to 1 or 2 to 1 ; but all concurred in show- ing the decidedly greater frequency of the chancroid especially when the observations were made in hospitals frequented by the lower classes of society. Now, taking this very same hospital, the Hopital du Midi, in 18G9 and 1870, Mauriac (op. cit.) observed the curious fact that these figures were, almost reversed ; the chancroid was in the minority ; and it bore the ratio of 1 : 1.8 to the true chancre ; in other words, there were nearly tivo chan- cres to every chancroid. But observe what took place in the same hospital in 1870-1 during the war with the Germans and the siege of Paris. Statistics at such a time were, as might be supposed, less perfectly kept, but they were sufficient to show that in 1870 the chancroid was to the true chancre in the ratio of two to one, and in 1871 in the ratio of three to one, thus reversing again the tables of their comparative frequency. Mauriac says : " After the reign of the Commune, our wards, which had been occupied during the siege by the wounded, were filled with venereal patients, and tlie greater part of them with simple chancres" (chancroids). In the years succeeding the Franco-German war, the ratio of tlie chan- croid once more gradually diminished until in 1874 it reached the lowest ' Rarete actuelle du chancre simple, par Chas. Mauriac, MeJecin de I'hOijital du Midi, Paris, 1876, p. 17. * FouKNiEK, Le(jf)us sur le chancre, p. 15. FREQUENCY OF THE CHANCROID 347 iigure it lias ever been known to attain, and \vas, compared with tlie true cliancre, as one to six and four-tentlis ; in other words, there was only one chancroid to six chancres recorded on the Register of the H6|)ital du Midi during that year. In the following year, it was a little more, viz., one to five. Doubtless some errors crejjt into the above statistics, but making every reasonable allowance for the same, they unquestionably show a gradual decrease of chancroidal ulcers in compai'ison with true chancres. It should be stated that Mauriac's statistics are confirmed by those from other large cities, as Lyons. I have no accurate statistics of my own to offer, but I cannot be mistaken in asserting that I meet with the chancroid much less frequently than I did twenty-seven years ago, when I was commencing practice. To what is this gradual decrease in the frequency of the chancroid owing? It is impossible, I think, to give a perfectly satisfactory reason. Mauriac, who believes in the existence of a specific chancroidal virus, ascribes it to the gradual extinction of this virus in consequence partly of the police regulations controlling prostitution in Paris, and partly owing to the fact that a chancroid rarely escapes observation, and, once cured, does not reappear ; whilst, on the contrary, syphilitic lesions are less likely to attract the notice of the patient, and are of constant recurrence. It is hardly necessary to state that the increase of chancroids during the siege of Paris is more readily explainable on the ground of the great laxity of morals and the inattention to cleanliness that prevailed at that time. Again, the comparative frequency of the simple and syphilitic chancre depends in a measure upon the position in the social scale to which patients belong, since, as shown by the observations of MM. Martin and Belhomme,^ and those of M. Fournier,^ in the better classes of society the chancre is much more frequent than the chancroid. M. Fournier says: " In private practice tlie simple cliancre is rarer than the syphilitic chancre. I have been especially struck with this difference, which may be expressed in figures as follows : — Simple chancres ........ 82 Syphilitic chancres ........ 252 " Thus it is a curious fact which may have some interest in a prophy- lactic point of view, that the simple chancre, which is common in the lower classes, becomes rarer and rarer, relatively to the syphilitic chancre, in proportion as we rise in the social scale." M. F'ournier would explain this fact, on the ground that men of the lower classes most frequently contract venereal diseases from old prostitutes who are already protected by one attack of syphilis from another, but who are still subject to chancroids ; while the women who are sought after by the higher classes are commonly younger 'und fresher, and hence more likely to be affected Avith true chan- ' Trait6 de pathologie syph. at v6n., p. 127. * N. Diet, de med. et de chir. prat., Paris, t. vii, p. 67. 348 CHANCROID. ores or secondary symptoms, and to convey syphilis to those with whom they have connection. The different habits of the upper and lower classes of society must also have an influence. Seat of the Ciianckoid TJie chancroid is most frequently seated in the neighborhood of the genital organs, simply because these parts are most exposed to contagion and not in conse(iuence of any peculiar aptitude which they possess. If chancroidal matter be inserted beneath the epi- dermis of any other part of the body, a chancroid is equally the result. Nor is this the limit to its seat ; it is also found within various mucous canals — as the urethra, vagina, and rectum — opening upon the surface, at as great a depth as these passages can be explored by the senses during life, and post-mortem examinations have been supposed to prove the possi- bility of its presence in the bladder, though such instances are questionable. The whole external integument, and whatever portions of the mucous membranes are accessible to the im|)Iantation of the poison, are therefore exposed to become its seat. The frequency with which it is met elsewhere than upon the genitals, depends in a great measure upon the habits and cleanliness of persons exposed to contagion. The most reliable statistics as to the seat of the chancroid, in the two sexes, are those of Fournier^ and Debauge,^ the former conlining his ob- servations to men, the latter to women. I. fourniek's table (men). Cliancroids of the glans or prepuce ...... 347 " on the sheath of the penis ...... 21 " on various parts of the penis, as, for instance, occupying the prepuce and sheath, the sheath and the glans, etc. 24 " on the penis (exact situation not recorded) . . 25 " " meatus ........ 11 • " within the urethra ....... 5 " of tlie scrotum ........ 3 " on the pubes ........ 3 '• " fingers ........ 2 " " upper and inner portions of the thiglis . . 2 " of the anus ........ 1 " " anterior thoracic region ..... 1 Total . . .445 ' N. Diet, de med. et de chir. prat., Paris, t. vii, p. 72. 2 These de Paris, 1838, jj. 62. Statistics collected in the service of M. Bonnarie, at the Hospice de I'Antiquaille, Lyons. SEAT OF THE CHANCROID. 349 II. debaloe's table (women). Chancroids on tlie fourchette or fossa navicalaris ... 78 " " labia majora . . . . . . . 19 " " " minora . . . . . . . 16 " of the meatus (of these 19 extended within the urethra) 21 " in the neighborhood of the meatus .... 2 " of the vestibule ........ 4 " " clitoris . . . . . . . .1 " at the entrance of the vagina (just external to the carunculse, and between the carunculse and the labia minora) ........ 17 " of the vagina, behind the carunculae .... 7 " " uterine neck . . . . . . . 1 " " margin of the anus ...... 23 " in the groove between the nates ..... 5 " of the perinseuni ....... 5 " on the internal surface of the thighs .... 5 " " hypogastrium ....... 2 Total . . .206 1)1 reviewing these tables, it is worthy of" observation how large a majority of chancroids are genital and "peri-genital," or those situated upon or in the neighborliood of tlie genital organs in both sexes; indeed "extra-genital" chancroids, or those at a distance from the genitals, are mentioned only as rare exceptions. As we shall see hereafter, there is a marked difference in this respect between the chancroid and the true chancre, the latter being found in a much larger proportion upon distant parts of the body. This difference is accounted for by the fact that the chancroid is transmitted almost exclusively in sexual intercourse, while the initial lesion of syphilis, arising as it may from either a primary or a secondary lesion, finds many other modes of origin than the mere act of coitus. Tiie chancroid is said not to be confined to tlie normal tissues of the body, but also to affect pathological growths. In a case related by Prof. Breslau. of Zurich, "a simple chancre was developed upon a mass of epithelial cancer attached to the cervix uteri, and the virulent nature of the sore was demonstrated by the successful inoculation of the pus upon the patient's thigh." This case must, however, be received with some reserve, now that we know that the secretion of lesions other than clian- croidal may sometimes be auto-inoculated. A singular exception to the rule tliat all portions of the body are equally prone to contract a chancroid has been noticed, viz., that this ulcer is rarely met with in practice upon the head, face, or buccal cavity, where, on the contrary, the initial lesion of syphilis is not uncommon. At one time this fact excited no little discussion, since it was supposed to conflict with the distinct nature of the chancroid and syphilis, and to favor the idea that the seat of the contagion exerted an influence either for or against contamination of the general system, and hence that the chancroidal and syphilitic poisons were one. 350 CHANCROID. The important bearing of this question led to an extensive investigation for the purpose of ascertaining if the alleged exemption was founded on fact. Fournier^ took a prominent part in this labor, and, from a diligent search through medical works, and inquiry of those who made a special study of venereal diseases, was able to collect 150 cases of venereal ulcers upon the head and face, all of which, however, with the exception of o, were chancres. These five exceptional cases, in which the ulcer was supposed to be a chancroid, had been observed by MM. Ricord, Venot, Devergie, Bassereau, and Diday ; but Ricord confessed that his case, an ulceration at the base of one of the superior incisor teeth (figured in his Icono- grapliie, pi. 21), was unreliable, and the other four were thought to be imperfectly reported ; and thus there could remain no doubt of the rarity of the chancroid upon the region in question. It has been since ascertained that the chancroid can be developed upon the head and face by artificial inoculation. Puche'* and Rollei^ liave in- oculated its virus with success u[)on diflerent parts of the head in 20 instances; Bassereau* and Prof. Huebbenet," of Kieff, upon the lips and cheeks in five ; Robert® upon the temple, nose, and lips in three, and in all tlie sore so produced was entirely free from induration, and was not followed by secondary symptoms — a fact which utterly demolishes the argument of the " unitists."' Still farther, at least two instances of the occurrence of chancroids upon the cephalic region have been met with in clinical experience, in which every precaution appears to have been taken to establish the diagnosis. The first is reported by Fournier himself, from the notes of M. Puche, of the Hopital du Midi ; the sore was situated upon the lower lip, and artifi- cial inoculation of its secretion upon the patient's abdomen, as well as an accidental inoculation upon the patient's thumb, proved successful ; no general symptoms showed themselves within seventy-four days from the appearance of the ulcer, during which period the patient was kept under observation,^ In the second case, observed by M. Rofeta,' at Palermo, a serpiginous chancroid, of two years' duration, was situated upon the face, and its secretion was inoculated in five places by M. R. upon himself, with ' Etude sur le chancre cephalique, Union med., Paris, fev. et mars, 1858. 2 Nadau des Islets, De I'inoculation du cliancrc iiiou h la region cephalique, These de Paris, 1858. 3 Gaz. Med. de Lyon, Dec, 1857. * BuzENET, Du chancre de la bouche, Th6se de Paris, 1858, p. 41. 5 Union med., Paris, 20 mat, 1858. 6 Nouveau traite des mal. veiieriennes, Paris, 18(;i, p. 380. 7 Robert's reply to this, that a chancroid may be forced upon the tissues of the head and face by artificial inoculation, but that the same tissues will develop a syphilitic ulcer even from the chancroidal virus, when contaminated in coitu, ap- pears to me weak and puerile. What possible difference upon the development of the sore can it make whether the virus is deposited by the surgeon's lancet or by the penis in connection ub ore? 8 N. diet, de med. et de chir. prat., Paris, t. vii, p. 7(i. 9 Gaz. ui6d de Lyon, 9 juin, 18(57, p. 275. CHANCROID FROM INOCULATION. 351 the effect of producing five chancroids, which have not been followed by any symptoms of syphilis during eighteen months tliat have since elapsed. I shall content myself with this brief sketch of the discussion relative to the " cephalic chancre," which for a time attracted no little attention, but which assumes less importance now that it is known not to conflict with a duality of poisons. Its only practical bearing is this : that the rarity of the chancroid upon the head and face, furnishes strong ground of belief that any venereal ulcer met with upon this region is syphilitic. The Chancroid fro-M Inoculation — Thanks to the ease with which the chancroid may be inoculated upon the person bearing it and the safety with which this operation may be performed, we have the rare opportunity of developing this disease at pleasure, and watching its progress from its very commencement. We may plant the seed and observe its growth, and tlius obtain a knowledge of its natural history, which we may after- wards compare with the various stages and varieties met with in practice. Artificial inoculation is usually performed upon the person from whom the matter is taken, and is then called auto-inoculation ; when practised upon another [)erson it is called hetero-inoculation. How is the operation performed ? Some portion of the external integu- ment should be selected which is sufficiently open to observation, and where, if the inoculation prove successful, the sore is least likely to attain a considerable size, or to affect the neighboring ganglia in case its early cauterization, as soon as the purpose of the inoculation has been accom- plished, should fail to destroy it. The experiments of the advocates of syphilization show that the sides of the chest, below the nipples, best fulfil these indications. In this situa- tion chancroids rarely attain a large size, and the axillary ganglia are too far removed to be readily affected. M. Clerc recommends an ordinary pin as the preferable instrument to be employed, for the following reasons : it is always at hand and may always be had clean ; it is not formidable to the patient ; it is not likely to make a deep wound, and we find that a sujierficial insertion of the virus affords greater security against large and troublesome sores. But for convenience no instrument is better than the common lancet ; only be certain of its cleanliness. Moisten its tip with the purulent secre- tion, and place the point iierpendicularly upon the spot you wish to inoculate ; with a slight impulse the point is made to penetrate to the derma ; the instrument is turned once round on its axis and withdrawn ; any remains of the pus upon the instrument is smeared over the orifice of the puncture, and tlie operation is com[)leted in less time than it has taken to describe it. No after- care is required. The evidence of a successful inoculation is usually apparent on the fol- lowing day ; sometimes not until after the lapse of two, three, or even four days. The point inoculated is of course reddened from the outset ; if the inoculation " takes," a pustule, surrounded by an inflammatory areola, appears within the time just mentioned, and on removing the epidermis 352 CHANCROID. an nicer is found, penetrating the whole thickness of the skin, its edges abrupt, jagged, and undermined ; its outline circular; its floor of a gray- ish color, and presenting slight elevations and depressions, best seen through a magnifying glass. If, on the other hand, the pustule be left unbroken, the contained matter concretes and forms a scab of conical form, whicii increases by additions to its circumference and covers the ulcer beneath, which is being further developed. The tendency of this ulcer is to extend, at first rapidly, and afterwards more slowly, for several weeks ; then comes a period during which no increase is perceptible, and the sore appears stationary ; and finally the process of repair is set up, usually commencing at the circumference, and the ulcer closes, leaving a cicatrix which is more or less permanent accord- ing to the depth and extent of the preceding ulceration. As soon as all doubts are removed, the sore should be destroyed, by first removing its secretion and then applying a strong caustic, as the carbo- sulphuric paste, or fuming nitric acid. From this experiment, which has been performed in many thousand instances with the same result, we are justified in inferring: — 1. That the chancroid has no period of incul)ation; that the pathological process is set up the moment the poison is introduced beneath the epidermis. 2. That the chancroid first appears as a pustule, but that it essentially consists in an ulcer underlying the elevated epidermis, and presenting the characteristics above stated. 3. That the course of a chancroid may be divided into three stages: the progressive, stationary, and reparative. 4. That the chancroid is capable of healing spontaneously, without the intervention of art. We shall presently see how far these conclusions are confirmed by cases met with in practice. There should be no marked difference, since the circumstances attending the inoculation and contagion are the same, except that in the former we take care to remove all disturbing influences, and leave the disease to pursue its regular course. The Chancroid from Contagion — Development — The first point that claims our attention is the time of development of the chancroid after exposure ; in other words, is there an absence of a period of incubation with the chancroid from contagion, as we have found to be true of the chancroid from inoculation ? This question becomes more complex as soon as we turn to cases met with in practice; since patients have often had several recent connections, and we cannot tell with certainty which was really the infecting one. Even if there has been but one exposure after a long period of continence, we are still obliged to rely u[)on the state- ments of unprofessional persons, often careless in their habits, in our at- tempts to ascertain the exact time of the appearance of the sore. Their testimony can include only what they themselves have observed, and not necessarily what has actually taken place. The chances are that many of CHANCROID FROM CONTAGION. 353 them will post-date the appearance of the ulcer, which was entirely unex- pected, and consequently not observed at its commencement. Yet with this liability to error, we find in the main that the testimony of patients confirms the results of artificial inoculation, and that they repre- sent the time after exposure when their ulcers had attained sufficient size to attract their attention as having been but a few days. Thus, in fifty- two cases in which there had been only a single connection for along period (three to five months or more), Fournier found that the patients assigned the date when they first noticed their chancroids as follows : — Casks. The first day after exposure 6 The second day after exposure ....... 2 The third day after exposure ....... 9 From the third to the fourth day ...... 4 The fourth day 3 The fifth day 1 The sixth day 3 From the seventh to the eighth day ...... 13 The ninth day .......... 1 The tenth day 2 The eleventh day ......... 1 The thirteenth day 2 From the thirteenth to the fourteenth ..... 3 From the seventeenth to the twentieth ..... 2 Total 52 It appears from this table that the existence of the chancroid was recog- nized by the patient in 24 cases, from the first to the fourth day ; in 17 cases, from the fourth to the eighth day; and in 11 cases after the eiglith day ; hence that in 41 cases out of 52, or in about 4 cases out of 5, it was seen during the first week, and in only 11 cases at a later period. With regard to these eleven exceptional cases, Fournier also states that the sore, at the time it was discovered, presented such a degree of devel- opment as to show that it had already existed for a number of days, ranging probably from five to twelve. Taking into consideration the inadvertence and the incapacity of patients as observers, we are therefore justified in concluding that there is the same absence of incubation with the chancroid from contagion that we know to exist with the chancroid from inoculation. And as stated by Ricord, there is still another circumstance to be taken into account ; when the virus is deposited upon the sound integument or mucous membrane, it cannot immediately take effect ; it has first to act as a common irritant, eroding the surface and destroying the epidermis or epithelium; and only wlien this is accomplished can it exercise its specific action. But this preparatory work recpiires time, and by so much delays the appearance of the ulcer. In this manner we can readily explain the rare instances in which the evo- lution of a chancroid has taken place after an interval of several days following exposure. In point of fact, it has no period of incubation, whether produced by contagion or inoculation. 23 354 CHANCROID. As we shall see hereafter, this constitutes one important means of diag- nosis between the chancroid and the true chancre. In practice we do not often see the initial pustule of the chancroid, which has usually been ruptured before the patient comes under observa- tion, or the virus may have inoculated some previous solution of continuity; and in such cases we find at the outset either a scab formed by concreted pus when the ulcer is situated upon the external integument, or an open sore when it occupies some moist surface, as the balano-preputial fold or the mucous membrane of the vulva. A rent or abrasion is not necessarily inoculated at once to its full extent ; a single point may at first exhibit the characteristic appearance of a chancroid, and the remaining portions be only gradually involved. Period of Progress A chancroid, when fully formed, is usually circular in outline; its edges are abru})t and sliarply cut ; its floor is uneven and covered with a grayish secretion ; the discharge is abundant and purulent ; its base presents to the touch the normal suppleness of the underlying tissues ; the tendency of the sore is to extend and enlarge its area. Several circumstances may render the outline of a chancroid other than circular. If a rent or abrasion has been inoculated, the resulting ulcer will naturally at first assume a corresponding sliape. If two or more contiguous ulcers have united, the outline may be quite irregular. Certain situations may modify the form of tlie chancroid ; thus, those met with in tlie furrow at the base of the glans are more oval than circular, probably owing to the facility with Avhich the virus flows along this groove, and macerates and inoculates the tissues in the transverse direction ; for a similar reason, chancroids at the margin of the anus and prepuce tend to follow the folds of tliese orifices. Moreover, the ulcer would appear to extend in whatever direction the tissues are most lax and most readily per- meated by the virus; thus, if a chancroid be seated in part upon the glrns and in part upon the prepuce, its increase is the more rapid upon the latter, and its outline loses the circular form. The edges of a chancroid are abrupt and sharply cut simply because the ulcer penetrates the whole thickness of the skin or mucous membrane. The sore is, as it Avere, punched out of the integumental layer; and as the ulceration readily encroaches upon the lax cellular tissue beneath, the edges are often undermined, and consequently slightly elevated or even everted ; during the period of progress they are also somewhat jagged, as if gnawed by the erosion, and are surrounded by an areola which varies in width and depth of color according to the degree of the attendant inflam- mation. The floor of the ulcer is uneven, studded with minute elevations, " worm- eaten," and covered, especially at the centre, with a pseudo-membranous secretion of a grayish-yellow color, which cannot be removed without violence. This layer is made up of the disorganized tissues. Under the microscope, it is found to consist : "1, of the elastic fibres of the derma ; 2, of the other elements of the integument or mucous membrane, more or PERIOD OF PROGRESS — STATIONARY PERIOD. 355 less changed, and reduced, for the most part, to an amorphous and granu- lar mass; 3, of numerous pus-globules." (Cusco.) The discharge from a chancroid is somewhat abundant, and decidedly purulent; not the pure, creamy pus, however, which we see in the acute stage of gonorrhoea, and from which it may be readily distinguished, but thinner, and often mixed with organic detritus or streaked with blood. Mr. Henry Lee, of London, regards the presence of pus-globules, as shown by microscopical examination, in the secretion of a venereal ulcer free from irritation, as diagnostic of the chancroid. As previously stated, the pus-globules are the vehicle of the chancroidal poison, and the secretion often gives rise by inoculation to successive chancroids in the neighborhood. The condition of the tissues around and beneath a chancroid is one of the most important elements of diagnosis between it and a true chancre. In the former the parts preserve their normal softness and suppleness, unless suVjjected to some irritant, or attacked by simple inflammation. Inflam- matory engorgement, however, is not well defined like the specific indura- tion of the initial lesion of syphilis, but gradually subsides into the normal suppleness of the neighboring tissues ; it is also less firm, and of a more (loughy feel, and disappears shortly after the cessation of the inflammation which occasioned it. The application of any astringent lotion, or caustic, as nitrate of silver, potassa fusa, nitric acid, and especially corrosive sub- limate or chroraate of potash, may cause hardness which so closely resembles s[)ecific induration, that it cannot be distinguished from it, ex- cept by its shorter duration ; and, for the time being, the diagnosis must be founded upon other symptoms. In short, as regards the condition of its base, the chancroid does not differ from any simple wound, which, when free from irritation, is soft and supple, but which may became engorged from any of the ordinary sources of inflammation. The fictitious hardness which sometimes surrounds a chancroid is often found after, the applfcationi of caustics or astringents "to mere vegetations, hei'petic exulcerations,, or other solutions of continuity. The pain and uneasiness occasioned by a chancroid are usually only moderate, tliougli greater than tliose attending the true chancre. They are the more severe the more rapidly the ulcer extends, and are heightened by any stretching and laceration of the tissues, or by the application of irritant dressings or lotions. They diminish and disappear as the repara- tive stage sets in. The duration of the progressive stage of the chancroid is very variable, and depends very much upon the mode of treatment, the faithfulness of the patient in attending to the sore, and also upon his general condition. It is rarely less than four or five weeks, unless cut short by treatment, and it may be prolonged for montlis or years by the causes alluded to, or especially by tlie supervention of [)hagedajna. The size which the ulcer may attain is subject to equal variations, and dependent upon the same causes ; it rarely exceeds that of a twenty-five cent piece, in the absence of phagedaina which has no limit to its action. Stationary Period The progress of a chancroid gradually slackens 356 CHANCROID. and finally becomes imperceptible. For a while the ulcei' appears to be stationary. It makes little difference whether this period of inactivity is real, or whether it is merely apparent, as some authors would have us believe; the fact remains the same, that the progressive force of the virus seems to be spent, and the ulcer remains for a while in statu quo^ prior to any signs of healing. It is evident that this, like the progressive stage, must be variable in its duration in different cases, and subject to the same influences. Reparative Stage Tliis stage is marked by several changes in the appearance of the ulcer. The inflammatory areola, if such has existed, disappears, and the neighboring tissues assume a healthy aspect. The floor of the ulcer also " clears up ;" its grayish covering becomes thinner, and is soon replaced by florid granulations which spring up over certain portions of the sore, generally towards the circumference. The edges lose their reddish color, and are less ])rominent; they can no longer be everted, but become adherent to the sul)jacent tissues; and their margin, which was "sharply cut," becomes sloping. No decided diminution in the area of the ulceration can be expected until the loss of substance is supplied by granulations. The patient often complains that his sore is no smaller, while the surgeon can see that its floor is approaching the level of the surrounding surface, and that its progress is all that could have been anticipated. But at last, a fine and delicate cicatricial membrane, which is best seen with a magnifying glass, extends from the margin upon the surface of the ulcer. Or, in exceptional cases, this membrane first shows itself at some point within the circumference. . Macerated by the discharge, it has a whitish look, and resembles a fragment of lint which has not been removed at the last dressing; but at the subsequent visits of the patient it is found to be still present, gradually increasing in size until it becomes continuous at some portion of its periphery with the margin of the sore, and it thus contributes towards the final closure of the wound. It was at one time supposed that a chancroid was contagious only during its progressive and stationary periods, and that its virulence ceased either with, or soon after the commencement of the reparative stage. Fournier's experiments, however, have shown that such is not the case, and that even when the ulcer is already far advanced towards cicatrization, the tliin and barely purulent secretion from its surface may sometimes be inoculated with success, as shown by the following table: — Fournier's inoculations during the reparative stage. 1. This stage fairly established . 2. This stage well advanced 3. This stage nearly completed It is thus evident that it is never safe to allow patients with chancroids to indulge in sexual intercourse until the ulcer has completely closed. The work of cicatrization being once accomplished, however, the chan- croid is at an end ; without a fresh contagion there can be no subsequent relapse or .reopening of the sore with its former virulence, as is sometimes Result Re-ult positive. Degative. . 9 3 . 3 . 2 5 NUMBER OF CHANCROIDS. 357 seen with the true chancre. The cicatrix may be torn or abraded at will, only a simple wound can be reproduced, and not a virulent ulcer, and this simply for the reason that there is no constitutional infection behind the local sore to regenerate the virus. The scar left by a chancroid varies in its character and its permanency according to the extent and depth of the ulceration, and also, in a mea- sure, according to its situation. As a chancroid is usually more destruc- tive in its action than the chancre, so the former is much more likely than the latter to be followed by a cicatrix. Upon the external integument this cicatrix is often permanent ; upon a moist mucous membrane it fre- quently fades away and soon becomes effaced, unless the ulceration has produced a loss of substance which has not been filled up during the re- parative stage. Number of Chancroids. — Patients are much more frequently affected with several than with a single chancroid. Thus, in 327 cases, observed chiefly at the Hopital du Midi, only 63 patients had a single ulcer, or about one in five. Of the remaining 206, there were — Presenting two ......... 50 " fi-om three to six ....... 152 " " six to ten ....... 45 " " ten to fifteen 8 " " fifteen to twenty ...... 5 " " twenty to twenty-four ..... 6 Total . . . .266 Of 118 men who were admitted at the Antiquaille Hospital, Lyons, M. Debauge found — Presenting a single ulcer ........ 50 " two 22 " four n " five 11 " from six to ten . . . . . . .17 " " eleven to fifteen ...... 6 " twenty ......... 1 Total . . . .118 Sometimes the chancroid is multiple from the first ; more frequently it becomes so by successive inoculation of points in the neighborhood of its original site. The first ulcer pours out an abundant secretion, and its pre- sence confers no immunity against others. We shall see hereafter how 0|)posite is the case witii the true chancre, the initial lesion of syphilis. The ciiancroid is multiple from the outset only when several points have been inoculated at the time of contagion. It is evident that certain regions will militate either for or against successive inoculation. Thus, if the sore ha situated upon the external integument, as tlie sheath of the penis, the virus is not likely to find a door of entrance within the hardened epidermis of the surrounding suHace. On the other hand, if it be seated at the base of the glans, its secretion will extend along tlie furrow, mace- 358 CHANCROID. rate the thin epithelium, and will generally occasion successive inocula- tions, especially in cases complicated with phimosis. M. Clerc^ states that successive chancroids are generally mild in their character compared with the original sore ; that they usually occupy a less extent of surfixce, and that they tend to heal more speedily ; and I think, judging from my own observation, that this rule will be found to be true generally, although not invariably. Condition of the neighhoring Ganglia In the majority of cases of chancroid, or, as nearly as we can determine by statistics, in about two cases out of three, the neighboring lymphatic ganglia remain intact through- out the whole course of the disease. In the remaining minority, these bodies take on inflammatory action, either^/'s^, as the result of the exten- sion of simple inflammation from the local ulcer along the course of the lymphatics, or secondly, in consequence of the absorption and conveyance to the ganglion of the chancroidal virus. In the former case (inflamma- tory or simple bubo), resolution is possible without suppuration ; in the latter (virulent bubo), supi)uration is inevitable. Of 207 cases of chan- croid observed at the Hopital du Midi in one year, 05 were attended with bubo, and 142 were not.^ Of 140 patients in the service of M. Rollet, at Lyons, 57 were free from inguinal reaction, while 83 had buboes, of which 60 were virulent.^ We shall see hereafter that the initial lesion of syphilis is always attended with induration of the nearest lym[)hatic ganglia, which rarely become inflamed and suppurate, and it cannot be too often im- pressed upon the mind of the student that an examination of the ganglia in the neighborhood of a venereal ulcer affords assistance of the highest value in distinguishing a chancroid from primary syphilis. Varieties of the Chancroid There is a form of the chancroid called by M. Clerc the exidcerons. In this variety, the sore is little, Jf at all, depressed below the level of the surrounding surface, and conse- quently its edges are not perpendicular and sharply cut. Otherwise its appearance is the same as already described ; its floor is irregular, and covered with a grayish secretion ; its discharge abundant and purulent, and its base soft. This variety is sometimes observed on the margin of the prepuce, in cases of phimosis with concealed chancroids at the base of the glans. Again, the chancroids may vegetate above the surface, and constitute one form of what has been described as the ulcus devatum. When the virus has gained entrance within a follicle, and inoculated its internal surface, the chancroid may at first appear like a pustule of acne indurata. Ulceration soon commenoes at a minute point upon the surface, and gradually extends until it lays open a sore presenting the usual char- acteristics of a chancroid. This variety is knovvn as the follicular form. Cullerier depicts a number of such sores upon the external surface of the ' Traite jn-atique, p. 182. 2 Foukniek, op. cit. p. 34. 3 Debauge, oj). cit. p. 72. DIAGNOSIS OF THE CHANCROID. 359 labia niajora and inner surface of the thighs.^ This is an important variety of the chancroid, liable to be overlooked, and should be borne in mind hj the student. The ecthymatoas form is nothing more than a chancroid which, from exposure to the air, has become covered with a scab, composed of its dried secretion. It is evident that this form is not likely to be met with except upon the external integument. The form of the chancroid may be modified by its seat, as will be de- scribed in tlie next chapter. Diagnosis of the Chancroid — In the great majority of cases, a chancroid is readily recognized by a practised eye, from its various symp- toms already described ; yet there is not a single one of these symptoms which may not be found in lesions of an entirely diflerent nature. It was formerly supposed that an unfailing and absolute test of a chan- croid was to be found in its experimental inoculation upon the person bearing it ; if auto-inoculation pi'operly performed was successful, it was inferred that the sore must be a chancroid ; if unsuccessful, it could not be. We cannot now rely upon this test so implicitly, tor reasons that will be obvious to the reader of the preceding pages ; at the same time, the ready auto-inoculation of any sore affords a sti'ong ground of probability that it is of this nature. The method of performing artificial inoculation has already been given, and I have only to add a few precautions concerning it. In the first place, while this experiment is of great practical value, and, if properly per- formed, Usually devoid of danger, yet it should not be rashly resorted to, and should only be employed either for the benefit of the ])atient or the interests of science. In careless hands, very troublesome and even serious results have been known to follow. I have myself seen two such cases ; one in the New York Hospital, in which artificial inoculation, performed before the patient's entrance, had given rise to an extensive ulcer upon the thigh of several years' duration ; and another similar case in the Pennsylvania Hospital, Philadelphia. Other cases are reported in works on venereal. Such evil results may, I believe, be avoided l)y observing the following simple rules : — 1. Avoid artificial inoculation in all cases of phagedenic ulcers, and in all persons of a broken-down constitution, for fear that the inoculated point may lake on ulcerative action whicii will be beyond the control of caustics. 2. Avoid artificial inoculation, unless you are reasonably certain of having the patient under your continued observation. Hence this method of diagnosis may be used much more freely in hospitals than in [)rivate jtractice. 3. SoJect as a site for the inoculation some portion of the integument, as the chest, Avhere experience proves the occurrence of phagedaena to be rare. ' Cl'Llekieu and Bumstead's Atlas, 1*1. ix, fig. 1. 360 CHANCROID. 4. INIake your incision no deeper tlian the surface of the vascular hxyer of the skin, for a reason previously given. 5. Thoroughly cauterize the inoculated point with a strong caustic, as nitric acid or tlie carbo-sulphuric paste, as soon as the diagnosis of a re- sulting chancroid can be made. The value of this test depends, of course, upon the thoroughness of its application. Unless the matter be implanted under the requisite condi- tions, it cannot take effect. Other points of distinction between the chancroid and those lesions most apt to be mistaken for it now claim our attention. An abrasion due to violence during coitus will be recognized by the patient himself — unless intoxicated — either at the time of its occurrence, or during those reflective moments which follow the exposure.^ Independ- ently of its history, an abrasion may often be recognized by the jagged outline of its edges and by the appearance of its surface and its secretion, differing as they do, from those of a chancroid already described. Sub- sequent neglect, a low condition of the general system, the accumulation of filth or even of the natural secretion of the part, may perpetuate the solution of continuity thus made, and transtbrm it into an ulcer which can with difficulty be distinguished from a chancroid ; and the diagnosis can only be made either by artificial inoculation or by waiting for farther de- velopments, at the same time paying attention to cleanliness and to general hygiene. " But," it may be said, "an abrasion occurring at the time of coitus may have served as the door of entrance either to the chancroidal or syphilitic poison." Very true; and consequently wlien a patient seeks advice, a few days after coitus, with a solution of continuity evidently due to violence, the surgeon can only estimate its present but not its future char- acter. Under such circumstances, a guarded opinion only should be given, as for instance, " You have torn yourself in the sexual act; but whethej' you have been inoculated or not through the rent, 1 cannot say ; time will determine." A mere abrasion or tear, in a healthy constitution, and under conditions of cleanliness, will heal in the course of a few days; while an abrasion inoculated with the chancroidal virus will extend and assume the character of a chancroid. An eruption of herpes usually appears on the first or second day after exposure, is attended with itching, and consists of a number of small vesi- cles which are arranged in one or more grou])S affecting the form of a circle. The contained fluid soon becomes turbid, and if the epidermis be ruptured or removed, a superficial ulceration is found beneath. With attention to cleanliness and the interposition of a piece of dry lint between the glans and prepuce, the vesicles or erosions will usually heal in the course ' There is an old adage bearing on this point commencing " Omnennimnl poM coitum trlste est,^' etc., wliicli the able reviewer of the last edition of this book in the Am. .lour. Med. Sci. corrects me in having attributed to Aristotle, of whom, however, it would have been worthy. The reviewer is shocked at the allusion to tliis adage in a scientific book, and I will therefore refer to his own article in the Am. Jour. Med. Sci., .Jan. 1S71, where he gives the text in full. DIAGNOSIS OF THE CHANCROID 361 of a few days. Their circular arrangement, small size, watery contents, superficial character, the pruritus which they occasion, and their speedy cica- trization, present n marked contrast to the symptoms of the chancroid. Again, in many cases, we find on inquiry that the patient has been subject to herpes, which recurs upon the slightest provocation, as after coitus with any woman however pure, or after dining out or indulgence in wine, and in some instances without apparent cause. ^ The discovery of this fact should put us upon our guard, and lead us to resort toother means of diagnosis in doubt- ful cases. The diagnosis between herpes and the chancroid may, therefore, be said in general to be easy ; but, as noticed by Fournier, there is a rare form of herpes consisting of a single and somewhat excavated ulceration, which very closely resembles a chancroid, and which in some instances cannot be distinguished from it except by inoculation. I shall defer the consideration of tlie diagnostic signs of the chancroid and cliancre until I come to speak of syphilis. Witii regard to mucous patches, which are so often seated U]jon the genital organs, their superficial character, the history of the case, and the coexistence of other secondary symptoms ai*e commonly sufficient to enable us to distinguish them. There is another class of cases, fortunately uncommon, in which the diagnosis is less easy, and which sometimes occasion much annoyance. I refer to old syphilitic patients, who have probably advanced to the tertiary stage of the disease. These men occasionally make their ap- pearance with an ulceration closely resembling a chancroid, with sharply- cut edges, a grayish excavated floor, an abundant purulent secretion, and a soft base, which I have seen most frequently in the furrow at the base of the glaris where it tends to undermine the integument of the penis. It also occurs on the surface of the glans and at the meatus. The glands of the groin are not affected. On inquiry you find that the patient has not presented any sypliilitic symptoms for months or even years, and exami- nation of other parts of tlie body may fail to show any evidence whatever that the poison is still active. Very likely, also, the man is of dissipated habits and has frecpiently been exj)Osed of late in promiscuous intercourse, so that chancroidal contagion is highly probable. All the circumstances, therefore, except, perha{)S, the fact that the sore is solitary in a region where the chancroid is almost always multii»le, point to the simple chancre ; and yet if you treat it as such with caustics, cleanliness, astringent lotions, etc., you fail utterly, but it heals under the mixed constitutional treatment of iodide} of potassium and mercury. ^ I have one patient in mind, in whom these symptoms occurred some four to six times during a period of several years, the last time six months after his marriage, during which I have reason to believe that he had not been exposed to contagion. Another instance is that of a medical man, who has had tfiree attacks of the kind. AVlien I first met with these cases, I ' Dr. A. DoYON lias written an interesting monograph on this form of lierpes, entitled De I'herpes recidivant des parties genitales, Paris, 1868. 362 CHANCROID. was quite at a loss regarding them, but further study of numerous cases has shown them to be ulcerated gummata of the glans. In arriviijg at a diagnosis of the chancroid, as well as of other venereal diseases, especially in their early stages, the value of the confrontation of patients should not be forgotten. Tlie recipient can have no other disease than that possessed by the giver, in whom the symptoms are probably more marked, because they have had a longer time for development. I would also call the reader's attention to the possibility of the double inoculation of the chancroidal and syphilitic poisons, or to what has been improperly called the " mixed chancre," which we shall consider here- after ; and again to the occasional develo])ment of a chancroid upon the old induration of a chancre, which is very apt to lead to error in the diag- nosis, on account of the hardness of the base of the sore. After all, cases do occur, in which auto-inoculation is impracticable, and in which the diagnosis is for a time impossible. A degree of rapidity and facility in diagnosis with regard to venereal diseases, is often demanded by patients and even by physicians, which it is simply unreasonable to expect. The specialist is expected to be able to decide at once in all cases, from a single examination, and often with a very imperfect knowledge of the his- tory, whether a given sore is a chancroid, a chancre, an herpetic ulceration, etc. Now, the same latitude should be allowed here as obtains in other diseases. Doubtful cases will occur, with regard to which the most ex- perienced specialist must for a time be undecided, and he will, if an honest man, confess his ignorance rather than assume knowledge which he does not possess. It is important to distinguish between the chancroid and epithelioma or cancer of the penis. I was called in consultation by a country physician, to see a case of supposed venereal ulcer of the glans penis. The patient was a married man, and, the diagnosis of his doctor having become known, his reputation was ruined. I found it to be a case of epithelioma, and am- putated the organ. E[)ithelioma is more frequent than true cancer, in the proportion of five to one (Demarquay). In the majority of cases, it commences in the glans or prepuce, and may extend to the corpora cavernosa or involve the whole penis. The glands in the groin are subsequently engorged, and become deeply and extensively idcerated. Epithelioma usually commences as an irregular warty excrescence, which soon ulcerates, and presents, at first, superficial erosions covered with sa- nious mister. There follow deep and irregular excavations and cauliflower excrescences. The surrounding skin is tumefied and scattered over with tubercles, w'hich in their turn become degenerated and add to the extent of the disease. " By pressure upon these papillary tumors, plugs of flat- tened or cylindrical epithelial cells, resembling the sebaceous matter of comedones, can be squeezed out." (Klebs.) True cancer may be either of the scirrhous or encephaloid form, but more frequently the latter. Lebert says that in most cases the form is intermediate between the two. True cancer may at the same time affect PROGNOSIS — PATHOLOGICAL ANATOMY. 363 distant organs, while the influence of epithelioma is never seen beyond the inguinal glands. In a large majority of cases, these affections occur in persons who have permanent phimosis, either congenital or accidental. The distinction between epithelioma and true cancer on the one hand and the chancroid and truly syphilitic lesions on the other, is not always easy. The amount of pain is 7iot always a reliable sign, for this may be absent for some time even in true cancer. The diagiiosis, however, may usually be made out from the history of the case, from the appearance of the surface, base, and edges of the ulcer, and from its progress. In doubt- ful cases, the patient should have the benefit of a trial of treatment adapted to venereal ulcerations (whether chancroidal or sy^jhilitic) before amputa- tion is resorted to. Pkognosis OF THE Chanoroid The chancroid, aside from its com- plications, is of less serious import than either the chancre or gonorrhu?a; less so than the chancre, because it does not depend upon and is never followed by constitutional infection, and less so than gonorrhoea, because it does not result in deep-seated urethral contractions. A chancroid at the meatus will indeed probably produce a stricture at this point, but one which is amenable to treatment and unattended with danger. The presence of complications may add seriously to the gravity of the disease. Phimosis may result in gangrene and loss of the prepuce. Lymphitis or adenitis may confine the patient to his bed for months ; and, above all, the occurrence of phagedaina may involve the destruction of important tissues or organs, or be the source of misery and suffering for many years. Tliese complications will be described in another chapter. The chief point, however, Avhich commonly excites the anxiety of the patient is with regard to constitutional infection, and of this the surgeon may assui'c him there is no danger. Pathological Anatosiy Kaposi^ gives the following description of the microscopical appearances of the "soft chancre" (chancroid) : — "Microscopical examination of a perpendicular section, including the margin, the inflamed parts in the neighborhood, together with a portion of the floor and the inflamed base of the ulcer, shows that the portion of the skin occupied by the chancroid, consists of two parts, which have evidently undergone different anatomical changes. " From the floor of the ulcer (Fig. 112, cd) to a considerable depth in the corium is a uniform and uncommonly thick cell-inflltration, which terminates sharply at the line fg. This infiltration is continued beneath the intact papilla? of the margin of the ulcer {el), and laterally far beyond the limits of its floor [k). The tissue bordering on the infiltrated mass (/(/, hi) is composed of loose meshes, and exhibits scattered cells with a large nucleus, that is well brought out by carmine. ' Syphilis der Haat und der angroiizondon Schleimhiivite, 1 Liefcruiig, s. 42, Wien, 1873. 364 CHANCROID. " In the swollen margin (ftb) a number of the papilla? (e) lying nearest to the floor of the ulcer are thickened and closely infiltrated with cells. The layer of Malpigliian cells between these papilli\3 is thickened. " The floor of the ulcer [cd) is formed by the exposed, cell-infiltrated corium, and is destitute of papilla;. Both the corium and papilke, wherever infiltrated with cells, exhibit numerous enlarged vessels, the most of which are bloodvessels, but a few are lymphatics. Fig. 112. Section of a chancroid. Hai-tnack, oc. 3, obj. 4. (After Kaposi.) ab, swollen niaririn of the chancroid, cd, floor of same, be, e|iiderinis. e, undermined border, cd, fij, tissue infiltrated with small cells and traversed by several dilated vessels, fg, hi, tissue subjacent to the ba.se of the chancroid, composed of larf,'e (edematous meshes free from cellular infiUration. «, enlarged papillaj infiltrated with cells, k, continuation of the tissue iiifiltJated with cells beneath the papillae at the margin of the ulcer, which still remain intact. " Under a high jiower, tlie cell-infiltrated portion consists of a close network of partly narrow, partly broad, bundles of fibi-es with faint con- tours, in which is deposited a great number of nucleated and evenly dis- tributed cells, some of them very large and resembling lymph-corpuscles, and others smaller. The cells lying near the floor of the ulcer and the neighboring parts are mostly small and irregular in outline, with scattered nuclei. Free nuclei and nucleoli are also found in large numbers. " In the deeper tissues the cells have generally the appearance of in- flammatory-cells, but there are also many smaller ones. TREATMENT OF THE CHANCROID. 365 " Of great interest is the remarkable thickening of the walls of the vessels, the cavities of which appear to be enlarged both in the infiltrated and the neighboring oederaatous portions. " The degeneration of the tissue and of the infiltrated cells takes place only in the upper portion, and to an extent which is but limited in pro- portion to the extent and depth of the infiltration. Interstitial abscesses do not exist. We have not found any characteristics which would enable us to distinguish the cell-infiltration of the corium and ])apillre or the sub- sequent degeneration of the same from similar processes of simple origin." Treatment of the Chancroid. Prophylaxis The use of a con- dom will protect those parts which it covers from contagion, but the neighborliood of the root of the penis, as the scrotum and pubes, will still be exposed. As Kicord was wont to express it in his lectures, " carrying an umbrella over the head in a rainstorm will not prevent the feet from getting wet." Whether any such protective covering has been used or not, the genital organs should be assiduously cleansed after any suspicious connection, especially in those folds, as in the furrow at the base of the glans, where contagious matter is most likely to be deposited. General Treatment — The internal use of mercury has no beneficial influence whatever upon the chancroid, which continues in a state of stubborn persistency, or even progresses, after the system is fully under the influence of this mineral. This statement is not a mere inference from the distinct nature of the chancroid and syphilis, but is founded upon experience. I was fully convinced of the fact by personal observation, and ceased to employ mercury for " soft chancres," several years before the distinction between the two species was recognized. Since abandon- ing it in my own practice, I have had numerous opportunities of observin"' other surgeons administer mercurials for the chancroid, and my former opinion has only been confirmed. In most instances no general treatment is required, except'tliat which common sense would dictate, and which has for its object to place the patient in a healthy condition and thereby enable nature untrammelled to accomplish the work of cure. For this purpose, the secretions should be attended to; a plain but nourishing diet administered; and congestion and inflammation avoided by maintaining a comparative state of (piietude. Nocturnal erections are not only painful but interfere with cicatrization, and should be controlled by the means mentioned when speaking of cliordee. Abortive Treatment — This treatment has for its object the removal or destructi(»n of the virulent ulcer, and the substitution for it of a simple wound, the tendency of which shall be to heal. The removal of the ulcer is accomplished by cutting instruments ; its destruction by the more power- ful caustics. Practically, we find that the excision of a chancroid is rarely successful. However carefully tlie sore and the surrounding surface may have been cleansed of its secretion before the operation, the fresh wound usually be- 366 CHANCROID. comes inoculated ; either the incision lias not been carried wide enough from the "sphere of specific action," or in spite of our precautions, some of the virus has remained upon the surface ; and we now are worse off than before, because we have a large virulent ulcer instead of a small one. For this reason, excision should be employed only in certain situations, as in cases of chancroids upon the margin of the prepuce or the free border of the labia minora, where the knife or scissors can be carried wide of the ulcer, and the bleeding surface should be fi-eely cauterized, so that it may for a time be protected by an eschar. Destructive cauterization is much more frequently employed than ex- cision ; hut is only adapted to the curly staye of the chancroid — say within the first five or ten days of its existence — when it may act as a true " abortive" method, cutting short the duration of the ulcer, preventing inoculation of parts in the neighborhood, and averting all danger of gan- glionary reaction. A few years ago it was much more frequently resorted to than at the present time, and patients were subjected to much sutl'ering from which they might have been spared. The chancroid under proper attention to cleanliness and mild local apj)lications, will in the great majority of cases soon take on reparative action, and with the discovery of the healing power of iodoform, we are now able to obtain even better results than formerly, when cauterization was the rule and not the excep- tion in treatment. In private practice, I do not recollect having applied a strong caustic to a chancroid five times within a year. Let it he under- stood then, that destructive cauterization as an a,hortiiie metliod is recom- mended solely in the earliest stage of the chancroid. If applied sufficiently early, it prevents the occurrence of virulent buboes by removing the source from which the poison enters the lym- phatics ; but if deferred until a bubo has commenced, the latter goes on to sui)puration unchecked, and may furnish inoculable pus in the same manner as if the chancroid had been allowed to remain. Even the simple bubo is often benefited by destruction of the ulcer and undergoes resolu- tion.^ Destructive cauterization is impracticable Avhen the chancroid cannot be fully exposed, as in consequence of phimosis, concealment within the urethra, os uteri, etc. It is inadmissible in ulcers situated directly over the urethra either in the male or female on account of the danger of open- ing this passage; for a similar reason, in chancroids of the deeper portions of the vagina, the walls of which are in contact with the bladder, rectum, or peritonteum ; in those upon the margin of the meatus, from the fear of the cicatrix occasioning stricture ; and, finally, in all cases in which the presence of other ulcers in the neighboi'hood, which cannot be subjected to the same treatment, would expose the wound after the fall of the eschar to a second inoculation.^ Thus it would be useless to attempt the destruc- tion of a chancroid upon the margin of the prepuce in a case of phimosis • RoLLET, Gaz. mdd. de Lyon, March 1, 1858. * De la methode destructive des chancres, par M. Dion ; Annualre de la sypli. et d. mal. de la peau, Paris. Ann^e 1858, p. 202. CHOICE OF A CAUSTIC. 367 with concealed chancroids within, since the secretion from the latter would be sure to inoculate the wound after the slough comes away. If the application of the caustic has been successful, a healthy granu- lating wound will be left on the fall of the eschar. If the sore still present the appearance of a virulent ulcer, even only over a portion of its surface, the caustic should be reapplied. Choice of a Caustic. — Works upon materia medica inform us that the nitrate of silver is superficial in its action, and incapable of affecting the tissues beyond the surface to which it is applied, yet this is the caustic selected by the great majority of the profession for the purpose of destroy- ing a chancroid! Let a patient with a rent, abrasion, or ulceration following suspicious intercourse, apply to any one of four doctors out of five, "as doctors run," and his sore will be daubed with a stick of lapis infernalis. With what result? The part is irritated and the patient's suffering increased ; the symptoms are obscured and an accurate diagnosis rendered for a time difficult or impossible; if the sore heals, the nitrate has the credit of destroying a chancroid, or, perhaps, of " preventing con- stitutional infection;" at any rate the patient's mind is relieved by the idea that "something has been done," and the surgeon may flatter himself that he has done his duty. I feel tempted to apply to this indiscriminate and senseless mode of practice the adjective which, in Latin, is given to the "lapis" em[)loyed! The stick nitrate of silver is capable of destroying a chancroid only in the very earliest stage of its development, and even then cannot be relied upon witli the same certainty as the stronger caustics. Still it has been used with success by Kicord and others for the destruction of the sore resulting from a successful artificial inoculation. If employed for this purpose, the epidermis covering the pustule should be removed, and the cavity thoroughly cleansed of its secretion. A sharpened crayon of the nitrate should then be bored into the surface of the underlying ulcer, or a small fragment from the extremity of the crayon be broken off and be fastened in place by means of a strip of adhesive plaster. This dressing may be removed at the end of forty-eight hours, and the wound be subse- quently protected by plaster or a bandage. Of the strong caustics which are of more general application, the most noteworthy are the sulphuric and nitric acids, chloride of zinc, Vienna paste, the pernitrate of mercury, and the actual cautery. Of these, frequent trials have led me to give the preference to sulphuric acid, in the combination which has been so higldy recommended by Kicord, C'ullerier, and others, and which is known as the " carbo-sulphuric [)aste." This paste is easily prepared by simply saturating willow charcoal with strong sulphuric acid. The ingredients should be mixed in a glass-stop- pered bottle,, wliich should be kept standing in a tumbler to receive the moisture \vhich is apt to collect around tlie stopper and flow over upon the sides of the bottle. The paste is to be applied by means of a glass rod, or a glazed crockery spatula. The advantages of this paste are the facility with wliich it enters every nook and crevice of the ulcer, the thorough- 368 CHANCROID. ness with which it does its work, and especially the fact that it forms a dry scab, which, together with the slough beneath, is very adherent, and often remains until the sore is nearly healed. Meanwhile, the secretion is so diminished that the dressings require but infrequent changes, and the danger of successive inoculations in the neighborhood is materially lessened. The chief objection to it is the pain produced by its application, which is decidedly greater than that from nitric acid. A patient who had recently tried both at a short interval, told me he tiiought " the paste hurt him eight or ten times as much as the acid," but the former accomplished what the latter had failed to do. Nitric acid is preferably applied by means of a glass rod with a rounded extremity; a "drop bottle," with a tapering glass stopper, the point of which extends nearly to the bottom of the flask, is still more convenient ; but a simple piece of wood, as an ordinary lucifer match, will answer. Brushes of fine glass are objectionable, since the filaments are liable to break off upon the surface of the sore and excite irritation. The pain is for an instant severe when the acid first touches the ulcer, but becomes much less acute. on subsequent applications, of which there should be several in order to render tlie destruction com|)lete. I usually occupy several minutes in making these applications, watching the effect produced, and judging by the changes which take place in the tissues when enough has been applied. Any residue should be carefully removed or neutralized by an alkali, and the neighboring surfaces be protected from contact by the interposition of dry lint. A water dressing may be substituted as soon as suppuration takes place. The liquor hydrargyri pernitratis may be applied in a similar manner ; I am not aware, however, that it possesses any advantages over nitric acid, and it is attended with some danger of producing salivation or even alarming symptoms of mercurial poisoning, although the surface to which it was applied may have been quite small in extent. Such an occurrence is rare, but none the less to be avoided, as may be seen from a case reported in the London Lancet for Jan. 3, 1874, p. 4L Potassa cum calce made into a paste and spread upon the chancroid, where it is allowed to remain from five to fifteen minutes, is another con- venient means of applying the destructive method. A valuable caustic, judging from the high encomiums bestowed upon it by many French surgeons, especially of the Lyons School, is to be found in "Canquoin's paste," composed of equal parts of chloride of zinc and flour, which was first recommended for the destruction of the chancroid by MM. Rollet and Diday. The use of the actual cautery in the treatment of chancroids had been almost abandoned, when it was recently revived by Dr. Henry G. Piflard,^ of New York, who employs a piece of platinum wire bent upon itself and brought to a white heat by a small galvano-cautery battery. In seven cases to which it was applied at the Charity Hosj)it;»l, the duration of the ' Archives of Clinical Surgery, Nov. 1876. LOCAL APPLICATIONS. 869 lesion varying from a few days to several months, the average time re- quired for the healing of the sores is said to have been eleven and a half days — surely a very satisfactory result. Paquelin's thermo-cautery is also a convenient apparatus for the ])urpose. Local Applications As already remarked, most chancroids will heal under attention to cleanliness and suitable local applications and dressings. A point of no little importance is to place the ulcer under such condi- tions as to favor a return of blood from the part. Thus, if it be seated on the genitals, and especially if it be of considerable size, it will be well to keep the patient in the recumbent posture with the hips elevated by means of a pillow. If it be on the penis, this organ should be kept elevated upon the abdomen both during day and night. Friction of the clothes and nocturnal erections should, if possible, be avoided. It is evident that the form of dressing must vary with the situation of the sore. If the latter is seated between two opposed, layers of mucous membrane, as in the balano-preputial fold or within tlie vulva, a dry dressing will be the best, and will be kept sufficiently moist by the secre- tion of the part. If the sore is upon the external integument, the di'essing must be kept wet, otherwise it will adhere to the surface ; the patient will shrink from changing it as often as is necessary ; and the violence done to the ulcer by its removal will open new fissures to be inoculated by the virus. The advantages of dry lint are not generally appreciated. There is no better dressing for most chancroids situated upon mucous membranes. Obtain the '' patent lint" so called, and tear it into shreds : place a mass of this charpie over the ulcer and draw the opposite fold of mucous mem- brane over it. The " pre])ared absorbent cotton," now obtainable of drug- gists, is also excellent. The sore is thus isolated, and the lint absorbs the discharge as fast as it is secreted ; of course the dressing should be changed before it becomes soaked. The only obstacle in the way of this form of dressing is the false idea of the patient that some " wash" is required. Patients often inquire whether they should cleanse the sore at the time of changing the dressing. I commonly tell them that it is better, with a piece of soft lint and without friction, to absorb any moisture or discharge upon the surface around the sore, but to let the sore itself alone. If the dressing is changed with sufficient frequency, the ulcer will not require any extra cleansing. With chancroids upon the external integument we must use some lotion to keep the lint moist ; but this object is attained with much greater ease in some situations than in others. If the sore is on the body of the penis, it is easily covered with a fragment of lint soaked with whatever lotion is employed ; a narrow strip of rag moistened with water is then wound around the organ, a similar strip of oiled silk is added, and the whole retained in. place by a double-tailed bandage. With chancroids upon the margin of the prepuce the dressing is apt to slip off, but may be kept in . place by means of an ordinary condom. With sores upon the external 24 3t0 CHANCROID. surface of the labia majora, upon the perinaeum in both sexes, etc., the ingenuity of the surgeon may be taxed to keep them moist and clean. As a local application to tlie surface of tlie ulcer, nothing has been found equal to iodoform. It acts as a sedative to relieve pain and irritation, and, o^ still greater importance, it clears off the sloughy surface of the sore and covers it with " healthy" granulations. It should be reduced to a fine powder by trituration, either with or without the addition of an equal quantity of sugar of milk, which facilitates its minute subdivision, and be sprinkled at each dressing over the surface of the sore, until the latter has assumed a granulating appearance, when it should be omitted. Still more convenient is a solution of iodoform in ether, one-half drachm or a drachm of iodoform to an ounce of ether (which partially removes the unpleasant odor). This is to be painted over the ulcer with a camel's hair brush. The ether evaporates, and leaves a thin yellowish pellicle of iodoform on the surface. Dr. John Ashhurst, Jr., recommends it in the following form : — ^. lodoformi 5ss 2 Glycerinje ^v] 30 Spt. Villi Rect. 3ij 8 M. The only objection to the use of iodoform is its bad odor, but this must be endured for the sake of the benefit it affords. I have tried it with the addition of an equal part of tannin, as recommended by Dr. Cole, of Hot Springs, Ark. This mixture is indeed much less odorous, but it cakes on the surface of the sore and does not act well. In the following pre- paration the smell of iodoform is almost entirely masked : — I^. lodoformi ^ss 2 Ung. Petrolei gj 30 01. Meiitli. Pip. gtt. vj M. 40 "W hen the objection to the smell of iodoform is insuperable, I order :- GO I^. Hydrarg. Chloridi Mitis 3ij . . . . 8 Hydrarg. Protiodidi ^ij 2 CretiB Precip. §j 30 M. Whichever of these applications has been made, the subsequent dressing is to be applied according to the rules above given — dry lint to chancroids situated on moist mucous membranes; wet lint covered with oil-silk to those on external surfaces. Next to iodoform, a solution of the nitrate of silver, about fifteen grains to the ounce, is probably the best application, the lint which is to be placed upon the sore having first been soaked in it. Other formulae are as fol- lows : — R. Acidi Carbolici 5i-ij 4] — 8| Aquifi Oj 5001 M. LOCAL APPLICATIONS. 371 I^. Balsam. Peruvian. ,^ss 15! Argent. Nit. Cryst. vel Cupri Sulphat, gr. iij |20 M. (Zeissl.) I^. Ferri Potassio-tart. §ss 151 Accuse §vj 180| M. (Ricord.) R. Acidi Tannici 9j 130 Aquse Jvj 180 M. I^. Liquoris Sod;B Chlorinatre 3.1 •• ■ 41 A(|use Purfe§ij 60| M. I^. Acidi Nitrici Diluti Jj 4| Aquc-e Purse 3viij 250] M. ^.. Vini Aromatici §j 301 Aquae §iij 90 1 M. A formula for a convenient substitute for the French aromatic wine may be found on page 204. The strength of these lotions must be adapted to the sensibility of the part, which varies in different cases. They should never be so strong as to excite pain or produce irritation. The black wash, composed of from one to three scruples of calomel to four ounces of lime-water, is a favorite application with many surgeons. The dark-colored sediment in this mixture is an oxide of mercury, and is inert unless it aifords mechanical protection to the sore. In my opinion, black wash is a less cleanly and less desirable lotion than those before mentioned. A solution of the disulphate of quinine (gr. j ad ^j) with just enough dilute sulphuric acid to dissolve it is recommended by Mr. Nunn (London Lancet). A fact too little known, or too little appreciated by the profession, is that ointments of whatever kind are not only useless but positively inju- rious on account of their tendency to become rancid. They should never be employed unless, from the position of the sore, or from the necessarily long intervals between the dressings — as at night or during a journey — the evaporation of a water dressing cannot be prevented, even with the assistance of oiled silk and glycerine. Mercurial ointment, although very commonly used in Sigmund's wards in Vienna, is, in my opinion, especially objectionable. Zeissl also regards it with disfavor, and prefers the glycerite of starch. One of the following formuliie may be used in the rare instances in which an unctuous dressing is required : — R. Ung. Petrolei §i 30 Tincturre Opii 5j 4 t Caloraelanos gr. xxxvj .... 2 35 M. R. Balsarai Peruviani, 0!ei Ricini, aa §j 30| M. 312 CHANCROID. R. Ung. Petrolci gj 30! Pulv. Opii 5j • 4' M. Before one dressinjij is soaked with the discharge, another should be substituted. If the first adhere to the surface, it should be carefully moist- ened before attem[)ting its removal, in order to avoid any abrasion, which, by subsequent inoculation, would increase tlie size of the sore. The dress- ing of most uncomplicated chancroids need be renewed only two or three times a day, but phagedenic ulcers require a much greater frequency. During the progress of cicatrization, exuberant granulations may spring up and require repression by pencilling with a crayon of nitrate of silver. A superficial application of this agent is also beneficial in relieving the irritability and pain of some ulcers in the progressive and stationary periods. Other applications than those now mentioned may be required. For instance, in chancroids attended by much inflammation, leeches to the groins or perineum, and poultices or sedative lotions, may be of service. Pain should be relieved by the exhibition of opium in large doses internally, and by its application externally. CHANCROIDS OF THE FR^NUM. 31; CHAPTER II. PECULIARITIES DEPENDENT UPON THE SEAT OF CHANCROIDS. The seat of a chancroid often modifies the symptoms and necessitates clianges in the treatment. Chancroids upon the Integument of the Penis The majority of venereal ulcerations following suspicious connection, and seated upon the integument of the penis, are chancres and not chancroids ; why, I do not know ; but it behooves the surgeon to look sharply to his diagnosis with ulcers in this region. The rule is far from being invariable, for I have met with many cases of simple chancres situated between the pre- putial orifice and the root of the penis and even upon the pubes. Chan- croids upon the integument of the penis often originate in a follicle, and when first noticed resemble a pustule or small abscess {follicular chan- croids, see p. 358). Not unfrequently they extend to the loose cellular tissue, and undermine the skin around a small external opening through which the pus can be made to well up on pressure. The mobility of the integument over the concealed chancroidal cavity interferes with cicatri- zation and prolongs the duration of the ulcer. The cavity, first, thor- oughly cleansed of matter, should be cauterized by means of a sliver of wood (as a lucifer match) dipped in strong nitric acid ; or sometimes it becomes necessary to enlarge the external opening even at the risk of inoculation of the edges of the wound. The ulcer having been thoroughly exposed and freely cauterized, should be kept moist by the application of wet lint, a layer of oiled silk, and a retentive bandage, in the manner previously indicated. Chancroids of the Fr.enum Chancroids of the fra-num are espe- cially painful, persistent and exposed to hemorrhage. They may com- mence either upon the free margin or at the base of the bridle. In the former case a rent or fissure, the result of violence during coitus, has probably been inoculated ; and the resultant chancroid gradually eats away the whole bridle, and hollows out a narrow longitudinal groove upon the under surface of the glans, giving great annoyance, long persisting, and resistirtg ordinary modes of treatment. Again, they may proceed from chancroids in the neighborhood, which exhibit a remarkable tendency to involve the bridle, if situated near it. In this case the base of the fraMium is first attacked and often becomes perforated from side to side ; the chan- 374 CHANCROID. croidal opening gradually enlarges, extends to the free margin, and, as in the former case, probably destroys the whole bridle. The frtenum is copi- ously supplied with blood and exceedingly sensitive ; hence, ulcers of this part are very liable to bleed and give rise to much suffering. Their per- sistency and destructive tendency are due to the frequent rupture of the longitudinal fibres of the framum, occasioned by the constant motion to which it is exposed, in walking, handling the penis during micturition, in erections, etc. Minute rents are thus caused in the sore which become inoculated and increase its depth ; and ulcerative action goes on until the whole bridle is destroyed, including the portion buried in the under sur- face of the glans ; and hence the fossa already referred to. Occasionally they extend to the urethra and give rise to a urinary fistula. In the treat- ment of these ulcers, the patient should be directed to avoid all motion of the part which will stretch the fra;num ; the glans should not be un- covered except to dress the sore, and even then no further than is abso- lutely necessary to insert the dressing. If the chancroid threaten to de- stroy the whole bridle, time will be gained by accomplishing the same at once by means of caustic. When perforation has taken place, the remain- ing portion of the bridle should be divided with scissors, and the raw sur- faces freely cauterized. The flow of blood in this operation is often trou- blesome, and should be avoided by previously passing a double ligature through the opening and tying a thread at either extremity of the fra^num, all of which should be removed. Diday heats one blade of a dull pair of scissors over a-spirit lamp, and" passing the opposite cold blade through the opening to serve as a support, thus divides the froanum by the actual cautery.^ The galvano-caustic wire would seem well adapted to this pur- pose. SuB-PREPUTiAL CHANCROIDS Thesc are almost always multiple ; they suppurate freely and are quite destructive in their tendency. Thi'ee conditions of the prepuce may obtain : — 1. This envelope may be so large as to be readily retracted. 2. Tiie prepuce may be naturally tight, or it may be edematous from attendant inflammation, so that the sores are with difficulty exposed, and the attempt occasions rents in their surface, and considerable pain to the patient. 3. There may be complete phimosis, eitlier congenital or supervening as a complication of the disease. In the last case, the sores are more effectually " concealed" than if situated within the urethra or vagina, and, indeed, cannot be exposed at all except by an o[)eration. The discharge which collects in the balano- preputial fold before escaping from the or i rice, may usually be distinguished from that of balanitis. It is of a different color and less homogeneous, and is often streaked with blood and mingled with organic detritus. The • Du chancro primitif du frein cle la verge; Gaz. liebd. de mdd., Par., Oct. 19, 1855, p. 749. SUB-PREPUTIAL CHANCROIDS. 375 exact situation of the ulcers may sometimes be detected by palpation, whenever the inflammation of the surrounding tissues is sufficient to con- vey the impression of hardness to the fingers applied to the external surface of the prepuce, and also by the pain excited by pressure. Chancroids are apt to appear upon the margin of the preputial orifice in consequence of successive inoculation from the discharge of those within, and they present a few peculiarities worthy of notice. Thus they are often extilcerous, or superficial, their floor being nearly or quite on a level with the surrounding integument, a fact, which has been attributed to the constant irritation to which they are subjected from the sub-preputial dis- charge and the urine. The same cause frequently occasions a fictitious indui'ation of their base, so that they may be mistaken for true chancres. They sometimes appear as rents or fissures in consequence of their occu- pying the folds of the orifice, and they are then, as it were, doubled upon themselves, so that two jwrtions of their surface are in apposition. Any attempt to destroy them by cauterization will fail, so long as the ulcers beneath the prepuce remain open and secrete inoculable pus. Sub-preputial chancroids ai"e especially exposed to become complicated with balanitis, abscesses between the two layers of the prepuce, phagedtena, and gangrene. Several neighboring ulcerations may unite and form a large sore, which may result in the destruction of more or less of the glans, or, by extending along the furrow at its base, nearly enucleate this organ. The treatment varies according to the presence or absence of phimosis. When the prepuce can be kept retracted without becoming oademcitous, and incurring danger of paraphimosis, the ulcers may be cauterized and dressed like chancroids upon the external integument of the penis. They will thus heal much more readily than if the prepuce be kept forward. In cases of partial phimosis, in Avhich retraction of the prepuce can be effected only with pain and violence, it is better to allow it to remain for- ward and treat the ulcers as if the phimosis were complete. Destructive cauterization is here, of course, impossible, and attention to cleanliness, the use of astringent lotions, and in cases attended with inflammation, hot hip- baths and rest are the only means of relief. The balano-preputial fold should be thoroughly cleansed with injections of tepid water, repeated from three to six times a day, according to the copiousness of the discharge by means of a syringe with a nozzle long enough to reach the base of the glans. An astringent or slightly caustic lotion may afterwards be thrown in ; one of the best for the purpose is a solution of nitrate of silver, from five to ten grains to the ounce of water. Tliis application is not contra- indicated even by the presence of inflammation, since its effect is found to be sedative. Abscesses occurring between the layers of the prepuce must be opened. The reader is referred to Chaps. III. and IV., of Part I. of this work for a fuller account of the treatment of balanitis and phimosis complicating the chancroid. Sub-preputial chancroids, especially when accompanied by chancroids 376 CHANCROID. of the preputial orifice, are often followed by such an amount of permanent contraction of the prepuce as to render exposure of the glans difficult or impossible. In these cases it is better, after the sores have healed, to resort to circumcision, otherwise the abnormal condition of tlie parts is a constant source of annoyance, interfering with cleanliness and exposing to repeated attacks of balanitis and herpes. Urethral Chancroids — Chancroids are not unfrequently met with at the meatus, occupying either a portion or the whole of the margin of this orifice, and they occasionally occur within the fossa navicularis, which is richly supplied with follicles whose moutlis afford ready entrance to the poison. In this manner a number of small follicular chancroids may arise in the fossa, which in consequence of the ulceration of the intervening walls subsequently form a sore of considerable size, and this has been known to extend into the subcutaneous cellular tissue and undermine the integu- ment of the penis even up to the pubes (Zeissl). 1 have never met with chancroids in any deeper portion of the canal, and the possibility of their existence is doubted by most authorities of the present day, including Zeissl. Ilicord,' indeed, presented to the Academy of Medicine, of Paris, two specimens of ulcers affecting tiie deeper portions of the urethra and even the bladder, of which he has given plates in his Atlas, and in his Notes to Hunter on Venereal. These he believed to be chancroids, on tlie ground that he had successfully inoculated the secretion coming from the patient's urethroe before death. With our present knowl- edo'e, we cannot now regard this proof as conclusive ; and, even at the meeting of the Academy referred to, a number of the members present expressed their belief that the ulcerations were tubercular. We conclude that the existence of uretliral and vesical chancroids, except at or near the meatus urinarius, is not proven. A case of tuberculosis of the urethra simulating urethral chancre, was published by Emanuel Soloweitschick in the Archiv fiir Derm, and Syph., vol. ii, p. 1. Any lesion confined to the lips of tlie meatus is of course visible to the unassisted eye. For ex[)loration of the fossa navicularis, Toynbee's ear- specula may be used, the uniform calibre of which permits of their intro- duction for about an inch, and if the patient be placed in direct sunlight, or reflected light be used, an excellent view of the lining membrane for this distance may be obtained. Any short endoscopic tube, will, of course, answer the same purpose. Dr. T. Skeene, of Brooklyn, has recently in- vented one (Fig. 113) which has some advantages. No special treatment, other than that described in the previous chapter, is required. The dressing, with perhaps a thread attached to facilitate its withdrawal, should be renewed after each act of micturition. If con- tact of the urine be painful, tliis may partially be relieved by holding the penis in a glassful of warm water during the act. These ulcerations may eat away the lips on either side, finally leaving the urethral opening funnel-form in shape. Still more frequently a stricture ' Bull. Acad, de Med. 1838, t. ii, p. 506. CHANCROIDS OF FEMALE GENITAL ORGANS. 377 at or near the meatus is formed during the process of cicatrization. To prevent this a pledget of lint or a piece of a bougie about an inch long, Fi.cr. 113. Skeene's endoscope. smeared with some ointment, and retained in place by an appropriate bandage, should be kept in the canal while the sore is healin"-. Even with this precaution, " slitting the meatus" will often be required subse- quently. Chancroids of the Female Genital Organs. — Upon the external and integumental surface of the labia majora, chancroids often assume the appearance of pustules or abscesses, in consequence of the virus having inoculated the internal surface of one or more of the follicles (follicular chancroids) ; and there is frequently more or less oedema of the subcuta- neous cellular tissue, as evinced by the swelling and hardness of the labia. When the pustule breaks, the underlying ulcer, if exposed to the air, be- comes covered with a scab and resembles ecthyma. Chancroids are also common on other portions of the vulva ; on the in- ternal surface of the labia majora, where they occasion pain and difficulty in walking ; on the labia minora ; and in the neighborhood of the clitoris and meatus. Their base is engorged from the irritation of the urine and vaginal discharges, which likewise renders them difficult of cure. Those situated at the meatus often penetrate the urethra for some distance, giving the orifice an infundibuliform shape, or, by destroying the posterior wall of the canal, throw its opening backwards into the vagina. When attacked by phagediBna, as not unfre(iiiently happens, the loss of tissue may result in great deformity and inconvenience. Vulvar chancroids are, however, much more common at the fourchette than elsewhere, partly in consequence of its dependent position where con- tagious secretions gravitate, and partly owing to the rents and abrasions to which it is exposed in sexual intercourse, and to its being neglected in the ordinary aftentions to cleanliness. They have been attributed to inocula- tion of discharges from the deeper parts of the vagina, and have conse- quently been regarded as affording a strong probability of the existence of chancroids upon the os uteri. These ulcers often assume the form of fis- 378 CHANCROID. sures, like chancroids of the preputial orifice and of the anus, and for the same reason. Examination of the vulva and lower part of the vagina is greatly facili- tated by passing one finger up the anus and pressing the recto-vaginal wall forwards. Chanci'oids often occupy the interspaces between the caruncles, where they may readily be overlooked unless carefully sought for. In the lower portion of the vagina, chancroids are generally irregular in their outline, and often invade the walls of this passage for a certain distance internally, and the vulva externally. Among low prostitutes especially, they may open a communication with the rectum, forming fistula? which are difficult or impossible to close after the healing of the sore. I am informed by my friend, Dr. Emmet, that the ordinary operation for recto-vaginal fistulsB, when such fistula? were due to venereal ulcerations, has always failed, even in his skilful hands. As we ascend the vagina, chancroids are less fre- quently met with. They are least uncommon in the lower third, and are exceedingly rare in the upper two-thirds. They are oftener seen on the cervix uteri, but their occurrence even here is a rarity. Among 332 cases of venereal sores of the female genital organs, including both cliancroids and true chancres, observed by Klink,^ eight were situated on the cervix and one on the deeper portion of the vagina. Klink remarks that French authorities regard their existence upon the cervix as much more frequent than do the German ; while, on the other hand, the French look upon a chancroid of the upper part of the vagina as an extreme rarity, yet the Germans think it not of such very uncommon occurrence. He, although a German, thinks the French are in the right. It has been observed, as might be expected a priori^ that in chancres on the cervix, the contagion was often derived from a man having a ^ore situated on the glans penis, and especially at the meatus. These ulcers upon the cervix may be single or multiple. They may occupy one or both lips of the os, or involve a large portion of the cervix. They occasion little or no pain. Similar sores are usually present at the vulva. They are commonly accompanied by catarrhal inflammation of the vagina, often by inflammation of the womb. They are prone to take on phagedenic action and destroy a portion or the whole of the cervix ; in one case mentioned by Bernutz^ pelvic peritonitis was induced. They may extend into the cervical canal, and, according to Despres,^ even into the uterine cavity. When seated upon the margin of the os externum, their cicati'ization results in a firm stricture of this orifice. Can a chancroid exist so far within the cervical canal as not to be visible and not to present any evidence of its presence upon vaginal ex- amination with a speculum ? It can, if we may credit tlie following case : — ' Vrtljschr. f. Dermat., Wieii, 1876, p. 542. 2 Traite des mal. de.l'utefus, t. ii, p. ]17. 3 Traitd iconographique de rulceration et des ulceres du col de I'uterus, Paris, 1870. CHANCROIDS OF FEMALE GENITAL ORGANS. 379 " In March, 1840, a woman from the neighborhood of Aries, aged 22, and remarkably beautiful in form and appearance, was thoroughly ex- amined in the usual manner, by Prof. Lallemand, and no symptom of venereal disease discovered. This examination was made at the request of an officer who complained that she had infected him ; and several simi- lar complaints being subsequently made by others, she was sent to the police station, where she was again examined by M. Delmas in the presence of a considerable number of students. The neck of the uterus still appeared healthy, but on pressing it with the speculum, it discharged a muco-purulent fluid, which was inoculated in four places upon the patient's thigh, ivitli the effect of producing four well-marked chcciicroids."^ AVe shall see hereafter when considering the true chancre, that one of its most prominent symptoms, viz., induration of its base, which is almost always present in men, is often poorly marked or even absent in women. It may hence be inferred that the exact diagnosis of venereal ulcers in women, as to whether they are chancroids or chancres, is frequently diffi- cult or even impossible, unless indicated by the condition of the inguinal ganglia or the occurrence of secondary symptoms at the usual period. This dithculty is increased when the sore is situated upon the cervix, since the normal consistency of this part is so great as readily to mask to the touch any induration, especially of the parchment form, of- the base of the ulcer. The treatment of chancroids of the female genital organs does not differ materially from that already laid down. The application of the speculum to venereal diseases, introduced by Ricord, has rendered these ulcers nearly as accessible as if situated upon the external integument. Almost the only modifications requii'ed in the treatment are due to the difficulty of maintaining and changing with sufficient frequency the local dressing, and to the danger in certain regions of resorting to destructive cauterization. With chancroids about the vulva the stronger caustics may be used with the same freedom and the same benefit as in the male sex. It requires no little care and attention to keep the di'essing in such immediate contact with the sore as to be of any service, but this may still be accomplished by means of a T bandage, or by the ingenious contrivance with regard to which women beyond the age of puberty need no instruction. Here, as elsewhere upon the female genital organs, the dressing soon becomes soaked with the natural or abnormal secretion of the parts, and requires more frequent changing than in the male. With chancroids situated upon the walls of the vagina, destructive cauterization should be used with great caution, for fear of opening com- munication with the rectum, urethra, or bladder, or in the deeper portion of this passage, of inducing peritonitis. This objection does not apply to chancroids of the cervix, which may be tiioronghly cauterized through a speculum. If the patient can be seen often enougli, the sore may be iso- lated and its secretion absorbed by the insertion of a tampon of lint either • J. Soc. de m6d. prat, de Montpel., 1845 ; and Gaz. m6d. de Paris, 1845, p. 670. 380 CHANCROID. dry or medicated ; but this requires a visit at least once in twenty-four hours, and may, tlierefore, be impracticable in private practice. The best substitute is the frequent use by the patient herself of copious vaginal in- jections, either disinfectant or astringent, as a solution of carbolic acid, nitrate of silver, alum, tannin, etc. Chronic Chancroid of Prostitutes — Among public Avomen, especially those of the lowest class, there is a form of chancroid which is often seen in our public hospitals, and which is entitled to be regarded as a variety of the simple chancre. Examples of it are always to be found in the venereal wards of Charity Hospital, Blackwell's Island. It was first noticed by MM. Boys de Loury and Costilhes,^ and more recently by Rollet,*" of Lyons, who speaks of it under the head of phagedena, and whose description I shall chiefly follow. " Chronic chancroids may be seated upon any portion of the genital organs, but especially at the posterior commissure of the labia majora. There is also another point where they are very frequent, viz., at the entrance of the vagina, on either side of the urethra, in the furrow exter- nal to this canal. These ulcers often acquire a considerable size, less, however, than serpiginous chancroids, whose progress is always more rapid. In most cases, no difference can be recognized between the appear- ance of a chronic chancroid and a chancroid of the ordinary type ; but it is found on inquiry that the ulceration has persisted for an unusually long time, and that it is indolent — a character, however, which must not be regarded as belonging exclusively to this variety, since an acute chan- croid, occupying the mucous membrane of the vagina, is often free from pain. Yet we find women with chronic chancroids of the genital organs either multiple or of large extent, the existence of which they do not even suspect, since they experience no inconvenience from them. "There is rarely any inflammation, but usually an infiltration of thg sur- rounding tissues. The surface of the ulcer is of a pale color, and often covered with a somewhat firm secretion, beneath which the tissues are also hardened ; hence the name given them by M. S{)erino of callous and chronic vulvo -vaginal chancres. This variety is usually met with in women from thirty to forty years of age, who are debilitated, of a pallid complexion, and exhausted by their excesses." M. Rollet thinks, with reason, that other affections than chancroids have been included under this name ; for instance, that a mere rent in a debilitated subject may terminate in a chronic ulcer under the irritation of filth, contact of the urine and vaginal secretion, and frequent indulgence in sexual intercourse. The callous condition of the surrounding tissues has appeared to me to be the greatest obstacle in the way of their cure. I have treated them successfully at Cliarity Hospital, when their situation, as in the furrow ' Des ulcerations chroniquos, ou chancres clironiqiies des parties geni tales de la femrae. Paris, 1845. 2 Traite des mal. veil., Paris, 18G5, p. 186. CHANCROIDS OF THE ANUS AND RECTUM. 381 between the nates, permitted ; by putting the patient under the influence of ether, excising the hardened and hypertrophied masses of tissue, and freely applying the actual cautery to the fresh wound as well as to the sur- face of the ulcer. But there are other cases at the above-named institu- tion, in which the situation of the sore at the entrance of the vagina does not admit of such heroic treatment, and in which the patients make their appearance from time to time during a period of years, leaving the hospital whenever they are somewhat improved, and returning when their condi- tion is again so aggravated that they cannot carry on their trade. In many such cases, powdering the surface of the ulcer several times a day with iodoform or with the persulphate of iron (Monsel's salt) will be found to have an excellent effect. Hypertrophy foUoiving Chancroids of the Female Genital Organs Hypertrophy, especially of the labia majora, is frequently seen in Avomen who have been the subjects of venereal ulcerations, and is regarded by Gosselin (^Arch. gm. de med., Dec. 1854, p. 684) as so exclusively the etfect of chancroids, that its presence is sufficient to justify the conclusion that a woman has been thus diseased. We see the same effect in the thickening of the prepuce in the male following sub-preputial chancroids, to which I have already referred. Chancroids of the Anus and Rectum Chancroids of the anus and rectum may occur in either sex from unnatural coitus, but are more frequent in women owing to the facility with which these parts are soiled with the secretion of sores situated upon the vulva. When seated upon the margin of the anus, they may readily be mistaken for fissures. They are best exposed in women by passing a finger into the vagina and pressing the vagino-rectal fold out through the anus. They are attended by much pain, especially during the passage of the feces, which should always be rendered liquid before going to stool by a mucilaginous injection. It is sometimes advisable after clearing out the bowels, to thoroughly cauterize the sore, and to confine the patient to bed and a low diet, and administer opiates for the purpose of preventing any further stools until cicatrization has taken place. M. Tardieu* calls attention to the fact that in cases of the communication of chancroids (and the same is true of chancres) in unnatural intercourse, the ulcer is usually found upon the same side in both of the guilty parties — upon the right or left side of the penis in the one, and upon the corre- sponding side of the rectum in the other. This, of course, is the reverse of what holds good in natural coitus, in which a sore upon one side of the penis or vulva is most apt to be inoculated upon the opposite side of the other sex. Chancroids of the folds of the anus, even when cured — as virulent ulcers — may term-nate in fissures, which are still difficult to heal, in consequence of the fre(iuent passage of the feces, and the spasmodic contraction of the ' Etude niedicu-l(;galo sur Ics attontats aux mocurs, 1867, p. 200. 382 CHANCROID. sphincter ani. In sucli cases the only certain means of relief is to be found in the well-known forcible dilatation or rupture of the sphincter, employed in ordinary cases of fissure of the anus. , . Rollet advises repeated cauterization of the fissure with nitrate of silver, and a dressing of the following ointment : — I^. Glycerine |j 38 Aniyli §ss 15 Zinci Oxidi 3ij 8 This treatment may possibly succeed in mild cases. Chancroids of the anus and rectum not unfrequently escape observation from the natural reluctance of patients, especially women, to have this part of the body examined ; and, indeed, the surgeon himself is often con- tent with an inspection of the external orifice of the alimentary canal, when a digital examination would reveal the presence of a chancroid in the rectum. Chancroids in this situation often take on phagedenic action and open a communication with the vagina.^ • Des chancres jihaged^niques du rectum, par le Dr. A. Despres, Arcli. g6ii. de rued., mars, 1868. INFLAMMATORY OR GANGRENOUS CHANCROID. 383 CHAPTER III. THE CHANCROID COMPLICATED WITH EXCES- SIVE INFLAMMATION AND WITH PHAGED.ENA. Excessive inflammation terminating in gangrene gives rise to the inflammatory or gangrenous chancroid; and phagedenic ulceration, in several different forms, to as many varieties of the phagedenic chancroid. Inflammatoiiy OR Gangrenous Chancroid. — The inflammation attendant upon a chancroid is sometimes so excessive as to terminate in gangrene, and produce a slough of the surrounding tissues, like that caused by the application of a powerful caustic. Age is said to be a predisposing cause, as is undoubtedly a constitution originally defective, or one debili- tated by excess of any kind, and especially by the habitual use of alcoholic stimulants. Among exciting causes, are to be mentioned mechanical con- striction, violence, indulgence in coitus, excessive exercise, want of clean- liness, and retention of the secretion upon the surface of the sore, the use of improper dressings, as fatty substances, and especially mercurial oint- ment. The supervention of some acute disease may also produce it. M. Sperino found this complication occur in many of the chancroids which he inoculated upon persons who were afterwards attacked with fever, and particularly with intermittent fever, which was very common in the neigh- borhood of his hospital, at Turin, situated in a marshy district. But this complication is most frequently met with in cases of congenital or accidental phimosis, in which the sore is imprisoned beneath the prepuce. Tlie inflammation progresses rapidly and soon terminates in gangrene. The slough may be limited to the tissues surrounding the ulcer, and in- volve only the internal layer of the prepuce; in which case the chief evidence of the occurrence of the complication is found in the ichorous appearance and fetid odor of the discharge from the preputial orifice, and the ultimate effect may be to produce adhesions of greater or less extent between the glans and its envelope. In other cases, both layers of tiie prepuce are involved. The extremity of the i)enis becomes swollen and (jcdematous, resembling a club or the clapper of a bell ; a dark violet-colored spot appears, either with or with- out phlyctenulaj upon its surface, generally upon the dorsal aspect, and involves more or less of the prepuce. If the arteria dorsalis penis be- come corroded, dangerous hemorrhage may ensue, which, as shown by experience, is not always arrested by ligatun; of the artery. If the slough is limited in extent, the glans penis often protrudes through the opening 384 COMPLICATED CHANCROID. formed, while the preputial orifice remains intact, and the virile organ has the appearance of being bifurcated at the extremity. In other in- stances the whole of the prepuce comes away, but the progress of the gangrene is usually limited at the furrow at the base of the glans, and the patient is circumcised as accurately as if by the surgeon's knife. Paraphimosis complicating chancroids may i-esult in a similar manner, and produce a slough of the whole or a part of that portion of the prepuce (its mucous layer) lying in front of the constricting ring, together with more or less of the glans. After the fall of the slough, there remains only a simple wound destitute of virulent properties. It is evident that excessive inflammation, which is due to simple causes, is a mere complication of the chancroid, and does not in itself change its nature ; but its effect, when it terminates in gangrene, is exactly the same as that produced by the application of a strong caustic, viz., the tissues surrounding the ulcer are involved in the slough to an extent exceeding the sphere of the specific influence of the virus. Consequently, the re- maining wound presents all the characteristic's of any simple sore, and its secretion is not inoculable. Inflammatory or gangrenous chancroids are included by most English ■writers among the phagedenic, but there would appear to be sufficient rea- son to follow the classification adopted by the French, and consider them as distinct. Buboes are rare in connection with this variety. Inflammatory chancroids are to be treated by confining the patient to bed, low diet, mild purgatives, leeches to the groin or perinseum — never on the penis itself — the local application of cold or evaporating lotions, or, at a later stage, of warm poultices, as of chamomile flowers, recommended by Dr. Hammond as the best (op. cit. p. SG) and other antiphlogistic measures, so long as the acute symptoms continue ; but if gangrene super- vene tonics and stimulants are in most cases required. If the case be complicated with phimosis and the ulcer be concealed beneath the prepuce, the prepuce should at least be slit up by means of a bistoury carried along a director introduced from the orifice, care being taken to extend the in- cision to tlie furrow at the base of the glans. I think it desirable, how- ever, to avoid, if possible, these incomplete operations, which leave the penis in a condition of deformity, and I therefore resort to complete cir- cumcision in many cases, and especially when the foreskin is unnaturally long. If the slough of the tissues surrounding the ulcer has already formed, there is no danger of inoculation of the edges of the wound ; and even if the gangrene is only commencing and the wound should become inoculated, the fresh ulceration will commonly heal as rapidly as the sub- preputial chancroids, and the patient will be left in a much better condi- tion than when only a partial operation has been performed. Fuller directions may be found in the chapter on phimosis. Mr. William Lawrence, whose experience has been very extensive, has the following remaiks upon the indications for an operation : " To deter- mine whether the prepuce should be divided or not is sometimes a difl[i- PHAGEDENIC CHANCROIDS. 385 cult matter of diagnosis. The degree of redness, swelling, and pain will not enable us to decide. The propriety of the measure depends on the condition of the sore which we cannot see. The discharge from the ori- fice of the prepuce must assist our judgment in doubtful cases. An ichor- ous or sanious state of discharge, with fetor, indicates sloughing ; and in such circumstances the division ought to be performed. If the discharge should be purulent, even though somewhat bloody, and the glans tender on pressure, we may be contented with leeches, tepid syringing, and mild aperients.'" If gangrene shows no tendency to self-limitation, destructive cauteriza- tion should at once be employed. Phagedenic Chancroids. — In the chancroid, as commonly observed, the process of ulceration is generally slow and limited in extent, and ad- vances with nearly equal rapidity in all directions ; whence the sore main- tains a rounded form, and does not involve the tissues to any great extent or depth. Phagedenic chancroids, on the contrary, are characterized by their more rapid, extensive, and irregular progress ; though these charac- ters vary greatly in degree in different cases. The following remarks are intended to apply to phagediena, not only when it attacks the original ulcer, but also when it affects a virulent bubo or virulent lymphitis, which are in reality chancroids of the gUmds or of the lymphatics. These remarks, so far as the symptoms are concerned, are also applica- ble to cases of phagedicna attacking the initial lesion of syphilis, in whicli the indurated base of the sore is commonly destroyed. But, it sliould be noticed, a true chancre is less frequently affected with phagedtena. In mo.-t such instances that I have seen, the induration remaining after the healino- of the original sore has itself become ulcerated and taken on phagedenic action. Induration of the ganglia, in the rare instances in which it terminates in suppuration, is never followed by phagedasna. Phagedcena attacks a bubo only when the latter is virulent and due to a chancroid. In the mildest and most fretjuent form of phagedtena, the sore merely extends in surface and in de|)tli sliglitly beyond its ordinary bounds ; this is sometimes observed at all parts of tlie circumference, but generally at one part more than another, so that the circular form is lost and the out- line becomes irregular, but yet the ulcerative action is not excessive. SerpifjinoHS Chancroid Piiageda^iia may stop here, or it may go on to form a serpiginous chancroid which is slow in its progress, but to the extent and duration of which there is no limit. The edges of the sore in this variety are thin, livid, and cedematous. and so extensively undermined that they fall upon the ulcerated surface or may be turned back like a flap upon the souud skin ; they are often perforated at various points, and are very irregular in their outline, resembling a festoon. The surface of tiie ' Lecturt'S on Surgerv, London, 18(J3, p. 390. 25 386 COMPLICATED CHANCROID. sore is uneven, and covei'ed with a thick pultaceous and grayish secretion, through whicli florid granulations at times protrude and bleed copiously upon the slightest touch. Serpiginous chancroids are not attended by much constitutional reaction. They exhibit a predilection for the super- ficial cellular tissue, and are inclined to extend in surface rather than in depth. They sometimes undermine tlie whole skin of the penis as far as the pubes, or make their way down the thigh nearly to the knee, or up- wards upon the abdomen, or follow the course of the crest of the ilium. They often advance on one side while they are healing upon the opposite. Their progress may appear to be arrested and the sore nearly cicatrized, when rapid ulceration again sets in and destroys the newly-formed tissue. Their secretion is copious, thin, and sanious, and preserves its contagious properties through the many years that the ulcer may persist. They leave behind them a whitish and indelible cicatrix, resembling that produced by a deep burn. This sore may be mistaken for the serpiginous ulceration of tertiary syphilis. It is distinguished from it by the fact that it commences with a chancroid — usually sfeated upon the genitals — or with a suppurating bubo in the groin ; that from this point of origin it extends by a continu- ous process of ulceration, the course of which is evident from the foul cicatrix which it leaves behind; and that it never overleaps sound por- tions of the integument. Moreover, the fluidity of its secretion does not favor the formation of scabs, and its contagious properties are manifest if inoculated upon the person bearing it.^ Sloughing PJiagedenic Chancroid A third variety is called the slough- ing phagedenic ulcer, and is characterized by the greater acuteness, rapidity, and depth of the destructive action. Its symptoms closely resemble those of hospital gangrene. There is considerable constitutional disturbance, a full and hard pulse, furred tongue, and other symptoms of fever.- The pain is often excessive, and almost insupportable. The ulcer extends chiefly to dependent parts in the neighborhood, which are infiltrated by its copious and foul secretion. It respects no tissue whatever, and its ravages are sometimes terrible ; the glans, penis, or labia may be wholly destroyed, and the testicles entirely laid bare. Fatal hemorrhage has been known to occur from ulceration of the arteria dorsalis penis. The sloughing phagedenic chancroid is most common among the intempe- rate and lowest class of prostitutes, and also among persons visiting hot climates or exposed to various hardships. It was this variety which deci- mated the English troops in the Peninsular war, although venereal dis- eases were at the time comparatively mild among the natives. Phagedenic chancroids are not unfrequently attended by buboes, which generally take on the same destructive action as themselves. Fournier's confrontations, already referred to, prove that the phage- denic chancroid is not always transmitted in its kind, and that hence it cannot dei)end upon a distinct poison. This does not, however, conflict ' Bassereau, op. cit. p. 475. TREATMENT OF PHAGEDENIC CHANCROID. 887 v,'itli the fact that contagious matter possesses noxious properties propor- tionate to the degree of its putrescence, when such has taken place. ^V'e have an instance of this in the disastrous effects of wounds acquired in the dead-house. Witness also the mortality in the town of Westford, Mass., in the spring of 18G0, following vaccination with scabs originally pure, but which were dissolved in water and exposed to air and heat until they were decomposed.' In most cases, however, phagedaina is doubtless dependent upon some form of constitutional cachexia, the exact nature of which is not always apparent. The abuse of mercury in the treatment of venereal ulcers is another cause, which was more frequent a few years since than now, and the improved practice of the present day may account in a measure for the partial disappearance of this variety. Treatment of Phagedcena The general treatment of phagedenic ulcers should be based upon a knowledge of the cause of the destructive action when this can be ascertained. Phagedena most frequently occurs in persons debilitated by various causes, as intemperance, irregularity of life, want, or a residence in damp, unhealthy apartments ; in these cases, nourishing food, the ordinary comforts of life, and the mineral or vegetable tonics are required. Scrofula is another fruitful source of phagedtena, and calls for preparations of iodine and other antistrumous remedies. Moderate doses of opium repeated at short intervals, so as to keep the patient gently under its influence, are often of essential service in allaying pain, and in controlling the progress of the disease. Numerous observers have called attention to the beneficial effect of this agent upon ulcerative action, and have ascribed to it a decidedly tonic influence. Rodet reports several cases of serpiginous chancroids which resisted a great variety of means, but which yielded to opium. This surgeon commences with about one o-rain of the extract of opium morning and night, and gradually but rapidly in- creases the dose so that the system mny not become habituated to it before its therapeutic effect takes place. He prefers two large doses in the twenty-four hours to smaller ones more frequently repeated, in order that digestion may go on unimpeded in the intervals. Light wines ai'e largely administered at the same time, and are said to correct any tendency to constipation. In many cases it is impossible to discover the cause of phagedasna. The general condition of the patient is good; all his functions are duly per- formed ; and yet his ulcer continues to extend. In such cases our chief reliance must be placed u{)on local applications and deep cauterization, and the general treatment must be experimental. Ricord placed great reliance on the potassio-tartrate of iron, which he called the " born enemy of phagedfcna." He administered it internally in doses of two teaspoonfuls to a tablespoonful of the following mixture three times a day after meals, also applying a lotion of the same salt to the ulcer : — * ' Boston M. and S. J., May, 1860. 388 COMPLICATED CHANCROID. I^. Ferri et Potassse Tartratis, §ss ... 151 Aquse, ^iij • . . . 90| Syrupi, gUj 1101 M. Ricord's praise of this remedy has not been confirmed by my own, more matnre experience, or that of others. Great benefit is to be derived from the local application of iodoform, as recommended in the treatment of the chancroid. Under its influence the pain is allayed and the ulcer will frequently, without other measures, take on healthy action. The iodoform may be applied in powder or ethe- rial solution once a day, and the sore be dressed with an ointment contain- ing a drachm of iodoform to the ounce of lard or vaseline. Probably no treatment affords better results in obstinate cases of phage- denic ulcerations than the prolonged immersion of the parts in hot water, a method employed by Ilebra in various affections of the skin. If the ulceration be confined to the genitals, an ordinary sitz-bath will answer the purpose ; if more extensive, a full bath will be required. In the former case, a large sponge is convenient for the patient to sit upon. Immersion for eight or ten hours a day, care being taken to keep the parts affected below the surface of the water, is desirable ; as the case improves, immer- sion every other hour may suffice. The water should be kept at a tem- perature of about 98°, and the upper part of the body be protected by suitable covering. At night, a dressing of iodoform should be applied, and the same be allowed to soak in the bath the next morning before removal. By this treatment, the sufferings of the patient are not only greatly relieved, but the effect in arresting the progress of the ulceration and inducing reparative action is, in most cases, astonishing.^ Weisflog- uses a Faradic bath, one electrode being connected with the bottom of the tub. The patient, when immersed, touches the other elec- trode, covered with a moistened sponge, with one or more fingers, according to the sensations produced in the ulcer. Our last resort for the cure of phagedenic chancroids is the complete destruction of the sore by a powerful caustic or the actual cautery. In cases of a comparatively mild character, we may rely upon the application of fuming nitric acid, taking care to apply it to every crevice, especially beneath the edges of the undermined integument. If the smallest loophole be left from which virulent pus can proceed, it will inoculate the wound remaining after the fall of the eschar, and the only effect of the treatment will be to increase the size of the ulcer. It is evident, therefore, that cauterization, in order to be a benefit and not an injury, must be thorough and complete. In severe cases Ricord repeats the application as often as twice a day, and in the mean while dresses the sore with lint soaked in • See articles by — Dr. Simmons, of Yokoliama, Med. Rec, N. Y., Sept. 11, 1875. R. W. Taylor, Review in Arch, of Dermat., N. ¥., vol. ii, 1876, p. 183. Arthur Cooper, Lancet, bond., May 24, 1879, p. 731. 2 Arch. f. path, anat., etc. (Virchow), Berl., B. (jC, s. 311, and Practitioner, Lond., March, 1879, p. 216. TREATMENT OF PHAGEDENIC CHANCROID. 389 aromatic wine or a solution of the potassio-tartrate of iron. Pain and swelling are not always contra-indications to the use of the caustic,- which is frequently the most effective sedative that can be employed. The carbo-sulpliuric paste (see p. 367) is also an excellent caustic, and does its work better than any other, with the exception of the actual cautery. Other caustics recommended by authors are — Pure hromine. The permanganate of potassa,^ of which a saturated solution (gr. 85 to water ^j) may be applied three or four times a day, and the sores dressed meanwiiile with lint soaked in a mixture of a di-achm of the satu- rated solution to the pint of water. Carbolic acid has been more recently employed for the same purpose, and is, I believe, still more efficacious. The surface of the sore may be painted over with the impure liquid acid, and afterwards dressed with a solution of the same, of the strength of two drachms to the pint of water. T/ie actual cautery may still be required in the more severe cases of phagedaina, when other means have failed; and the extent of tlie surface involved by the ulceration should be no bar to its free application. P^ither the old cauterizing irons, or, better still, Paquelin's thermo-cautery or the galvano-cautery, is best adapted. A "white heat" is required, and the patient should be rendered insensible by an anaesthetic. The ulcer should first be cleansed by washing it copiously with water, removing all adherent matter, and then drying it. Every portion of the secreting surface should now be deeply cauterized, carrying the hot iron into every nook and sinus, and paying special attention to the parts over- lapped by the skin of the edges. These flaps of integument should be cauterized not only upon the under, but also upon the outer surface, so as to be for the most part destroyed. A cold water-dressing is afterwards applied, and the patient, on waking, does not suffer much more than he did before the operation. When suppuration commences, Goulard's ex- tract or aromatic wine may be added to the lotion. An attack of erysipelas has been known to arrest the progress of phage- dsena and to induce cicatrization of serpiginous ulcers which have proved intractable under almost every form of medication. An instance of this kind is contributed by M. liuzenet to Ricord's Lcr^oas siir la chancre, and several are re{)orted by other surgeons. Attempts to cure serpiginous cliaiicroids by means of " syphilization" have signally failed. ' Soo "Remarks on the Use of Permanganate of Potassa," by Dr. F. Iliiikle, Am. M. Times, N. Y., Nov. 28, 1863. 390 CHANCROID COMPLICATED "WITH SYPHILIS. CHAPTER IV. THE CHANCROID COMPLICATED WITH SYPHILIS. — "MIXED CHANCRE." Syphilitic infection of the system presents no barrier to the existence of a cliancroid, and vice versa. Universal experience confirms the state- ment that a person presenting sypliilitic symptoms, whether primary, secondary, or tertiary, may contract a chancroid, which will run the same course as in a person free from syphilis. Moreover two inoculations, one with the. chancroidal and the other with the syphilitic virus, may occur side by side, and the resultant chancroid and chancre will each pursue its normal course uninfluenced by the neighborhood of the other; and, finally, two such inoculations may take place at one and the same point and pro- duce a sore possessing all the properties of the chancroid and the primary syphilitic ulcer, viz., on the one hand, ready auto-inoculability and the power of producing a suppurating bubo secreting inoculable pus; and on the other, an indurated base, induration of the neighboring ganglia, and a secretion capable of communicating syphilis to a person free from previous syphilitic taint. I have denominated such a sore a "chancroid complicated with syphilis." It would clearly be just as appropriate to call it "primary syphilis com- plicated with the chancroid." The French have named it the "mixed chanci-e," and it has been the subject of much discussion, as noticed in the Introduction to the present work, in connection with the doctrines of the Lyons school. It is hardly deserving of a distinct name, since A '■'■mixed chancre" is nothing more nor less than a sore resulting from the inoculation, at the same spot, of the syphilitic virus and of the chan- croid(d poison, the product of simple inflammation. The implantation of the two kinds of virus may take place synchronously, as, for instance, in the same act of coitus when a man has connection with a woman affected with a cliancroid and also with syphilitic manifestations; or the inoculation of either virus may occur upon a previously existing ulcer of the opposite species. In either case, when fully developed, the mixed chancre may be perpetuated in its kinds by successive inoculation from one individual to another. Prior to its full development — supposing the inoculations of the two kinds of virus to have taken place at the same time — the chancroid, having no period of incubation, will first appear, and can only by contagion give rise to a chancroid; while, again, towards the close of the ulceration, wliichever virus persists in the sore the longer will ultimately transmit itself alone in its species. CASES. 391 The following instance in which a mixed chancre was developed by tlie inoculation of a primary syphilitic ulcer with the chancroidal poison, is reported by Fournier : — Alphonse N., aged 17, contracted a chancre in the latter part of Sept. 1857. He became an out-patient of the Hopital du Midi, Oct. 3, when a chancre, surrounded with cartilaginous induration, was found in the fossa behind the corona glandis, and the glands in both groins were enlarged, hard, and indolent. A dressing with aromatic wine was ordered for the sore, and mercury internally. Oct. 14. The chancre has entered upon the period of repair ; it is less excavated, and its edges less prominent. Oct. 24. There has been a change for the worse. The original chancre has increased in surface and in de|)th;its base is still very much indurated. Moreover, upon the skin of the penis is found another large ulcer ; its base oedematous, but without true induration. There are also several small ulcers with soft bases upon the external surface of the prepuce. Tlie patient declares most positively that he has had had no sexual connection since he contracted his first chancre. Are the recent sores to be attrib- uted to accidental inoculation from the first ? N. is this day admitted as an in-patient. In the early part of Nov. one of the lymphatic ganglia in the left groin became acutely inflamed, and presented all the characters of a bubo de- pendent upon a chancroid. It suppurated, and its pus loas inoculated tvith success. In the right groin, the enlargement and induration of the ganglia characteristic of a chancre remained as before. In Dec. secondary symptoms appeared ; roseola and multiple mucous patches. In spite of the patient's denial, Ricord attributed the more recent ulcers to a second exposure and fresh contagion ; and a i'ew days after his entrance into the hospital, the patient privately confessed to M. Fournier, the In- terne, that on Oct. l.oth he had connection with a woman whose name and address he gave. He also stated that on the following day his first ulcer began to enlarge, and the others appeared two days after. Fournier immediately visited the woman indicated by N., and found that she had three large chancroids with perfectly soft bases, situated upon the internal surface of the left labium, on the fourchette and u])on tlie folds at the entrance of the vagina, and of about three weeks' duration. The inguinal ganglia were in a normal condition. This woman also confessed to M. Fournier that she had infected her lover, Charles V., who, by a singular coincidence, was at that moment a patient in the I16i»ital du Midi, and who likewise had several chancroids with soft bases upon the prepuce and an acute bubo in the left groin. To sum vp this history : a man with a primary syphilitic ulcer in tlie period of repair and an indolent indurated bubo has connection with a woman affected with chancroid. He contracts fresh ulcers, which i)rove to be chancroids, and one of which is seated upon the surface of the orig- inal chancre. An inflammatory bubo appears, which suppurates and fur- 302 CHANCROID COMPLICATED WITH SYPHILIS. nishes inoculable pus. Finally, symptoms of general syphilis are devel- oped.' Rollet relates a similar case: — G. Francois, aged 20, entered the Antiquaille Hospital, at Lyons, with a sore situated upon the meatus, which was slightly indurated and pre- sented the usual aspect of a chancre. The fossa at the base of the glans was also studded with several ulcers which were as soft as possible. The ganglia in the groin were indurated. In six weeks after exposure, the patient was attacked with headache, syphilitic roseola, and rheumatic pains. In order to confirm the diagnosis as to the nature of the sores, Rollet inoculated matter from the one which was indurated upon the left thigh, and the secretion of the others upon the right. The result was positive in both. It was then thought that pus from the simple sores might have been deposited upon the indurated one, and thence taken up upon the lancet. Rollet therefore waited until the chancroids in the fossa behind the corona had completely Iiealed, and then, after repeatedly cauterizing the indurated sore with solid nitrate of silver, inoculated its secretion a second time. This inoculation produced the characteristic pustule of a chancroid as before ; thei'eby showing that the success of the first inocula- tion was not owing to the presence of matter which had been simply de- posited and again taken up, but to the inherent properties in the secretion of the sore itself.'' M. Rollet and his Interne, M. Laroyenne, were led by this case to try the effect of inoculating cliancres with matter from a chancroid. Their experiments are briefly related as follows: — Case 1. Fieri M. ; indurated chancre of the meatus; duration three weeks; indurated ganglia; inoculation of the secretion of the chancre, negative. Sept. 14, the pus of a chancroid was deposited upon t\ve sore. 8e[)t. 15, a[)plication of the solid nitrate of silver; lotions; dressing with aromatic wine. Sept. 19, second inoculation ; chancroidal pustule. Case 2. John L. ; indurated ulcer almost healed; indurated ganglia: general treatment and local application of aromatic wine ; inoculation neg- ative. Nov. 18, pus from a chancroid is applied to the ulcer ; treatment continued. Nov. 23, second inoculation ; this time positive. Case 3. Robert M. ; parchment variety of chancre upon the skin of the penis; duration five days. Dec. 11, inoculation without result; dress with opiated cerate and calomel. Dec. 16, application of the virus of a chan- croid. Dec. 17, same dressing. Dec. 22, inoculation positive. Case 4. Peter M. ; chancre of six weeks' duration, occupying three- fourtiis of the circumference of the fossa glaudis. Dec. 11, inoculation unsuccessful. Dec. 16, application of the virus of a chancroid. Dec. 17, dress with opiated cerate with addition of calomel. Dec. 22, inoculation successful. • LeQons sur Ic chancre, p. 119. 2 Lakoyenxe, Etudes experimentales sur le chancre, Annuaire de la syph. et d. mal. de la peau, Paris, Annee 1858, p. 248. CASES. o93 According to Rollet, t%A-o or three days after the application of the vims of a chancroid to a chancre, the sore assumes a grayish aspect like an or- dinary chancroid, hut is less excavated; its edges become jagged, and its purulent secretion more copious and sanious ; it may give rise to successive chancroids in the neighborhood or to a virulent bubo. It preserves, how- ever, the essential characters of a chancre, and, among others, induration of its base, which is always pathognomonic ; the ganglia of both groins are indurated as usual, unless a virulent bubo supervenes, when those of the opposite side may still indicate the nature of the disease. The general symptoms following the chancre are not modified by this inoculation, and secondary symptoms appear at the same time and in the same manner as under ordinary circumstances. The more copious secretion of the chan- croid renders this species more liable to be ingrafted upon a chancre than the latter upon the former. Thus far we have supposed the inoculation of one species of virus to succeed that of the other, but both sometimes, though rarely, occur during the same act of coitus. In this case the chancroid, which has no period of incubation, is first developed in its usual form, with abrupt edges, gray- ish floor, and soft base ; subsequently the chancre appears, when the base of the sore and the neighboring lymphatic ganglia become indurated. The union of the two species of virus in this variety is analogous to the mixture which takes place when gonorrha3a is complicated with urethral chancre, constituting the only true " gonorrhoea virulenta ;" and also to the union of either the chancroidal or syphilitic virus with that of vaccinia, of whicii a number of examples are recorded. The mixed chancre requires the local treatment of the chancroid and the general treatment of syphilis. 394 THE SIMPLE AND THE VIRULENT BUBO. CHAPTER V. THE SIMPLE AND THE VIRULENT BUBO. Bubo, derived from the Greek j5ov^icv, originally signified either the groin, the glands in the groins, or, again, inflammation of" these glands. In more modern times, the term has been applied in general to auy affec- tion of the lymphatic ganglia. Thus we read of sci'ofulous buboes depen- . dent upon a strumous diathesis; of cancerous buboes dependent upon a scirrhous tumor in the neighborhood ; and of the Plague of the Levant (the bubo-pest), characterized, among other symptoms, by an affection of the lymphatic glands of the groins and axillae. The meaning of the word, so far as having any connection with the groin, and so far as dependent upon any causes which can exclusively affect the groin, has, therefore, been departed from. In common parlance, however, if we hear the expression " that man has a bubo," we infer that he has an affection of one of the lymphatic ganglia dependent upon venereal disease ; and venereal diseases are, of course, those only which concern us in the present work. At the same time, let it be observed, so far as the situation of the tumor is concerned, that a venereal bubo is a bubo, no matter where situated ; and that, even if dependent directly or indirectly upon venereal contagion, other causes than venereal often play an important part in its evolution. We shall find hereafter that sypJiilts exerts a peculiar influence upen the lymphatic ganglia at two periods of its course: 1, In its initial stage, upon the glands in anatomical relation with the chancre; 2, In its period of full development, upon the glandular system at large. With these, so-called " indurated" and " constitutional" buboes, which are inevitable to syphilis, and which will be considered further on, we have at present nothing di- rectly to do, although what we have to say of the anatomical connection between the glands and the lymphatics will be found to have a bearing ui)on them. In speaking of buboes in this chapter, we refer, therefore, only to those which are not specific in their origin. They are two in number: — • I. The Simple Bubo. II. The Virulent Bubo. Frequency of Buboes — All persons are not disposed alike to the de- velopment of buboes. In those of a strumous constitution, the lymphatic system ai)pears to be much more sensitive than in others, and buboes are of more frequent occurrence. In general, they are found oftener in men than in women, partly, doubtless, in consequence of the different habits of SEAT OF BUBOES. 395 life in the two sexes. It has been estimated that 40 out of every 100 men with chancroids are attacked with buboes ; and of these 40, that from 30 to 35 have suppurating buboes ; while of every 100 women affected with chan- croids, only 20 have acute inflammation of the ganglia, of which lo sup- purate. Zeissl ascribes this difference not only to the more active habits of the male sex, but also to the fact tliat the majority of venereal affections in women are situated upon the mucous membrane and not upon the external integument, wliere their occurrence is found by experience to be followed most frequently by buboes in the male sex also. As to the comparative frequency of the simple and virulent bubo, sta- tistics vary greatly. Jullien' states, as the result of the collected observa- tions of a number of authorities, that of 287 buboes, 149 were simple and 138 virulent. These statistics, however, must not be regarded at all as conclusive, since the diagnosis between a simple and a virulent bubo requires an amount of care and precision on the part of the observer which is rarely given. Seat of Buboes — The inguinal ganglia are most frequently affected in cases of buboes, and the anatomical seat of these ganglia is of no little interest as showing what course such tumors may take. This subject has been most thoroughly investigated in two admirable lectures by Prof. Auspitz,^ of Vienna, one of whose plates (Fig. 114) we reproduce, and whose description we shall closely follow. The inguinal ganglia are divided by anatomists into the superficial and the deep. The former are the more constant, indeed always present, and of the greater importance. They are seated in the subcutaneous cellular tissue, separated from the surface only by the skin and a thin layer of con- nective tissue — the " superficial fascia," and lying upon the " fascia lata." The richness of the tissue in which they are imbedded depends greatly upon the amount of corpulency of the individual. They vary to some extent in their number and situation ; these, however, are so generally con- stant as not to differ materially from the accompanying representation, which includes the lymphatic vessels merging into them. Of these groups of glands, A and B are strictly inguinal, while D is strictly femoral. The group C belongs rather to the inguinal glands, with which it stands in closer anatomical and pathological relations tlian to the femoral. Deep-seated inguinal ganglia, underlying the fascia lata, described by most anatomists as four to six in number, are far from being constant. Auspitz lias found only one usually [)resent, and this, " Rosenmiiller's gland," situated between the semilunar edge of Gimbernat's ligament and the vena cruralis. In women, vessels from the lym[)hatic network of the labia majora and ' Traitelow the varix, the supply of blood will be cut off, and the tumor colhipse ; if the same be done above tlie varix, the tumor will become more teJise and prominent. ' S.-.! two casos loported hy Rollct, Gaz. d. hop., Paris, 3 dec, 1861, no. 141, 2 0[,. fit., vol. i, p. 228. TREATMENT OF BUBOES. 407 An ulcerated epithelioma of the groin, which often accompanies epithe- lial cancer of the penis, may closely resemble a phagedenic bubo. The diagnostic signs have already been given, when speaking of the chancroid. Is it possible that any one should fail to distinguish between a bubo and a simple abscess, an aneurism or a dislocation of the thigh ? Diagnosis between the Simple and Virulent Buboes There is no certain means of diagnosis between a simple and virulent bubo on their first appearance. If tiie jiatient has simply a gonorrhoea, balanitis, herpes, eczema, or a mere abrasion, a supervening bubo can of course be only a sinijde bubo. If he has a chancroid, the bubo may be either simple or virulent. We find, in general, that a simple bubo appears during the first fortnight of the existence of the cause upon which it depends, a virulent bubo after this period; that a virulent bubo is ushered in with more acute symptoms, as a chill, pain, and febrile disturbance ; moreover, the glandu- lar tumor is more circumscribed, and presents a hardness and elasticity which are not met with in the simple bubo. The virulent bubo also hastens with greater rapidity and witli certainty to suppuration. When a virulent bubo is left to open itself or is opened by the knife, the contained pus is found to be thick and creamy ; the secretion of a simple bubo, on the contrary, is usually thin, watery, and fiocculent. Auto-inoculation of the secretion of a virulent bubo, provided the matter be taken from the cavity of the gland itself, will produce a pustule followed by a chancroidal ulcer; inoculation of the matter of a simple bubo will fail. Finally, when the bubo is virulent, the whole surface of the incision becomes inoculated by the virus discharged from the gland, and the sore presents those characteristics which have alreale, the late appearance of diseases of the periosteum and bones, without the secondary link, in persons who have taken mercury. When once the primary ulcer is healed, it cannot be reproduced except by a new contagion ; while secondaiy and tertiary symptoms may appear repeatedly, and at various intervals, within periods which cannot be limited. An apparent inversion in the succession of secondary and tertiary symptoms is observed only in persons who have undergone treatment. After the appearance of constitutional symptoms, the syphilitic diathesis may cease spontaneously or in consequence of appropriate treatment, and yet the symptoms persist under the influence of purely local causes, as is observed especially in many cases of diseased bones. "^ In another place Ricord says of tertiary symptoms: "They not only differ from primary and secondary symptoms in affecting the deeper tissues, but also in the fact that in tliem syphilis loses, in part, its peculiar type. Tiiough the skin is often affected at this period with the most severe • Notes to Hunter, p. 396. INTRODUCTORY REMARKS. 425 tubercular eruptions, yet the subcutaneous and submucous cellular tissues, and the fibrous and osseous systems are far more frequently involved. But, in addition to these parts, where the tardy effects of constitutional syphilis are so common and clearly admitted by all good observers, we may well inquire whether there be any privileged tissues of the body which are invariably exempt from its effects. We would inquire, also, if syphilitic infection, though it may not produce all the evils with which it is reproached, be not in a multitude of cases the cause of the evolution, or ' putting into action' — to use an expression of Hunter's — of diseases which have previously existed in a latent state, and of which it is thus only the exciting cause ? Observation replies in the affirmative to these questions, and also teaches us that tertiary symptoms may continue under the influence of the virulent cause, or persist as local effects after this cause has been destroyed or neutralized by treatment ; it shows, in a multitude of cases, that the syphilitic virus, after having been the cause of other diseases, may cease to exist or persist as a complication ; and these are circumstances which, though real, are unfortunately not always easily appreciated. "Tertiary symptoms rarely occur before the sixth month following the appearance of the primary ulcer, and the latter seldom remains at the time of their development; but they are frequently attended by some secondary symptom. They never furnish inoculable secretions, nor trans- mit characteristic constitutional syphilis from parent to child ; their only hereditary influence being the frequent transmission of a taint as injurious and almost as fearful, viz., a scrofulous diathesis." Ricord's classification may, I think, be resolved into two parts. The first is the chronological system, which, originating with Fernel and Hunter, has been freed from many errors by Ricord, and greatly perfected by this surgeon's keen powers of observation, and which is both natural and eminently ])ractical. The second part consists of various additions relative to the inoculai)ility of the different orders of symptoms, their trans- mission by hereditary descent, and the effect of treatment; some of which are open to criticism. I shall speak of each in turn. The general symptoms of syphilis are not drawn at hap-hazard, l)ut make their appearance with a great degree of order and regwlai'ity. This fact is most ap])arent in those lesions which follow immediately upon the period of incubation, and which vary but little in difllarent subjects. Allow any patient with a chancre to go without treatment, and it may be predicted with almost absolute certainty, that within three months he or she will be attacked by the following category of symptoms witii but little variation, viz., general lassitude, accompanied by headache and fleeting pains in various parts of the body; alopecia; an eruption of blotches or papules upon the skin; pustules upon the hairy scalp; engorgement of the post- cervical glands; and whitish patches, which may become ulcerated, upon the mucous membrane of the mouth, anus, or vulva. Subsequent to the first outbreak of general syphilis, the same uniformity does not prevail; and certain symptoms are absent in one case and present 426 SYPHILIS. in another, or they appear to be modified by the constitution of the patient, the hygienic conditions in which he is placed, his habits, and especially Ity treatment. But if we take a number of cases, some of which supply what is wanting in others, we find that we can, as it were, make up a comi)lete series, in which the symptoms progress by a regular gradation, and may be divided into two classes, distinguishable by the time of their ajjpearance, their character, and their seat. Those of the first class follow immediately upon the earliest general symptoms before mentioned, with which they are evidently identical in character. Those of the second class never occur until after a certain interval which experience enables us to determine with great precision. Again, the order of the two classes is never i-eversed. For instance, a patient who has been suffering with symptoms belonging to the second, as deep tubercles of the cellular tissue or caries of the bones, is never known to exhibit the premonitory fever, exanthematous eruption, and other early symptoms of the first. The disease progresses with greater rapidity in some cases than in others, yet owing to the general uniformity referred to, simple inspection of a patient will enable any one familiar with its natural course to arrive at an approxi- mate conclusion as to the length of time that has elapsed since contagion, and also as to the character of the preceding symptoms, unless these have been altogether suppressed by treatment. A[)parent exceptions to the regular succession of the general symptoms of syphilis are met with, and may readily deceive an inexperienced ob- server. One of the most frequent of these is due to treatment. It often happens that a patient had a chancre many years ago, and perhaps early secondary sym[)toms, for one or both of which he took mercurials; a long period has since passed without further general manifestations; but his system has continued under the infiuence of syphilis, wliich finally becomes active again and gives rise to tertiary lesions. Evidently the exemption from late secondai-y symptoms may be ascribed to mercury. Again, the date of the first appearance of any lesion determines its posi- tion in the syphilitic scale; while its persistency may be due to many causes, too lumierous to mention. It is a very common occurrence for a chancre to remain until secondary symptoms break out ; but we do not thc^refore conclude that both belong to the same order. In the same way, secondary are often present long after tertiary manifestations have super- vened. In Kicord's admirable remarks already quoted, allusion has been made to the fact that syphilis may give rise to symptoms, which are con- tinued by various causes and especially by a strumous diathesis, long after tlie exciting cause has been subdued. Moreover, many syphilitic lesions, and particularly eruptions u])on the skin and mucous membranes, may, either with or without treatment, disappear, and again return within a limited period with the same characters as at first. This tendency, how- ever, ceases with time ; and relapses after a considerable interval are in all cases rare. For instance, syphilitic erythema, whi(!h usually appears aljout the sixth week after the development of the chancre, may perhaps INTRODUCTORY REMARKS, 427 return as late as the eighth or ninth month, but never several years after the chancre. Finally, the same name is, in several instances, applied to symptoms which are in reality distinct, and which are widely separated upon the syphilitic scale. Thus there is a form of alopecia which is one of the earliest general symptoms, and in which the hair is freely shed from the scalp and eyebrows, but may grow again, since the hair-bulbs are not seriously affected; and there is another and rarer form, observed only in the later stages of syphilis, in which the whole integumental surface becomes permanently bald. Two forms of iritis, ecthyma, etc., are also observed at distinct periods ; but these constitute no exception to the law of succession of syphilitic manifestations. We thus see that a simple chronological division of constitutional symp- toms may be maintained; but there are several objections to the additions made to this system by Eicord, as I shall proceed to show. In the first place, Ricord's statement that "secondary symptoms are not capable of inoculation," is true in the guarded sense in which it was in- tended, viz., that they are not inoculable upon persons bearing them; but the inference which was also designed to be conveyed, that they differ in this respect from a chancre, is not true, as Eicord himself has since acknowledged. Both are contagious and inoculable upon persons free from syphilitic taint, but neither are auto-inoculable. Again, Ricord's statements relative to tertiary symptoms cannot at the present day be implicitly received. This author maintains that tertiary lesions are not inoculable and cannot be transmitted by hereditary descent under their peculiar type, and hence that the virus in tins stage must be entirely changed from its original character. The first of the above asser- tions is doubtful, the second incorrect. The inoculability of tertiary symptoms has never been tested upon persons free from syphilitic taint, and its possibility, therefore, may yet be demonstrated, as that of secondary symptoms has been. Their transmission by hereditary descent in a few instances, still preserving their peculiar type, is a known fact. The most frequent instance of this is the occurrence of syphilitic hepatitis and deep tubercles of the subcutaneous cellular tissue in infants affected with heredi- tary syphilis. Virchow^ has also found small collections of the deposit peculiar to tertiary syphilis in the cerebral substance of children born of syphilitic mothers. Hunter attributed the difference in the situation of eai'ly and late gene- ral symptoms to the influence of cold, which, as he supposed, rend(;red the more superficial parts of the body most susceptible to, and earliest affected by the virus. This anatomical distinction, without Hunter's explanation, has been retained in Ricord's classification, in which the skin and mucous membranes on the one hand, and the osseous, fibrous, and cellular tissues on the other, are regarded as the exclusive seat of secondary and tertiary ' La syphilis constitutionnollo, ti-caduit dc rallciucaml par lo Dr. I'ioanl, Paris, 1860, p."4. 428 SYPHILIS. manifestations respectively. But this rule cannot always be maintained, since one of the earliest symptoms of general syphilis — preceding in many cases the eruption upon the skin — consists of pains resembling rheumatism, some of which are evidently seated in the periosteum (cliiefly that of the cranium and in the neighborhood of the joints), and this tibrous tissue has l)een known to take on acute inflammatoiy action at this time. In order to avoid this dilficulty, Bassereau asserts that general syphilis attacks in- differently the integumental, fibrous, and osseous structures in all periods of the disease, but that the more superficial portions of each are affected in the earlier and the deeper in the later stages. A'irchow^ would exclude all consideration of situation from the classifi- cation of general symptoms, and has proposed a system based upon the nature of the pathological changes in the difterent lesions, but which is too widely at variance with the ideas at present received to meet with general adoption. Von Baerensprung^ offers a similar classification in which secondary symptoms are made to include those lesions which are charac- terized by hyperaimia and simple exudation; and tertiary symptoms those in which there is tubercular deposit. But it is easier to pull down than it is to build up, and attempts in the latter direction may well be deferred until many preliminary points are settled. Meanwhile, we have every reason to be satisfied witli the simple and natural chronological division which forms the basis of Ricord's classi- fication, and which owes its excellence in a great measure to the keen powers of observation of this truly eminent surgeon. The few errors which he introduced are not essential to the system, and may well be forgotten, when we recollect his important contributions to our knowledge of the natural history of syphilis. The time of the appearance of any given syphilitic lesion will be influ- enced in a measure by the constitution of the patient, his mode of life, and the treatment to which he is or has been subjected, and can therefore be determined only approximately. The following table compiled by M. Martin^ from the statistics of McCarthy, Bassereau, Sigmund, and Four- nier, is however, of value in exhibiting the usual period of development, following the appearance of the chancre, of the more important syphilitic lesions : — ' Op. cit. 2 Annales de la Charite, vi, p. 56, et vii, p. 173. 3 De I'accident primitif do la syphilis constitutionelle, Paris, 1863, p. 87. INTRODUCTORY REMARKS. 429 Bate of usual 1 Date of earl'st Date of lates Symptoms. development. development. development. Roseola 45th day 25th^day 12th month Papular eruption 65th " 28th " 12th " Mucous patches ...... 70th " 30th " 18th " Secondary affections of the fauces 70th " 50th " 18th " Vesicular eruption ... 90th " 55th " 6th " Pustular eruption ..... 80th " 45th " 4 years Rupia 2 years 7tli month 4 " Iritis eth month (iOth day 13th month Syphilitic sarcocele ..... 12th " (3tli month 34th " Periostosis (Jth " 4th " 2 years Tubercular eruption 3 to 5 years 3 years 20 " Serpiginous eruption . • . 3 to 5 " 3 " 20 " Gummy tumors 4 to 6 " 4 " 15 " Onychia 4 to 6 " 3 " 22 " True exostosis ...... 4 to 6 " 2 " 20 " Ostitis, changes in the bones and cartilages 3 to 4 " 2 " 41 " Perforation or destruction of the velum palati 3 to 4 " 2 " 20 " According to Bassereau's statistics, the administration of mercury for the primary lesion has a decided influence in delaying the appearance of secondary manifestations ; and I am convinced from my own observations that this is the case. Admitting this to be true, it may seem strange that I should deny the power of the same agent to altogether prevent general manifestations. I am, however, irresistibly led to this conclusion, by the fact that I have never seen an unquestionable case of true chancre, which was not followed, sooner or later, by some general lesion, no matter what treatment had been employed. In most cases, when syphilis is abandoned to its natural course uninflu- enced by treatment, the earliest general manifestations nearly or quite disap- pear spontaneously, and, after a time, are succeded by another set, which, in its turn, may give place to a third, and so on; the number of successive outbreaks varying in diffei-ent cases, and commonly being in proportion to the intensity of the action of the virus. Thus sypliilis usually shows itself not in a continuous, but in an interrupted succession of lesions, — a fact of some importance, because too often the reappearance of syphilitic mani- festations is regarded as a relapse, while it is really but the natural course of the disease. In many cases, even in the absence of treatment, syphilis tends to self- limitation, and its lesions ultimately cea.se to appear, leaving the patient in a fair state of health. The Sources of Syphilitic Contagiox. The older writers on syphilis fully believed in the contagiousness not only of secondary lesions, but also of the sweat, saliva, semen, milk, blood, and even the breath of persons affected with general syphilis. Hunter, founding his opinion u[ion a few unsuccessful inoculations of the secietion 430 SYPHILIS. of secomlary lesions upon the persons bearing them, declared that the power of" contagion was confined to the primary sore. Auto-inoculations, similar to those of Hunter, were repeated in thousands of instances by Ricord, and, in imitation of his example, by numerous surgeons in various parts of the world, the resvdts of which were uniformly unsuccessful with scarcely an exception worthy of notice. On the other hand, the chancroid was re- garded by Ricord and by the profession generally as the chancre-type, and its secretion was found to be inoculable with the greatest facility. The inference which was drawn was a natural one, viz., that a radical distinc- tion existed between primary and secondary lesions in the contagiousness of the former and the incommunicable character of the latter ; and the zeal, energy, and ability with which this idea was for many years defended are known to the whole medical world. The plausibility of this evidence, the immense number and uniform results of the experiments resorted to, the keen powers of observation, in- genious reasoning, attractive manners, and evident sincerity of the Surgeon of the Hopital du Midi, united in adding weight to a doctrine which had ali'eady been sanctioned by the great name of Hunter, and which was consecpiently for a time received as beyond dispute. Yet cases in appa- rent contradiction to Ricord's " law" were met with by many careful ob- servers, especially in infants affected with hereditary syphilis, whose early age, incapacitating them from sexual intercourse, greatly diminished the chances of error of observation ; and although instances of the transmission of 55econdary lesions from the nursling to the nurse, and vice versa, wei'C explained away with great ingenuity by Ricord and his adherents, yet they gradually came to be admitted by the majority of the profession. At the same time it was felt to be highly desirable to demonstrate this power of contagion by experimental inoculation, and thus place it beyond a doubt ; and afterwards to study the phenomena of the process and compare them with those attending the evolution of general syphilis when originating in a chancre. Until this was done, the subject was likely to remain an open question. This test, however, could not readily be applied. Ricord and his school liad confined their inoculations to persons already infected, and it was generally admitted that further experiments, in order to be decisive, must l)e made upon those who were free from syphilitic taint — a course which could not be justified in a moral point of view even for the purpose of ad- vancing science. Wallace had already, in 1835, succeeded in inoculating the secretion of condylomata upon healtliy individuals, but the want of precision in his observations rendered them of little value. Subsequent inoculations, however, by Waller of Prague, Rinecker of Wiirzburg, a surgeon of the Palatinate who concealed his name, Gibert and Vidal of Paris, and others, settled this question in fiivor of the contagiousness of secondary lesions and even of the blood of syphilitics, for all time. The novelty of this subject at the time of the publication of the earlier editions of this work, led me to give the experiments referred to in detail. These INTRODUCTORY REMARKS. 431 will now be omitted, and I shall content myself Avith a bare statement of what must be regarded as proved both by clinical observation and artifi- cial experiment, and what, moreover, is universally admitted at the pre- sent day. AVe must admit as sources of syphilitic contagion — 1. The .secretion and the organic debris of the primary lesion or chancre. 2. The same of any of the secondary lesions of syphilis, among which the various forms of mucous patches are eminently contagious. 3. The blood of persons in the secondary stage of syphilis. For the absolute demonstration of this fact by actual experiment in 1862, we are indebted to Dr. Pellizari, Clinical Prof, of Venereal Diseases at the Ecole Pratique of Florence. It is generally believed that tertiary lesions are not inoculable, and per- haps no cases have as yet been reported with sufficient accuracy of detail to prove the contrary ; but, as the boundary line between secondary and tertiary syphilis is not definitely defined, so are the limits of contagion to some degree uncertain. Admitting the contagiousness of the blood of syphilitic persons, we might from a pj-iori reasoning suppose that the various fluids which are secreted from the blood, as the saliva, milk, sweat, and semen, are also contagious, and this was the belief of the earlier writers on syphilis. This supposition, however, is not in accordance with clinical observation, and has been disproved by actual experiment with a number of the secretions mentioned. Diday inoculated two healthy persons wath the lachrymal secretion taken from the eye of a patient in the height of secondary mani- festations ; the result Avas negative.' The non-inoculability of the semen of syphilitics was fully proven in a number of experiments made by Mireur.^ A number of cases, which have appeared in medical journals within a few years, and which have been sup- posed by their authors to establish the contrary, have been so loosely ob- served as to deprive them of any claim to serious consideration. The innocuity of the milk is proved by the fact, that a mother who con- tracts syphilis after the birth of her child, may nurse that child with im- punity, provided she has no lesion upon her breasts. Moreover, Pardova,' in 18GG, attempted to inoculate the milk of eight syphilitic women, by pricking it into the skin, by applying it to a vesicated surface, and even by hypodermic injection, and in all without effect. In sliort, we have no reason to believe that any of the normal secretions of syphilitic persons, when free from admixture with the secretions of secondai;y lesions or with the blood, — as, for instance, saliva, not mixed with the secretion of buccal mucous patches, — are contagious. ' Gaz, med. de Lyon, No. 3, 1865. ' Ann. de derm, ct sypli., Paris, No. 6, tome viii, 1877. 3 Gior. ital. d. mal. ven., Milano, t. ii, p. 153, 1867. 432 syphilis. Tfik Modes of Syphilitic Contagion. Sypliilitic contagion may be direct or mediate, like that of the chan- croid ; and much that has already been said in reference to the latter (see Part II, Chap. I.), is here applicable. Direct contagion takes plac(i most fi-equently from the genital organs of one person to those of another in sexual congress, and it is often the result of unnatui-al and beastly modes of indulgence between persons of the op- posite or the same sex. Hence arise many ciiancres of the anus, of the tongue, of the fold between tlie breast and side of the chest, etc. etc. I have seen a chancre of the tonsil in a man, due to inoculation from a mucous patch upon the tongue of another man. More innocently, contagion takes place in the contact of mouth to month, as in the act of kissing. Tlie most innocent girls are thus often con- taminated by the freedom, which is unfortunately common in some families of saluting their male visitors in this manner. The frequency with which mucous patches in the mouths of sucklings will infect the nipples of a wet-nurse, is well known, and the same is sometimes met with in adults. I recently prohibited a man who had contracted syphilis from having con- nection with his wife. He obeyed my instructions, but, thinking it safe to suck her nipple, gave her a chancre in that situation. It is commonly by direct contagion, that so many sui-geons, and especially accoucheurs, contract chancres upon the fingers from contact with the lesions of syphilis ui)on their patients. The number of such cases is greater than is com- monly supposed, for the unfortunate victims, although innocent, are usually most careful to conceal their misfortune. I have known dentists to suffer the same fate. Syphilis is also said to have been conveyed in the rite of circumcision, from mucous patches in the mouth of the operator to the wound upon the infant's penis, which it is customary to suck, and Sigmund has reported a case of this kind. In a number of cases referred to Dr. R. W. Taylor, he was unable to find sufficient evidence of such transmission, although its possibility cannot be doubted. Dr. Taylor's paper' contains an able resume of the subject. Mediate contagion may occur from the passage of a cigar or a pipe from mouth to mouth ; from the use of common utensils, as a tooth-brush,'* wine-glass, a cup, a spoon, etc. etc., by different persons ; from sleeping in the same bed ; from matter conveyed on certain tools used in manufacture, as the pipes of glass-blowers (many instances of which have been recorded as having occurred in France and have led to the passage of a law that each workman should have his own mouth-pitice). Washing utensils used in common, surgical appliances, as sponges, bandages, etc., and surgical » N. York M. .J., Dec, 1873. 2 A case of syphilitic inoculation by a tootli-brush, by Dr. E. B. Baxter, Lancet, bond., May 31, 1879. We have also met with a case in which this was probably the mode of contagion. INTRODUCTORY REMARKS. 433 instruments, especially the Eustachian catheter, are also recorded as havino- been the medium of contagion. In 1877, Albert Josias^ reported a case of the transmission of syphilis by tattooing, the instrument used for the purpose having first been mois- tened in the mouth of the operator, who had mucous patches in the buccal cavity. Since then Drs. Maury and Dulles^ have reported fifteen similar cases occurring in this country. At a late meeting of the Society of Public Medicine, in Paris, Dr. Ga- lippe related a number of cases of the transmission of syphilis through children's toys, as whistles and trumpets, which had been blown upon by the vendor before being passed to the child. But the different ways in which mediate contagion may take place are so self-evident, that it is not necessary to enter into them more fully. I shall, therefore, only briefly refer to one which has attracted much attention and which should ever be borne in mind ; I refer to syphilitic contagion conveyed on the point of the lancet in performing vaccination. There is every reason to believe, as stated in an admirable paper by Viennois,' that the agent of contagion in these cases is not the lymph taken from the arm of the syphilitic infant, but the blood which is often drawn in collecting the lymph, especially toward the close of the operation if a number of punctures have been made. Moreover, because an infant develops general syphilis after vaccination, it is not always true that the syphilis is due to the vaccination, since this disease may have been in- herited from its parents and its appearance have been merely hastened by the irritation of the integument induced by the vaccination. These con- clusions are thus formulated by M. Viennois : — 1. Vaccination with pure vaccine matter is sometimes the exciting cause of the appearance of a syphilitic eru[)tion in inftinfs already tinder the syphilitic diathesis ; in the same manner that it gives rise to non-spe- cific eruptions in strumous subjects. The history of the case and the order of evolution of the symptoms are generally sufficient to establish the diagnosis. For instance, the appearance of the eruption within a few days or weeks after the vaccination, without the ordinary period of incu- bation of syphilis, will render it probable that the disease was already latent in the system. 2. Syphilis cannot be transmitted to a healthy person by the inocula- tion of vaccine matter taken from a syphilitic subject, unless the lancet at the same time be charged with blood ; in which case a ciiancre is pro- duced, followed by general symptoms in tlieir usual order of evolution. It is still believed by some that, in these cases, the blood is not tiie only vehicle of contagion, and that epidermic scales, or leucocytes, or the secre- tion of an ulcer underlying the vaccine vesicle (liinccker*), may also be responsible. ' Progres med., Par., 1877, p. 205. 2 Am. J. M. Sc, Phila., Jan., 1878. ' Arch. gen. de med., Paris, jiiin, 18G0. » Vrtljschr. f. Dermat., Wien, 1878, p. 25. 28 434 SYPHILIS. Two remarkable instances of the transmission of syphilis by vaccina- tion are reported by jM. Lecoq.^ By far the most important and interest- ing series of cases, liowever, occurred at Rivalta, Italy, in which forty-six out of sixty-three children who were vaccinated became syphilitic and transmitted the disease to nurses, mothers, fathers, brothers, and sisters, making a total of eighty persons. In these cases, also, blood is said to have been drawn with the lymph from the arm of the first vaccinifer, and the initial lesions in those who received the poison were indurated ulcers (chancres) which were preceded by a period of incubation averaging twenty days.^ Numerous instances of a similar character, in some of which the dis- ease spread to a large number of persons, have been collected by M. Viennois, and are sufficient to show that although vaccination is commonly a harmless operation, yet that it may, if proper precaution be omitted, be the means of transmitting a fearful constitutional disease. In the above remarks on " vaccino-syphilis," it will be seen that refer- ence has only been made to the conveyance of syphilis from the person from whom the lymph was taken to the person upon whom the lymph was implanted.- But there is still another danger in vaccination which had nearly or entirely escaped notice, until attention was called to it by Dr. R. W. Taylor : I refer to the transmission of syphilis by using the same instrument uncleansed upon a number of individuals in succession, one of whom is syphilitic. In performing vaccination in this manner, as is often done in charity institutions, the vaccine matter may be never so pure, but the scarificator may be contaminated by contact with one person under the influence of syphilis and convey the disease to the next. In the case re[)orted with great detail by Dr. Taylor,^ a number of the inmates of iTie Penitentiary, Blackwell's Island, were ordered to be vaccinated. The vaccine was in quill form, and furnished by the Board of Health. The physician vaccinated about twenty persons in succession, using the same scarificator without cleansing it. The operation had been done upon six persons, when a young prostitute affected with syphilis was vaccinated ; next to her an infant, aged nine months. All did well with the exception of this infant, in whom a chancre was developed at the point of inocula- tion, followed by the usual train of general lesions. General Syphilis alavays folloavs a Chancre. In the great majority of cases of acquired syphilis (excluding those of hereditary origin), general symptoms can clearly be traced to a preceding chancre. Thus of 82G patients with general syphilis who were treated at ' GnvEXoT, Tli6se de Paris, 1859, Soc calso Gaz. hoLd. de nied., Paris, 27 janv., 18tJ0. 2 For an able resumfe of these cases, see Mr. Henry Lee's Lectures on Syphilitic Inoculation and its Relations to Vaccination, London Lancet, 1862. 3 Arch, of Dermatol., N. Y., vol. ii, 1876, p. 203. INTRODUCTORY REMARKS. 435 the Hopital dii ]Micli in 185G, the previous existence of a chancre in 815 was established beyond a doubt either by examination or by voluntary confession ; in 9, there was strong reason to suspect it ; and in the remain- ing 2, the disease was evidently due to hereditary taint. Of 267 cases of secondary syphilis observed by Fournier/ the same fact was proved in 265. Of 198 cases of syphilitic erythema under the care of Bassereau,^ either a chancre or unquestionable traces of one were seen in 170 ; in 19, the patients confessed to the fact, although no evidence of it was found upon their persons ; 4 acknowledged having had a gonorrhoea ; 5 declared that they had had no preceding lesion. Thus we find that in a total of 1291 cases, general syphilis was undoubtedly preceded by a chancre in all except 22. These statistics agree with the experience of all physicians, that, as an almost invariable rule, syphilis evidently originates in a chancre ; and the small number of cases in which the existence of the ulcer cannot be estab- lished renders it extremely probable that there are no exceptions to this law, especially when we take into account the following considerations : — • Chancres are capable of spontaneous cicatrization, and all traces of them may disappear in time, even without treatment. They may occupy unusual situations, where their presence may readily escape notice, or be almost impossible to detect ; among which the interior of the urethra, vagina, cervix uteri, and the buccal and rectal cavities de- serve special mention. Exceptional cases almost invariably rest upon the testimony of patients alone ; and are the more frequent, the later the lesion presented in the order of succession of syphilitic symptoms, in other words, the longer the time which must have elapsed since contagion took place. For instance, cases are rare in which a patient with syphilitic erythema does not confess that he has had a chancre ; on the contrary, they are not infrequent when the general lesion is syphilitic rupia, tubercles, orchitis, or periostitis. This fact leads us to suspect that the defective memory of patients will explain some apparent exceptions to the rule. From various motives, patients often conceal facts within their knowl- edge. With perfect memory and unquestionable honesty, patients are incompe- tent witnesses upon subjects ivhich involve medical kuoioledye, xohich they do not possess. The superficial chancre — the form which most frequently precedes general syphilis — is so indolent and so insignificant a sore, that it may readily pass unnoticed, or, if seen, be mistaken for a mere abrasion. I have met with several instances in which patients bearing this form of cliancre iq plain sight upon their persons, were entirely ignorant of its pi-esence, or thought it of no consecjuence. A chancre may be overlooked by the patient because seated elsewhere than upon the genitals — the exclusive seat of venereal ulcers in the esti- ' De la contagion sypliilitique, Paris, 1860, p. 15. 2 Op. cit. p. 103. 436 SYPHILIS. mation of the public — or may not be discovered, because concealed within the vagina, or beneath the prepuce when phimosis is present, or when the glaus is never uncovered. In many instances married men have applied to me with chancres, and within a few months their wives have exhibited tlie early symptoms of general syphilis, without having noticed or suspected the presence of a chancre wliicli undoubtedly existed, but which fear of exposing tlie iiusbands prevented my searching for. In other cases where an examination has been made, I have found chancres of which the patients were entirely ignorant. Again, chancres sometimes occur within the urethra beyond the reach of vision, where an unprofessional person cannot be expected to be aware of their presence from the slight discharge, pain in micturition, and indu- ration, which constitute their only symptoms, and wliicli may be obscured by a coexisting gonorrhoea. I repeat,' therefore, that when we consider in how great a proportion of cases general lesions are known to have been preceded by a chancre, and when we reflect upon the numerous sources of error attending the testimony of patients in apparently exceptional cases, it is infinitely pro- bable that a law which is known to be commonly true, is in fact invariable, and that general syphilis always follows a chancre. Syphilis pursues essentially the same course, wiiErnER derived FROM A Primary or Secondary Symptom; in the latter case, AS in the former, the initial lesion is a Chancre. This proposition may almost be said to be self-evident, for wlio would ever dream tiiat a case of scarlet fever, measles, or smallpox would vary in its symptoms according as it was contracted from a person in the early or the late stage of the same disease? We are surprised, therefore, when we look back only a few years to the time when some of the most eminent authorities maintained that contagion from a chancre would indeed produce a chancre, but that contagion from a mucous patch would produce a mucous patch, etc.; equally surprised must we be at the incredulity with which tliis proposition was met on its first announcement, in 185G, by Dr. Edward Langlebert, at a meeting of the Societe Medicale du Pantheon, of Paris.^ Langlebert's paper, however, contained no adequate proof and was nearly forgotten, when the subject was again taken up by Kollet,^ who adduced such an amount of evidence in favor of this proposition as to leave no doubt of its truth. It is unnecessary at the present day to dwell upon tills subject; suffice it to say that, as sliown by many cases of artificial inoculation, tlie results of syphilitic contagion are the same whether the matter be taken from a primary or a secondary lesion. ' Proceedings of the above Society for 1856, p. 8. See also a letter from M, ]-an days more than the one immediately preceding it. Tlie extreme limits of variation are not widely .separated (certainly not if compared witli the variation from a few weeks to thirty years, whicli is given by some authors), and we find on examination tliat in by far the larger proportion of cases, tlie periods of incubation terminated witliin two weeks of each other; thus in 38 of the 52 cases, or in about four-fifths, this period was from 3o to 50 days. Taking the average of the whole number, it was 4G days. Nouvellcs doctrines sur la syjihilis, p. 265. 438 SYPHILIS. Similar testimony is given by Bassereau/ Victor de Meric,^ Fournier,^ MacCarthy,* Sigmund,^ Kicord,'' and others. The testimony derived from artificial inoculation (which has the advan- tage that all the steps of the process ai'e under the dii'ect observation of the surgeon) is essentially the same. Thus in 12 cases of inoculation of the secretion of a chancre, the mean length of the second period of incubation was 48 days; in 14 cases, in which the secretion of various lesions of the skin and mucous membranes was employed, it was 45 days; in 4 cases, however, in which the matter was taken from pustules, it was 82 days. In my own practice, I have learned to regard the appearance of secondary symptoms between the fortieth and fiftieth day after the de- velopment of the chancre as almost certain, and I have never seen a case which was carefully watched, in which they failed to show themselves within three months. Ricord's limit of "' six months" will certainly include the most extreme cases. The conclusions at which we have arrived furnish the strongest induce- ment in all ulcers of a doubtful character to defer general treatment, and keep the patient under careful observation until the time lor secondary symptoms to appear is passed. To sum up tills whole matter : — A venereal ulcer which is not subjected to specijic treatment (so called) ivill usnalli/, if at all, be followed by secondary symptoms within fifty days, and always icithin six months. It follows as a corollary from this proposition that The earliest symjjtoms of general syphilis (excej)t in cases of hereditary origin) have been preceded by a chancre, probably within fifty days, and certainly ivithin six months. I will merely add that the development of general syphilis is hastened by an elevated temperature, and by those causes which tend to depress the vital powers, as excessive or prolonged exertion, or a dissipated course of lite; and tiiat it is, on the other hand, retarded by the contrary influences, and also by the supervention of an acute disease, as continued fever, in- flammation of the lungs, etc. It also appears to be earlier in women, in whom mucous patches are developed with great rapidity, sometimes even three weeks after the chancre. • Op. cit., p. 176. 2 Lettsomifin Lectures, 1858, p. 31. ' Notes to Ricord's L(>9ons sur le chancre, 2d ed. p. 46(5. < These de Paris, 1844. s -wieii Wochenschrilt, 1856. 6 Lettres sur la syphilis, 2d ed. p. 300. THE NATURE OF SYPHILIS. 439 CHAPTER II. THE NATURE OF SYPHILIS. Ix its nosological relations syphilis has been called a contagious and a virulent disease, a specific fever allied to the exanthemata, a disease of the lymphatics, a disease originating in a fungus, a purulent diathesis (Des- pres), and a blood disorder. Although these appellations, with the exception of the purulent diathesis, are applicable in a restricted sense, they are all of them more or less incor- rect and unsatisfactory. It is true that acquired syphilis is communica- ble through the blood and certain secretions which are contagious, but this is only a comparatively minor feature of the disease. The same remarks apply with even more force to the term virulent, since the only reason for using it is that virulent diseases, like glanders, farcy, and hydrophobia, are transmitted by means of a morbid secretion termed virus, and have periods of incubation. There is, however, no pathological resemblance, much less a relation, between syphilis and these diseases. Though the adoption of the term *' specific fever" in classifying syphilis is urged even by celebrated syphilographers, a careful examination and comparison of the course of syphilis and of the exanthemata shows only certain resemblances in prominent, but from a pathological view, merely accessory features. Syphilis originates in a fixed contagion ; the exan- themata likewise in a volatile or fixed contagion ; they have periods of incubation ; syphilis two, the exanthemata one, which are followed by constitutional disturbance and fever ; syphilis in this feature being com- paratively mild. Further tliey all have extensive integumentary and mucous membrane lesions, which in the exanthemata are always inflam- matory during their whole course, while in syphilis they are moderately hypera;mic and essentially proliferative. Here is a radical point of differ- ence ; the exanthematous eruptions are simply inflammatory, and if cell- proliferation occurs it is of a simple nature, a mere increase of the normal cells. The opposite occurs in syphilis; the inflammatory processs is less active and always results in infiltration of new cells entirely foreign in their nature. In order to complete the comparison which places syphilis in the group of specific fevers, it is urged by the chief advocate of this view, Mr. Hutch- inson, of London, that the late or tertiary lesions of syphilis have tiieir analogue in the sequela? which sometimes follow the exanthemata, and, instead of calling them tertiary lesions, he woidil call tiiem sequeUii. Ac- 440 THE NATURE OF SYPHILIS. cording to this view, syphilis ends with tlie secondary period, and all sub- sequent lesions are not, as we believe them to be, new, pathological pro- cesses originating in the one virus, but they are simply non-specific tissue- changes induced by the previous ones in the secondary stage. Not only is this comparison false, but it is founded on false assumptions. The sequela? of the exanthemata are simple tissue changes, resulting without doubt from inflammatory processes ; they are in fact true sequelae, and are etiologically related to the acute stage of the disease. Now tertiary lesions are simply a late series of specific pathological processes following, at vary- ing intervals, somewhat similar processes, called secondary lesions, which are etiologically related to the same morbid cause, the syphilitic diathesis. We can scarcely imagine a greater difference. The one is a simple, chronic, inflammatory process depending on acute antecedent inflamma- tion ; the other is the definite and late expression of a diathesis, which manifests itself by a series of proliferative lesions separated by varying periods of time. Although the lymphatic vessels and ganglia are largely affected by syphilis, and although they are the means of its diffusion and probably its occasional depots of deposit, this relationship, though intimate, is but trans- itory, since the full development of syphilis takes place not in the tissues of either vessels or ganglia but in the connective tissue to which these are freely distributed. Syphilis cannot therefore be classed among diseases of the lymphatics. It would be a waste of time to entertain the probability of syphilis being caused by a fungus. It was claimed by Salisbury, some years ago, that the disease had its origin in a certain fungus, the " crypta syphilitica" which he said he found in the blood during the activity of the diathesis, and which he did not see when the disease was cured. Since no one else has been able to find this source of the disease, we conclude that it does not exist, and that the specimens, upon the study of which the theory was based, were those of syphilitic blood, into which, owing perhaps to care- lessness of preparation and exposure, fungus growths had permeated and fructified, Perliaps the most remarkable theory of the nature of syphilis is that of Despres, who, in a work of over 500 pages, elaborates the assertion that syphilis is a purulent diathesis; that the blood is contaminated by an animal poison containing the syphilitic elements ; that it is altered little by little by contact of the debris of syphilitic pus with its globules, thus infecting them, and multiplying the poison, which seeks to escape by the skin in the form of eruptions. Among humoralists, this author goes to an absurd extreme. His work need only be mentioned to condemn it as a piece of theorizing, utterly at variance witii facts, and not supported by any tenable simile. Tlie truth is, tliat of all diseases, syphilis is essentially the least purulent. It is not so in its origin, since the unirritated secretion of the initial lesion never contains pus ; its most extensive lesions are peculiar in the fact that pus is rarely present, and then only accidentally. Further, the course of purulent infection is widely different from that of syphilis. THE NATURE OF SYPHILIS. 441 Lastly, syphilis, according to the views of humoral pathology, is a blood disease. The main fact in support of this opinion is that its contagion is in some stages transmissible through this fluid, yet we must admit the qualification that this is true only at certain times. In order to prove that it is not in its essence a blood disease, we must show what form of disease it is. Weliave found that it originates in the secretions of active lesions and in the blood during an active stage of syphilis. These fluids inserted beneath the integument do not at once pass into the circulation but cause a local cell-increase, which forms a peculiar circumscribed tissue entirely foreign to the parts. We then have a local new growth wliich is limited but exuberant. Remaining local until mature, this tissue or initial lesion passes away, having been accompanied by marked indurated enlargement of neigliboring lymphatics. Such being the facts, the pre- sumption is that these new cells have, like those of cancer and sarcoma, passed into and infected the lymphatic ganglia. That here, owing to the profusion of lympliatic globules, which we know to be protoplasm, or living matter of the most active kind, this new tissue, or rather these new cells, undergo great change, increasing in numbers according to the suscep- tibility of the patient. Having been thus proliferated, these cells are now taken into the blood, either gradually or suddenly, and by it are carried over the body, chiefly, however, at first to the periphery, where they are deposited. Being deposited in the connective tissue, they take root in this soil, which is peculiarly susceptible to the influence of the syphilitic diathesis. Here they luxuriate, and are stiU further developed, not attacking pri- marily other tissues. Inducing, in scattered circumscribed spots, cell- proliferation in the middle layer of the blastoderm, they cause increase of the cells of this connective tissue itself, as well as the development of a new tissue, the granulation tissue, also called gummatous tissue, gumma, and syphiloma. This is a young transitory tissue composed of cells, some- times called cyto-hlastonies and ryto-blastions, which resemble white cor- puscles. In describing their development, Virchow says : " The j)rocess begins by a proliferation of cells which augment in volume (liypertrophy), and of which the nuclei are multiplied, often in an astonishing manner. Then follows segmentation of these cells, and finally the veritable develop- ment, ordinarily, the production of numerous cells which in general are very small and usually contain nuclei, these latter being large and for the most part round. They have a certain resemblance to the lymphatic globules, and have been heretofore called lymph-corpuscles or exudation- corpuscles, as they were thought to be due directly to this process. On cutting such a tissue, we find a great number of free nuclei, which are round -or oblong, pale, slightly granular, and containing one or more nucleoli. In short, it is essentially a young production, but slightly ad- vanced in development, and especially indifferent in its cellular nature." This description applies to a gummy tumor of recent date. Such a tissue is not always sliar[)ly limited and compact, but is infiltrated; its sliape being moulded by the surrounding parts. In old cases, however, there is 442 THE NATURE OF SYPHILIS. often !i collection of fully developed cells, with but few free nuclei. Among them may he stellate and fusiform cells, and, frequently, Baumgarten has clearly shown that giant cells, foi-merly considered distinctive of tubercu- lous infiltration, are found also in these tumors. These stellate and fusiform cells are distributed through the tumor, ■which is frequently traversed by an intercellular substance which is some- times fibrous. In some instances these tumors merge gradually into the surrounding parts, while in others they are encapsulated. Their structure varies in compactness ; they may be firm and fibrous or they may have a gelatinous consistence, resembling mucous tissue. Such is the general formation of syphilitic tumors; it must be remembered, however, that their structure depends largely upon the configuration of the region in which they are developed and the arrangement of its anatomical elements. In the development of these tumors, as well as of syphilitic papules and tuber- cles, the fir^t morbid change is in the adventitia of the vessels. The description here given applies to the fully developed gummy tumor. The cells of the earlier stages are mainly similar. Tiiose of the initial lesion are mingled with molecules of fibrine, showing a more inflammatory process, while those of tubercles form infiltrations rather than distinct tumors. All of these cell-changes are similar and etiologically related. The cells, being immature, are liable to fatty degeneration, and for this reason syphilitic lesions often disappear spontaneously. These cells belong to the group called by Virchow granuloma^ which also includes the tumors of lupus and leprosy. The cells of each of these diseases are similar and resemble those of granulation tissue. Those of syphilis are peculiar in their arrangement, mode of develo[)ment and course, and in being absorbed under the influence of mercury. An important and almost unansweraille question is, whether these cells of syphilis are specific. They are so re- garded by Wagner, who gives the name " syphiloma''' to the tissue which they form. Virchow, on the contrary, denies their sjjecific nature, and pre- fers the terms ^'' gumma" and '■^granuloma.'' Although the appearance of these tumors is almost identical, it must be acknowledged that tiie property of contagiousness is peculiar to the cells of the syphilitic tumors. We now come to the consideration of hypera^mia. Chronic congestion is an important feature in the pathology of syphilis. It is especially notice- abhi in the early stage, and is best exemplified in the exanthematous syph- ilide and in the hyperiemia of the fauces. Many other secondary symptoms have a similar nature, and hypera^mia of the viscera probably occurs in this stage, yet generally it altogether escai)es observation. Early in syph- ilis, this hyperajmia precedes and accompanies the extensive lesions, though it may exist merely as capillary stasis without cell change. In the late stages, the hyperiemia is milder and more localized. It is probably alvvays a forerunner of gummy tumors. An additional phenomenon of syi)liilis is the production of connective tissue, either without gummatous cells or accompanying gummy tumors. This tissue increase is the result of mild hypenemia, and occurs in firm, fibrous tissues, such as the periosteum and the capsules of the viscera. It THE NATURE OF SYPHILIS, 443 is best seen in syphilitic periostitis and in the fibrous bands observed in the liver, spleen, lungs, and testicles. It is noticeable that suppuration rarely accompanies syphilitic lesions ; •when it does, as in the early pustular eruptions, it is a secondary result or an accidental occurrence, and is not an essential part of the syphilitic process. Although it was long since claimed that the lymphatics were the active agents in syphilitic infection, and although Virchow has for years insisted upon a similar theory, the question has never been properly studied, and modern authors are vague and uncertain in their opinions. The majoi-ity, however, regard the blood rather than the lymphatics as the vehicle of contagion.^ Our own conclusion is that syphilis is a disease of the connective tissue, and not primarily of the lymphatics or of the bloodvessels, although the blood may be temporarily modified and may be the vehicle of contagion. The secretions of syphilitic lesions are found to consist of a serous fluid containing numerous sliining granules or molecules, which are masses of proto[)lasm or germinal matter, holding the contagious properties of syphilis. These microscopic bodies are probably taken into the circulation by the lymphatics and conveyed over the body. Possibly they are absorbed by the blood corpuscles, or the latter are infected in some mysterious manner by these actively increasing morbid cells. The fact tliat serum alone does not convey the sy[)hilitic poison goes to prove that the corpuscles hold the contagious material. In the secondary period of sypliilis these cells are very numerous, and the body may be covered with papules and tubercles composed of them. As the disease wanes, these lesions become more localized and fewer in number, and the blood is less contagious. Finally these cells may be limited to a few gummous tumors; the blood no longer carries the mole- cules, and it loses its contagious properties. The cells no longer have a tendency to reproduction, which characterizes them in the early stages, but rather degenerate. Hence we consider the blood and the secretions in tertiary sy})hilis innocuous. Even if cells are present, they are old and inactive, and are incapable of reproducing themselves. Lancereaux states ' In the year 1871, Dr. F. N. Otis published two articles, endeavoring to explain the periods of incubation and the course of syphilis upon the theory that infection occurs only through the lymphatics. Assuming the syi)liilitic virus to consist of disease-germs, the aiithor thinks tliat the first period of incubation is occupied in their passage through the tissucss, the process varying induration in proportion to the de])tli of the lymphatics and the resistance of the tissues. He believes that the syphilitic virus coagulates the superficial tissue-fluids, causing obstruction to the circulation and attraction to the spot of wandering white corpuscles, which by their ama'boid movement entrap the specific disease germs. The latter are de- veloped and increase within the white corpuscles, which themselves multiply. According to this view, the initial nodule is simply an aggregation of diseased white corpuscles. These latter pass into the ganglia and there again multiply, passing finally from the lymphatics into the circulation. 444 THE NATURE OF SYPHILIS. that he has often punctured himself in making autopsies on subjects with gummy tumors, and lias never seen any bad result. The periods of latency observed in the course of syphilis are of interest, and may perhaps be explained in the following way. Each outburst is attended by the development and multiplication of the peculiar cells, which run their course and are finally absorbed. Some remain and after a time are excited by unknown causes to activity. Thus repeated exacerbations may occur, each one depending upon the multiplication of cells remaining from a previous outburst. But each relapse is less active and less pro- longed than its predecessor, until perhaps only one nodule, and that com- ]>osed of effete cells, may remain. The disease is then cured. This explanation may seem to apply imperfectly to those cases of prolonged latency in which no lesion whatever has been perceptible. Virchow thinks that in these cases the lymphatic ganglia have been the places of deposit of the syphilitic cells, which, at the expiration of the period of latency, undergo the changes mentioned. In any case, the specific cells must be hidden away somewhere in the system, since the continuance of the disease depends upon their existence. With this view of the nature of syphilis, its effect upon the health and upon the organs and tissues may be readily comprehended. In the early active stage of proliferation the red globules are diminished and the white increased in number. The depressing influence of syphilis is thus fully accounted for. Digestion is impaired and the tissues are poorly nourished. Finally, the functions of vital organs may be perverted or destroyed by the cell-changes produced. INITIAL LESION OF SYPHILIS. 445 CHAPTER III. THEIXITIALLESION OF SYPHILIS, OR CHAXCRE. Logical accuracy as well as simplicity and perspicuity of language require the abandonment of the terms " hard," "indurated," and " infect- ing chancre," as applied to the initial lesion of syphilis, which should be called simply by the name of chancre, syphilitdc chancre, initial lesion of syphilis, or primary syphilitic ulcer. If the name " Hunterian chan- cre" be retained, it should be applied exclusively to the less frequent form of chancre which Hunter designated, and which is characterized, in addi- tion to the induration common to all forms of chancre, by a degree of ulcei'ation that involves the whole thickness of the skin or mucous mem- brane. The term " infecting chancre" is especially objectionable, as it implies that it is the chancre which infects, whereas the very development of this sore is the result of constitutional infection. As Diday remarks, when a man contracts syphilis, the only chanci-e that can properly be called infecting is the one upon the woman who gave him the disease. For a comparison of the frequency of the initial lesion of syphilis with that of the chancroid, the reader is referred to the first chapter of the second part of this work, where the remarks upon the seat of the chancroid are also applicable in the main to the sore under consideration. The fol- lowing table exhibits the seat of 471 chancres in men, comprising all that were observed at the Hopital du Midi in the year 1856 : — Chancres on the glans and prepuce ...... 314 " oil the skill of the penis ...... (JO " oil various parts of the penis . . . . .11 " involving the meatus ....... 32 " within the urethra (not visible on forced separation of the lips of the meatus, but recognized by pali)atioii, inflammation of the lymphatics, etc.) . . .17 " on the scrotum and peiio-scrotal angle . . .11 " of tlie anus ........ 6 lips 12 " " tongue 8 " " nose 1 " " pituitary membrane ...... 1 " " eyelid 1 " " fingers ........ 1 " "leg 1 Total . . . .471 In 1.30 women aflfected with true chancres at the Antiquaille Hospital, Lyons, where wet-nurses are admitted, M. Carrier found the seat to be : — 446 INITIAL LESION OF SYPHILIS. Times. The labia majora ......... 43 " entrance of the vagina ....... 12 " meatus .......... 14 " nymphre .......... 10 " fourchette .......... 7 " sheath of the clitoris 3 " anus ........... 12 " buttocks 1 " thighs. 1 " under lip .......... 6 " ujjper lip . . . . . . . . . ■ . 4 " labial commissures ........ 1 " nostrils .......... 2 Both breasts .......... 3 The right breast 1 " left breast 5 Regions not determined ........ 5 Total .... 130 By comparing these tables with those upon pages 348, 349, it is seen that the seat of chancres is still more extensive than that of the chancroid, since it embraces tlie face and buccal cavity, where the last-mentioned ulcer is rarely met with in practice, but where the syphilitic virus is often inocu- lated from a secondary lesion in the contact of mouth with mouth, etc. Among the rarer situations of a chancre, should be mentioned the walls of the pharynx, where a certain aural specialist of Paris is said to have inoculated several of his patients by means of a Eustachian catheter which he neglected to cleanse. A remarkable instance came under our observa- tion of a chancre concealed beneath the upper eyelid, showing no signs of its presence externally, even upon the free margin of the lid. The })atient aj)[)lied to me for disease of the eye, and on everting the upper lid I found a superficial excoriation which bore a striking resemblance to a chancrous erosion, and just in front of the ear on the same side was an indurated ganglion. The genital organs were sound. I exhibited the case and stated my diagnosis to my class at the College of Physicians and Surgeons, and under ex[)ectunt treatment secondary symptoms made their appearance after the usual period of incul)ation. The man was a stu])id Irishman, made his living by slaughtering .sheep, was married, and I never could obtain any clue to the manner in which he contracted the disease. Has the chancre a period of incubation ? This is an important question, since it involves two others of great practical interest: 1. AVhether the fliancre is a local or constitutional lesion; 2. Whether its abortive treat- ment can prevent systemic infection. As I have shown in another chapter, the chancre produced by inoculation of the secretion of secondary symp- toms undoubtedly has a period of incubation, amounting on the average to more than three weeks. Again, in three cases of artificial inoculation of the secretion of a chancre, performed by RoUet,^ Rinecker, and Gi"bert, ' Arch. gen. de med., avril, 1859, p. 409. PERIOD OF INCUBATION. 447 the period of incubation Avas 18, 25, and 24 days respectively. In clinical observation, the same difficulties obtain as have already been mentioned with regard to the chancroid, but many careful observers have noticed the fact that, as a general rule, advice is sought at a later period for a chancre than for the chancroid, and the interval between contagion and the appearance of the ulcer is represented by patients as longer in the former than in the latter. Diday made minute inquiry of twenty-nine persons whose chancres were of recent origin, who appeared to be trust- worthy, and certain of the facts which they stated, who had been exposed^ but once, and. who had had no previous connection for at least a month, and found that the average interval between the sexual act and the appear- ance of the sore was fourteen days.' M. Chabalier, in an examination of ninety cases of chancre, found an average period of incubation of from fifteen to eighteen days; and states that the chancroid, on the contrary, is visible within thirty-six to forty-eight hours after contagion.- M. Clerc has especially insisted upon the presence of incubation as diagnostic of the chancre, and has reported several cases which were preceded by a period of incubation of thirty days. A gentleman of this city, of high social position, whom I know so inti- mately tliat I can vouch for the truth of his statements, visited Paris, unaccompanied by his wife, and, while under the influence of wine, for the first time during fifteen years of married life had connection with a woman of the town. This was on the eve of his return to America, and his subsequent remorse and anxiety were so great that on his voyage home he examined himself daily with the greatest care to see if he had contracted any disease. His prepuce was very short, so that the glans was habitu- ally uncovered, and no lesion was likely to escape observation, yet he found nothing until the day of his arrival home, the thirty-fifth after ex- posure, when he noticed a slight excoriation upon the internal surface of the prepuce. Pie showed it to his family physician, a " Homoeopath," who told him that it was a mere abrasion which would heal in a few days, and that he might with safety have connection with his wife. As the promised cicatrization did not take place, on the fourth day after his arrival he applied to me, and I found a superficial chancre with well- marked parchment induration and attendant indurated ganglia. Since then he and his wife have had several attacks of general syphilis. Castelnau reports a case communicated to him by the physician of a venereal hospital, who was himself the subject of tlic observation, in wliicli a chancre appeared thirty-three days after an impure intercourse.' Fournier* relates a number of cases of comparatively long incubation, amounting to 28, 21, 39, 28, 21, 21, 40, 29, 23, 25, 21, 34, 28, 30, 30, 30, 27, 35,-42, 45, 21, 42, 42, 30, 42, 35, 48, 21, 33, 40, 25, 28, 34, 28, 30, ' Gaz. med. de Lyon, mars 1, 1858. * Tliese de Paris, No. 52, 1860, p. Ill, 3 Anuales des maladies de la peau et de la syphilis, t. i, p. 212. * Kecherches sur la incubation de la syphilis, 18(J5. 448 INITIAL LESION OF SYPHILIS. 35, 17, 30, 37, 21, 30, 70, 2i), 28, und 30 days. The longest incubation that we liave ourselves observed was 50 d.ays. But further evidence on this point is unnecessary. There can be no question that the initial lesion of syphilis, as of otiier infectious diseases, possesses a period of incubation, upon an average of froni two to three weeks, and sometimes extending to five, six, or even, in rare instances, to eleven weeks; and this fact leads to the important conclusion that An interval of tivo loeeks or more hettveen the last exposure and the ^appearance of a, suspicious sore upon the genitals, renders it extremely probable that the latter is a true chancre. To ascertain its shortest limit is attended with more difficulty, since the virus is sometimes deposited in a wound or abrasion occurring at the time of coitus, and, in consequence of inattention to clealiliness or other acci- dental causes, remaining open until the development of the chancre, so that it is impossible to say precis«dy when the simple is transferred into the specific ulcer. The inoculation of the same point with the chancroidal and sypliilitic poisons will also explain why in some instances the initial lesion of syphilis appears to be develo[)ed in some cases earlier than in others, since the action of the former virus commences at once and gives rise to an ulcer which may be perceived by the patient in the course of two or three days, and which masks the later development of the chancre. When inquiring into the incubation of a venereal ulcer, the surgeon must be on his guard. A patient applies to him with a sore and says he w^as exposed three days before. The careless surgeon chimes in with the idea of tlie patient that the sore was thus recently contracted, and, on the ground that there has been no period of incubation, pronounces it a chan- croid, forgetting to ask the patient wdien he was exposed before this lo?t time I Such inquiry will often elicit the fact that the previous exposures have been frequent and closely approximated, and that at which of them the inoculation took place is a " conundrum." If the sore prove to be a true chancre, it was certainly not at the last one — three days before — that the mischief was done. Symptoms. — The following table, prepared by M. Bassereau,^ of the chancres which preceded 170 cases of syphilitic erythema, will indicate the various forms which a chancre may assume, and afford some idea of the comparative frequency of these forms in the milder cases of the disease, of which the more severe instances exhibit a larger proportion of excavated ulcers : — Superficial erosions ........... 146 Circumscribed ulcers, with abrupt edges, involving the wliole thickness of the skin or mucous membrane ........ 14 Circumscribed x^hagedenic ulcers, witli a pultaceous floor, involving the tis- sues a short distance beyond the skin or mucous membrane ... 10 Total, 170 ' Op. cit. p. 140. SYMPTOMS. 449 It appears from this table that the chancre has no exclusive form, but that it most frequently assumes one which differs widely from the chancre type as formerly described by many authors. The frequency of the superficial form of chancre excited my attention several years before I had met with any description of it in books, and the first cases which came under my notice were mistaken for mere abrasions until the appearance of secondary symptoms corrected the diagnosis. The superficial form of chancre is most marked on the internal surface of the prepuce, by which it is protected from the air and friction, and kept free from scabs ; and it is in this situation that it is most frequently met with. It has generally a circular or ovoid, but sometimes irreo-ular, outline. Its floor is but slightly, if at all excavated, and occasionally is even elevated above the surrounding integument by the subjacent indura- tion. Its surface is smooth, often looking as if polished, destitute of the consistent and adherent exudation of the chancroid, and of a red or gray- ish color ; or, at times, it is dark or even black, owing to molecular o-an- grene. Moreover, there is a frequent feature of the chancrous erosion which I have often observed, and which Avas first described by my friend, M. Clerc, of Paris, wMio gave several admirable representations of it in his Traite pratique des maladies veneriennes. I refer to a "kind of false membrane, presenting some resemblance to the diphtheritic patches which characterize certain forms of syphilitic symptoms occupying the mucous membranes." It is entirely distinct in its appearance from the membrane covering a chan- croid, but the difference is better seen than described. I can only say, that it usually occupies only the centre of the chancre, that its edges shade off into the reddish circumference, that it is of a translucent, slightly greenish, and pultaceous appearance, unlike the dull or yellowish-gray membrane which covers the whole surface of a chancroid. M. Clerc be- lieves that this diphtheritic layer is a consta^it feature of a chancre durin^ the early stage (first two weeks) of its existence. I cannot regard its pre- sence as thus invariable, but it is certainly very frequent, and is well worthy of careful ol)servation. The secretion of this form is a clear serum — free from pus-globules, unless the sore has been irritated — which may often be seen issuing from minute pores, after the previous moisture has been wiped away. It has no surrounding areola, and leaves no cicatrix to mark its site. Barely one-third of the chancres in Bassereau's 170 cases, left any visible traces aside from induration. When situated upon the external integument, as the sheath of the penis — where most venereal ulcers are chancres — and exposed to the air, it becomes covered with scabs, which give it the appearrwice of a pustule of ectliyma, or a patch of scaly erujition, and which may readily lead to an error in diagnosis. The cliaracters of the chancrous erosion are also modified by the application of irritants, or by a want of cleanliness ; its secretion may become purulent, and its surface resemble tliat of the chancroid ; but its normal ;ippearance may be restored by applying a water-dressing for a few days. 29 450 INITIAL LESION OF SYPHILIS. Frequent as is the chancrous erosion, it must not be regarded as the exclusive form of clinncre. Diday believes that it is due to inoculation from a secondary, and that the excavated chancre is produced by inocula- tion from a primary lesion, but this distinction will not hold. Between this form and the indurated excavated ulcer, known as the Ilunterian chancre — which was so long and so erroneously supposed to be the especial harbinger of general syphilis — there may exist many gradations which it is unneces- sary to describe in detail. Ulcerative action may go beyond this point, and terminate in phageda^na ; but, generally, it is limited by the plastic inflammation of the surrounding tissues, as is evident from an examina- tion of the edges of nearly all the forms of chancre, which are sloping, somewhat prominent and adherent, unlike the abrupt and detached mar- gins of the chancroid. If phagedaMia occur, the destructive process is usually limited to the induration (neoplasm), and, on the final healing of the ulcer, it is sur[)rising to see how little mischief has been done to the normal tissues. 3Iultiph Herpetlforin Chancres Under this title Dubuc first called attention to a variety of syphilitic cliancre, liable to be mistaken for herpes. These chancres have a diameter of a line or less ; they look like small round excoriations, of a deep-red, sometimes coppery hue, which bleed readily and have very slight induration of their bases. The induration often increases at a later period. From five to fourteen chancres may be observed upon the jjrepuce or glans. In their first stage the diagnosis is difiicult ; but the absence of itching and burning, their dark color and their chronicity are points which aid in distinguishing them from herpes. Another important feature is that their surface is very smooth and shining. Moreover, induration of the inguinal ganglia is soon developed. Tlie duration of these herpetic chancres, is, according to Dubuc, a month or six weeks. In exceptional cases, in which the chancres are not close together, they remain separate during their whole course. In the majority of cases they are closely groujjcd, and after remaining for several weeks in the herpetic form, they unite and form a single chancre. Anomalous Appearance of the Initial Lesion of Syphilis The chancre is subject to various modifications. One of the rarest is that described by Dr. P. A. Morrow' as '•'■ diphtheroid of the ylans." In the case which he had under his care and which we had the op[)ortunity of observing, '• the anterior four-fifths of the glans penis was covered with a glistening grayish-white coaling of a leathery consistence, simulating in all its physical character- istics a diiihtheritic exudation. This coating was of uniform thickness, raised about two lines above the licalthy mucous membrane, and covered tlie entire surface of the ghms, except a narrow zone embracing the corona. "The edges of the coating were abruptly raised, and the line of demar- ' On a rare form of initial lesion, Diphtheroid of tlie glans penis : Report of a case with renaarks. P. A. Morrow, M.D. Arch. Deruiat., N. Y., 1876, vol. ii, p. 383. INDURATION. 451 cation between its border and the healthy tissue was distinct and unmasked by any inflammatory areola. This appearance was suggestive of a white membranous hood drawn over the head of the penis, with a slit-like open- ing for the meatus in front. So evenly and smoothly was it moulded over the glans that the contour was perfectly preserved. A sensation of a smooth greasy feel was communicated to the finger passed over the surface. There was absolutely no erosion — its epithelial coat seemed to be con- tinuous with that of the healthy mucous membrane, wdiich limited its circumferential border above. Its base was supple, with no trace of indu- ration. Its surface was moist and glistening, with no appreciable secretion. It was intimately adherent, and could not be detached from the tissues which supported it without leaving a bleeding base." It was painless and indolent ; it appeared several weeks after coitus, and was followed by secondary symptoms. In three cases which we have seen at the New York Dispensary, the lesion was developed in round or oval [ atches, less than an inch in dia- meter. In one case the patch was continuous with an indurated nodule. The lesion disappeared slowly, leaving the parts normal or slightly pig- mented. For reasons given in our published reply' to Dr. Morrow,, we do not consider this a diphtheroid condition of the initial lesion. We regard it rather as a form of scaling or dry chancre, the '■'■ papule seche" of Lancereaux. In this lesion the syphilitic cells are developed in the super- ficial tissues of the glans, which are thereby thickened and assume a leathery appearance. The whitish color is probably due to the close packing of the cells. Infecting Balano-posthitis Under this title Mauriac has described a form of initial lesion which is liable to be mistaken for simple balano- posthitis. In this lesion the mucous membrane of the prepuce is thick- ened, has a deep red color, and is slightly excoriated either partially or completely. Tiie glans may be superficially thickened, and is generally hypera^mic and eroded. Retraction of the i)repuce, which may be some- wliat difficult or quite impossible, best displays its infiltrated condition. Tlie induration may be evenly distributed or irregular; its localization may be marked in the fossa near the fnenum, in which case there exists merely an indurated nodule. The course of the lesion is chronic, but it yields readily to internal treatment. The lesion consists of an infiltration of the subnuicous tissue with hyperannia ; in other words, it is a combina- tion of cell-infiltration and litu'd oedema. Induration was recognized at a very early [)eriod in the history of syphilis, first by Torella, in 1497, by John de Vigo,^ Gabriel Fallopius," Leonard ' XotHH on a rare ai)pearaTice prosentcd by the initial losiou of syphilis. R. W. Taylor, M.D. Arch. Derinat., N. Y.. 1877, vol. iii,. p. 5. * "Nam ejus origo in partibus gt^nitalilius, videlicet in vulva in mulicribus et in virga in homiinl)us, semper, fuit cum pustulis parvis, interdum lividi coloris, aliquando iiigri, non nuiiquam sulialbidi, cum callositate eas circuiudante." (Jou.v UE Vico, Pritcticd cojiiosa in Ai-te Cliiruryica, etc. Ilom«, 1514, lib. v.) * Tractatus de Morbo Gallico, Patavium, 15G4. 452 INITIAL LESION OF SYPHILIS. Botal/ and Ambrose Parc,^ as a prominent symptom of the sore which precedes general syphilis; nearly forgotten by subsequent writers, though occasionally mentioned, as by Nicholas Blegny,'' it again assumed im- portance in modern times fi-om the teachings of Hunter,* Bell," and especially Ricord, and is now justly regarded as the most characteristic feature of a chancre, when seated upon a person exempt from previous syphilitic taint. The induration of a chancre is a peculiar hardness of the tissues around and beneath the sore. Simple inflammation may occasion an effusion of plastic material and consequent engorgement about any sore ; but specific induration is of an entirely distinct character. The latter is formed, as the French say, " a froid,''^ that is, without inflammatory action ; the deposit takes place in the absence of all the symptoms of inflammation, "pain, heat, redness, and swelling;" and so silently, so insidiously, that the patient is often ignorant of its presence, or discovers it only by acci- dent. No event is more common than for a surgeon to be consulted by a man who states that he had a sore a few weeks ago, " which did not amount to much;" he " burnt it with caustic and it healed up;" but he hag recently found that it left a "lump" behind it. This "lump" is specific induration and denotes that the constitution is infected. A gentle- man applied to me for phimosis — neither congenital nor inflammatory — which occasioned no inconvenience except an inability to retract the prepuce. He was not aware that he had had any venereal trouble, but, on examination of the parts, a mass of induration as large as an almond was perceptible to the touch and even to the sight — so great were its dimen- sions — situated about the furrow at the base of the glans. The phimosis was simply due to the mechanical obstruction presented by the induration to the retraction of the [)repuce, and this difficulty alone induced him to seek advice. Frequently, also, patients ap[)ly to a surgeon for treatment for general syphilis, and honestly declare that they have never had a chancre, though the previous existence of such, and even its very site, are unmistakably indicated by the remaining induration. Again, specific induration and inflammatory engorgement differ in their objective symptoms. The boundaries of the former are clearly defined, while the extent of the latter cannot be limited with nicety ; the one ter- minates abruptly, the other shades gradually into the normal suppleness of the part ; the first is freely movable upon, the second adherent to, the tissues beneath. The difference in the sensations they impart to the fingers is still greater; specific induration is so firm, hard, and resistant, that it ' Luis Venerec-e Curand 15 12 3 INDURATION. 455 of tlie chancre, and, unless dissipated by treatment, may, in most cases, be felt for at least two or three months, and often longer. Some statistics collected by M. Puche show that its persistency becomes rarer after the third month, and is quite exceptional after the eighth, though this surgeon reports thirteen cases in which it was perceptible from 390 to 20G2 days after contagion ; in nine of the thirteen, the induration occupied the furrow at the base of the glans, a favorite seat for its full development and long persistency. M. Puche met with still another instance in which induration persisted for nine years. I have met with several cases of two and three years' duration, and Ricord with one of thirty years. It follows from tlie above data that induration is an early symptom of syphilis, and that the time within which its presence or absence is of diagnostic value is limited, though variable in different cases. Induration is sometimes much shorter lived; the parchment form espe- cially, may entirely disappear before the chancre heals, and the cicatrix present as soft a base as the chancroid. This form of induration is, how- ever, in many instances, as durable as any other. As the process of absorption goes on, the indurated mass becomes less fii"m and resistent, and gradually softens until it can finally no longer be detected. In other instances, after partial absorption has taken place, the induration suddenly resumes its earlier dimensions, and this is most likely to occur upon the first appearance of secondary symptoms, or at a subse- quent relapse of the same. Under the name of '•'■indurations de voisinage" Fournier^ describes masses of induration, contemporaneous with the chancre, but occurring secondarily at a short distance from it. I have seen several cases of the kind. The induration is probably seated in the tunics of the bloodvessels emanating from the seat of the chancre, and in the surrounding cellular tissue. Although the surface of such indurations usually remains intact, it may take on ulceration in the manner hereafter described. Relapsinff Induration The genital organs may at any time in the course of sypliilis be the seat of indurated nodides whicii are liable to be mistaken for primary lesions. They are of two kinds — the superficial and deep. The superficial indu- ration is in every respect like a true cliancre, consisting of a localized infiltration, somewhat elevated, having a smooth exulcerated surface, which secretes a scanty mucous fluid. It generally appears upon the mucous layer of the prejiuce or upon the glans in the form of a small papule. It runs an indolent course, but may reach quite a large size. It is usually accompanied by enlargement of the inguinal ganglia. It some- times appears exactly on the former seat of a primary lesion, and is gene- rally solitary. The deep relapsing induration occurs in the submucous connective tissue of the pre[)uce and of the laljia majora. It consists of a sharply-defined ' Etude clinique sur riiiduration .syi)liiliti(iue primitive, Areli. gen. de m^d., nov., 1807. 456 INITIAL LESION OF SYPHILIS. nodule of cartilaginous hardness, freely movable and generally not adherent to the mucous membrane. Its growth is rapid, and it sometimes reaches the size of a nutmeg. There may be several of these tumors, and we have seen five in one case. The lesion may remain inactive for a long time, causing no pain but giving some inconvenience in coitus. In some cases it contracts adhesions with the surrounding soft {)arts; exceptionally, it undergoes necrosis and forms a deep ulcer, which is difficult of cure. In women the infiltration is often very large, involving perhaps the whole . labium. The induration is very marked and often persists for years. In rare cases the labia minora are involved. There is usually no enlargement of the inguinal ganglia with the deep induration, either in men or in women. These indurations may occur as early as the first and as late as the tenth year of syphilis. They are amenable to early treatment, but are more obstinate with age. They have been known to undergo spontaneous invo- lution, and to relapse after complete cure. It is important to distinguish them from primary lesions of syphilis. Many of the reported cases of reinfection have no doubt been in reality examples of relapsing induration. Secretion The secretion from a chancre is much less copious than that from the chancroid and is chiefly serous. This difference is especially evident in the superficial erosion, but is also perceptible in the excavated forms, the discharge from which is less free and purulent than in the chancroid. Numerous ex[)eriments show that the immunity conferred by one attack of syphilis extends in most cases even to the initiatory sore. This fact was first announced by M. Clerc in 1855. Fournier inoculated the dis- charge of ninety-nine chancres upon the patients themselves, and succeeded in but one, in whom the experiment was performed within a very shwt period after contagion. M. Puche states as the result of his own experi- * ments that auto-inoculation of the chancre is successful in only two per cent. Poisson obtained like results in fifty-two cases,^ and Laroyenne was unsuccessful in every one of nineteen.^ Do not these facts tend to show that the chancre is from the very first a constitutional lesion ? Their bear- ing upon the use of artificial inoculation as a means of diagnosis is evident ; failure favoring the supposition that the sore is a chancre. AVhenever auto-inoculation has proved successful, it has been with virus taken from the sore at a very early period of its existence, or from one which has been irritated and its secretion rendered purident, and in the latter case, the resulting sore is not a chancre but a chancroid. (See In- troduction.) In the same manner vaccine lymph may be successfully reinocnlatod within a day or two after the first appearance of the future pustule, while if the attempt be deferred until its full development, it will fail. Hence we infer, that although absorption is instantaneous and gene- ral infection is inevitable from the first, yet that time is requisite to bring the system fully under the influence of the virus. ' Lp^ons sxir le cliancro, p. 274. 2 Anmiaire de la sypli. ut d. inal. do la poaii, Paris, annee 1858, p. 241. DURATION AND TERMINATION. 457 Mr. Henry Lee, of London, as early as 185G, also called attention to the difficulty of inoculating chancres, or " syphilitic sores affected with specific adhesive inflammation," upon the persons bearing them.^ This surgeon afterwards maintained that if a chancre — the discharge from which, under ordinary circumstances, is destitute of pus-globules — be irri- tated, as by the application of a blister or ung. sabinae, until its secretion becomes purulent, it is susceptible of inoculation.^ This statement was confirmed by Prof. Boeck and other advocates of " syphilization." The difficulty of inoculating tlie secretion of a chancre is equally as gi'eat upon a person who has arrived at the stage of secondary syphilis as upon one who has but recently been infected. Duration The chanci-e, as a general rule, is of somewhat shorter duration than the chancroid, but often remains until after the appearance of secondary symptoms — a remark which I should not think it necessary to make had I not met with persons who supposed that primary syphilis must terminate before secondary commenced ! Of 97 cases observed by Bassereau, in which no treatment had been employed, syphilitic eiythema, one of the earliest general symptoms, occurred in bH before, in 18 during, and in 21 after the cicatrization of the chancre. Termination As previously stated, most chancres are not attended by any loss of substance, and consequently leave no cicatrix. A chancre situated upon the external integument, as the sheath of the penis, often leaves a peculiar discoloration of the skin of a sombre brown or brownish-red color, whicli is never seen after the chancroid; in time its dark hue fades into a white. An instance of this kind is figured by Ricord in his Iconographie des maladies venerieyines, pi. xviii. A chancre may have entirely liealed, leaving an induration in its site, and the latter again take on ulceration, commencing either upon its sur- face or in the centre of the mass, and form a sore precisely similar in every resi)ect to the original chancre. In this case, the secretion is just as infectious as that of the first ulceration. Moreover — and this is an important point — I have known this second ulceration to take on phagedenic action, which, under these circumstances, requires the active use of mercury to arrest it, although the destructive nature of the process and possibly the recent administration of this mineral would seem to demand a contrary course. I have met with several in- stances of this kind, in which tiie phagediena tlireatened to destroy the glans or penis, and only yielded to the timely administration of mercury. Ricord first called attention to the fact, which has since been verified by many observers, that a chancre during the reparative period may be transformed into a mucous patch, and thus a primary be changed into a secondary lesion. This transformation may take place upon any part of the body, whether of skin or mucous membrane, but more frequently upon the latter, especially when habitually in contact witli an opposed surface, ' Brit, and For. M. Chir. Rev., London, Oct. 185G. « Ibi.l. for Ai-ril, 1859. 458 INITIAL LESION OF SYPHILIS. whereby heat and moisture are maintained ; as, for instance, upon the internal surface of the prepuce and labia majora, and upon the lips and tongue. Davasse and Deville have carefully studied the progressive clianges by which this process is accomplished.^ The surface of the chancre loses its grayish aspect and fills up v/ith florid granulations, com- mencing at the circumference as in the ordinary period of repair ; but just as these changes are reaching the centre of the sore, a narrow white border of plastic material appears around its margin, and extending towards the centre, finally covers it with the membranous pellicle which is characteristic of a mucous patch. If the patient does not come under observation until these changes have been effected, the initial lesion of his disease may be supposed to be a mucous jiatch instead of a chancre. Number of Chancres Unlike the chancroid, the chancre is rarely met with in groups of two or more upon the same subject. Of 556 patients under the observation of Fournier, 402 had but one, and 154 several chancres. Debauge collected 60 cases at the Antiquaille Hospital, at Lyons, in 41 of which there was a single chancre, and in 19 several. These statistics would show that the chancre is solitary in three cases to one in which it is multiple. The ratio is still greater in M. Clerc's obser- vations, in which the chancres were single in 224 out of 267 cases. If multiple at all, it is almost always true that they are so as the immediate effect of contagion, and because several rents or abrasions were inoculated together in the sexual act. If solitary at first, they continue to be so ; since successive chancres rarely spring up in the neighborhood, as in the case of the chancroid, owing to the fact that the virus ceases to act u[)on the system as soon as it is once infected. Phmjedcena — Pliagediena generally spares the chancre or limits its ravages to the destruction of the surrounding induration. In some instances, however, as I have seen in my own practice, an extensive phagedenic ulcer is the initial lesion of syphilis, and, in this case, the subsequent general symptoms are usually of an aggravated character. Babington says : " The secondary symptoms which follow the phagedenic sore are peculiarly severe and intractable. They commonly consist of rupia, sloughing of the throat, ulceration of the nose, severe and obstinate mus- cular pains, and afterwards inflammation of tlie periosteum and bones. Similar complaints will follow the ordinary chancre ; but when they follow a phagedenic sore they are very difficult to be cured ; and it is not uncommon that the constitution of the patient should at length give way under them, and that the case should terminate fatally."^ Bassereau also found a correspondence between the severity of the chancre and that of the syphilitic eruption. Thus, of 68 chancres which preceded a pustular syphilide, 20 were phagedenic and 4 others serpigi- nous f and 18 of 50 chancres followed by a tubercular eruption produced ' Etudes cliniques des maladies ven^riennes ; des plaques muqueuses. Arch, gen. de med., 4e s6rie, vol ix, p. 182. "^ RicoKD and HcjxTER on Venereal, 2d ed. p. 371. ^ Qp. cjt. p. 442. DIAGNOSIS. 459 destruction of the tissues to a greater or less extent. It will be recollected, on the contrary, that 143 of 170 chancres followed by syphilitic erythema were mere erosions, and that 10 only exhibited a very slight tendency to phagedoBna. Bassereau states that a similar relation exists between the primary sore and other syphilitic lesions, and lays down the rule, that " mild syphilitic eruptions and, in general, those constitutional symptoms which exhibit but little tendency to suppurate follow the mild forms of chancre ; while pustular eruptions, and, at a later period, ulcerative affec- tions of the skin, exostoses terminating in suppuration, necroses, and caries, follow phagedenic chancres." Tlie degree of ulceration of the chancre is also regarded by Diday^ as one of the most valuable indications to enable us to determine whether the attack of syphilis is to be mild or severe, and whether mercury can or cannot be dispensed with in the treat- ment. Admitting the truth of this rule, it does not follow that the con- dition of the chancre in any manner determines the severity of subsequent symptoms, but merely that it is an indication of the activity of the virus and of the state of the patient's system — the two causes upon which the severity of the attack chiefly depends. Condition of the neighboring Ganglia — We have already seen that most chancroids are free from ganglionic reaction, and that when this occurs it is always inflammatory and chiefly involves one ganglion, which tends to suppuration and often furnishes inoculable pus. The chancre, on the contrary, gives rise to changes in the neighboring lymphatic ganglia, which, by their constancy, and the peculiarity of their symptoms, are of the highest value in diagnosis. A number of these bodies become enlarged and indurated in a similar manner to the base of the chancre, without in- flammatory action ; they do not suppurate except in rare instances, and the pus is never inoculaVjle. The induration of the neighboring ganglia, at- tendant upon a chancre, will be more fully described hereafter. Diagnosis of the Ciiaxcre The most valuable diagnostic signs of a chancre are its period of incubation, the induration of its base, and the induration of the neighboring ganglia. Both of the latter are rarely, if ever, wanting. Of the two, I believe induration of the ganglia to be the more constant. Absence of induration of the base cannot always be de- pended upon, even according to Ricord's showing, who says that this symptom sometimes disappears after a few days' duration, and it may, there- fore, have passed away before the patient comes under the care of the sur- geon. Cases are reported by competent observers of chancres with a perfectly soft base, which have yet been followed by general syphilis ; such instances, however, are extremely rare. If a caustic or astringent has recently been applied to a sore, induration of its base should be admitted with caution : examine the condition of the neighboring ganglia ; direct simple applications only for a week or two, and see if the hardness persists. Inflammation of the surrounding tissues may counterfeit or mask specific ' Histoire naturelle de la sji)hilis, p. 84. 460 INITIAL LESION OF SYPHILIS. induration: here again, refer to the ganglia, or defer the diagnosis until the inflammatory products shall have time to undergo absorption. Even admitting that cases may possibly occur in which induration of the base and of the ganglia are both absent, yet these two prominent symp- toms of a chancre are as constant and as valuable as any others in the whole range of pathology ; more than this we can neither ask nor expect. Since absorption of the sypliilitic virus takes place instantaneously so soon as it has penetrated beneath the epidermis, and since there is, therefore, no o[)portunity of preventing constitutional infection by abortive treatment, there is less necessity for an early diagnosis than was formerly supposed ; and, in obscure cases, we may wait, if necessary, until after the time Avithin which, if ever, secondary symptoms invariably appear. The su[)erficial form of chancre does not differ materially in appearance from a common excoriation, or from the superficial ulcerations of balanitis ; it may be distinguished by its late appearance after exposure, its indura- tion, and greater pei'sistency. No suspicion of a chancre, however, may be awakened if the erosion be surrounded by simple inflammation of the mucous membrane, unless the induration of the inguinal ganglia be dis- covered, and hence the condition of these bodies should always be examined in apparent cases of balanitis. Inoculation of the secretion of a sore u[)on the person bearing it is presumptive of a chancroid, but is of less value in the diagnosis of a chancre. Diagnostic Characters of the Chancre and Chancroid. The Chancre. The Chancroid. Origin. (Confrontation.) Origin. (Confrontation.) Always due to contagion from the In jjractice generally due to contagion secretion of a chancre, syphilitic lesion, from a chancroid, or chancroidal bubo, or from the blood of a person affoctod or lymphitis. with syphilis. Incubation. Incubatioii. Constant ; usually of from two to three None. The sore appears within a weeks' duration. week after exposure. Commencement. Commences as a papule or tubercle, which afterwards, in most cases, be- comes ulcerated. Commencement. Commences as a pustule, or as au open ulcer. Number. Number. Generally single ; multiple, if at all, Often multiple, either from the first from the first ; rarely, if ever, by sue- or by successive inoculation, cessive inoculation. iJeptfi. Depth. Most frequently a superficial erosion, Perforates the whole thickness of the "scooped out," flat, or elevated above skin or mucous membrane; "punched the surface ; rarely deep, and then cup- out," and excavated. shaped, sloping towards the centre. DIAGNOSIS. 461 Edges. Sloping, flat, or rounded, adherent. Floor. Edges. Abrupt, sharply cut, eroded, under- mined. Floor. Red, livid, or copper-colored, often Whitish, grayish, pultaceous, "worm- iridescent. Sometimes covered by a false eaten." membrane, scaly exfoliation, or scabs. Secretion. Secretion. Scanty and serous, in the absence of Abundant and purulent, complications. Auto-inoculable with great difficulty. Readily auto-inoculable. Inditration. Induration. Firm, cartilaginous, circumscribed, No induration of base, although en- movable upon neighboring tissues ; gorgement may be caused by caustic sometimes thin, resembling a layer of or other irritant, or by simple inflamma- parchment, or, again, annular ; gene- tion ; in which case the engorgement is rally persistent for weeks or months. not circumscribed, shades oflT into sur- rounding tissue, and is of short duration. Sensihilitg. Sensibility. So little painful as often to pass un- Painful, noticed. Destructive tendency. Phagedaena rare and generally lim- ited. Frequency in the same subject. One chancre usually affords comjjlete, and always partial protection against another. Lynijthitis. Induration of the lymphatics common. Destructive tendency. Often spreads and takes on phage- denic action. Frequency in the same subject. May affect the same person an inde- finite number of times. Lymphitis. Inflammation of the lymphatics rare. Characteristic gland affection. Characteristic gland affection. Tlie superficial ganglia on one or both Ganglionic reaction absent in the ma- sides enlarged and indurated, painless, jority of cases. When present, inflam- freely movaVjle ; suppuration rare and matory ; suppuration frequent, pus often pus never auto-inoculable. auto-inoculable. Transmission to animals. Peculiar to the human race. Prognosis. A constitutional disease. General symptoms usually occur in about six weeks after the appearance of tlie sore, and very rarely delay longer than three months. Effects of treatment. Improves under the influence of mer- cury. 'Transmission to animals. May be transmitted to the lower ani- mals. Prognosis. Always a local aflfection ; the general svstem never infected. Effects of treatment. Treatment by mercury always use- less, and, in most cases, injurious. 4G2 INITIAL LESION OF SYPHILIS. Pathological Anatojiy Kaposi gives the following account of the microscopical appeai'ances of sections of a chancre : — " In the histological investigation of the hard chancre, the point of greatest interest is the minute anatomy of the induration. In a perpen- dicular section, the microscope shows a uniformly and thickly distributed deposit of cells in the papillae and in the corium throughout its whole thickness down to the subjacent cellular tissue. This cell infiltration is limited somewhat abruptly at the sides and below, and is suiTounded by a coarse (tcdematous) tissue of fibres, in wliich are found irregularly dis- tributed cells containing a large nucleus that strongly refracts the light. " Under a higher power the infiltrated cells of the induration are roundish, corresponding in size to granulation cells, but generally some- what smaller, with one or two nuclei and a finely dotted protoplasm evidently overlying the enclosed nucleus. "The cells are deposited in a network of narrow meshes, whose walls are tliin and somewhat sharply outlined. Corresponding to the surface of Fis. 11(5. '/ Section of a Chancre, Hartnack, oc. ^^ ; ohj. 4. (After Kaposi.) a h, surface of tlio ulcer. The indurated mass lieneath, to the base of the section g, is uniformly infiltrated with small cells, d, papillie hypertvophied and infiltrated with cells. The epidermic layer covering them, becomes thinner and thinner up to a, where it disappears. At c anj h are si'oii remains of the epidermis, and, beneath, an infiltrated papilla, which can only ne recognized by its ascending vessels. In the indurated mass are several vessels with thickened walls and contracted calibre, e, a vessel cut longitudinally. /, a vessel cut transversely. the lUcer, the network and its cell-deposit is irregularly exposed. Here, as well as in the parts lying nearest the surface, the cells are mixed with numerous isolated nuclei, small shrivelled cells, larger cells filled with granular elements, and free nucleoli. PATHOLOGICAL ANATOMY. 463 " The papillae, Fig. IIG, d, at the sides of the ulcer are preserved, but are thickened, club-shaped, and infiltrated with cells extending from the corium. The rete between them and especially over them is much thinned. At several points on the surface of the ulcer are remnants of the epidermis and the rete, lying on the infiltrated corium. At still other points traces of the papillae are seen with indications of the slings of the vessels, Fig. 116, c b. "Within the cell-infiltrated portion there are but few bloodvessels, the walls of which are notably thickened, and their calibre diminislied in size." These microscopical appearances should be compared with those of the chancroid given on page 364, and their resemblance is so great as to lead Kaposi to say : " It appears to me allowable, from a histological stand- point, to regard the hard chancre as different from the soft only in the intensity and suddenness of the cell-infiltration and cell-degeneration, but not in their essence." Since Kaposi's observations, however, further light has been thrown on this subject by Caspary* and others, but especially by the admirable inves- tigations of Auspitz'^ and Unna.^ Caspary arrived at the following conclusions: "The essential difference in the structure of the soft and hard chancres consists in this, that in the latter a new growth of connective tissue occurs, which in the former is not developed at all, in consequence of the loss of tissue (destructive meta- morphosis) which is constantly going on. Tiiis new formation is charac- terized, even in recent indurations, by a firm, closely-woven network everywhere inclosing the cells; in old indurations, by entire bundles of fibres which interpenetrate the new growth of cells. The narrowing of the vessels, which I could not demonstrate in fresh cases, appears to me to be the effect, not the cause, of the sclerosis. It appears to me probable that the formation of fibres proceeds from the infiltration cells, and not from the growth of young connective tissue occurring at the periphery, and extends into the interior of the neoplasm, because such a growth has not been found in the interior of the sclerosis. I would look upon the embryonic connective tissue found at the periphery as a kind of capsule caused by reactionary inflammation." Auspitz and Unna iiave furtlier studied the changes in the vessels of the mass of induration, resulting in a diminution of tlicir calibi'e or in their complete obliteration, which they compare to those observed by Ileubner in the arteries of the brain ; and they express the opinion that in future investigations of syphilitic neoplasms, the condition of tlie vessels is the chief point for study. As to the manner in which tliese changes take place, Unna concludes: — ' Vierteljschft f. Derm. u. Sypli., Wien, 1876, s. 45. 2 An.'itomie d. syphil. Initial Sklerose, von Prof. Heinr. Auspitz u. Dr. Paul Unna, Vierteljschft f. Derm. u. Syph., 1876, s. 161. ' Zur Anatomie der syphil. Initial-sklerose, VierteljsLhft f. Dorm. ii. Syph., 1878, s. 531. 464 INITIAL LESION OF SYPHILIS. 1. The fibrous constituent of the cutis, which, through its hypertrophy, occasions the hardness of the initial-sclerosis, is composed of pure collagen.^ 2. A sclerosed vessel arises in consequence of the fibrous hypertrophy of the connective tissue of the outer coat (adventitia) attended by the disappearance of the lymph-meshes (comi)licated with more or less infil- tration of round cells), and of the same change in the connective tissue immediately surrounding the vessel. 3. In endarteritis obliterans syphilitica acuta, as takes place in the initial-sclerosis, the thickening of the endothelium is certainly not the first change. The constant and early implication of the vasa vasorum renders it probable that the starting point is here. Where there are no vasa vasorum the pathological process always begins in the outer coat. 4. Still more extended than the typical endarteritis obliterans is the closure of the vessels tlirough obliteration of the walls by means of round- cells (granulating arteritis). Both processes, independent of each other, combine, and one may, by its excessive development, crowd out the other. The larger vessels are most frequently the victims of endarteritis obliterans, the smaller, especially the capillaries, of closure through infiltration. Figs. 117 and 118, taken from Unna's latest paper on this subject, admirably represent the changes which take place. in the arteries. The sections are represented as they appeared after having been prepared and colored. Fig. 117. Section of an artery, vein, aud lyinpliatic, highly magiiifled. In Fig. 117 are seen sections of an artery (a), a vein (i), and a Ij'niph- atic (/). In the tunica intima of the artery the nuclei of the endothelium are very marked and appear to project more than usual into the lumen. ' For the properties of " collagen," see Dalton's Treatise on Human Physiology, 6th cd., 1875, p. 91. PATHOLOGICAL ANATOMY. 465 The whole intima is in a swollen condition. The media is also swollen and, like the intima, more yellow than normal; the nuclei of the muscular fibres are sharply shown. Round cells, in rows and in groups, are first seen at the border line between the media and the adventitia, and espe- cially at a spot where a clear lumen is seen to be thickly and concentrically surrounded by round cells, and where also a small nutrient vessel enters as far as the media. The adjoining portion of the adventitia is more thickly infiltrated with round cells than elsewhere. The same appearance is presented in the adventitia of the vein : thick bundles of connective tissue, separated by isolated round cells and regions of the same, — but the round cells are here generally more abundant, and in the upper quadrant especially they completely mask the structure of the media. The most striking appearance, however, in the vein, is the ex- uberance of the endothelial cells, which changes the shape of the lumen to that of an irregular pentagon. In marked contrast to this is the condition of the lymphatic endotlielium, which is not at all changed. Several small vasa vasorum (e, e) are seen thickly surrounded and partially closed by round cells. The surrounding cellular tissue (&) presents hypertrophied fibrillae and round cells. A later stage of the above process is shown in Fig. 118, in which a is probably an artery, h a vein, and/" a lymphatic. The first two are oblite- rated or nearlv so, while the last is unaffected. Fig. 118. Similar sections showiug ouliter.itioa of tlie artery and vein. Virchow,^ in his celebrated work on the Pathology of Syphilis, advocated the complete correspondence of an indurated chancre with a gumma of the skin. The identity of these two lesions is^ not now, however, to be maintained, as is shown by the following comparison of the two. " A gumma is a collection of small cells with large nuclei, lying in a network of fine connective tissue. It forms a roundish mass, whose separation from tlie neighboring tissues is more apparent on gross than on microscopical examination. Its regular course is to undergo dry atro])]iy (cheesy degeneration), or fatty degeneration and ulceration. Fre- ' Ueber die Natur der constitutionell-syphilitischen Affectionen, 1859. 30 466 INITIAL LESION OF SYPHILIS. quently, especially in the cutis, it is surrounded by sclerosed, brittle bundles of connective tissue, but we can ap^jly the name of gumma only to the cen- tral, <>um-like, richly cellular mass, which, especially in the corium, almost always forms an abscess. "The initial sclerosis, on the other hand, presents a syphilomatous, new cell-o-rowth, permeated by a new formation of fibrous connective tissue, which of itself renders the formation of cavities of considerable size im- possible. No tendency to the formation of even miliary abscesses is shown." (Unna.J Treatment of the Chancke It was formerly supposed that a chan- cre was at first a mere local affection, and that the general circulation did not become contaminated until some days after the appearance of the ulcer ; and hence that its early and complete removal was capable of averting infection. of the constitution. The advice was therefore given to cauterize or excise a chancre as soon as it appeared ; and we were told, that, if the caustic was sufficiently powerful to kill the tissues to an extent exceeding the sphere of specific influence of the virus, or if the excison was carried to a sufficient extent, a simple wound would be left after the fall of the eschar, and our patient would be preserved from syphilitic infection. This treatment, known as the " abortive treatment of chancre," was supported by the distinguished names of Ricord and Signiund, who assigned the fourth day after contagion as the limit within which destructive cauteriza- tion could be employed with a certainty of success ; but it should be known that these surgeons have since abandoned their early views on this subject. Belief in the efficacy of " the abortive treatment" never could have been entertained, had it not been for confounding the chancroid and sy[)l!ilis, whereby surgeons were led to believe that when a patient whose chancroid had been cauterized escaped general syphilis, post hoc eryo propter hoc his immunity was due to the cauterization. A chancre is never a mere local lesion, as is proved by its period of incubation, by the analogy of other morbid poisons, and by the fact, as shown by repeated experiments, that its destruction within a few days and even a few hours after its appearance fails to avert constitutional in- fection. The average duration of the incubation of a chancre is, moreover, from two to three weeks. During this period the inoculated point remains in a state of quiescence and exhibits no traces of inflammation ; hence the sub- sequent appearance of the chancre can only be ascribed to the reaction of the absorbed virus. It may be remarked, in passing, that this period of incubation renders the conditions of the so-called abortive treatment (cauterization within four days after contagion) impracticable, since the sore very rarely appears until the time specified has elapsed ; and the same consideration increases the probability that Ricord and Sigmund, in their " thousands" of supposed successful cases, really applied the method only to the chancroid. Experiments with other morbid poisons prove that absorption is almost instantaneous. Bousquet inoculated the vaccine virus, TREATMENT OP THE CHANCRE. 46t and immediately applied cups and washed the parts with chlorinated water without preventing the evolution of a pustule.^ Renault, Surgeon of the Veterinary School at Alfort, inoculated horses with acute glanders, excised the part and applied the actual cautery one hour afterwards, yet the animals died of the disease.'^ Similar experiments with the sheep-pox virus proved that its absorption does not require more than five minutes. Hence analogy would show that the syphilitic virus also reaches the gene- ral circulation almost instantaneously after its implantation beneath the epidermis. We have still farther the evidence of direct experiment. Numerous cases are recorded in which destructive cauterization within a few days, and ei:en a feiv hours after the development of the chancre^ has failed to avert constitutional infection. Diday has thoroughly cauterized chancres within four days and a half, and others within five days, and secondary symptoms have still appeared. In another case, occurring in a patient who had watched himself with the greatest care from day to day and almost from hour to hour, the chancre was not developed uniil a month after the sexual act, but the abortive treatment was applied within six hours of its first appearance ; the sore healed in the course of three days, but secondary symptoms appeared three weeks afterwards.* More recently,* Diday has reported several additional cases. It was desirable that thus much should be said in deference to any of our readers who may have imbibed their only notions of venereal from the teachings of authorities a few years ago ; but the "abortive treatment of syphilis" is now so generally recognized to have been founded in error, that we need not dilate farther on the subject. But if destructive cauterization is inefficacious as a means of preventing constitutional infection, it is equally unnecessary in most cases for tlie purpose of hastening the cicatrization of the chancre, which rarely tends to spread, and which is commonly sufficiently under the control of mercury. I would, therefore, limit its application to those few chancres Avhich are complicated with phageda^na, and to those cases in which conjugal relations and the necessity of secrecy render it desirable to effect cicatrization of the sore as speedily as possible in order that coitus may be indulged in with comparative safety. Even then, it is a question whether much time wmU be gained by its use. When employed, induration usually reappears in the wound, and general lesions are developed within tlie normal period. The m.ode of its application has already been described. Excision of Chancres Excision of chancres with the view of aborting syphilis was practised in earlier years, but was afterwards abandoned on account X)f its failure to accomplish the object. Tlie method has of late years been again revived and advocated, especially by Auspitz, Koliiker, and Otis. During the past ten years we have ourselves carefully tested * Traite de la vaccine. * Acad(;mie des sciences, 1849. 3 Gaz. ni6d de Lyon, 1 mars, 1858. * Anuuaire de la sypli. et d. iiial. de le \wa.\\, Paris, annee 1858, p. 134. 468 INITIAL LESION OF SYPHILIS. this form of treatmont in fifteen cases. Tliose wlio rely upon it as a means of aborting syphilis regard the disease in its primary stage as merely local, a position which we are not yet willing to assume. We shall, how- ever, give the details of the treatment and its most important results. The observations of Auspitz were made upon thirty-three cases, from which his conclusions are drawn with such care that we shall give them here in brief. It is his custom to seize the tissues with an anatomical pincette, with toothed forceps, or with a serre-fine, and elevating the parts, to cut with scissors well beneath the indurated mass. The surface of the wound generally bleeds but little, and should be carefully examined to avoid leaving any indurated tissue. In some cases the wound is closed >vith a few sutures, or a carbolized compress is applied. In several of our own operations, in case of extensive and deep indura- tion, we passed several threads, for the purpose of traction, under the mass and transfixed the parts beneath the threads, cutting outwards in one direc- tion and then in the other. In some cases of long prepuce, where the chancre was seated at its free margin, the excision was performed by a single cut of the knife or scissors. Previous to the operation, the parts should be thoroughly cleansed, and the nodule should be cauterized with equal parts of water and carbolic acid. In two of our cases induration recurred in the cicatrix. Auspitz says that phagedajna and a diphtheritic condition were observed by him in a few instances, and in most cases the inguinal ganglia were indurated. The latter feature was present in all of our cases. The indura- tion is regarded by Auspitz not as an indication of infection, but as an ordi- nary result of the local inflammatory process on the penis. In fourteen of his thirty-three cases no syphilis followed. This experience is decidoTily at variance with our own ; we have never succeeded in aborting syphilis by this procedure. Auspitz recommends excision in cases of recent indu- ration, even though accompanied by indolent enlargement of the inguinal ganglia. Chancres on the external surface of the limbs and on the pre- puce are selected as most l"avorable for operation, while those in the sulcus coronarius are considered unfavorable. The results of Kolliker with this operation are of interest. In seven out of eiglit cases he excised a chancre on the seventh, the ninth, the tenth, the fourteenth, the twenty-first, and the forty-ninth day after its appearance, while in one case the date is not given. In six the wound healed by first intention, and in two by granulation. In three cases induration appeared in the cicatrix, and in two of these sy()hilis followed, while in two other cases induration apjjcared later and was the forerunner of syphilis. Kolli- ker says that in but tliree of his cases was syphilis probably aborted or prevented by excision. He concludes that in certain cases, excision may prevent, retard, or modify constitutional infection. He does not regard lymphatic induration as a contra-indication, and like Auspitz, thinks " that the chancre is not to be considered an expression of constitutional infec- tion." In the local treatment of chancres, cleanliness and the interposition of TREATMENT OF THE CHANCRE. 469 some absorbing medium, as dry lint, are of the same importance as in the treatment of the chancroid. Tiie same rules should also govern us in the selection of any medicated applications, except that on theoretical grounds at least, mercurials may be used with some show of reason, and "black wash" may not be entirely lost to memory. Fatty preparations of mercury are not to be recommended when the chancre is seated within the balano- preputial fold, but, when seated on the external integument, the unguen- tum hydrargyri, the mercurial plaster, or the emplastrum de vigo cum mercurio will usually be found to be good applications. In the superficial variety of chancre which is the most frequent, the degree of ulceration and the amount of the secretion are so slight, that the simple interposi- tion between the glans and prepuce of a piece of dry lint, or lint soaked in some mild astringent, is all that is necessary, and the dressing need not be changed oftener than once or twice in the twenty-four hours. General Treatment The chancre is decidedly under the influence of mercury, and presents in this respect a marked contrast to the chancroid. Under the use of this mineral reparative action is speedily induced, and unless the ulcer be deep and extensive or the system much depressed, complete cicatrization may be promised the patient in the course of from one to three weeks. I do not propose at present to enter fully into the subject of the treat- ment of syphilis, which of course includes the treatment of its initial lesion. A few remarks, however, may be better made here than elsewhere. And, in the first place, let me say that no course of mercury administered for a chancre, however thorough or prolonged, is likely to prevent the sub- sequent evolution of general manifestations. Some eminent authorities maintain the contrary, but their opinion has not been confirmed by our own experience. In the very many attempts that we have made to sub- due the disease during the existence of the initial lesion and prior to the appearance of general manifestations, we have alvvays failed. Moreover, although the use of mercury retards the appearance and probably amelior- ates the severity of secondary symptoms, yet it is a fact attested hy many observers, ourselves included, that those cases ultimately do best, in tohich specific treatment is deferred until the secondary stage. The exceptional cases of chancre in which it is advisable to administer mercury before secondary symptoms appear may be summed up as follows : — 1. Chancres Avhich, from their size, depth, and progress, occasion pain and inconvenience, or which threaten to destroy important parts. 2. Chancres occurring in married persons who cannot long avoid sexual intercourse without exciting suspicion. 3. CHancres in persons who are either too anxious or too unreasonable to be willing to submit to delay. In other cases, especially when the sore is superficial and attended with little or no inconvenience, we prefer to (h'lay the use of mercury until secondary synq)toms appear, meanwhile resorting to tonics, as one of the preparations of iron, iodide of potassium, or cod-liver oil. 470 INITIAL LESION OP SYPHILIS- In using mercurials during this period of sypliilis, we commonly employ either the blue mass or gray powder ; giving one or two grains of the former, or from three to five grains of the latter, twice a day for a week ; increasing the dose at the end of that time if, as is rarely the case, there is no perceptible effect upon the ulcer; always avoiding action upon the gums and bowels, and suspending treatment as soon as reparative action is established. After cicatrization of the sore it is desirable to resort to iodide of potassium and iron, in order to combat the chloro-anajmia which exists in the early stage of syphilis, and thus diminish the severity of the premonitory symptoms which usually usher in secondary manifes- tations, when mercui'ials should at once be resumed. CHANCRES OF THE URETHRA. 471 CHAPTER IV. SPECIAL INDICATIONS FROM THE SEAT OF CHANCRES. Under this head there is much less to be said than has already been presented with regard to the indications arising from the seat of chancroids, for the reason that a chancre is merely the initial lesion of a constitutional disease, while the chancroid is a local affection, and is to be treated as such. Chaxcres of the urethra are more frequent than is commonly sup- posed, and are much more common than the chancroid in this locality. Our experience leads us to believe that they occur with rather more frequency in Jews and in patients who have a short prepuce. They are found most frequently at the meatus and in the fossa navicularis, but we have seen several one, two, and even three inches from the orifice. Chancres at the meatus are sometimes seated on one lip only, but they usually involve the entire circumference of the canal. They first attract attention by causing a slight impediment in urination, and the mucous membrane is found to be thickened, and the li[)s glued together by a scanty viscid discharge. The whole canal at the site of the ulcer finally becomes thickened and rigid, and it is often impossible, owing to the congestion of the parts, to clearly circumscribe the induration. The normal opening of the urethra often becomes greatly reduced, even to the size of the head of a pin, so that the pain and difficulty of micturition are excessive. The parts have a reddish-blue appearance, and give forth a muco-pus. The urethral walls are excoriated rather than ulcerated, and very often a few drops of urine escape several minutes after urination. The case is fre- quently mistaken by the inexperienced for an anomalous case of gonorrlifca. Chancres of the fossa navicularis and of the deeper parts begin pain- lessly, with mere gluing of the lips of the meatus as their first symptom. Soon there is slight pain as the urine first passes, and the patient discovers a thickening of the tissues at the site of the chancre. The discharge is sometimes muco-purulent, but again may be decidedly purulent and as consideiable in quantity as in ordinary gonorrha-a. This is due to the fact that the lesion sets up a urethritis of the contiguous membrane. Ex- ternally is found in the corpus spongiosum a hard, tender, circumscribed nodule, wliich gives pain on urination and on erection of the penis. AVith the endoscope we observe rigidity and erosion of the urethi-al walls, which have a grayish-red color. This lesion is sometimes very chronic, and gives remarkably little inconvenience. It then occasions hard, non- 472 INDICATIONS FROM SEAT OF CHANCRES. inflammatory thickening of the prepuce on either side of the frjenum, a phenomenon so constant in our observation as to be of considerable diag- nostic value. Cliancres several inches from the meatus, acting like true fibrous stric- tures, often cause much inconvenience. They may be as large as a pea, or, exceptionally, of the size of a nutmeg. They are always accompanied by induration of the inguinal ganglia, and sometimes by engorgement and induration of the lymphatics, which arise at the side of the fra;num. After the disappearance of a chancre of the urethra the parts may be restored to their normal condition, or thickening and contraction may result, requiring to be relieved by internal urethrotomy or slitting of the meatus. The importance of distinguishing these chancres from gonorrhoea is evident. Tiie chief aids to diagnosis are the slight gluey, perhaps bloody, discharge, the localized impediment to urination, and the subacute course of the lesion. When the lesion is fully developed, the patient himself usually calls attention to the induration. The symptoms induced by these chancres are sometimes so urgent that an active mercurial treatment is demanded even before the evolution of secondary manifestations. In ordinary cases we have found benefit from the use of bougies made of mercurial ointment two parts and white wax six parts. These are sufficiently rigid, and when made conical at the end, and of a diameter of a line or two, can be I'eadily introduced and retained. They produce a beneficial effect by the gentle pressure which they exert as well as by their medicinal action. They are particularly efficacious when the pressure of an ordinary bougie cannot be borne. In some cases we have used similar bougies with one drachm of iodoform thoroughly inot)r- porated in each ounce of the other ingredients. Chancres of the Anus Statistics prove that chancres of the anus are much less common in the United States than upon the Continent and in South America. In the latter country, especially, the practice of Sodomy is sadly prevalent, and the occurrence of anal chancres corre- spondingly frequent. Jullien, in his elaborate work on venereal, records 11 chancres of the anus out of 2170 chancres of tiie male sex, and 39 out of 473 in females, making a [jroportion of 1 to 119 in men and 1 to 12 in women. Such chancres may be situated entirely without the anus or at its margin ; or, again, wholly within the anal ring, so that they can only be seen by gently opening the canal with tiie fingers, or by the use of a small speculum or, preferably, Nelaton's preputial forcei)S (see Fig. 24, p. 108). They rarely form open and closely circumscribed ulcers, but usually present a thickened, fissured, and ulcerated surface of a subacute character, devoid of the deep redness and free suppuration of simple fissures. They are of a pale rose tint, their base decidedly indurated. True chancres, seated at the anus in the form of fissures, which they often assume, have hard, pale margins and smooth, light red surfaces. Tlieir bases are resistent to CHANCRES or THE FINGERS. 473 the touch, and they are usually niucji less tender than simple fissures — a point of considerable importance in the diagnosis, which may also be aided by their slow and painless evolution, and, sometimes, by the early develop- ment of mucous patches in their neighborhood. Extra-genital Chancres — Chancres of the skin, occurrin in other parts than the genital organs, are called "extra-genital chancres." They may appear on any region of the body, but they are most commonly found on the face, the neck, the arms, forearms, and hyjiogastrium. These chancres begin as small, coppery-red, non-inflammatory papules which may be scaly. They extend until they attain a diameter of half an inch to an inch, and an elevation of about a line. Their margins are sharply limited, although there is not much induration. The scaly, papular condition of the lesions is seldom found in regions where two surfaces are in coaptation. We have several times seen it upon the hypogastrium, the cheeks, and the neck. The degree of induration is sometimes not greater than that of an ordinary papule; in other cases it is more marked. Frequently the primary lesion begins as a papule, extends slowly and without inflammation, becomes indurated, elevated, and sharply circum- scribed, and finally ulcerates. In some cases a thin greenish-brown scab covers the lesion, which then looks like an ecthymatous patch. The scab is formed of pus mingled with the new cells thrown off from the surface of the ulcer. In case of its absence the lesion presents a raw vascular sur- face, of about a line in elevation, free from granulations, and sometimes covered with a film of false membrane like chamois skin. It has a dense hardness and shows no reparative tendency. In addition to the history and appearance of the lesion, we find chronic, indolent enlargement of the lymphatic ganglia in anatomical connection with the part affected. Chancres of the Fingers. — Chancres of the fingers are by no means infrequent, and are especially common among obstetricians, surgeons, and midwives. They may be seated on any part of tiie phalanges, but are, perhaps, most common at the side or base of the nail or at its free margin. They begin either as a ))imple, as a pustule, as a slight excoriation, or as a fissure. They first attract attention as a "hang-nail" which Avill not heal, or as a small persistent sore. On examination, we find a hard, some- what elevated mass of moderate size, which has a deep red, perhaps cop- pery, color. Its exulcerated surface, which is free from granulations, gives forth a scanty serous secretion. The lateral borders of the nail may be somewhat thickened, and its free margin may be superficially ulcerated. Tliis tendency of the chancre to be confined chiefly to the soft parts is in marked contrast with the morbid condition in sypiiilitic onychia. The form of the ulcer is very irregular. The finger itself often has a bulbous shape, the entire distal phalanx being involved in the induration, which is always extremely chronic. The diagnosis is usually confirmed by enlargement of the epitroclilear and axillary ganglia; it is iu some cases attended by moderate lymphangitis. The fact that there is very slight tendency to the formation of abscesses in the lymphatics and in the 474 INDICATIONS FROM SEAT OF CHANCRES. glands is important in the diagnosis of syphilitic chancres of the fingers. On account of their exposed situation these chancres are very slow to heal. Numerous instances of the communication of syphilis by chancres of the fingers have occurred, but tlie most remarkable is the case reported by Bardinet. This physician was appointed to investigate an epidemic of sypliilis which occurred in the town of Brive, France. He ascertained that those affected were parturient women (and their husbands, children, and relatives) who liad been attended in confinement by a certain midwife, examination of whom revealed a syphilitic ulcer near the margin of the nail of the right middle finger. She afterwards had general syphilitic manifestations. Tliis chancre of the finger had been in an ulcerated con- dition for about six months, during which period she had attended fully fifty women in confinement. As a result, nearly one hundred persons became infected with syphilis, among them several children who died. The case illustrates the great importance of carefid attention to chronic rebellious ulcers of the fingers on the part of physicians and obstetricians. Chancres of the Lip — Chancres of the lips are quite common, and may exist in the form of a diffuse infiltration or of a fissure. Those seated near the vermilion border are usually much larger than those on the inner surfixce of the lips; Chancres in this region are seldom seen by a physician until they have reached quite a large size, since they are at first regarded as cold-sores or cracks of the lip. They begin either as sliglit, often painful, excoriations, or as fissures, which gradually enlarge and become indurated. Their course is not rapid, a month or six weeks generally elapsing before they become fully developed. When seated upon the lower lip, as they more commonly are, they often involve its whole thickness, and the lip becomes converted into a wedge-sha[)ed mass of induration with its base at the free margin, which is more or less ulcerated. Such a chancre usually presents a ligneous hardness. The lip becomes everted so that the patient is unable to close the mouth. The surface of the ulcer is smooth, and emits a scanty secretion. In other cases there exists a callous fissure with reddish-gray margins and a deep red base. The induration is usually very marked. Within ten days after the appearance of the chancre the submaxillary glands become swollen and indurated, and may give rise to much dis- comfort and pain. In children chancres of the lip are sometimes derived from lesions on the nip])le of the nurse. These chancres are small, round, or oval in shape, and are slightly indurated. They may readily be mistaken for mucous [jatches. AVhen chancres are seated at the labial commissure, tliey are divided into two portions, separated by a deep ulcerated fissure at the angle of the mouth. Chancres of the Buccal Cavity Chancres of the tongue are not frequent. They are usually seated on its lateral margins near the tip. CnANCRES IN THE FEMALE. 475 They consist of hard, quite sharply circumscribed nodules of the size of a pea, which involve the deep as well as the superficial structures. Their surface is flat and slightly elevated ; it has a dull red color, is smooth, raw, and highly vascular. In some cases the lesion is covered with a milky-white film and resembles a mucous patch. Chancres of the tonsil are never sharply circumscribed. They are dark red, superficially ulcerated nodules which secrete a scanty fluid. On account of the difficulty in examining them, it is not easy to deter- mine their density. Tiieir character is indicated by the history of the case, by their subacute course, by the absence of inflammatory sylnptoms, and the enlargement of the cervical and submaxillary ganglia. Chancres have also been observed upon the gums, internal surface of the cheeks, the palate, and the walls of the pharynx. Phagednena is a rare complication of the buccal chancre. A single instance was observed at Cullerier's clinique, in which irritant applica- tions had caused the ulcer to extend until it involved one-half of the lower lip and the inferior half of the cheek. ^ Chancres in the Female These are in general similar to those occurring in the male, but have certain features which should be clearly understood. We find in females, as in males, the two varieties, the indu- rated nodule and the superficial erosion, although their appearances are less distinctive than in the male. Upon the labia majora either variety may occur, the indurated nodule perha[)S being more frequent. The nodule is generally quite large, the induration sometimes involving the whole lip. In almost all cases it is deeply seated and does not project greatly above the surrounding level. In some cases the induration is cartilaginous and clearly defined, in others it is less marked at its periphery. The induration is painless, and the superjacent mucous membrane is but slightly inflamed. The course of the indurated nodule is very chronic, and may be attended by hard oedema of adjacent parts. The chancrous erosion is much less frequent in this region. It begins as a small red spot, which increases in area so as to form a dark coppei-y- red, slightly elevated patch. Its surface is smooth and velvety, being free from granulations ; its elevation above the surrounding level seldom exceeds half a line; its margins may be sharply cut, but owing to the tendency to hyperemia of the parts, the contour of the initial lesion in women is often obscured. In many cases we find the true parchment induration, while in others the induration may b<; so slight as to escape recognition. It was formerly claimed that syphilitic chancres in women were free from indura- tion. On the contrary these lesionsare in reality quite constantly indurated. Even with chancres ui)on the i)repuce the induration is not more marked than in chancres of the labia majora. The (cdem a of the surrounding parts is certainly greater in females than in males, and vulvitis is not uncommon ' BuzENETj Du chancro do la bouche, etc., Thfeso do Paris, 1858. 476 INDICATIONS FROM SEAT OF CHANCRES. in persons of uncleanly habits. Not unfrequently the chancrous erosion of the lal)ia, es[)ecially when seated on the cutaneous surface or when the lip is njuch everted, is covered by a. purulent crust. This occurrence is merely accidental and due to exposure of the ulcer, allowing its secretions to harden. Chancres of the labia minora have a similar history. The indurated chancres are usually large, often involving the whole of one lip and a por- tion of the other. The clitoris may be involved, in which case it becomes hard and prominent, and according to the simile of Fournier, resembles a ramrod. The clitoris itself and its sheath become much condensed and have a ligneous hardness. When the lower part of the labium minus is involved, the induration, as we Have often observed, may extend around to the opposite lip, forming a V-shaped mass. The initial lesion of the labia minora is usually less clearly defined than in other regions. Tlie indurated nodule is commonly surrounded by more or less hard oedema. The chancrous erosion of tlie labia minora is usually complicated by vulvitis and is often multiple. C/tancres of the fourcltefte and vestibule are very interesting and often difficult of diagnosis, both because they are not readily accessible and be- cause they are less indurated. The lesions are rarely circumscribed, and rarely present the typical appearance of chancres. We find rather a diffuse hardening of the mucous membrane, which has a dark coppery-red color, and gives forth a scanty sero-pus, which may be augmented by secretions from the surrounding parts. The parts are much less supple than normal, and the difficulty in thorough examination met with in health is greatly increased. The vulvitis, wliich so frequently complicates the case, rendei'S the diagnosis still more difficult. Induration, although by no means inva- riable, is often very marked. We have in several cases found the four- chette of ligneous hardness and the orifice of the vagina rigid and resistent. AVe know nothing of chancres of the vagina. The mucous membrane of tliat canal seems always to escape the virus or perhaps to possess an immunity to its action. Cernatesco has studied the course and duration of chancres and vulvar syphilides in pregnant women. Of the former he collected eleven cases, in whicli the chancres were on the vulva. In one case, the duration of the sore was less than a month, and in the other ten it was longer than eight weeks. Three lasted from four and a half to eight months. He concludes that, under the influence of pregnancy, the duration of the chan- cre is notably lengthened. Of the vulvar syphilides he examined thirty-three cases, which he di- vides into two groups: 1st, those which he was able to follow up after delivery; 2d, those lost to view prior to that time. These lesions were also more than ordinarily persistent during pregnancy, and in some instances disajjpeared soon after delivery, while in others, they were equally obsti- nate afterwards, owing to the bad general health of the women. The cause of tlie persistency of the above-named lesions is due to a passive congestion of the genital organs rather than general debility. In CHANCRES IN THE FEMALE. 47*7 twenty-one cases of pregnant women with chancres on the vulva, there were nine of abortion, Cernatesco, without committing himself, advances the hypothesis, that the abortion was caused by the lesions. Admitting that the latter may act as irritants, the author thinks that local treatment should not be too active, as it may hasten the expulsion of the foetus. We would simply add that syphilitic lesions, and especially condylomata, of the vulva in pregnant women, often present a most remarkable color resembling that of. Port wine, undoubtedly due to the venous congestion above referred to. Cliancres of the Breast Chancres of the breast, or, more properly, of the nipple, are of especial importance when occurring in a nursing woman, in view of the danger to the child of syphilitic contagion. These chan- cres are usually derived from mucous patches in the mouths of nurslings, or from similar lesions in the mouths of men. An instance of the latter mode of origin occurred not long since in our own experience. The areola as well as the nipple may be invaded by these lesions, and less commonly the breast itself. AYe find in this situation the chancrous erosion, the ecthymatous chancre, and the indurated fissure. The chancrous erosion is commonly found upon the areola. It consists of a sharply marginated, slightly elevated patch ; its surface is flat, smooth, and shining ; its contour may be round or oval ; its color deep coppery- red. The slight induration at first detected by the finger, gradually be- comes well marked. This lesion presents a similar appearance when it involves the nipple, but it is then usually more indurated. Such chan- cres may be single or multiple — two being the ordinary number — although we have seen as many as five. There is nothing peculiar in their course. The ecthymatous chancre may occur on the ni{)ple or on the areola ; more commonly on the former. It forms a hard, painless, circumscribed nodule, which may involve all or part of the nipple, or a portion of the areola. A dark-green, uneven crust, which is slightly adherent, conceals a smooth, grayish-i-ed, eroded surface. The ulcer becomes thus encrusted in consequence of the absence of moisture. Were the nipple subjected to suction and moisture, the secretion would cease to harden and there would be simply an exulcerated chancre. The name ecthymatous chancre, how- ever, may well be retained, since it suggests appearances necessary to be borne in mind. The induration may be extreme or moderate, and varies in extent. In some cases both the whole nipple and the areola arc in- volved in the induration. The indurated fissure of the nipple is merely an induration traversed by fissures which have a reddish-gray color. The fissures may be superfi- cial, or they may be extensive, invading tlie areola. Tliey may exude a more or less purulent secretion, and indeed the whole lesion may become encrusted. These lesions are slowly developed and are attended by scarcely any pain even in the fissured form, features of much diagnostic value. They are seldom inflammatory, but are usually insidious and sub- acute. In some cases the sebaceous glauds of tlie areola are enlarged and prominent. In all cases the axillary glands are eidarged, and in most the 478 INDICATIONS FROM SEAT OF CHANCRES. ganglia at tlie upper margin of the great pectoral muscle are indui-ated, the latter being recognized with difficulty in lat persons. In securing wet-nurses, physicians cannot be too careful in examining for mammary chancres. A woman having a sore in the least degree sus- picious slioukl never be allowed to nurse a healthy child. Careful inquiry should be made as to the condition and history of children nursed within at least tlie last montli. A woman who has nursed a child with sore mouth, eruptions, marasmus, or osseous lesions, should be suspended for from four to six weeks, during which time, if she has been infected with syphilis, the initial lesion will appear on her breast. Chancres of the Uterus Chancres of the uterus have been carefully studied within the past ten years by Fournier, Schwartz, and Jullien. Tiiey may be seated on one lip of tiie cervix, generally the lower one, or within the neck. There is generally but one which begins as a bright red erosion. of the mucous membrane. It gradually extends and becomes somewhat elevated, and when fully developed looks like a papule. In some cases there is no perceptible elevation of the ulcer, but its margins are circumscribed and are frequently surrounded by a dark-red areola. The floor of the chancre is smooth, of a grayish- or yellowish-red color, or it may be covered by a false membrane like chamois skin. The lesion, Avhen seated on the outer surface of the os, is rounded or oval, and about the size of an almond ; within the os it may be limited to one segment or mny surround the opening in the form of a ring. Its secretion is scanty and viscid. The degi'ee of induration varies, being limited to the neigh- borhood of the chancre, or being diffused. In a case of prolapsus with uterine chancre, seen by Ricord, the os was enlarged and very dense, and in other instances the wiiole neck has been found involved in the induration. The course of these chancres is indolent and painless. Fournier states that in five cases of chancre of the os uteri he observed vulvar and peri- vulvar herpes, and he thinks that the presence of these lesions should always suggest the possible syphilitic character of the uterine ulcer. He also calls attention to the fact that uterine chancres often disappear within a few days, leaving no trace. There is generally no enlargement of the inguinal ganglia during the course of a uterine chancre. INDURATION OP THE GANGLIA. 479 CHAPTER V. INDUPwVTION OF THE GANGLIA AND OF THE LYMPHATICS. As already mentioned, the induration of the base of a chancre has been su[)posed to be most developed in regions most copiously supplied with lym[)hatic vessels, and was consequently regarded by Ricord and others as consisting essentially in a specific lymphitis. But even if this supposition be incorrect, it is certainly true that we find a condition of the lymphatic vessels and ganglia in anatomical connection with a chancre, closely re- sembling the induration of its base, and of even greater diagnostic value than the latter. We may, therefore, regard this affection as an oflshoot or prolongation of the induration of the base of the initial lesion of syphilis previously described. Of the two — induration of the ganglia and induration of the lymphatic vessels — the former is by far the more frequent, just as we find adenitis, rather than lympliitis, the more constant attendant upon a chancroid. Induration of the Ganglia. (Syphilitic Bubo.) I have already stated the reasons which led us to exclude this affection from under the head of "buboes," but if it still be called a "bubo," the adjective "syphilitic" belongs to it exclusively, and is so applied by recent French writers. Constancy Does induration of the fjanglia necessarily attend a cliancre^ Rollet, in his own clinical experience, states that its absence is a "rare exception." Kicord regards induration of the ganglia as '■\fatale" '■'■ ohVu/tef "it follows a chancre as a sliadow follows a body;" "never a chancre without induration of the ganglia may be boldly asserted as a pathological law." Fournier says: "With very rare exceptions, it '\s, -a constant symptom of primary syphilitic infection." The testimony of most other modern observers is the same. For my own part I have never met with a chancre which was not attended by induration of the neighboring lym[)hatic ganglia, although this induration has been doubtful for a time, in a few instances, especially in strumous subjects, yr has been masked by the occurrence of acute in- flammation. I regard it as by far the more valuable symptom of a chancre than induration of tlie base of the ulcer itself, since it is less likely to be 480 INDURATION OF THE GANGLIA AND LYMPHATICS. counterfeited by extraneous influences, and is even more constant and persistent. Yet it would afjpear that this, like every other isolated symptom of syphilitic infection, may in very rare instances be wanting. In the twenty- six cases of artificial inoculation of the syphilitic virus upon persons pre- viously free from syphilis, collected by RoUet, induration of the ganglia is mentioned in only twenty, but we are left in doubt whether this was due to its absence or to the imperfection of the observation. Bassereau carefully examined the condition of the ganglia in three hundred and eighty cases of chancre, the diagnos^is of which was confirmed bv the evolution of secondary symptoms, and found induration in three iiundred and fifty-five. But here, again, the question may arise whether, in tiie twenty-five exceptional cases, induration had not previously existed but had disappeared at the time of the examination. Fournier. reports 2Go cases of chancre, of which the ganglia were in- volved in 2C)0, but in 3 cases only was the absence of induration from the outset certain. The instances in which this attendant upon a chancre is likely to be wantinof or of doubtful recognition may be classified as follows: — I. Strumous subjects. I have met with a number of patients of strumous habit who stoutly asserted that the enlargement of the inguinal ganglia had existed long before the sore upon the penis, and their evident scrofu- lous diathesis has added weight to their statements, and rendered the diagnosis for a time doubtful. II. In cori>ulent persons the mass of adi{)Ose tissue may render it diffi- cult to recognize the condition of the ganglia by means of external palpa- tion. Ricord, it appears, would go one step further and regard corpulent subjects as less prone than others to exhibit this lesion in its full develop- ment. He says: "The ganglionic system is usually in the inverse ratio, in respect to its development, to that of the adipose system. In very fat persons the ganglia are small; in connection with a true chancre they .are often only slightly enlarged ; sometimes, though rarely, they are not per- ceptible." (Oral communication to M. Fournier.) III. Again, Ricord and Fournier both assert that if a chancre be attacked by phagedicna, the ganglia will remain unaffected. "Pliageda^na would appear to be one of the conditions wliich prevent syphilis from affecting the ganglia." In my own experience, phagedtena has attacked a chancre in most cases, after induration of the ganglia had already appeared, so that I am unable to confirm this statement. IV. According to Fournier, " in very rare instances," induration of the ganglia is wanting "in connection with a chancre in the form of a superficial erosion, or an exulcerated papule, presenting a scarcely per- ceptible or doubtful induration." For my own part, in such instances I have always referred to the ganglia to confirm my diagnosis, and have never known them to fail me. , V. Finally, we have those cases, studied especially by Diday, and en- dorsed to this extent by Ricord, in which the rare inoculation of the SEAT. 481 syi>hilitic virus upon persons previously infected produces only a local sore, without reaction upon the ganglia or the system at large. I have nothing to offer on this point, because I have never met with such cases well established. The absence of induration of the base of a chancre and of its neigli- boi'ing ganglia may, in rare instances, be admitted, without materially detracting from the value set upon their diagnostic and prognostic indications; for why should absolute constancy be expected in syphilitic symptoms any more than in those of other diseases, and in the whole range of pathology it would be difficult to find two which are more uni- formly present than these. Seat — As already stated, the ganglia affected are those in direct anatomical connection with the initial lesion or chancre. Since a chancre is most frequently situated upon the genital organs, induration of the ganglia is commonly found in the groins. Chancres of the interior of the urethra in both sexes, of the perineum, of the anus, of the cervix uteri, of the buttocks, of the lower portion of the abdomen, and of any point of the lower extremities, will likewise manifest their presence by induration of the inguinal ganglia. According to Ricord, when the chancre is situated at the anus, it is the external portion of the inguinal group near the anterior su[)erior spine of the ileum, that is involved. With chancres upon the fingers the situation of the indurated ganglia varies. In one case of a chancre upon the forefinger I found a well-marked indurated ganglion in the web between the forefinger and thumb. More frequently, in these cases, the ganglion on the internal side of the elbow,, or those in the axilla are involved. Again, ganglia between the points mentioned — the hand and elbow, or the elbow and axilla — may become indurated. Thus, in a case under my care, the chancre was upon the thumb, and the ganglionic induration showed itself at the elbow (epi- trochlear gland), and also in a gland situated about half way between the elbow and axilla on the inner side of the arm. Chancres of the breast also affect the axillary ganglia. Chancres upon the lips, both upper and lower, upon the tongue, and upon the chin, cause induration of the submaxillary ganglia ; those upon the eyelids, induration of a ganglion situated directly in front of the ear. Fournier mentions a case of a chancre occupying the palatine arch,, in which a large ganglion was present in the thickness of the cheek ; also another case in which infection was "very certainly" the result of cathe- terization of the Eustachian tube, and in which there were two voluminous ganglia in tlie parotid region, one directly below the ear and tin; other somewhat beneath it imder the ramus of the jaw. Thus the situation of ganglionic induration points to the ap[)n)xiniate seat of a chancre, even after the latter has disappeared, and mny be of essential service in unravelling the liistory of obscure venereal cases. For instance, in the spring and summer of lb()3, a young man had two attacks of what was apparently simple gonorrhoia. In the autumn he applied to 31 482 INDURATION OF THE GANGLIA AND LYMPHATICS. mc with syphilitic iritis, alopecia, acne capitis, and post-cervical engorge- ment, and there coidd be no doubt that he had had a chancre somewhere near the genitals, although he was quite unconscious of the fact, since each groin presented the characteristic indurated pleiad. One of his attacks of gonorrluca was probably complicated with a urethral chancre. Again, a young j)hysician called upon me with well marked syphilitic papuhv, which he attributed to contagion incurred in attendance upon a midwifery case ^'■jive tveeks before," and he showed me a scar upon the forefinger M'hich he said was the seat of the chancre, at the same time denying any other exposure. It was so improbable that his eruption had been developed thus rapidly, that 1 examined his groins, and the indura- tion of the ganglia nailed the lie, which he subsequently confessed. The following table, borrowed from Fournier, gives at a glance the situation of the indurated ganglia, according to the varying seat of the chancre : — ■' Seat op the Chancre. Cokresponding Bubo in the — Chancres of the genital organs, i. e., of the penis, scrotum, the labia majora and minora, the fourchette, the meatus urinarius, the urethra, the entrance of tlie vagina, etc. Inguinal ganglia. Peri-genital chancres (those of the perin;enm, the genito-crural folds, the mons veneris, the thighs, the buttocks, etc.). Inguinal ganglia. Chancres of the anus and the margin ■of the anus. Inguinal ganglia. Chancres of the lii)s and of the chin. The submaxillary ganglia. Chancres of the tongue. The sub-hyoidian ganglia. Cliancres of the eyelids. The preauricular ganglia. Chancres of the fingers. The epi-trochlear and the axillary ganglia. Chancres of tlie arm. The axillary ganglion. Chancres of the breast. The axillary ganglia and sometimes the sub-pectoral ganglia. Chancres of tlie uterine neck. Theoretically the pelvic ganglia. Generally nothing is found in the groins. Exceptionally an inguinal bubo. TiMK OF AiTEAKANCE — According to Rollct, in cases of artificial syphilitic inoculation, induration of the ganglia appears on an average eleven days after the comnioicement of the chancre. In practice, how- ever, we find it earlier, and usually at the same time as the induration of the Ijase of the sore. In exceptional instances, its development is delayed, but, according to llicord, never beyond a fortnight. In some doubtful cases of venereal ulcers I have been obliged to defer my diagnosis for a week or ten days until induration of the ganglia became well marked and removed all doubt. Fournier refers to a case, which he says has been iniifjue iii his experience, of the induration not showing itself until the twenty-seventh day after the appearance of the chancre. COURSE AND TERMINATION. 483 Symptoms — Induration of the inguinal ganglia may affect one or both sides ; in the former case it is usually the side upon which the chancre it- self is situated, although occasionally this rule is reversed, as witli buboes attendant upon a chancroid. AVherever, as in tlie groin, a number of ganglia form a group, most of them, at least, are usually involved, but to an unequal extent. A " pleiad," as it has been called by Ricord, of small olive-shaped or globular tumors is felt, cartihiginous in hardness, freely movable upon each other and the surrounding tissues, and without attachment to the overlying integument. One is commonly developed more tlian the rest, and attains about the size of an almond ; the others as large as a bean or cherry, surround it like satellites. There are no symptoms of acute inflammation. The change has taken place insidiously and often without the patient knowing it. The skin is not altered either in color or temperature. Firm pressure sometimes reveals slight tenderness, but rarely excites severe pain ; and motion is usually not impeded. Indolence is one of the chief characteristics of a "syphilitic bubo." Less frequently, only a single tumor is felt in the groin, varying in size and shape in different cases : sometimes it may be compared to a good- sized plum, while at other times it is elongated, about the thickness of the finger, and corresponds in direction to the inguinal fold. In several in- stances, as the tumor subsided, I have found it resolve itself into several, sliowing that it was composed of a number of coherent ganglia, and this fact has been demonstrated by Bassereau in post-mortem examination. When a chancre is situated at a distance from any group of ganglia as upon the fingers or face, only one or tvvo of these bodies are usually in- volved. Course and Termination Induration of the ganglia usually reaches its full development in the course of a week or fortnight. If mercury be given for the primary sore, it may somewhat diminish for a time, but commonly undergoes a recandescence upon the evolution of secondary synn)toms, resembling in this res[)ect the induration of the chancre. It is usually more persistent than the latter, but its ultimate duration varies in different cases, from several weeks to five or six months, or even longer. Ricord states tliat he has found unequivocal traces of it several years after infection in exceptional cases. Resolution without suppuration is almost the constant termination of syphilitic induration of the ganglia, but to deny tliat suppuration never takes place as some authors have done is to assert tiiat induration protects the ganglia from every cause of acute inflammation, whicli is evidently absurd. Since the indurated ganglia are not in a healthy condition, the only wonder is that they do not more frequently inflame and suppurate, but the rarity of this termination is now well demonstrated. Bassereau found only sixteen cases of suppurating buboes in 3H3 cases of syphilis. 484 INDURATION OF THE GANGLIA AND LYMPHATICS. In the large number of true chancres treated by Ricord at the Hopital du Midi, and in its out-door department, in the year 1856, there were only three which were accompanied by suppurating buboes. Kollet has found 17 cases of suj)puration in 320, at the Antiquaille Hos- pital; Fournier only 2 in 205. In speaking of the rarity of suppuration in this form of adeno[)athy, it is of course understood that no chancroid coexists in the neighborhood or has been imjdanted upon the site of the chancre itself, constituting the so-called " mixed chancre," and capable of exerting its own peculiar influence upon the glands. The causes which may favor the occurrence of su[)puration in indu- rated ganglia are the same as those mentioned when speaking of buboes, but the most frequent is a strumous diathesis or general debility. In the following case several influences probably had a part : — B. belonged to a strumous family. His sister, aged 17, had been afflicted with an aggravated form of chronic eczema since early infancy. His brother, after hardship and exposure upon a wreck, was confined to his bed for six months with suppuration of the inguinal glands. B., who had always enjoyed good health, contracted a chancre in June, 1859, followed by glandular induration. Syphilitic erythema appeared in September, when the glands, which until then had been indolent, became inflamed, suppurated, and remained open six weeks. The general symptoms proved to be very obstinate, and he was still under treatment in July, 18G0, when, after violent exercise at leap-frog, another abscess formed in the same groin. It will be noticed in this case, that the inguinal glands remained in a quiescent state for nearly three months after the healing of the chancre, and their suj)puration at the end of this time can only be ascribed to the strumous diathesis of the patient, and also, in a measure, to the febrile excitement preceding the syphilitic eruption. The value of suppuration of the glands in a suspected case of syphilis as an element of diagnosis is a question of considerable practical import- ance. A patient with general symptoms of a doubtful character seeks advice of a surgeon, who learns that several years ago he had a venereal sore, but can obtain no accurate description of its symptoms. On further inquiry he also ascertains that there was tumefaction of the glands in the groin, and the patient rarely fails to remember whether they suppurated or not — a fact which may also be determined in most cases by the presence or absence of a cicatrix. What liglit will this investigation throw upon the nature of the sore ? If the description above given be correct, the fact that suppuration took place will Javor but will not absolutely prove the supposition that the sore was a chancroid. It is a common but not in- variable rule that general syphilis does not follow an open bubo. In the rare instances in which suppuration takes place the pus is never auto-inoculable like that of the virulent bubo ; whether it contains the syphilitic virus and that its inoculation upon a person free from syphilis would produce a chancre, is a question which has never been solved by experiment. INDURATION OF THE LYMPHATICS. 485 Diagnosis Induration of the ganglia is most liable to be confounded with strumous engorgement ; the history of the case and the concomitant symptoms must decide the diagnosis. Only great stupidity could lead the attending physician to regard cancer- ous degeneration of the inguinal glands with an ulcerated cancerous tumor of the glans penis as syphilitic, althougli this has actually occurred in a case to which I was called in consultation. Induration of the ganglia is so distinct from the simple inflammatory and virulent bubo that I need not dwell upon their points of difference. Induration of the Lymphatics. As both the simple and virulent bubo have their occasional attendants in simple and virulent lymphangitis, so has glandular induration its ac- companying induration of the Ij^mphatics, a more constant companion, though not invariably present, than either of the former. Specific engorgement of the lymphatics is dependent upon changes in the walls of these vessels identical with those which occasion' induration of the base of the chancre and of the ganglia, and is characterized by the same three important symptoms, viz., induration, absence of inflammation, and persistency. The indurated vessel feels like a hard cord running from the neighbor- hood of the chancre towards the pubes along the upper surface of the penis in the course of the dorsal vein and artery, or, in a few instances, it occupies the side of this organ. It is generally single, but sometimes multiple; of the size of a crow or goose-quill; in some cases of uniform diameter, when it communicates to the fingers a sensation like that of the vas deferens, while in others it is swollen at regular intervals like a neck- lace, or is, as botanists would say, moniliform. The distal extremity arises in the induration surrounding the chancre, and the cord can generally be traced for two or three inches towards the pubes, sometimes to the base of this prominence, but rarely as far as the indurated ganglia in the groin. Induration of the lymph.atics is most frequently observed upon the penis, but is not limited to tliis region, Bassereau relates a case of chancre upon the cheek, in which a hard cord could be traced from the indurated base of the sore to an indurated ganglion beneath the angle of the jaw. Induration of the lymphatics ai)pears about the same time and in the same manner as that of tlie base of the chancre, and the two generally correspond in degree of development. As already stated, the former is less constant than the latter, but if sought for may be found in a large proportion of cases. Induration of the lymphatics usually undergoes resolution about the same time as that of the base of the sore; but in a few rare instances.it becomes inflamed and terminates in suppuration, when fistulous openings may form along the course of the vessel. Bassereau met witii three cases in wiiich the indiu'ation of the chancre took on inflammatory action and was transformed into a plilcgmonous tumor, the cavity of whicli was found 486 INDURATION OF THE GANGLIA AND LYMPHATICS. to communicate Avith the interior of an hypertropbied lympliatic, through which a probe could be passed up to the pubes. In one instance he was able to make a post-mortem examination, the patient having died of an intercurrent acute disease. The dorsal vein and artery were found to be intact, and the fistulous canal evidently consisted of an hypertro[)liied lym- phatic with hard and thickened walls, which could be traced from the induration of the chancre to the right inguinal ganglia. Induration of the lymphatics may readily be distinguished with care from the dorsal vein and artery. It is more liable to be confounded with simple or virulent lymphangitis. The diagnostic symptoms have akeady been given when describing the latter. This symptom of a chancre has the same prognostic signification as the induration of the base of the sore and the inguinal ganglia, and denotes that the constitution is ali'eady infected and that general syphilis will soon make its appearance. Treatment of Induration of the Ganglia and Lymphatics. Uncomplicated cases of indurated ganglia require absolutely no local treatment wliatever. When, tlierefore, an otherwise healtliy patient with a chancre and induration of the neighboring ganglia anxiously inquires whether he is likely to be laid up with a suppurating bubo, he may be assured that there is no danger unless he commit some great imprudence. Under the mercurial treatment required by the constitutional infection which has already taken place, the indurated ganglia gradually diminish in size and lose the slight degree of tenderness which they possessed. In the excej)tional cases of su|)i)ui-ation the treatment is the same as for'in- flammatory buboes, thougli generally less active. The same remarks ai)i>ly to the treatment of induration of the lymphatics. STATE OF THE BLOOD. 487 CHAPTER VI. STATE OF THE BLOOD; SYPHILITIC FEVER; AF- FECTIONS OF THE LYMPHATIC GANGLIA. State op the Blood. A SERIES of analyses of the blood performed by M. Grassi under the direction of Ricord, shows that this fluid undergoes a material change in the early stage of syphilis, consisting chiefly in a diminution of the blood corpuscles, which, on an average amounted to a loss of one-seventh, and, in one instance, to one-half of the usual number. Under the administra- tion of iodide of potassium the number of the blood corpuscles was found to increase ; but no improvement took place from the use of mercury. This chloro-ana^mia is confined to the early stage of syphilis; the blood soon recovers its normal composition and retains it throughout the whole course of the disease unless syphilitic cachexia supervenes. Though foreign to our present subject, it may be mentioned incidentally, that the blood of persons affected Avith chancroids was sliown in a second series of analyses by Ricord and Grassi to remain unchanged ; and thus these ex- periments, which were performed before the question of the duality of the chancrous virus had been mooted, are confirmatory of the distinction which is now recognized between the chancroid and syphilis.^ These results of Gi'assi have more recently been confirmed by "\Yil- bouchewitch,^ who, in a series of ten observations, also determined that the i"ed blood glolndes are diminished and the white globules increased in number. The following table of this observer shows the modifications in the number of globules during the primary stage of syphilis. ' HicouD, Le9ons sur le Chancre, 2d ed., p. 184. 2 Arch, de physiologic, pp. 50!), 537, 1874. 488 STATE OF THE BLOOD. Red. White. No. of red to one white. Healthy mail' . . . . . -J 4,200,000 to 6,477,000 6,900 to 8,550 603 to 757 Si/philltic siihject : — 1st count 4,170,000 9,000 421 2(1 " 3 days later 5,510,000 10,000 437 1st " 5,282,000 13,900 380 2(1 " 4 days later 3,864,000 11,550 336 1st " . . . 4,338,060 10,000 433 2d " 3 days later . , 3,908,000 12,800 325 1st " 5,040,000 6,950 72.') 2d " 3 days later 4,269,000 5,600 762 1st " 4,392,800 8,800 565 2d " 4 days later 3,960,600 7,000 565 1st " . . . 4,314,800 13,900 332 2d " 3 days later 3,614,000 10,800 347 1st ". 3,950,600 7,900 564 2d " 4 days later 3,600,300 7,600 473 1st " 6,338,400 6,950 912 2d " 4 da^'s later 4,297.800 7,000 612 1st " 4,886,400 11,200 436 2d " 6 days later 4,200,800 13,600 308 1st " • 4,300,600 8,000 537 2d " 3 days later 3,600,400 11,200 321 From this it appears tliat the average diminution in the number of red globules as found in the second count was 638,870, and the increase in white was 550 ; the proportion of white globules to red in the first enume- ration was 1 to 530 and in the second ] to 448. Syphilitic Fever. The fact that elevations of the temperature of the body occur during the course of .syphilis has long been known. Much valuable information on the subject has been furnished of late years by Fournier, Courteaux, Lance- reaux, Bremer, Jarnovsky, and especially by Dr. T. E. Giintz, of Dresden. In the first volume of the Archives of Dermatology, N. Y., p. 345, may be found the results of observations made by us with reference to this subject in sixty-two cases. Giintz is of the opinion that syphilitic fever occurs in only about 20 per cent, of patients, but we believe that careful exami- nation will discover it in the majority of cases. It may be transitory or persistent ; it may be so mild as to escape notice, or it may be moderately intense. It presents two forms ; in one the febrile condition is continuous, in the other it shows distinct remissions. Let us first consider the continuous fever which accompanies the evolu- tion of syphilis, well-named by the Germans the " eruption-fever." It seldom occurs before the tliirtieth day of the secondary period of incuba- tion, that is, ten days prior to tlie evolution of secondary symptoms. In at least half the cases of syphilis there is no febrile reaction until within three or four days of the first evidences of constitutional infection. In SYPHILITIC FEVER. 489 rare cases the temperature may reach 103° or even 105° within twenty- four or forty-eight hours. Frequently it does not exceed 101°, remaining at that point until the eruption appears, when it again rises possihly to 105°. It then, as a rule, falls gradually or abruptly to about 102°. In almost all cases there is a difference of about one degree between the morning and evening temperature. In other cases a temperature of 105° is observed ten or twelve days before the end of the secondary {)eriod of incubation, and continues, without remission, until the eruption appears, when it falls abruptly to 102°, where it may remain for several days. In the majority of our cases 102° has been about the average temperature. Some observers consider the febrile reaction a reliable indication of constitutional infection, but in some cases the eruption precedes the fever by an interval of a week or ten days. The remarkable effect of mercury upon the temperature has been noticed. Its use causes a reduction nearly or quite to the normal standard in some cases within ten days, whereas without it the febrile condition may persist for several months. Early in the secondary period the fever is prone to relapse, possibly at the same time with a recurrence of general or special syphilitic symptoms. In these cases the temperature rarely goes above 102°. When phagedaina attacks the initial lesion and syphilitic cachexia ap- pears early, the fever is likely to be excessive and prolonged. In weak and sickly persons the elevation is notably greater than in the robust, and in women it is higher than in men. We fully agree with Fournier that syphilitic fever occurs more frequently in females than in males. The febrile reaction accompanving an erythematous syphilide is often as ex- treme as in a simple eruptive fever. In most cases of papular eruption the fever is moderate. In cases of pustular eruption and of iritis accom- ])anying general secondary symptoms, it is more marked. In general the febrile reactions of the early years of syphilis are more intense than those occurring later. Indeed lesions of much gravity may occur after the lapse of years, unaccompanied by fever. On the other hand it may coexist with the various nervous and visceral affections of the tertiary stage. Syphilitic fever not infrequently presents a distinctly remittent type, a peculiarity which may be notic<;d in the early period, but is generally not observed until late in the course of syphilis. We have seen but two cases in which the fever began in a remittent form ten days before the general outl>reak, and retained its character for nearly three weeks. When re- mittent fever occurs early, it usually accompanies the develoi)ment of con- stitutional symptoms. It is never very protracted. The exacerbations occur as a rule daily and towards night, beginning, perhaps, between six and eight o'clock with a general cold sensation, soon followed by fever. The chilly feeling may be insignificant, or it may be quite marked, and may last for an hour or more, being accompanied by a feeling of lassitude and soreness, and perhaps by headache, more or less severe. Thirst seems to be less than in other forms of fever. The sweating stage is incomplete, there frequently being only slight moisture of the surface. It thus differs 490 AFFECTIONS OF THE GANGLIA. from malarial fever in this respect, as well as in tlie fact that the stages are neither of them clearly defined, that of heat being most marked. The elevation of temperature varies from 102° to 105°. The pulse rate is not projjortionately increased. Relapses are quite common, even after long intervals. The gravity of the fever is greatest in cachectic subjects, in whom it may assume a typhoid type. This form of fever occurs most frequently in the secondary period during the first two years of infection ; yet it may appear in the tertiary period, possibly coexisting with lesions peculiar to that stage. The prognosis depends wholly on that of the associated syphilitic diathesis. Quinine has been found ineifective, but the remittent as well as the continuous form is strikingly amenable to mercury. The curious fact is reported by Jullien to have been observed by Donienico Copozzi, that in one instance the salts of quinia converted a quotidian syphilitic fever into a tertian and then to a double tertian, when it relapsed to a quotidian, which finally yielded to mercury. The relation of the febrile reaction to tissue metamorphosis has been made the subject of special study by Vajda. This observer found marked increase of urea in a patient who had mercurial stomatitis, the urea dimin- ishing under the use of proper doses of mercury. Uric acid and creatinine were not found to be increased. The excretion of the phosphates was greater in exanthematous than in bone syphilis. In some cases a distinct relation was observed between the excretion of urea and phosphoric acid ; and sulphuric acid was found to be increased in the papular syphilides in proportion to the extent of the eruption, while in bone lesions, under mercurial treatment, it at first increased and subsequently diminished. Much remains to be done in the investigation of this subject. Affections of the Ganglia. Engokgement of the Superficial Ganglia A very important symptom of the early stage of syphilis, and one which the surgeon should never fail to look for in cases of difficult diagnosis, is engorgement of the lymphatic ganglia in various parts of the body, and especially those situ- ated upon the lateral and posterior portions of the neck. We are not here speaking of the induration of the ganglia in anatomical connection with the primary sore — the indurated ganglia, which assume their cartilaginous hardness about the same time as the base of the chancre. The symptom referred to is an engorgement — not induration — of glands at a distance from the point where the virus entered the system, and first a[)pears some six or eight weeks after the chancre in conjunction with other early secondary manifestations. This symptom is present in a large majority of cases at this stage of the disease. Ricord speaks of it as "perhaps the most constant, the earliest, and the most characteristic symptom of constitutional syphilis."^ Basse- ' Iconograpliie, Remarks on the case figured in Plate XLV. AFFECTIONS OP THE GANGLIA. 491 reau^ found it in ninety per cent, of all the cases of syphilitic erythema which came under his observation ; and in most of the exceptional cases the patients had taken mercury or were not seen for some time after the eruption appeared. It is an early syphilitic symptom, and occurs, if at all, within a year after contagion. Ricord states that it is rarely seen in persons who contract syphilis after forty years of age, though Bassereau met with one case in a man aged sixty-three, and another in one aged seventy-four; from which it would appear that this rule is by no means invariable. The glands most frequently atfected are those situated along the upper two-thirds of the posterior border of the sterno-cleido mastoideus muscle ; but those on the back of the neck beneath the occii)ut, and one just poste- rior to the ear and over the mastoid process may also be involved. All the glands in the regions mentioned are- not, however, implicated in the same person; the number is frequently but one or two, and rarely exceeds six or eight. In a state of health these bodies can with difficulty be de- tected; but, when enlarged by syphilis, they may attain the size of a bean or almond, and are often so prominent as to be recognized by the sight as well as the touch, and even to attract the notice of the patient's unpro- fessional associates. As a general rule, their number and size correspond to the extent and severity of the neighboring eruptions upon the scalp. Other glands besides those of the neck may be engorged in the same manner. Sigmund has especially insisted upon enlargement of a lymphatic gland situated between the biceps and triceps muscles just above the in- ternal condyle of the liumerus, where we frequently observe it, although we do not believe it to be as constant as Sigmuntl's remarks would lead one to suppose. Bassereau has found the glands of the axilla affected, but only in case there was a papular or pustular eruption in the neighborhood of the shoulder. The submaxillary ganglia are also not unfrequently tumefied, when the throat is the seat of syphilitic angina or when the mouth is made sore by the use of mercury. This engorgement of the ganglia almost invariably terminates in resolu- tion. In one case only, so far as I am aware, has suppuration been known to take place. This occurred in a patient, aged 30, of a scrofulous habit, under the care of Bassereau, in whom two collections of matter were formed in the cellular tissue around the gland, attended by severe febrile excite- ment and re(piiring puncture. Some difference of opinion has been entertained as to the question whether this engorgement is necessarily dependent upon a neighboring eruption u[)on the scalp or integument. Ricord believes that it is not, and states in support of his opinion that it often occurs before the slightest trace of an eruption is visible ; and to meet the objection that a pustule of ecthyma might be concealed in the hair and escape notice, this surgeon has repeatedly shaved the head and proved the scalp to be intact. Ad- mitting, however, that the engorgenumt of the glands precedes the erup- tion, it does not disprove the connection between the two, which is ' Op. cit. p. 68. 492 AFFECTIONS OF THE GANGLIA. rendered probable by the correspondence in their intensity; and swelling of the submaxillary glands, as is well known, is often anterior to an erup- tion of erysipelas u})on the face. Diday is confident that engorgement of the ganglia does not exist without the ])resence of some affection of the neighboring integument or mucous membrane, and that it corresponds in intensity with the seventy of the latter. For instance, the epi-trochlear gland is always most enlarged upon whichever side syphilitic squamte u[)on the hand are most marked. Dkep Lymphatic Ganglia Lancereaux regards changes in these ganglia as among the most frequent and most constant of the effects of tertiary syphilis. They bear the same relation to syphilis of the viscera that adenopathy of the subcutaneous lymphatic glands does to syphilis of the skin ; in other words, they are its constant accompaniment. The affection of the deep lym[)hatic glands may, however, exist without any lesion of the viscera, just as the post-cervical and epi-trochlear glands may be enlarged without any eruption upon the scalp or arms. The glands most frequently affected are the prevertebral, lumbar, iliac, and femoral ; the mesenteric glands and those of the extremities are rarely involved. The changes are various. Most frequently there is hyperplasia of the glandular elements ; the gland is increased in length rather than in brciidth, is friable, of soft consistency, of a reddish or yellowish-gray color, its surface injected, and its substance cheesy. In other cases the connec- tive tissue of the gland appears to be the cliief seat of the lesion, and this body becomes indurated. Suppuration is never present, which is an im- portant diagnostic sign between this and the affections of the glands in typhoid fever, and in tuberculosis. Two forms of sy|)hilitic adenitis are described by Cornil ; the secondary, and the other of the tertiary stage of syphilis. In the former the micro- scope shows, besides the lymi)h-corpuscles. large spheroidal cells, more numerous in the cavernous than in the follicular structure of the gland. The cells contain several nuclei, the larger of which inclose nucleoli. There is also slight increase of the connective tissue, so that there exists cell-])roliferation combined with a moderate degree of sclerosis. In terti- ary adenitis the swollen ganglia form soft whitish masses of a medullary appearance. Round and granular lymph-corpuscles, and large multi- nucleated cells crowd the cavernous tissue and the lymph-passages of the ganglia. This is therefore a kind of catarrhal inflammation. Two forms of tertiary adenitis have been recognized and made the subject of a thesis by Gonnet,^ who calls them sclerous and gummatous adenitis. He says they may occur together, and the former may be converted into the latter. Thyroid Booy — In the post-mortem examination of old syphilitic subjects, this gland may be found to be hypertrophied, and to have under- gone more or less comj)lete fatty degeneration. The existence of gummy tumors has not been noted. ' L'ad^nopathie syph. tertiare, Th^se de Par., 1878. CACHEXIA, CHLORO-AN.EMIA, ASTHENIA. 493 CHAPTER VII. CACHEXIA, CHLORO-AX.EMIA, ASTHENIA. At certain periods during its course, syphilis produces an adynamic condition of the system, called "syphilitic cachexia." These periods are at, or just before, the evolution of the disease, during its secondary stage, and towards the close of its tertiary stage. In those cases, fortunately rare, in which phagp.dcenci complicates the initial lesion, there may be observed, soon after the onset of this process, loss of appetite and strength, emaciation, and a pale, sallow appearance. The pulse becomes rapid, weak, and small, and the temperature rises. The patient feels dejected, nervous, and apprehensive. The condition becomes graver in proportion to the extent of the local destructive process, and unless this be checked, complications, consisting of numerous functional disorders, accompany the inauguration of the secondary stage. Headache, neuralgic, or rheumatoid pains, with severe nocturnal exacerbations, may torment the unfortunate sufferer, whose mind is equally harassed by many forebodings, as for instance, in the case of phagedaina, by the prospect of losing his grenital orgjans. Decided sranslionic enlarpfement usually accom- panics this condition, and is a valuable symptom, since the secondary lesions of the skin and mucous membranes may be so trifling as to elude search, and the masked character of the initial lesion obscures the diag- nosis. We have often noticed the disproportion between the character of the primary lesion and that of the early general manifestations, and we have seen several cases in which the very considerable extent of the local process, and the insignificance of the secondary symptoms have prevented any suspicion of syphilis, the severity of the systemic disturbance being attributed to the phagediena. The )iecessity of thorough and repeated scrutiny of every possible seat of secondary symptoms in all cases is evident. In some cases, secondary and tertiary lesions of an extremely severe type, may coexist with the primary lesion, and the patient may lapse into a typhoid state, or serious nervous affections may be developed, and even terminate fatally. Fortunately such a result is rare, but it is not uncommon to see a phagedenic chancre accompanied by a cachexia, which may continue for several months, and from which recovery is tedious and attended by repeated relapses. The cachexia of the secondary period of syphilis may begin a few months after the onset of the disease. It is seen chiefly in weakly persons oftener than in the robust ; and again, more fre lie contracted an ulcer upon the penis from impure inter- course; three months after he had sore throat, scabs in the hair, alopecia, and an eruption upon the skin ; six months after he had an inflamed eye, attended with considerable intolerance of light, and pain. He was at the time young and ignorant of any such disease as syphilis ; was told by his attending physician that he had caught cold in his eye, and had never PROGNOSIS OF SYPHILIS. 503 suspected the nature of his complaint. The well-informed physician Avho brought him to my office told me that he had been under his observation for the last two years, and had never presented the slightest symptom of syphilis, and the most careful examination failed to discover any activity of the poison at the time. Again, a young lady, aged 18, accompanied by her mother, came to my office to be treated for interstitial keratitis. Believing, as I do, in the general truth of Dr. Hutchinson's views as to the specific character of this affection, I at once examined the teeth and found that conformation of the central upper incisors which is so characteristic of congenital syphilis. After closely questioning the mother, there could be no doubt that she, shortly after her marriage, was infected with syphilis by her husband, but she had never had the slightest suspicion of it nor had she ever been sub- jected to specific treatment, although she is now in the enjoyment of perfect health. Again, evidence of a tendency to self-limitation is found in many cases in which treatment is faithfully pursued, and in which the disease, under the best management on the part of tlie surgeon, and the utmost obedience of orders by the patient, repeatedly recurs for a time, and yet ultimately disappears, without our being able to attribute this happy termination wholly to the accumulated effect or prolonged use of remedies, which have failed to afford permanent relief in the earlier attacks. I have so often found this to be the case, that I do not hesitate to assure patients, when discouraged by the reappearance of symptoms which they supposed Avere cured, that the tendency to return will probably cease after a time, and leave them in the enjoyment of a fair state of health; although never, after treatment however prolonged, do I promise certain imniunity for the future. I can recall to mind quite a number of patients whom I treated for syphilis ten or fifteen years ago, and whose disease repeatedly returned, and was appa- rently uncontrollable by medicine for a period of from one to three years, but who have since been exem[)t from further trouble, and many of whom have married, and become the fathers of healthy children ; and I cannot honestly ascribe their present immunity wlioUy to the remedies employed, but in a measure to the fact that the activity of the disease has been exhausted.' Tliis tendency to self-limitation — or, as it may be called, spontaneous quiescence — of syphilis, has been carefully studied by several authors, notably by Diday and Zeissl. Diday's mode of practice has afforded liim a most excellent opportunity for deciding this point, since, in the great majority of syi)liilitic cases, he withholds all treatment, unless compelled to its resort by tlie urgency of the symjjtoms. As the results of his ex- perience since adopting this course, Diday remarks, in the first place, that he has been struck with the regular evolution and succession of syphi- litic phenomena, and afterwards goes on to say, that in many cases, the ' "That all the constitutional forms of sypliilitic aifoctions, if left to the un- aided i»o\vcrs of nature, liave a constant tcndenc^y to wear themselves out, I am fully convinced." — Eoan, Sj/j)hilUic Diseases, p. 245. 504 PROGNOSIS OF SYTHILIS. disease never, passes beyond the secondary stage ; that, after several suc- cessive attacks — as, for instance, of mucous patches, exantheinatous or pap- uhu- eruptions, etc. — the symptoms diminish in intensity ; the virus appears to be elimiuated by the natural jiowers of the system ; tlie tendency to fresh manifestation disappears, and a permanent and spontaneous cure is obtained. In other cases, on the contrary, he has found the disease be- come more serious and more deeply rooted by time ; hence, he admits two classes of cases, in one of which syphilis naturally decreases, and in the other increases in intensity ; in the former, he resorts to hygienic measures alone ; in the latter, he employs specifics, but not to the neglect of hy- giene.^ Out of forty-three cases, treated by the non-mercurial j)lan, in twenty- six the general symptoms never assumed a serious cliaracter and consisted merely of sy|)liilitic fever, acne ca])itis, roseola, and mucous patches. These lesions n^appeared on several occasions, but always with decreasing severity ; the disease never passed into the tertiary stage ; and finally the general health M'as completely re-established. In eighteen of these cases, sufficient time had elapsed to render the permanence of the cure all but certain ; thus, the period between the last syphilitic manifestation and the date when the patients were last seen in perfect health was in — 3 cases 3 4 3 1 1 1 1 1 3* 4 years, ^ 5 6 8 9 .6 On the other hand, in seventeen of the forty-three cases treated with- out mercury, the symptoms assumed a more serious aspect, threatening impairment of various organs and permanent injury to the constitutioi ; some of them passed into the tertiary stage ; and the safety of the patients demanded tiie administration of mercury, which was accordingly given. The following table exhibits the difference in these two classes of cases in respect to the number of the successive appearances or outbreaks of gene- ral symptoms : — Number of outbreaks. In THE MILD SERIES. In THE SEVERE 6 1 . 3 cases. 2 . 14 (( . . . 3 cases. 3 8 (( , . 4 " 4 . 1 (( . . 3 " 5 or 6 . . . . . 7 " Besides being more numerous, the outbreaks of general manifestations, as a general rule, occurred at shorter intervals in the severe than in the mild class of cases. • Nouvelles doctrines sur la syi^hilis, p. 302 et seq. PROGNOSIS OF SYPHILIS. 505 According to Diday, the following are the most valuable indications to show that an attack of syphilis in a given case will be mild : a long incu- bation and a superficial cliaracter of the initial lesion, or chancre ; simple roseola without papules as tlie first manifestation upon the skin ; a gradual diminution in the size of the engorged ganglia ; infrequent outbreaks of general manifestations, separated by comparatively long intervals, and de- creasing in severity. On the other hand, a severe attack is indicated — by a short incubation and deep ulceration of the primary lesion ; by the eru[)tion upon the scalp assuming a decidedly pustular character ; by ulceration of mucous patches in positions where, in mild cases, they are almost always superficial, as upon the sides of the tongue, on the scrotum, margin of the anus, or vulva ; a papular, vesicular, pustulous, or squamous eruption as the first syphilide ; persistency, or having once subsided, tardy reappearance of the glandular engorgement ; frequency and increasing severity of the successive out- breaks of general manifestations. The severity of the attack does not appear to be in direct ratio with that of the syphilitic fever which commonly precedes or accompanies the earliest outbreak of general symptoms, the fever frequently being most severe in those cases which prove the mildest ; nor, so far as we know, can any indication be drawn from the length of the period of incubation of general manifestations. Hereditary origin has an aggravating influence upon syphilis, both in the infant and in any person to whom the latter may communicate it ; on the contrary, syphilis contracted from a second- ary lesion (of acquired, not hereditary syphilis) has been supposed to be of a mild type.^ The above indications, however, should be received with much caution, as tliey are founded upon a small number of statistics, and require further investigation. In my own experience, they have re- peatedly been falsified, although I am not prepared to deny their value in general. Zeissl's views with regard to the self-limitation of syphilis and its ex- pectant treatment (given in the Wien. Med. Wchnschr., 1879, Nos. 1, 2, 3, 4) are essentially the same as Diday's, yet he freely confesses that he rarely carries them out in practice, either in hospitals or in private — not in the former, because economy reciuires that patients should be re- lieved and discharged as soon as possible ; nor in the latter, because patients are unwilling to submit to a prolonged duration of their symp- toms and demand speedy relief. While fully concurring with these views of Diday and Zeissl as to the self- limitation of syphilis in many cases, I am convinced that their tendency, unless great caution be used, is mischievous in underestimating tlie value and importance of treatment. It is true that many cases of this disease will do well under a merely expectant treatment, but no one can tell, a priori, ■which cases will do well and wliich will do bjidly. There is a dark side of the picture which must not be forgotten while looking at the liglit one, ' Diday, Ilistoiro iiatun^llo do hv syphilis. 506 TROGNOSIS OF SYPHILIS. and the former includes the many evils — the physical deformity, public infamy and disgrace, and the ignominious death — to which syphilis, when neglected, exposes its victim. Prolonged treatment, adapted to the re- quirements of each case, is the surest safeguard for every one who has been so unfortunate as to contract this disease. IRRITABILITY OF SKIN AND MUCOUS MEMBRANES. 507 CHAPTER X. IRRITABILITY OF THE SKIN AND MUCOUS MEM- BRANES. CHANGES IN THE SENSIBILITY OF THE SKIN. In the early stages of syphilis the skin and mucous membranes are peculiai'ly susceptible to inflammation ; the tendency becomes less marked as the diathesis grows older. It is greater in some subjects than in others, those having a delicate white skin possessing it more decidedly. The in- tegument of those who have had pustular and ulcerating syphilides is more liable to become inflamed from a slight cause than of those who have had erythematous and ])a])ular rashes. This altered condition of the skin and mucous membranes is seen in its most simple form in the extreme inflam- mation attending slight cuts and abrasions, and in a greater degree in the excessive ulceration and suppuration during the course of certain non-spe- cific skin diseases, such as acne, eczema, impetigo, and pemphigus. Not infrequently herpetic vesicles, in recently infected syphilitic patients, become very much inflamed and present the features of chancroids with their peculiar destructive tendency. (See p. 30.) Doubtless owing to this condition of the tissues, blennorrhagia sometimes becomes especially vii'ulent. Examples of auto-inoculation with blennorrhagic pus are not uncommon. Brought in contact with an abrasion or herpetic vesicles about the genitals, or becoming lodged in the follicles, it causes violent reaction and ulcers resembling chancroids. Our knowledge of the influence of various irritants upon the integument has been much extended by numerous experiments in inoculation with pus from venereal lesions, and by the observation of cases of sy[)hilis treated by syphilization. The results have confirmed what is sometimes seen clinically. It is proved that the integument of some persons is more sus- ceptible than tliat of others, and that certain kinds of pus are more active than others. The secretions from chancroids and from ulcerating syj)hi- litic lesions are much more active than those from wounds or from simple skin lesions. The experiments of Wigglesworth, already referred to, and of Morgan, who produced, with vulvo-vaginal pus, ulcers which resembled, and which were essentially chancroids, illustrate this abnormal irritability of the skin. Repeated inoculation is known to lessen this tendency to ulcer- ation, until finally scarcely any efiect is produced. Moreover, dilution of the pus diminishes its action. Irritation of the skin of syphilitics may also cause infiltration witli or withoirt ulceration. A splinter of wood, imbedded in the skin, has been 508 IRRITABILITY OF SKIN AND MUCOUS MEMBRANES. known lo give rise to a tubercle, having all the appearance and character of a spc'ciHc lesion. In many cases of artificially j)ro(luced ulceration in- filtration coexists, and remains long after cessation of the destructive pro- cess. Wounds, bruises, and ulcers are liable to become complicated by this nodular infiltration. This tendency to infiltration ceases with the extinction of the syphilitic diathesis, whereas the tendency to ulceration persists long after the completion of cure. This fact is exemplified in the ulcerations and fissures occiu-ring in the mouths of smokers, when syphilitic manifestations have long since disappeared. This peculiar condition of the skin is wortliy of special consideration in connection with the serpiginous syphilides. These creeping ulcers un- doubtedly originate in true syphilitic lesions, but the decided absence of characti^ristic features in tlieir future course warrants the sus[)icion that they become simple chronic ulcers developed upon a favorable soil. The fact tluit during syphilis slight abrasions and herpetic vesicles may give rise to ulcers resembling chancroids is of great practical import- ance, and its thorough recognition will enable the physician to avoid doing injustice to innocent persons. ■ Changes in the Sensibility of the Skin. As first noticed by M. A. Fournier, syphilis very commonly gives rise to various disorders of the general sensibility, esj)ecially in women. The most frequent of these is a loss of the perception of pain, or analgesia, with which is sometimes combined the absence of the sense of touch and of temperature. In such cases, for instance, a pin may be thrust deeply into the flesh without the patient's suftering any pain, or she may be also insensilde to the touch of the fingers, or cannot distinguish between hot and cold substances. Syphilitic analgesia varies in degree in different cases, and also in the extent of the surface affected. In some instances it extends from head to foot, in others it is confined to particular regions, when the extremities of the limbs, as the hands, the lower half of the forearms, the feet and ankles, are almost invariably involved. The back of the hand, over the dorsal surface of the metacarpus, is a favorite site, where it is likely to be found, if anywhere. This disorder occurs during the early secondary period, and most commonly lasts for several months. Fournier says that he has observed over a hundred cases within two years. Cases of this affection have frequently come under our observation both in the male and the female sex. It would ])robably be found oftener if looked for, but its presence is of no special value either in the way of prognosis or treatment, and is lience for the most })art neglected. SYPHILIDES. 509 CHAPTER XI. S YPHTLIDES. Lesions of the skin may appear at any period in the course of syphilis, being among its earliest symptoms and not infrequently among its latest. Syphilitic eruptions are caused by two distinct morbid processes, hyper- jemia and cell infiltration, each of which is extremely chronic in its nature. The hyperremic or erythematous syphilides present several varieties, and ai"e peculiar to the early stages of syphilis, being very rarely seen later than two years after infection. While hypera;mia is the essential morbid process, Ave not infrequently find associated with it a certain degree of cell increase, sometimes so slight as to be inappreciable to the naked eye, and again so marked as to form well-defined patches or nodules. The infiltrating cells of the syphilitic dermal lesions are round, granular, nucle- ated bodies, averaging -^jj^q^ of an inch in diameter, similar to the white blood-corpuscles in general appearance, and analogous to the cells of the initial lesion and of the later gummatous tumors of syphilis. The surpris- ingly numerous and varied appearances, resulting from these two simple processes, are modified and complicated by various subsequent changes. As a general rule the cell-infiltration is in proportion to the age of the syphilis. Thus, in the secondary period the superficial layers of the skin are involved, and papules are developed ; while at a later period, the infil- tration being deeper and more extensive, tubercles are formed. In the former the changes take place chiefly in the pajnllary and Malpighian layers ; in the latter the derma and the subcutaneous tissue are involved. A tubercle, therefore, is simply a papule of large size. Evidently there can be no distinct line of division between the two lesions, and we i're- quently meet with intermediate grades of infiltration, to which we may apply the term papulo-tiiberch. Tubercles may, however, a))pear early in the course of syphilis, but are usually not seen until after the evolution of a general superficial eruption. A syphilitic pustule may be looked upon as a pus-producing papule, the secretion of i)us generally being secondary to the formation of the papule. In some instances, however, the forma- tion of pus seems to precede or to be coincident with the cell infiltration. The occurrence of a vesicular syphilide is rare, and has indeed been denied by some authors. It is true that vesicles, similar to those of herpes and eczema, are not developed, but it is not uncommon to find minute collections of serum beneath the epidermis at the apices of papules, espe- cially those small conical papules wliicli have a more acute ciiaracter. The existence of a true bullous syphilide in the acquired disease liaa also been doubted, but we are convinced that it is occasionally developed at 510 SYnilLIDES. a late period in cachectic subjects. The degree of cell infiltration at the base of bulliv is usually much less than in any other syphilitic eruption. Thus we find in syi)hilis lesions of the integument which correspond to those of non-specific origin : erythemata, papules, pustules, vesicles, bullae, and tubercles, but the syphilitic eruptions present certain peculiar features whose recognition is important. In addition to the above-mentioned lesions are the syphilitic gmnmata or gummatous tumors. These result from cell infiltration in the sub- dermal tissue, either limited to this region or involving secondarily the entire thickness of the skin, which may be destroyed, thus forming gum- matous ulcers.. A syphilitic eruption may be composed exclusively of one or another of these lesions, or several may be simultaneously developed. Much confusion has followed the application to syphilitic skin lesions of the classification of non-specific eruptions instituted by Willan, who placed lichen among the papular, im[)etigo among the pustular, eczema among the vesicular, and psoriasis among the scaly affections. Such a nomen- clature in syphilis is far from being as useful as might be expected. For instance, a papular syphilide, in its early stage, would be called " lichen ;" but suppose it to be cajjped with pus, as frequently happens, and the name " im[)etigo" must be substituted, or we must designate it by the term " pustulating syphilitic lichen." Should the lesion lose its pustular fea- ture, and, becoming chronic, assume a scaly character, no term now in use could express the exact condition, and we should be compelled to add the term psoriasis. Another objectionable feature in the nomenclature of syphilitic dermal lesions, is the use of the word " lupus" in describing certain tubercular syphilitic lesions whose features and course resemble those of the non- specific affections. We have, therefore, thought best to apply the qualifying adjectives, " erythematous," " papular," " pustular," etc., to the generic term "• syphi- lide," using the words " ulcerating," " serpiginous," etc., in addition, as the peculiar features of an eruption, in exceptional cases, may require. We thus avoid the erroneous inference that many of the chief varieties of simple skin affections are caused by syphilis. Although we may use the word " scaling" in describing certain syphi- lides, it must be remembered that desquamation does not constitute the lesion, but that the latter consists of infiltrations into tlie skin, in the form of papular or tubercular eruptions, exfoliation of the epidermis being second- ary. In some cases the dermal irritation is so excessive that desquama- tion continues long after the original lesion has faded. It must then be considered merely a sequel of the specific process. Besides the classification of syphilides in accordance with their element- ary lesions, we have one based on tlie recognized fact that each symptom has a favorite period of development. A strict chronological order is not followed, for a tubercular rash may be met with at an early date, or a papular eruption may be developed very late in the course of syphilis. SYPHILIDES. 511 Some French authors call the early eruptions precocious syphilides (syphi- lides precoces), and limit them to the first eight months of the disease ; those of later appearance they term intermediary (<'na.\\\, numbness, and muscular weakness. In another case, seen by tlie same autlior, a small gumma over the track of the supra-orbital nerve gave rise to considerable pain. 554 SYPHILIDES. seldom over a bony sui-face. They are often multiple, but more than four are rarely observed. They select the sides of the leg rather than the pos- terior aspect. They are always surrounded by intense hyperaemia, and frequently, late in their course, they resemble non-specific ulcers, especially the varicose. Their edges become rounded and callous, and their surface is studded with granulations, thus losing their characteristic features. In some cases of precocious evolution, groups consisting of six or a dozen of these gummous tumors, form upon the legs, especially near the knees, less frequently upon the buttocks, and even on the forearms and forehead. They rapidly invade the skin and form ulcers, which are at first extraordinarily active, but soon pass into a chronic state. The extensive hyperaimia which usually accompanies these ulcers of the leg, is the cause of localized osdema. In very chronic and extensive ulceration the oedema begins about the ankle, and involves a portion or the whole of the leg, which becomes swollen, hard, and brawny, the in- tegument above the ankle being thrown into folds. This condition, which is very obstinate, and altogether resists internal treatment, resembles ele- phantiasis Ai'abum. When their edges become thickened and callous, these ulcers do not extend rapidly, but persist for many years. Their base is covered by a layer of greenisli-black slough, and from it exudes a thin, fetid, bloody secretion. Phagedaina is hap[)ily an infrequent complication of this syphilide. In broken-down subjects the ulceration rapidly destroys the skin and subja- cent tissues, sometimes even denuding the bones. The process is ex- tremely painful, and is attended by constitutional reaction, which some- times reaches a typhoid condition. The parts most subject to this complication are the face, feet, and genitals. Unless promptly checked there may be great destruction of tissue. This syphilide may appear within the first year of syphilis, but it is generally a late symptom, appearing at any time from the third to the fifteenth or twentieth year. Fournier reports a case of gummy tumor of large size, which was developed fifty years after infection, and was cured by iodide of potash. The prognosis is influenced by the date of the appearance of the syphi- lide, its extent, and the general condition of the patient. Its early and malignant appearance indicate an active and severe form of syphilis, in which visceral gummata are to be feared. Although only one or two gummous tumors or ulcers may be present, and the general health is not much afi^ected, thorough internal treatment is none the less necessary. The diagnosis is to be made in its stages of tumefaction and of iilcera tion. When it exists as a movable, subcutaneous tumor, it may be mis- taken for a fibrous, a sarcomatous, or a fatty tumor, or perhaps an en- larged ganglion. The syphilitic lesion is usually multii)le, and is not compressible like the fatty tumor, nor as hard as the sarcoma. Sarcomata tend to attach themselves to subjacent parts; tiie gummy tumors invade the skin. The history of the case, the absence of pain in the tumor, and its situation, may be of assistance. Tumor-like infiltrations upon the face, THE SERPIGINOUS SYPHILIDE. 555 in the female breast, about the genitals, near joints, and wherever connec- tive tissue is abundant, should always, in case of doubt, be subjected to specific treatment. Numerous cases have occurred, particularly with French surgeons, in which mixed treatment has dissipated tumors con- demned to excision. Tlie general appearance, situation, and history of gummatous ulcers are generally sufficient to establish their character ; but sometimes, especially on the face and lower extremities, they may be confounded with ulcerating lupus, or with simple eczematous or varicose ulcers. Lupus begins as small tubercles of the skin, which slowly ulcerate and become partially incrusted, and it extends by the formation of new tubercles, which in turn ulcerate. Lupus usually begins in early life, and on the nose. Eczematous ulcers are always preceded by eczema of the skin, which lies tense over a bony surface. They are painful, superficial, always ac- companied by a good deal of inflammation, and are seated, as a rule, on the lower third of the leg. Similar general features are observed in vari- cose ulcers, together with enlarged veins and more or less cedema. The Serpiginous Syphilide. This syphilide creeps over large surfaces by ulcerating at the periphery of patches while it heals in the centre. It may occur as early as the second, or as late as the tenth or fifteenth year of syphilis, possibly later. Its course is very chronic, and, although unattended by pain, it frequently causes great inconvenience. Its efil'cts on the skin may be slight, or it may leave disfiguring cicatrices. There are two varieties of tliis lesion, a superficial and a deep. Tlie superficial serpiginous syphih'de begins as a pustule, generally of the impetigo-form or of the variola-form syphilide. In its early stage it consists of a superficial ulceration, which has no characteristic features indicative of its future course, but which extends in the shape of a round or oval patch. If treatment, and particularly local treatment, is not em- ployed, the process continues and crusts form, until the patch reaches a diameter of about two inches ; granulations then spring up from the centre, and the crust falls off except at the periphery, where it adheres as an en- circling ring. Thus is formed not a continuously incrusted surface, but a ring of crusts inclosing a more or less hypera^mic area of a round or oval shape. The color of the crusts is usually yellowish-brown or greenish- black, and their thickness about one-tenth of an inch. The underlying surface is smooth, of a grayish-red ' color, and ulcerated at the margins. Around the edges is a narrow, red areola. The ulcerative process slowly progresses at the margins of the patch, a rim of crust at the same time forming. Healing of the inclosed surface keeps pace with the peripheral extension of the ulceration, so that the width of the crust, varying from half an inch to an inch, is steadily maintained. Tlie centre of this surface is l)Uu)ched, its margins are always red, and tliey merge gradually into the ulceration. This process may continue many years, and involve extensive 556 SYPniLiDES. surfaces. When healing begins, the crusts become harder and darker, and the redness of the central patch and of the ai'eola diminishes. Then seg- ments of crusts, having been lifted by the granulations beneath, fall off, and expose an ulcerated ring. Unless cauterized with a solution of nitrate of silver, as it should be, it may persist for a long time. At first the ulcer generally increases throughout its whole periphery ; subsequently, it may increase only in one direction, thus becoming oval or reniform. The extension of the ulcer is largely influenced by the tissues on which it is seated. Thus an ulcer on the inner surface of the forearm creeps up the arm much more rapidly than towards its outer surface, where the tissues are firmer ; and thus a long, oval ulcer is formed. A similar occurrence is observed on the thighs, while on the face, where the tissues are more uniform, the ulcers are generally round. The result of this superficial ulceration may be simply coppery pigmentation, which lasts several months, or very slight atrophy of the skin. The ulceration may even be extensive and protracted, and yet induce wonderfully little structural change. The deep serjiiginoi(s syphilide has for its focus of ulceration, one of the late or tertiary lesions, sucii as a tubercle, an ecthyma- form pustule, or an ulcerating gumma. Whatever the starting point, there is soon developed a deep, sharply-cut, active ulcer, with undermined edges and a coexten- sive crust. This ulcer increases in size, more or less rapidly, until it attains a diameter of two or three inches, when changes, similar to those obs(;rved in the superficial variety, may occur. The crust becomes thin at its centre, and thick at its margin ; the thin portion soon falls off, leaving a round, deep-red cicatrix, surrounded by a thick, greenish-black crust, less than an inch in width and quite thick. When this syphilide is fully developed, and has attained a diameter of from four to six inches, its changes are more marked. In the centre is a round or oval patch of cicatricial tissue, having a coppery-red color, and as yet firmly attached to the subcutaneous connective tissue. This is completely inclosed by a ring of crust. Tlie ulcerative process is not equally active at all parts of the ring, hence result certain modifications in the shape of the crust. The ulcerating ring, which encircles the central cicatrix, forms a furrow half an inch to one inch in width, and, at its most active portions, a line or more in depth ; it has a foul, grayish-red floor, and sharply-cut, somewhat everted, and undermined edges, which have a deep red color, and are continuous with an areola of similar tint. Portions of this ulcerating furrow may be partially filled by granulations, or even entirely cicatrized. Over the more active segments, there is a yellowish-brown crust, slightly depressed below the level of the skin, and which may be raised as a film from the surface. In portions further advanced towards healing, the crust is thicker, harder, slightly above the surrounding level, and of a greenish-brown color; continuous with it, on parts where the process is quiescent, or where healing is nearly complete, the crust is greenish-black in color, is hard and adherent, and its base on a level with the skin. Thus THE SERPIGINOUS SYPHILIDE. 55Y we can always infer the age of the ulceration from the size, color, con- sistence, thickness, and prominence of the crusts. Relapses may occur by ulceration of the cicatrix, sometimes destroying the whole of it. This occurs most frequently in debilitated and jworly- nourished persons, and in those who use alcohol to excess. The cicatrix following such a relapsing ulcer is very rough and unsightly. Sometimes the cure is retarded by repeated relapses at the margins of large ulcers, segments which had healed being again attacked by the ulcerating process, or again, parts more remote may be attacked. The course of this syphilide is always slow, often occupying many years. In some cases it is accompanied by profound cachexia, while in others there is no disturbance of the general health. This syphilide is of rather rare occurrence. It may appear as earlv as the third year, but generally later, even up to the fifteenth year after in- fection. It appears usually on the inner surface of the forearms and arms, on the breast, and on the legs. It causes little if any pain, but frequently gives great annoyance when near joints. When the resulting cicatrices are small they are generally thin and parchment-like ; but, if large, they are thick, uneven, and often traversed by fibrous bands, and covered by tubercles of false keloid. Often, however, even the large scars are thin, a fact of importance in making a diagnosis between this syphilide and serpiginous lupus. Blanching of the cicatrix extends from the centre towards the periphery. In large scars there may be a white central patch surrounded by a dull coppery-red areola, even long before healing is com- pleted. In all cases the pigmentation fades slowly, and remains longest in the areola. Contraction of the scar near joints often results in perma- nent deformity. The prognosis of this syphilide is never very good. Still a fatal result is by no means inevitable, and proper treatment is in many cases quite effective. The diagnosis from serpiginous lupus and serpiginous chancroid is sel- dom difficult. Lupus usually begins in early life, and attacks the face. Its ulcerations are less definite and sharply cut than those of the syphilide. In lupus, red tubercles of ulceration, covered by crusts of light yellow or bluish-brown are mingled with the cicatrices, which are always uneven and fibrous. The history of the case may add to the certainty of diag- nosis. A serpiginous chancroid usually has such a clear history that no mistake can occur. Its locality, its extensively undermined edges, its fungoid surface, and its erratic course are also sufficiently diagnostic. In opposition to the view of some that this eruption is not syphilitic, it is only necessary to say tliat it always begins in a syphilitic lesion, that its ulcers and crusts have features similar to those of other syphilitic lesions, and, finally, that its cicatrices are typical of syphilis. 558 syphilides. The Pigmextaky Sypiiilide. In 1853 Hardy described this lesion, which has since been the subject of monographs by Pillon, Tanturri, Fournier, Drysdale, Fox, and Atkin- son, but its nature and origin are still questions of discussion. It usually appears during the first year of syphilis, but may occur as late as tlie third year. It is composed of irregularly round or oval spots, with ill-defined or jagged margins, of a brown, cafe-au-lait color, which does not pale under pressure. The color of the patches may be so faint as to require a strong light and a certain position for their detection, and even then they might pass for spots of dirty skin. The patches vary in diameter from one-eighth of an inch to one inch, and are neither elevated nor scaly. Tiiey may be discrete or confluent, in some instances being sparsely scattered, and in others occupying a surface of the extent of one's hand, and presenting very different appearances under the two conditions. In the former the spots are small, and separated by wide intervals of un- altered skin. In but one instance of this kind have we found each spot surrounded by an areola of pigment of a deeper color. AVhen the spots are more numerous they })resent the peculiar appearance aptly compared by Fournier to a " network of lace with large meshes." The intervening skin seems even whiter than the normal skin, an appear- ance concerning which there is still difference of opinion, some believing that it is due to contrast with the adjoining brown patches, others that there really is a decrease or an absence of normal pigment. According to the latter view, there is, therefore, at the same time a de- crease of pigment in certain regions and an increase in others. The latter process we regard as the essential one, for some cases are seen, in which whitened patches cannot be detected, and, in any case, they are much less in extent than the pigmented patches. Tanturri is said to have found, by microscopic examination, as much pigment in the intermacular skin as elsewhere, but the probability is that the results of this observer w^ere obtained in cases in which the brown spots only were present. On the other hand, it is the opinion of Fox that this eruption is a local- ized loss of pigment surrounded by regions of increased pigmentation, and he considers the essential lesion to be the oval or circular s[)Ots of abnor- mal whiteness. He gives a case, in which this condition followed an ery- thematous syphilide upon the neck. We fully recognize the fact that decrease of pigment may, in rare instances, be observed on the previous site of a hypera^mic syphilide, but we believe that the lesion under con- sideration is spontaneous in its origin, and not a sequel of hypera3mia. It is impossible to speak positively of the early history of this eruption, because it has never attracted attention until fully developed. Its evolution is probably gradual, like that of chloasma and leucoderma, and like them it is a chromatogenous affection. The most frequent seat of this lesion is the sides of the neck, where, MALIGNANT PRECOCIOUS SYPHILIDES. 559 according to Fournier, it occurred in t'nenty-nine out of thirty cases. It may also invade the chest, abdomen, and even tlie lower extremities. It is much more common in women than in men, and is especially frequent in those of a light complexion. Its course is extremely chronic, and is uninfluenced by anti-syphilitic treatment. It may disappear, perhaps after months or even years, and it leaves the skin apparently unaltered. It is a very uncommon disease in this country. The question arises whether it is etiologically related to syphilis, or is a mere accident in the course of the disease. In favor of the former view, we have the opinion of six observers, who studied the lesion independently. Moreover it is supported by the well- known fact that grave systemic dyscrasite, among which we must include syphilis, may cause chromatogenous aifections. In opposition to its syphilitic origin, there are the facts that it differs in appearance from every other specific skin lesion, and that it is not influ- enced by anti-syphilitic treatment. In our opinion there is a remote and obscure connection between the lesion and the syphilitic diathesis. For a long time the affection was recognized only by the French and Italian observers, whose studies in syphilis were pursued among classes of persons more predisposed to various pigmentary changes than are the members of the Anglo-Saxon race. Yet it is distinctly stated by them that the affection was met with in persons of light complexion, and it is well known that such individuals are more disposed to ephelides and pig- mentary changes in general. We have sought for this eruption in nearly all the cases of syphilis under our observation for the last eight years, and have discovered only six well- marked instances. We have also seen a similar eruption in a patient with chronic renal disease. Two of our cases w'ere French women, and the remaining four were Anglo-Saxons of rather dark complexion. The diagnosis is to be made from chloasma, leucoderma, and tinea ver- sicolor. From the first, the clinical history and the peculiar appearance of the eruption will generally distinguish it. In leucoderma tlie white patches have distinct brown margins, and perhaps a background of similar color, just the reverse of the pigmentary syphilide. Tinea versicolor rarely exists on the neck exclusively, but is usually continuous with similar patches on the chest. It is darker in color, slightly elevated, and scaly, and may occasion slight itching. Moreover tlie few scales from the syph- ilide are composed of epidermis only, while those of tinea are loaded with the spores of microsp or on furfur. Malignant ruECOCious Sypiiilides. Under this title French authors have described certain syphilitic erup- tions, which have a malignant ulcerative character, appear early in syphilis and are accompanied by general cachexia. These eruptions vary greatly in exten+ and duration. In some cases the malignant tendency is exhib- ited from the first, while in others it attacks a previously mild eruption. 560 SYPHILTDES. It has already been stated that certain pustular eruptions, particularly the impetigo-form and the ecthyma-f'orm syphilides, and much less frequently the papular rashes, develop this character. In some instances this peculiar feature of the eruption is due merely to the excessively debilitating influ- ence of the syphilitic poison or to a lowered condition of nutrition. Dr. Ory, who has studied the etiology of the malignant syphilides, concludes that alcoholism is a very potent cause, but that any adynamic influence may have the same effect. These syphilides are divided into three classes : the syphilide pnro- crustucee ttlcereuse, the syphilide tnberculo-crustacee iclcereuse, and the syphilide tuberculo-ulcerante yangreneuse. The syphilide puro-crxstacee ulcereuse is a pustular rash attended by extensive ulceration and formation of scabs. It begins as rounded pustules grouped or irregularly scattered, which soon ulcerate and form flat or con- ical greenish-black crusts which may blend together. The ulcers are deep, with sharply-cut, undermined edges and a foul base secreting a fetid pus. Such an eruption appears first upon the face or scalp, where the lesions are often in groups; then it invades the arms and may even extend over the entire body, successive crops of pustules being developed in bad cases. There is rarely a tendency to ringed distribution, but sometimes one group of pustules is increased by the formation at its periphery of new pustules. Tiie syphilide tnberculo-crustacee ulcereuse begins as a small, red tuber- cle, of the size of a pea, which is rapidly converted into an ulcer with a thick crust. The subsequent course is similar to that of the previous variety, except that the destruction of tissue is often much greater. This eruption is prone to appear first on the head and upper extremities. In some cases these regions only are attacked ; in others the whole body is invaded. Upon the face the ulcers are often confluent ; upon the arms they are usually scattered, but later on groups may be formed by the con- tinual accession of new tubercles. The invasion of this eruption, like that of the preceding one, may be rapid or slow. Its course is chronic, some- times occupying six or eight months or even a year. During ulceration the lesions sometimes cause a dull pain, and are at all times a source of much discomfort. The syphilide tuberculo-ulcerante gangreneuse, also called by Auzias Tureiuie carbuaculus venereus, one of the most formidable manifestations of syphilis, is hapi)ily rare. It is always accompanied by cachexia, and if not fatal, always leaves a condition of permanent ill-health. It begins as round tubercles of a dark-red color, slightly elevated and deeply seated in the skin, which attain a diameter of an inch or more. A small blackish slough forms in the centre of each tubercle, and is at first firmly adherent ; it extends rapidly and, soon becoming loosened by the secretions, is cast off as a fetid, cup-shaped mass, looking something like an inverted rupia crust. The ulcer thus exposed is very deep, has a foul, dark-brown sur- face, with hard, everted edges and secretes a fetid ichor. To the touch it gives the impression of being deeply seated and indurated like a typical initial lesion or chancre. Surrounding each tubercle is a broad, deep-red MALIGNANT PRECOCIOUS SYPHILIDES, 561 areola. Pliagedfena may occur and run a course similar to that of phao-e- denic gummous ulcers. From time to time brownish-green crusts form and are thrown off. In favorable cases the surface of the ulcer gradually assumes a more healthy appearance, the edges become softer and the areola fades. Granulations appear, and true pus replaces the ichorous discharge. The healing process is finally completed, leaving a depressed cicatrix of a coppery-red color, which gradually fades from the centre towards the periphery of the cicatrix. When fully formed the cicatrix is of a dead- white color, flexible and thin like parchment. The invasion of this syphilide is generally rapid, but its subsequent course is slow. Usually tubercles are developed in region after region, followed, perhaps, by additional crops. They are irregularly scattered, with no tendency to a ringed form. The face, the extremities, the shoul- ders and buttocks, are its favorite seats. The eruption may persist for several months or even years, altliough in the most malignant cases it runs a course called by French authors " galloping.'^ In such cases the inva- sion is very rapid and the result is generally fatal. At or shortly before the appearance of these precocious syphilides, the patients complain of weakness, and appear pale and sallow. They often suffer from fugitive pains and neuralgias and from a general sense of dis- comfort. They have no appetite and become emaciated. At the same time some febrile reaction may be noticed. If not checked, this adynamic condition increases pari passu with the eruption ; the patient falls into a typhoid state and dies. Possibly some intercurrent visceral lesion, of the lungs or of the nervous system, hastens the fatal result. In some cases, no definite visceral affection can be detected, and the patient dies of ma- rasmus. Very often lesions peculiar to a later period, such as nodes, neci'oses, sarcocele, etc., appear with this malign eruption. In other cases, although the syphilide is essentially malignant, health gradually returns after a prolonged period of impaired nutrition and extreme debility. The prognosis of these syphilides is always grave, since they indicate a most intense and active form of syphilis. The health of the patient pre- vious to infection, his habits, the extent and character of the eruption and the degree of cachexia must all be considered. The course of the lesions and the influence of treatment must be watched. Death almost always results from the intercurrence of some pulmonary or nervous affection. As regards treatment, every efl"ort should be made to improve nutrition. Much can be done towards checking the course of the eruption by the employment of local measures. Careful dressing of the ulcers, their tho- rough disinfection, and the early removal of secretions, not only add to the comfort of the patient but promote healing. In spite of every precaution, indelible cicatrices are generally left. Internal treatment must also be employed. The guarded use of mercury, preferably by inunction, with iodide of potassium, sodium, or ammonium, internally, is indicated. Opium is often found [)articularly useful in these cases, by calming the restless- ness of ihe patient, and (piieting the pain of the ulcers. In a recent case of our own, in wliich the malignant syphilide was accompanied by profound 36 562 SYPHILIDES. cachexia, by severe and persistent rheumatoid pains, and by double iritis, this dejdorable condition was, in less than a week, markedly improved by the addition of a little opium to the mixed treatment, combined with tonics. We may sometimes resort to mercurial vapor baths with iodide of potassium or sodium, combined with bitter tonics, internally, beginning with ten- to fifteen-grain doses three or four times a day, and gradually increased by two or three grains daily. Mercury given in this way is supposed to have a beneficial local as well as general effect. The condition of the stomach demands that the most digestible and nutritious food be taken, if possible in small quantity and at frequent intervals. Stimulants, prefer- ably good port wine or brandy, must be given regularly. Such treatment as the above is suitable Avhen the patient is still able to move about. In a typhoid condition, treatment applicable to the adynamic fever is called for, together with the careful use of the iodides. The crusts of the ulcers should be removed after softening them with simple ointment or cosmoline, to which a few drops of carbolic acid have been added. AVhen they cover the whole body, an alkaline bath may be required for this purpose. The exposed surface of the ulcers should be touched with carbolic acid, applied with cotton wool or a brush. Its action is twofold ; it allays pain and destroys the diseased tissue. The formation of scabs may be prevented by the application of an ointment or the water dressing. An ointment composed of one part of mercurial ointment, one part of Balsam of Peru, and six parts of Cosmoline, applied on lint and frequently renewed, is of great service. Simple lead water or a solution of the Bichloride of Mei*- cury (gr. xij (0.80) to water gxv (4G0.00) and glycerin sj (40.00) ) is to be preferred, when there is much hyperaemia. The latter has a special detergent and stimulating effect. As the case progresses, such superficially destructive stimulants as nitrate of silver in strong solution, or fluid car- bolic acid, may be indicated. The ulceration is sometimes arrested and repair hastened by prolonged immersion of the body in hot water. These hot baths may be rendered more efficacious by the addition of two or three drachms of corrosive sublimate to each thirty gallons of water. Care must be exercised as regards their frequency and duration. The mercu- rial vapor bath is often of benefit after removal of all the crusts, but its effect must be carefully watched. By way of prophylaxis, when the eruption shows a tendency to extend, all possible sources of irritation of the skin must be removed. Spontaneous Gangrene in the Course of Syphilis. Very little is known of this possible consequence or complication of syphilis. Prof. Podres, of Crakow, has reported the case of a man, forty- five years old, who, six years after infection, began to have pain in his legs, which became very anaemic, sensitive to cold, ccdematous and, finally, gangrenous. This condition necessitated amputation : first of the toes, then of the foot, and finally of the thigh. Microscopic examination showed inflammation of the external tunic of the arteries, defeneration of their LOCAL TREATMENT OF SYPHILIDES. 563 endotlieliuni, with tl)ickeniiig of their walls and obliteration of their calibre. There was also atrophy of the cutaneous glands and nerves. All of these changes were attributed by Podres to syphilis.^ Local Treatment of the Syphilides. The syphilides always require thorough constitutional treatment, and this, as a general rule, should be mercurial. Those of the secondary statue re- quire mercury alone, while those of a later stage are best treated by mercury combined with the iodide of potassium. The opinion largely prevails that gummata of the subcutaneous tissues, being tertiary lesions, demand only the potassium salt, but we regard this idea as erroneous. Under the iodide alone we have often found the result slow and unsatis- factory, while a combination of the two remedies has almost invariably led to a speedy and beneficial action. In spite, however, of the best directed internal medication, some of the syphilides urgently require local treatment. The exanthematous syphilides are generally ephemeral, and do well under internal treatment alone. In some cases, however, their persistence upon exposed parts, as the face, the hands, and particularly about the wrists, demands something more for their removal. For this purpose, the best application is an ointment or lotion containing a mercurial salt: I^. Hydrarg. Oxid. Rubri, vel Ammoniati gr. x-xx . . , 65 — 1 30 Cerati SimpL, vel Ung. Aq. Rosse ^j 30| M. A small quantity of this ointment is to be rubbed in twice a day, and a liberal quantity be left on over-night. The following may also be rec- ommended : — I^. Ung. Hydrarg. §ij 81 Cerati Simplicis, vel Ung. Aq. Rosse §j 30| M. The five or ten per cent, oleate of mercury is also generally useful in the erythematous and papular eruptions. When using any of the above, brisk friction of the parts should be employed within the bounds of avoid- ing dermal inflammation. In urgent cases, the ointment may be spread on lint and kept constantly applied to the spots. Lotions are sometimes of very decided benefit, especially in cases of deep coppery pigmentation so often left upon. the foreliead, which is very annoying to patients and is but slightly influenced by internal medication. I^. Hydrarg. Chloridi Corrosivi gr. iv Ammonii Chloridi gr. x Aq. Colognieiisis ^ss 15 Aquam ad §iv 125 M. > Centralbl. f. Chir., Leipz, No. 33, 1876. 564 SYPHILIDES. This should be freely sponged on the parts, or, in obstinate cases, be constantly applied by a piece of lint saturated with it. When the pig- mentation is scattered generally over the body, or when the erythematous eruption is very chronic, as also in its relapsing form, mercurial vapor baths are our most efficient remedy. If these are unattainable, baths of corrosive sublimate (5j-iv to 30 gallons of water, with the addition of ^ij of the chloride of ammonium to facilitate solution) will answer the purpose. The pa[)ular sypliilidcs are, as a rule, amenable to internal treatment, but in some cases in which this has been neglected, and in others of the small miliary form, they are often annoyinglj persistent. If the eruption be confined to small areas, the ointments and lotions just mentioned will be all sufficient. If large surfaces are involved, we may employ tliese ointments in the form of inunction, but, in general, baths of various kinds are desirable, and should be repeated as often as may be necessary. In some cases, we have derived decided benefit from sulphur baths, and, again, from alkaline baths (one pound of the bicarbonate or the borate of sodium to thirty gallons of hot water). Brisk friction with one of the above ointments will greatly hasten the result. The most rebellious forms of the early syphilides are those of the palms and soles iii their chronic scaly stage. These will persist for long periods unless local be added to internal treatment. The applications should be varied according to the stage of the eruption, and it is desirable to attend to them from their very commencement. When treated early by daily inunction of a salve composed of equal parts of strong mercurial ointment and cosmoline, the papules will rapidly disappear ; the cure is hastened by the continuous application of the same, the hands being covered with gloves constantly worn. This ointment will sulfice for cases in the true papular stage, but is not sufficient when the papules have become scaly and the skin thickened. We should then adopt the treatment of simple psoriasis, and immerse the parts in hot water, to which an alkali has been added in the proportion of one or two ounces to two quarts. The addition of a handful of bran is excellent when painful fissures are present. This should be repeated every day or two, and the scales be removed when they are softened. After drying the parts, they should be anointed with R. Ung. Hydrarg. 5ij 8 01. Rusci, vel Betuhe Alb., vel Olei Cadini 3ss-j ... 2 Gelati Petrolei §j' 30 M. R. Hydrarg. Ammoniati, vel Hydrarg. Oxid. Rubri gr. x-xx . . . 65—1 30 Olei Rnsci, vel Cadini 3ss-§j . 2 4 Ung. Simplicis §j 30 M. ' Vaseline and CoBmoline (essentially tlie same, but the latter more consistent) have received no officinal name, but the suggestion of their manufacturer, Mr. Chesebrough, "Gelatuni Petrolei," is good. LOCAL TREATMENT OP SYPHILIDES. 565 a mild mercurial ointment, to which a stimulant tarry preparation is a valuable addition in many cases. These ointments should be thoroughly rubbed in and applied contin- uously on lint, retained by gloves. In some cases, gloves of India-rubber are best worn during the day, the ointment being applied two or three times. Cases occur in which the thickening is so extensive and severe, that we are obliged to resort to still stronger solutions, as of potassa fusa or pure caustic soda, in the proportion of from one-half to even two drachms to the ounce of water. After soaking the bands or feet in warm water, they should be briskly rubbed with a small pad of flannel tied to the end of a stick and saturated with one of these solutions, paying particular at- tention to those parts where the accumulation of scales is greatest. The duration of the rubbing is to be determined by the sensations of the patient and the effect produced, but it is desirable to avoid producing a very raw surface or too acute inflammation, the object being merely the removal of effete epidermal scales. The parts may subsequently be so tender as to require the use of a water dressing for a few hours, but, as soon as possi- ble, one of the ointments above mentioned should be applied. By the judicious use of this treatment, continued if necessary for a considerable time, cases of great severity may be cured. We have omitted to mention that in some cases of syphilitic psoriasis of the palms, the patches are in an inflamed condition, which must first be relieved. For tliis purpose we envelop the parts in emplastrum plumbi spread on strips of linen, and later on use the following ointment : — 5. Emplast. Plumbi ^vj 24 Ung. Hydrarg. 5ij 8 01. Betulae Alb., vel 01. Cadini 3] . . 4 M. Pustules upon the scalp are commonly so small and ephemeral as to re- quire no special treatment, but in some cases they are so cojnous and persistent as to render local applications desirable. Shampooing with an alkaline lotion, careful removal of the scabs, and the application of the following ointment, is all that is necessary. I^. Unguent. Hydrarg, Nitratis ^ij . . 8| Gelati Petrolei §j 3U| M. Pustules of the malignant precocious syphilides, wherever situated, often exhibit a destructive tendency. The removal of tiie scabs is the first necessity, and to this end one or more immersions in alkaline baths are generally sufficient to soften them so that they can b<; taken of!' without difficulty. If the exposed ulcers are very i)ainful, they may be touched once or twice with carbolic acid diluted in water, about one part to live. This application not only stimulates the sores but relieves the pain. If the ulcers are numerous, the subsequent dressings are somewhat tedious. Tliey should be powdered over with iodoform, or this may be used in etherial solution or in a salve, or, again, these and other open ulcers may be covefcjd with the Emplastrum de Vigo cum Mercurio spread on lint or soft leather. 566 SYTHILIDES. Serpiginous ulcerations may be treated in the same way as the above, or, after the removal of the scabs, a stimulating lotion as the following, may be kept constantly applied. ;^. Hydrarg. Chloridi Corros. 3ss .... 2 Acidi Carbolici gj 4 Glyceriiiae §j 40 Aquae §xv 460 M. Profuse granulations may spring up in the ulcerated ring and require pencilling with the stick nitrate of silver. Besides the lotion just men- tioned, the following ointment is often very beneficial. I^. Ung. Hydrarg. Nitratis ^^ij 8 Bals. Peruv. gss 6 Gelati Petrolei §j 30 M. This treatment is applicable to almost any form of syphilitic ulcerations, and to rupia especially. The vegetating or hypertrophic syphilides should be treated by repeated slight cauterizations with carbolic acid (one or two ])arts to six of water), or with a solution of nitrate of silver (5j to Jj). They may also be benefited by the various mercurial baths. The treatment of gummata varies according to their condition. In the stage of infiltration before ulceration has occurred, vigorous internal medi- cation, combined with tlie constant application of equal parts of mercurial and oxide of zinc ointments, may cause their absorption. When they exhibit fluctuation or point like a furuncle, it may become necessary to incise them, but it is well not to be precipitate, as they will sometimes be absorbed even in this stage ; and we then escape any solution of continuity in the skin. Gummatous ulcers vary so much in depth and in the amount of morbid tissue at their base, that no absolute rule can be laid down as to their local treatment. When we find a foul, indolent, necrotic base, thorough cauterization should be made with a strong solution of caustic potash or soda (3J-ij to §j of water). Healing will not take place until the gummy tissue is destroyed, hence it is necessary to cauterize until a healthy, granular base is seen. After the cauterization, a water dressing may be applied until all infiammatory action has passed oiF, when the ulcer may be dusted with iodoform, while to the reddened areola the mer- curial and zinc ointment, already mentioned, may. be applied. As the base of the ulcer becomes more superficial, the necessity of cauterization ceases, and should exuberant granulations spring up, as is often the case, they may be touched with nitrate of silver. The latest application for ulcerating syphilides, recommended by Guil- laumet,^ is the bisulphate of carbon. Other than a slightly stimulant action, it possesses no medicinal qualities, and its use is much restricted by its disgusting smell. • J. de tlierap., Paris, No. 3, 1875. CUTANEOUS HEMORRHAGE IN SYPHILIS. 567 CHAPTER XII. CUTANEOUS HEMORRHAGE IN SYPHILIS. Any of the secondary eruptions of syphilis may be accompanied by hemorrhagic effusion, either around or into the substance of the lesion. It may occur on the lower extremities of those whose general health is unimpaired and is then not of serious import ; or it may occur on various other portions of the body of broken down and scorbutic persons. In all of these cases the effusion is secondary to the specific process, spontaneous transudation of blood into the skin of syphilitics being quite a rare occur- rence. A case of much interest has been reported by Balz,' as follows : a man, aged twenty-five, healthy but having had typhus fever, when syphi- litic one year, suddenly and without premonition became covered with a blood-red exanthem. This was composed of discrete and confluent spots, varying in size from a millet seed to a silver dollar. The blood-red color rapidly faded and left slightly scaly, reddish- and greenish-yellow patches similar to those seen in scorbutus. Coincidently he had swelling of the joints of the little finger, wrist, right elbow, and both feet, due to ultra- and peri-articular hemorrhagic effusion. The cheeks and eyelids were swollen, but the gums were normal. The urine did not contain blood. Four days later a new eruptioTi occurred simultaneously with an attack of pleuro-pneumonia. For the latter an ice-bag was a|)plied to the chest, resulting in the development of a large patch of effused blood, which slowly subsided, the skin being (Edematous and sensitive. A second application of the ice-bag produced a similar result. Under the use of iodide of potash the patient was cured in four weeks, Biilz thinks that syi)hilis induced in this case a hemorrhagic diatiiesis. He also speaks of another case of a healthy man, who, a short time after syphilitic infection, was attacked by a general hemorrhagic eruption, with epistaxis, bloody urine, bloody stools, and febrile reaction. Several days later a papular sy[)hilide api)eared among the patches of effusion, and on the tenth day the man died. Whether this hemorrhagic condition was a mere coincidence or was etio- logically related to syphilis it is impossible to say. We have also seen a case of hemorrhagic effusion occurring late in syphilis. The patient, a man forty-six years of age, had suflered severely from various lesions, and of late with extensive ulcerating gummata. Twelve years after infection, being in a cachectic state, he was attacked Ueber haemorrhagischo Syphilis. Arch. d. Hoilk., Fob. 1875. 568 CUTANEOUS HEMORRHAGE IN SYPHILIS. by a general but not copious eruption of bulla;. These when first seen contained sero-i)us, but soon became of a deep red color, and around them a wide areola of effused blood appeared, with large, slightly raised hemor- rhagic patches between them. The bullae became large, foul ulcers ; the eftused patches grew larger, and some coalesced. The patient finally passed into a lyplioid condition and died. In this instance the hemor- rhagic condition or diathesis was probably caused by syphilis. ECZEMA OP THE SCROTUM AND PENIS. 569 CHAPTER XIII. CERTAIN SIMPLE CUTANEOUS AFFECTIONS OF THE GENITALS. Under this head are included some of the more common diseases of the skin, and especially those affecting the genital organs, Avhich are some- times regarded by inexperienced persons as of venereal oi'igin. Eczema of the Scrotum and Penis. The male genitals, especially the scrotum, are frequently the seat of eczema, either limited to these regions, or constituting a part of a general eruption. This begins as a slight redness of the surface, attended by pruritus. The scrotal surface becomes thickened and cedematous, the normal furrows being much deepened. In most cases the lesion is a dry, scaling eczema, but it is sometimes of the moist variety. The affection is very persistent, and is accompanied by itching and a burning heat, often almost intolerable. The suffering may be increased by the formation of deep fissures. In many cases the lesion spreads to the thighs and perinceum. When the penis is attacked, its integument becomes much thickened and phimosis may be produced. This affection is rarely seen before puberty, occurring usually in young and middle-aged men. Relapses are often observed. The etiology of this, like other varieties of eczema, is not clear. Pro- bably in many cases local irritation is the starting point of the affection, while in some the rheumatic and gouty diatheses may act as predisposing causes. Treatment. — The treatment of eczema of the scrotum is often very un- satisfactory. In its early stages, when there is much hyperaimia, the best application is diachylon ointment, to which a little powdered camphor may be added. The inflamed surface should be covered with pieces of lint smeared with the ointment, and the parts be then placed in a suspensory. The acute oedema of the early stage is often benefited by immersion of the parts once or twice daily in very warm bran-water, followed by the appli- cation of the ointment. As the case becomes chronic and the infiltration more dense, some stimulating agent, such as the oil of cade, or the oil of white birch, should be added to the ointment. Half a drachm of the oil may be- combined witli an oinice of diacliylon ointment, and the mixture should be used when fresh, since it readily decomposes. The proportion 570 CUTANEOUS AFFECTFONS OF THE GENITALS. of the oil may be increased according to the toleration of the parts. It is rarely necessary to add more than two drachms to each ounce. Wliile treatment is thus followed, the patient should, if possible, avoid active exercise. In some chronic cases the thickening is so dense and the pruritus so severe, that more active stimulation is required. We then resort to a strong solution of caustic potassa or soda, in the proportion of from half a drachm to two drachms to the ounce of water. This should be carefully ai)plied with a sponge or pad of flannel for five or ten minutes. Its imme- diate effect is to produce much redness and swelling, with more or less superficial excoriation. From the excoriated surface small drops of viscid secretion slowly exude for an hour or two. Water-dressing maybe needed to control the reaction. Finally tlie parts may be enveloped in strips of lint smeared with the ointment, which should be renewed twice daily. The reapplication of the caustic solutions may be indicated. In occasional instances we have used vesicating collodion, instead of the caustics, with similar results and with decided relief of the intense pruritus. Tinea Circinata Inguinalis. Under the titles, herpes inguinalis (Baerensprung) and eczema margi- natum (Hebra) has been described a form of ring-worm occurring about the genitals, particularly of males, which sometimes resembles eczema. The eruption begins as a small round spot on the inside of the thigh, vi'liere it is in contact with the scrotum, or upon the pubic region. It is rarely seen by the surgeon in its early stage. If uncomplicated, we find a narrow ring, not very much elevated, often scaly, and composed in part of vesicles. Its color is darker than that of ringworm, as seen on the neck and on other exposed regions. The inclosed area of skin is sometimes almost normal ; it may be red and scaly, and the hairs growing from the part are broken and lack their normal lustre, as though their nutritioji were impaired. In some cases the hairs seem to be unaffected. The rings formed by the eruption tend to spread down the thighs, over the perinaeum to the buttocks, and up the hypogastric region to the umbilicus. Not infrequently the affection appears at about the same time in the axillse and from there extends in the form of rings. In the chronic cases, in which a large extent of surface is involved by the eruption, the skin inclosed by the rings undergoes various changes. Sometimes new rings appear within the larger ones, so tliat we may find the thighs, buttocks, and abdomen covered with large and small circles and segments of circles, or simply by wavy and irregular lines. This condition may continue for months or even years, or the lesion may assume an eczematous character as it extends at the periphery. The affected skin becomes thickened and inflamed, and papules, pustules, and perhaps numerous scales may form upon it. Owing to greater cleanliness and early treatment we do not frequently see this aggravated form of ringworm, but in Austria, according to Hebra, it is quite common among shoemakers SCABIES OF THE GENITAL ORGANS. 511 and cavalry men. English authors state that it is often seen in patients returning from China, India, and other Eastern countries. The course of this aff'ection is quite chronic ; while it yields readily in its early stages, it is very rebellious to treatment at a later period, and is prone to recur. The most reliable remedy is sulphurous acid, which should be thoroughly applied once or twice a day after cleansing the parts with soap and water. In many cases simply painting the affected region with tincture of iodine is sufficient. German authorities speak in high terms of Wilkinson's ointment, which is modified by Hebra as follows: — ^. Flor. Sulph., 01. Fagi., aa giij 90 Cretfe Albc-B §ij 60 Saponis Viridis Axungi£e Porci, aa §viij 240 This ointment should be well rubbed in, and, instead of washing it off, the anointed surface may be dusted with powdered starch. Another oint- ment we have used with benefit in these cases is made as follows : — I^. Hydrarg. Precip. Alb. gv. xlv .... 31 Potass. Sub-carb. 5iss 6 01. Cadini Piii] 12 Uiig. Simplicis, | Ung. Petrolei aa §j 30| M. The subcarbonate of potash should be dissolved in a few drops of water and then the other ingredients may be added. When there is much hyperemia and eczema it is necessary to use soothing and astringent appli- cations to reduce tlie inflammation, before attacking the parasite wliich is the cause of the affection. It is important to guard against reinfection, which is liable to occur from spores lodging in the meslies of the under- clothing. This affection occurs much more frequently in males than in females and is usually observed in young and middle-aged persons. It is caused by the parasite known as the tricophyton tonsurans. Scabies of the Genital Organs. Scabies, or itch, may be limited to the genitals, or it may involve these organs at the same time with other regions of the body. It occurs rather more frequently upon the penis than upon the female genitals, and is sometimes very persistent. Upon the mucous more commonly than upon the tegumentary covering of the penis we find slightly elevated papules and moderately distended pustules. Sometimes we also find the maiks of scratching and patches of hyperjEmia. In some cases very careful ex- amination will reveal the furrow of the acarus, as a small whitish linear elevation, varying in length from one-eighth to one-half an inch. These furrows or cuniculi deiinitely prove the presence of the itchmite. They are sometimes, however, not found here as in other localities. In bad 572 CUTANEOUS AFFECTIONS OF THE GENITALS. cases an eczematous condition of the penis is produced by the excessive irritation. This affection tends to remain in a chronic condition ; papules and pus- tules succeeding each otlier and uniting to form patches. In some cases the lesion is conveyed from tiie hands or other parts by the act of scratch- ing the genitals. The occurrence of a localized eczema of the penis or of the extra-genital region of the female should always excite suspicion. The points of diagnostic significance, therefore, are the irregular mingling upon the penis or mons Veneris, of a number of small papules and pustules, the excessive itching, and perhaps the presence elsewhere of a similar eruption. Tlie discovery of the acarian furrow establishes the diagnosis beyond doubt. Tiie treatment is very simple. The best application is a salve composed principally of balsam of Peru, as follows : — I^. Bals. Peniv. fi] 81 Gelati Petrol(3i ^j 30| M. After immersion of the affected parts in quite hot water containing a little borax, the above ointment should be thoroughly rubbed in and afterwards spread upon lint and applied to the region. The cause of this affection, as of the itch in other localities, is the insect, the acarus scahei. Phtheiriasis Pubis. Phtheiriasis, commonly called lousiness, is an affection caused by animal parasites or pediculi, of which there are three varieties: the pediculus capitis, the pediculus corporis, or vestimentorum, and tlie pediculus pubis. The first two attack the head and body, the third is usually limited to the extra-genitals, and we shall confine our description to the changes pro- duced by it in these parts. The pediculus pubis, also called the crab-louse, piithirius inguinalis, phthirius pubis and morpio, is the smallest variety. Its body resembles in shape a shield, being broad, flat, and rounded. Its head is proportionately Large, and is somewhat the shape of a fiddle. From each side of the head project stout, five-jointed antenna?, anterior to which are two small eyes. There is no indentation between the thorax and the abdomen. To the former are attached six-jointed, hairy legs with strong claws, and along the margin of the abdomen are eight conical feet, from each of which pro- ject from four to ten bristles. The insect has a very light-brown color, and is somewhat translucent. The female is larger than the male, and has a triangular indentation at its posterior part. Although the insect is usually found only in the pubic and femoral re- gions, it is sometimes transferred by tlie fingers to the axilla and to the eyebrows and lashes. The presence of the parasite upon the genitals is made known by an intense pruritus, which is paroxysmal. In many cases the itching is trifling during the day and severe at night. Very often the insects are so few that The formivla on p. 573 should read — I^. Hydrarg. Bichlor. gr. viij .... 50 Aquae Cologn., Aquae, aa ^ij .,....,. 60 M. TINEA OR PITYRIASIS VERSICOLOR. 573 they may be overlooked, except upon the most careful search. In some cases no visible lesions of the skin are produced. In other cases we may find crusts of dried blood, as small as the head of a pin. These result, not from the bite of the insect, but from the puncture of a sucking apparatus, or haustellum. In addition to these lesions, we sometimes find secondary changes, such as hypera^mia, congestion of the hair follicles and even pus- tulation. Examination of the hairs shows dirty white particles attached to their shafts, which are the nits or ova of the parasite. Upon separating the hairs small, light-brown spots, sometimes mistaken for particles of dirt, may be discovered. On each side of this body, wdiich is the pediculus, may be seen its minute hair-like legs. This feature is diagnostic, and should be looked for in every case of pruritus of the genitals. Treatment. — The treatment of phtheiriasis pubis is strictly local and is very efficacious, if carefully applied. Although mercurial ointment is considered a specific by the laity, its use is objectionable on account of the acute and severe dermatitis which it often produces. The most eligible preparation is the following solution, which may be sopped on the parts freely once or twice a day and allowed to dry : — R. Hydrarg. Biclilor. gr. viij .... 50 Aquse Cologn., Aquae, aa gij 60 M. After its use a warm sitz bath is very beneficial. Care should be taken that the underclothing and bed-linen are thoroughly cleansed and pressed with a hot ii'on. In cases of extreme persistence of the parasites it may be necessary to cut the hair from the pubes. Besides the solution already recommended the tincture of delphinium, or larkspur, is equally efficacious and pleasant to apply. Tinea or Pityriasis Versicolor. This parasitic skin-affection is so often mistaken for syphilis, and those affected with it are so frequently subjected to unnecessary mercurial treat- ment that a description of the lesion seems desirable. It begins on the chest as small, round, light yellow spots, which may be slightly or not at all elevated above the surface. These spots may be scaly, or smooth and sliining; they seem to be seated around the sebaceous and sweat follicles, and they gradually extend until quite large patches are formed. When the eruption is chronic and very extensive, numerous small patches surround those of larger size, an appearance which has been compared to a map representing continents and islands. The color varies from a light yellow^ to a dark brown or even coppery hue. When the cir- culation is active, or the lesion is irritated by scratching, the patches may become red. In some cases this affection is limited to the breast, while in others it extends over the entire anterior surface of the trunk, sto[)pingat tlie neck. 5*74 CUTANEOUS AFFECTIONS OF THE GENITALS. perhaps invading the axilhv to some extent and encroaching slightly upon the thighs. It sometimes begins upon the mons Veneris and about the inguinal region, but very rarely extends around to the back. It occurs in both sexes, perhaps with greater frequency in females than in males. It is of common occurrence among those who perspire freely, in weak and debilitated subjects, and especially those suffering from pulmonary troubles. On the other hand, those in robust health are by no means exempt. The affection is sometimes attended by mild pruritus, or tingling and slight itching may be complained of only when the patient is warm or ex- cited. In very rare cases the pruritus is severe and troublesome. The disease runs a slow, chronic course, sometimes persisting for years ; again it sometimes disappears in winter to return in summer. It is only mildly contagious, cases of undoubted infection from the parasitic fungi being not often seen. Instances have been known in which husbands have had the disease for years without infecting their wives. The affection is perpetuated by the wearing of flannel, wliich seems to be a nidus for the parasite, and it is particularly persistent in uncleanly persons. Yet in some cases the utmost cleanliness does not prevent a recurrence. The affection is not seen in very young persons, but in those of adult and middle age. Some authors have claimed that a peculiar state of the system, generally one of debility, is essential to its development. In our opinion free pers[)iration seems to favor its appearance, which is quite inde- pendent of a morbid condition of th,e system. Tinea versicolor is a distinctly parasitic affection, being caused by a vegetable parasite, the microspor on furfur. Diagnosis This affection is sometimes regarded as an evidence of syphilis or of a disordered condition of the liver. It certainly has no rela- tion whatever to hepatic derangement, and resembles syphilis only in the l)rown or sometimes coppery color of the patches. The distinction is very readily made. Syphilitic coppery stains are always discrete and not con- fluent; tliey are scattered all over the trunk as well as elsewhere on the body ; they are sharply circumscribed, and rarely if ever scaly, are not itchy, and are not effaced by scratching, as is the case with patches of tinea. Finally, the scales of sy[)hilis are simply epithelial, while those of tinea contain the spores of the [)arasite. Treatment The patches should be well scoured with a pad of flan- nel smeared witli soap. Strong solutions of sal soda or borax employed with active friction are of benefit. After a thorough washing, either of the following parasiticide lotions may be applied : — I^. Sodse Hyposulphitia giij , . , . 121 Aquje §iv 120| S, To be freely sopped on the parts, I^. Hydrarg. Bichlor. gr, v .... 130 Aqufe Cologn. §ss 15 Aquae §iijss 105] M, LUPUS ERYTHEMATOSUS OF THE PENIS. 575 After each application clean underclothing should be put on, and that previously worn must be boiled for a long time, in order to prevent rein- fection. Lupus Erythe^iatosus of the Penis. Lupus erythematosus, although occurring most commonly upon the face, occasionally attacks the penis, sometimes being limited to the latter region and again appearing at the same time on other parts of the body. The lesion begins as a small, circular, red spot, slightly elevated and covered with a few small adherent scabs. The margin is sometimes raised, while the surface may present numerous little elevations caused by plug- ging and swelling of the sebaceous follicles. The patch increases in size, healing taking place at its centre while its border extends. The eruption has a dull red, but not coppery, color, and is seldom attended by any ab- normal sensations. Its course is very chronic. In two cases seen by us the lesion began on the outside of the prepuce. Diagnosis This affection may be mistaken for the papular syphilide, in its ringed form,, or for psoriasis. The rings of syphilitic papules gene- rally have a coppery red color, are very slightly scaly, and the inclosed area of skin is normal. The patches of psoriasis are usually multiple, are very scaly, and coexist with similar ones elsewhere. Treatment The treatment of this affection is not always satisfactory in its results. As an application mercurial plaster or a dilute mercurial ointment may be tried. Electrolysis may be employed at the advancing border of the patch. In case these methods fail it may be well to resort to excision of the entire patch unless too large. 576 AFFECTIONS OF APPENDAGES OF THE SKIN. CHAPTER XIV. AFFECTIONS OF THE APPENDAGES OF THE SKIN. AFFECTIONS OF THE HAIR. Alopecia is one of the most common symptoms of syphilis. It varies from slight to almost complete loss of hair, which is rarely permanent, and its course may be rapid or chronic. It is attended by no subjective symptoms, such as heat or itching, and in most cases there are no marked lesions of the scalp, while in other cases the hair follicles may be involved by macules, papules, pustules, or ulcers. The eyebrows, the beard and moustache, the hair of the pubes and axillte may also be involved. The eyelashes are seldom attacked, except by ulcerative lesions, and alopecia never exist elsewhere without affecting the scalp. There are two varieties of syphilitic alopecia, one consisting of a simple thinning of the hair, and the other of loss of the hair in patches. On the scalp the result of alopecia is generally striking, but it may be so slight as to pass unnoticed, the hair merely being thinned. The hair may be lost in one or more patches, which vary in size and occur without symmetry or order ; they may be as large as the palm of one's hand, and several may fuse together. Their outline is irregular, and they show no tendency to assume a circular form. The surface of the patches is rather dry and somewhat scaly ; the follicles are quite prominent, and scattered irregularly may be a few long hairs, sometimes one or more tufts, and minute hairs. The surface of the scalp is dry, and presents a few furfuraceous scales. In patients who have been subject to seborrhoea capitis, or, as it is generally known, pityriasis capitis, this condition is often much more marked. The hair follicles may be involved by erythematous spots, papules, or pustules, coincidently with a general eruption. In such cases the loss of liair is generally slight and scattered. The arch of the eyebrows may be interrupted by the fall of a few hairs, or may be totally destroyed, giving the jjatient a very peculiar appearance. In the beard, in the axilla?, and upon the pubes, the loss of hair may also be partial, complete, or in patclies. Syphilitic alopecia is peculiar to the secondary period, and generally begins about the third month, at the decline of the earlier secondary symp- toms. It may occur at any time before the end of the second year, and is very frequently associated with cachexia. Alopecia is undoubtedly a result of impaired nutrition of the hair folli- cles, due to the adynamic influence of syphilis. Under the microscope the hair bulb, instead of appearing expanded and rounded, is seen to be AFFECTIONS OF THE HAIR. 577 wedge-sbaped or otherwise imperfectly formed. It is probable that the papilla no longer nourishes the bulb, which therefore withers and contracts, the hair becoming detached. For a short time the hair may remain in the follicle held by the root-sheath. In this case a new hair will probably grow ; but should inflammatory or ulcerative changes occur in the follicles, or when pustules attack the scalp, and sometimes even when erythematous spots and papules occur, the papilla may be destroyed and the follicle be- come obliterated, permanent baldness resulting. This hapjiens in a marked degree in connection with late tubercles and gummatous ulcers. Diagnosis. — The diagnosis of syphilitic alopecia is to be made from pityriasis capitis (seborrhoea), senile baldness, and alopecia areata. The suddenness of invasion and the generally marked character of the bald- ness in syphilitic alopecia and its non-inflammatory course are in marked contrast with the chronic course, and the scaly and somewluit pruritic condition of pityriasis capitis. Moreover, the suspicion of syphilis is confirmed by the history of the case and tlie discovery of other specific lesions. Senile alopecia, incorrectly so called since it usiuilly begins in middle life, extends backwards from the forehead or begins at the vertex, and is wholly unlike the syphilitic affection. Moreover, the scalp is smooth and shiny, and the follicular openings are no longer visible. Alopecia areata is much more common in children than in adults, and occurs in round, oval, or serpiginous jiatches, the liair on other parts of the scalp being preserved. The surfaces of the patches are very smooth and polished, and of a yellowish-white color; they are not scaly, and they are completely destitute of hair. The prognosis of syphilitic alopecia is in general good. In some cases the loss of hair is so extensive and its renewal so slow that permanent baldness seems to be inevitable. The main points upon which to base the prognosis are the extent of the baldness, its duration, and the patient's general health. If the affection has been severe, and has existed for some time, if treatment has been neglected and incomplete, and if cachexia has taken place, the prognosis must be veiy guarded. The treatment of syphilitic alopecia is that of the secondary period. Although we cannot agree with Fournier that mercurial treatment is the only requisite, we are confident that it sliould never be neglected; and we believe that local treatment also should l)e employed. Tiie indications are to apply stinmlation with the hope of restoring the healthy condition of the scalp. Frequent shampooing of the head with brisk friction is of much benefit. For this purpose we prefer a simple tincture of German green soap, made as follows : — R. Saponis Viridis, ^ij 641 A^sured mucous patches upon the margin of the anus, between the toes, or else- wliere, are called rhagades. Condylomata upon the vulva are generally elevated and of u reddish color, TVS is well represented in Ricord's Iconographie, PI. XX. Those that I have seen within the vagina and upon the cervix uteri, have more 588 AFFECTIONS OF MUCOUS MEMBRANES. closely resembled mucous putchcs upon the external integument than those situated upon other 'mucous membranes, as, for instance, within the buccal cavity. jNIucous patches upon tlie genital organs in both sexes sometimes give rise to a discharge resembling gonorrhoea from the neighboring mu- cous membrane, which is not unfrequently observed about the time that early secondary symptoms appear, or when a I'elapse of general symptoms takes place. Unlike most syphilitic eruptions mucous patches are frequently attended by pruritus, especially when seated ujion the scrotum or perinaeum, and when proper attention is not paid to cleanliness or the parts have become Avarm and moist from exercise or prolonged contact in bed. The unques- tionably contagious character of these lesions has previously been men- tioned. Mucous patches within the buccal cavity present a somewhat different appearance from those now described. Their most characteristic feature is the grayish-white color, appearing as if they had been pencilled over with a crayon of nitrate of silver, which has given them the name of "opa- line patches." They are more irregular in their outline than condylo- mata, and unlike the latter are not, as a genei-al rule, perceptibly elevated above the surface. In some cases, the adventitious deposit which gives them their grayish color and which is with difficulty removed, is confined to the irregular margin of the patch, while the centre remains sound ; and when presenting this appearance they have been compared to the track of a snail.' The most frequent seat of this form of mucous patches is upon the in- ternal surface of the lips and cheeks, upon the sides' and dorsum of the tongue, upon the gums, tonsils, and soft palate. Tiiey sometimes extend beyond the pillars of the fauces, and are seen upon the walls of the pharynx and the posterior nares. Since the invention of the laryngoscope they have also been seen upon the epiglottis and mucous membrane of the larynx. A frequent situation is at the angle of the mouth, where they are often intersected by cracks and fissui-es, the sides of which present the charac- teristic grayish color of this lesion, and where they are continuous with small patclies of impetigo upon the external integument. Upon the dor- sum of the tongue, their base is sometimes hard, indurated, and fissured ; or the pellicle which at first covers them may be rubbed off by the food, leaving a slightly depressed surface resembling an aphthous ulceration ; or, again, they may granulate above the surface and form vegetations. Wh(!in seated upon the tonsils, mucous patches are peculiarly exposed to irritation and ulceration from friction of the food in deglutition, and ulcers are formed, attended by considerable inflammation and swelling of the surrounding parts, and in which the characters of the original lesion are entirely lost. Deglutition is very much impeded, and the surrounding in- inflammation may extend to the Eustacliian tube and produce partial deafness. ' Iconographic, pi. XX, bis. MUCOUS PATCHES. 589 Bassercau states that mucous patches may react upon the neighboriiior lymphatic ganglia, in the same manner as syphilitic eruptions situated upon the scalp, but only in case their development is attended b}- acute inflammation. Thus the submaxillary glands are frequently swollen from sympathy with mucous patches upon the fauces ; and the inguinal glands may be enlarged in consequence of the presence of condylomata upon the scrotum, but the effect upon the latter is less readily perceived because they are generally indurated from their anatomical connection with the primary sore. In two cases observed by Bassereau, in which the chancre was situated at a distance from the genital organs, the inguinal "lands were enlarged in consequence of mucous patches in the last mentioned situation. This effect upon the ganglia is, however, exceptional, and always consists of mere engorgement and never of induration. The following tables from the same author exhibit the period of devel- opment of this lesion after contagion when no treatment had been insti- tuted, and also when mercury had been given for the primary sore: In the former case, mucous patches appeared — On the 20th day after contagion in . " 29th '" " " ... From 1 to 2 months after contagion in . " 2 " 3 " " •'' ... " 3 " 4 " " " ... " 5 " G " " " . . , In the latter case — From 2 to 3 months after contagion in . 3 ' ' 4 4 ' ' 5 5 ' ' 6 a ' ' 7 7 ' ' 8 8 ' ' 12 2 ' ' 18 1 instance. 1 25 instances 5 7 5 3 2 instances (i 5 5 6 2 I will again remind the reader that these dates have reference to the first development of the eruption only. The difference in the two tables shows the power possessed by mercury to delay tlie appearance of second- ary symptoms. Mucous patches are exceedingly chronic and persistent, and are very prone to reapi)ear ; they are, indeed, the most frequent evidence of the renewed activity of the syphilitic poison. Tkkatmknt — In addition to the general treatment by mercury which mucous patches require in consequence of the indication they afford of the existence of syphilitic intoxication, certain local applications are advisable. In the case of condylomata, Uicord's favorite tniatment, which consists in washing them twice a day with Lal)arraque's solution of chlorinated soda, then sprinkling them with calomel and separating the opposed surfaces by the interposition of lint, is generally very successful, but it is sometimes 590 AFFECTIOXS OF MUCOUS MEMBRANES. necessary to destroy tlieni witli nitrate of silver, nitric acid, or the acid nitrate of" mercury. Mr. Victor de Meric speaks highly of an ointment employed by several physicians of the German Hospital, London, consisting of two drachms (8.00) of calomel, the same quantity of sulphate or oxide of zinc (it matters not which), and one ounce (30.00) of lard. After a few applications, the excrescences become dry and horny, fall otF and leave a raw surface which soon heals. When there is much inflammation present, the application of poultices should precede this treatment.^ Mucous patches in the mouth should be touched with nitrate of silver or one of the stronger caustics, and other applications may be employed which will be mentioned in a subsecjuent chapter. Tiiis local treatment should by no means be neglected, since without it these lesions will often persist in spite of the use of remedies directed to the cause of the disease. Aubert and Cheron claim that the treatment of obstinate cases of condy- lomata may be greatly shortened by tirst i)encilling them with the stick nitrate of silver and then ap[)lying to the surl'ace a piece of zinc. This method is based upon the decomposition of the nitrate of silver, and the formation of a nitrate of zinc, which is a very powerful caustic, especially in the nascent state. This mode of treatment usually excites very con- si dei'able pain. ' Lettsomian Lectui-es, p. 42. AFFECTIONS OF THE MOUTH. 591 CHAPTER XVI. AFFECTIOXS OF THE ORGANS OF DIGESTION. The Mouth. Erythe^ia — Erythema of tlie buccal cavity is usually confined to the neighborhood of the fauces. It may readily be confounded Avith the effects of an ordinary cold, from which it often can be distinguished only by the history of the case. The presence of narrow, dusky-red lands of inflam- mation along the border of the velum ending abruptly at tlie base of the uvula is considered by some observers to be characteristic of syphilitic erythema. Associated with this condition, as well as with other lesions, there is often a general ojdema, especially of the velum and uvula. The latter organ may become much swollen, but no portion of it should be removed, since under treatment it soon resumes its normal proportions. Tlie uvula also may be completely or partially eroded by ulceration. In the latter case, even when its attachment to the soft palate is very slender, the uvula need not be excised, since during the process of repair adhesions form between the eroded surfaces. In this way the natural conformation of tlie parts may be restored to a remarkable degree. Mucous Patches The most common syphilitic lesions of the mouth are mucous patches. They are most frequently found upon the tonsils, the uvula, the velum palati and its pillars, the sides of the tongue and the mucous surfaces of the lips, especially the lower. At the angles of the mouth tliey are often continuous witli a pustular eruption u[)ou the integu- ment. The inner surface of the cheek near the last molar tooth is anotlier favorite seat. The dorsum of the tongue and the gums are less fi'equently affected. Pai'Iles axd Vesicles — Papules are often seen in the mouth coinci- dently witii a general papular eruption. Owing to the constant maceration of the mucous membrane of the mouth, the formation of vesicles is rare if not impossible. The name ^'"plaques des fnmeiirs " has been given to certain patclies most frequently seen on the mucous lining of the cheeks near tlie angles of the moutli. Fournier' considers their location absolutely diagnostic, and, in view of their situation and color, he lias called them " plaques nacrees conii/ii'ssifraires." Tiiey occur most frecjuently in the mouths of ' Des glossites tertiaires, Paris, 1877, p. 54. 592 AFFECTIONS OF THE ORGANS OF DIGESTION. inveterate smokers, and are due to accumulation of the epithelium, which becomes opaline, as though the spots had been touched with collodion, or with nitrate of silver; the patches are sometimes fissured and may become eroded, although the epithelium is usually very adherent. They are generally quite obstinate and persist long after the a[)parent extinction of the specific virus. The Tongue. The tongue is the seat of many interesting and important lesions of syphilis, whose I'esemblance to each other aud to certain non-specific affec- tions may be somewhat confusing. The rarity of other secondary affections of the tongue has led to the inclusion of many of them under the term " mucous patch." A single case of roseola is referred to by Jullien^ as having been seen by Hardy in a patient who had at the same time a general erythematous eruption. Zeissl describes mucous papules of the tongue, and says of mucous membranes in general that syphilis does not develop pustules in their structure. Secondary lesions of the tongue are, as a rule, the source of but slight pain at their inception, and even in process of ulceration they may give rise to remarkably little inconvenience, unless subjected to irritation. In extreme cases there may be some difficulty in mastication and moderate increase in the secretion of saliva. The tendency to assume the circular form has been observed in some of these lesions of the tongue. They generally yield readily to treatment and leave no trace of their existence, but frequent recurrences, especially in smokers, are seen. The compara- tively greater frequency of these lesions in men may be referred to the use of tobacco and alcohol, irritating causes to which women are thought to be less exposed. A condition of so-called ^^ psoriasis of the tongtie" has been described by several writers, particularly Bazin,^ Debove,* and iMauriac,* the syphi- litic origin of which is doubtful. It occurs on the dorsum of the tongue in patches, which may be recognized by their silvery white color, their leathery consistence, and the epithelial exfoliation attending them. Four- nier, Trelat, Fairlie Clarke, and others regard them as frequent antece- dents of epithelioma. Clarke thinks that they assume a malignant character when they invade the papillae and the submucous tissues. A similar affection, originally described by Samuel Plumbe,* under the name " ichthyosis" occurs very rarely in the course of syphilis. In 1875, Weir" reported ten cases of ichthyosis in addition to fifty-eight previously recorded by other authorities. The proportion of syphilitic subjects in whom this ' Mai. veneriennes, Paris, 1879, p. 737. 2 Le9ons sur les affections artliritiques et dartreuses, 18G8. ' Le psoriasis buccal, 1873. * Du psoriasis de la laiigue, etc., 1875. 5 Diseases of the Skin, London, 1837, p. 514. 6 Ichthyosis of the Tongue and Vulva, N. York M. J., Mar. 1875. AFFECTIONS OP THE TONGUE. 593 lesion has been observed is extremely small. The idea that ichtliyosis, psoriasis and the condition called plaques des fumenrs ai-e identical lesions, has been advocated by Hugonneau,^ who believes that they are due to different causes, not necessarily specific, and that they may develop into cancer. Their resistance in many cases to anti-syphilitic treatment, and their frequent occurrence in those who never present any evidence of syphilitic infection, create a doubt whether these lesions should be con- sidered truly specific, although syphilis may furnish a predisposition to their development. The term " gummata" was applied to all tertiary syphilides of the tongue until Fournier^ classified them as " scleroses" and " gummata." In either case hyperplasia is the morbid process, but in scleroses the newly- formed cells persist and become organized in a definite manner, while in gummata they are eliminated by a degenerative process. Sclerosis — Sclerosis of the tongue is most frequent about the fifth year of syphilis. It is usually developed near the median line and always on the upper surface of the tongue, and may be superficial or deep. Superficial sclerosis involves the mucous membrane only, and produces a lamellated induration analogous to the " parchment" induration of the chancre. It may be circumscribed or ditFuse, and ulcerates only as a result of injury by the teeth, tobacco, or similar irritants. Parenchymatous or deep sclerosis may be considered an aggravated form of the superficial lesion, and invades the muscular as well as the mucous tissue. The tongue may be greatly increased in size, but after long per- sistence of the lesion the newly-formed fibrous tissue retracts, and, as in cirrhosis of other organs, atrophy results. At first the hypertrophied tongue receives the imprint of the teeth at its margin, the body of the organ being lobulated in a manner almost pathognomonic. The lobules are separated by furrows which cannot be effaced by stretching, in this respect otfering a contrast with the rugae which occur on the tongue in dyspepsia and other depraved conditions of the system. The induration is deep and cartilaginous, and the mucous membrane becomes changed in color and perfectly smooth. Ulceration may result from causes similar to those which produce it in the milder fonn of sclerosis. When parenchy- matous sclerosis involves the whole tongue, which fortunately it seldom does, the tumefaction may be enormous. Gummata — Like scleroses, gummata, which are later lesions, may be designated as superficial or parenchymatous, since they may be found in the mucous or the muscular tissue of the tongue. The superficial or mu- cous gumma begins as a small nodule, which soon softens and ulcerates, leav- ing an excavation with perpendicular margins and an infiltrated base, which is often covered by tenacious false membrane of a yellowish-white color. ■ Sur la glossile interstitielle syphilitique, Paris, 1876. * Des glossites tertiaires, Paris, 1877. 38 594 AFFECTIONS OF THE ORGANS OF DIGESTION, Parenchymatous gumniata are developed in the muscular tissue of the tongue.^ They begin as small tumors, which are sometimes difficult of detection on account of their depth and of the surrounding induration. The process of degeneration extends from the middle of the tumors until the thinned mucous membrane over them on the upper surface of the tongue becomes ruptured, exposing a deep cavity with over-hanging and sloughy walls, surrounded by an areola of induration. In view of the great size of the cavity, one would expect excessive deformity, but cicatri- zation often takes place with relatively slight permanent damage. In rare cases two or more gummatous tumors coalesce, and lead to enormous enlargement of the tongue and proportionate destruction of its tissue. The ulcers may be attacked by phagedtena, when the condition becomes still more aggravated. Without treatment these ulcers are remarkably chronic. One has been reported which persisted, with comparatively little change, for twenty years. According to Clarke^ gummatous tumors occasionally undergo calcific degeneration. The importance and oftentimes the difficulty of differentiating syphilitic tumors of the tongue from others of non-specific origin, especially cancer- ous, are very great. Boyer, Clarke, Lagneau, and many other authorities have given great diagnostic value to their situation at the base and near the median line of the tongue. The experience of Fournier, however, has led him to conclusions quite the reverse. Their insidious formation, their chronic course, and their freedom generally from spontaneous pain are characteristic features of gummatous tumors. The observation of Anger^ that lancinating pain shooting towards the ear is diagnostic of can- cer of the tongue has been repeatedly confirmed. Gummatous tumors may appear at a period much earlier than is usual with cancerous. In addition to these facts, and to the individual and family antecedents of a patient, the ulcerating surfaces of the tumors present somewhat constant features, which may assist in the diagnosis. Gummatous ulcers are usually multiple, bilateral, and are always upon the upper surface of the tongue ; cancerous ulcei's are usually single, and may occupy its under surface. The ulcerative process of gummata destroys the tumor; carcinomata present an ulcerating tumor, the induration of which extends with the eroding process. Tlie fioor of a gummatous ulcer is sometimes sloughy and is slightly vascular ; that of a cancerous ulcer bleeds readily, and, at an advanced stage, secretes an ichorous pus. Zeissl* gives diagnostic importance to the fact that •' sebum-like plugs" may be pressed from the mucous membrane in epithelioma of the tongue. Interference with the functions of the tongue is much less in gummata than in cancer. Ganglionic enlargement is rare in syphilitic lesions of • Bouissox. Gaz. mecl. de Par., 184G, p. 563. 2 Diseases of the Tongue, London, 1873, p. 147. 3 Du cancer de la langue, Paris, 1872, p. 78. See Hugonneau, oj>. cit., x"'- 42, and Foiirnier, op. cit., p. 66. < Lehrbuch der Syphilis, 1875, p. 210. NECROSIS OF THE MAXILLARY BONES. 595 the tongue, with the exception of the chancre, wliile in cancer it always occurs. Confirmatory evidence may be furnished by microscopic examination of the tumor, and by the effect of anti-syphilitic treatment, which, in cancer, is sometimes evidently harmful. The diagnosis between syphilis and tuberculosis of the tongue is some- times difficult, especially in those cases where the two diseases coexist, and in rare instances where tubercular deposit takes place in the tongue prior to the development of pulmonary symptoms. So many instances of the development of cancer on the site of a o-um- matous ulcer have been recorded that a relation between the two affections cannot be doubted, although the accident is not peculiar to syphilitic lesions, a similar transformation being observed in a simple ulcer as a result of neglect or exposure to continual irritation. Sub-lingual Gland. In 1874 Fournier^ reported a case of "tertiary degeneration" of the sublingual gland, in a man aged 30, which was developed eleven years after primary infection. The right sublingual fossa was occupied by an oval tumor, quite hard and painless, which merely gave slight trouble in swallowing and in articulation of certain words, the patient speakino- " as though he had a foreign body in his mouth." Fournier was uncertain whether the tumor was a gummous infiltration of the gland, or a form of hyperplasia analogous to that of syphilitic sar- cocele. His belief in its syphilitic origin seems to have been confirmed by its rapid disappearance under treatment with the iodide of potasli, and by the subsequent appearance of other lesions unquestionably syphilitic. Necrosis op the Maxillary Bones. This affection is most frequently met with in the hard palate and in the alveolar processes of the superior maxillary bone. In the former case, a swelling first appears upon the roof of the mouth, usually near the median line ; softening takes place ; tlie abscess opens, and the necrosed bone is exposed. After evolution of the sequestrum, an opening is left communi- cating between the buccal and nasal cavities, wliich imparts to the voice a nasal sound and intei'feres seriously with the distinctness of speech and with deglutition. When the progress of the disease has been arrested by internal treatment, and the ulceration has healed, the question not unfre- quently arises whether an attempt should be made to close these openings by a plastic operation. I have never felt disposed to make the trial, be- lieving as I do, that the wearing of a plate will better and more surely accomplish the desired end. Necrosis of the alveolar processes almost invariably takes place in tlie • Ann. de derm, et syplu, Par. t. vii. p. 81. 596 AFFECTIONS OF THE ORGANS OF DIGESTION. neighborliood of the upper central incisors; indeed, I cannot recollect a case in which the lower jaw was affected. The bony support of a number of the teeth is often involved, and the teeth themselves, of course, become loosened and detached. An opening not infrequently is formed into the nasal cavities, affecting speech in the manner above mentioned. In the treatment of these cases the mixed method affords the best results, but, after the arrest of the disease, time is required for the sequestra to become sufficiently detached for removal. Fortunately the present ad- vanced state of dental surgery can, in most cases, remedy the damage done. Gummy Tumor of the Soft Palate. In its insidiousness of approach, and in the irreparable injury it is likely to inflict, but few syphilitic lesions equal this. Early symptoms are insignificant or entirely wanting. Possibly the patient notices a slight uneasy or tickling sensation in the fauces, and experiences some difficulty in deglutition, which he naturally attributes to an ordinary cold ; he may even find when attempting to swallow liquids that they regui'gitate through the nostrils, but this lie regards as accidental. Suddenly, however, and without further warning, he is nearly deprived of the power of speech and deglutition. His voice is transformed to an almost unintelligible nasal whisper, and, upon attempting to eat, solids, and espe- cially liquids, ai"e returned through the nose. If we are so fortunate as to observe this affection in its earliest stage, we find that it has two modes of commencing. 1st. A deposit of gummy material may take place in a circumscribed mass, within the substance of the soft palate, and between its buccal and nasal surfaces. This mode of origin is the one usually described by authors. The deposit then appears as a flattened tumor, of the size of a bean or almond, enci'oaching upon the cavity of the mouth. It is at first hard, to the touch, but subsequently, when secondary degeneration has taken place, soft and fluctuating. 2d. In other cases the infiltration is diffuse. No tumor exists, but the velum is generally thickened, its raucous membrane reddened, and its mobility impaired, as is evident when the patient attempts to articulate or to swallow. Rupture of the abscess or ulceration of the infiltrated tissues may involve both mucous surfaces or only one : in the latter case it is usually the buccal ; a cavity with sharply cut and ulcerated edges is then visible in the soft palate, while possibly the ^oice and the power of swallowing remain unimpaired. The destructive process, however, proceeds with great rapidity, and complete perforation soon follows, even when not at first produced. The perforation may be limited in extent, but frequently a large portion or the whole of the velum is destroyed, together with the uvula and the pillars of the fauces, and thus an immense door of communication is GUMMY TUMOR OF THE SOFT PALATE. 59t opened between the mouth and nose. It is thus easy to account for the indistinct and nasal voice, or "duck's voice," as the French call it, of such patients, and also for the reflux of liquids and even solids, and yet the absence of pain which characterized the onset of the disease is still a remarkable feature, since deglutition, although so difficult, is attended with a merely trifling sensation of discomfort. In addition, there is often some dulness of hearing, due, doubtless, to the oedema of the tissues composing the walls of the pharynx and surrounding the orifices of the Eustachian tubes. In time, the subsidence of the infiltration is followed by amelioration of these symptoms. What remains of the velum recovers in a measux-e its pliability and renews its function. Practice also assists in teaching the patient how to avoid regurgitation of solids and even fluids. Some im- provement also takes place in the voice, and this may be greatly increased by wearing a proper plate, or by the ingenious artificial palate of India- rubber, the invention of Dr. Stearns, but complete restoration of the normal voice cannot be expected. The impairment of hearing is only temporary. It remains to speak of a remarkable sequel of this affection, viz., the change which usually takes place in the fauces, as a consequence of the process of repair. Directly after the mischief has occurred, the remains of the soft palate are dependent, and the opening communicating between the mouth and nares is very large. One would naturally suppose that this condition would continue or would even be aggravated at a subsequent period, after cicatrization had taken place. Strange to say, such is not the course of events. The dependent remains of the palate become ele- vated, the ulcerated edges contract adhesion with the ulcerated walls of the pharynx, and the opening, which at first was simply immense, gradu- ally contracts, until finally complete atresia is the result, or, more fre- quently, a diminutive channel of communication remains between the buccal and nasal cavities, less in diameter than the normal opening.^ Witness many old syphilitic cases in our hospitals. Attempts to remedy this condition by operation have been made by Hoppe, Pitha, Coulson, Dumreicher, and Paul, but with very indifferent success. Cases not unfrequently occur in which the surgeon may hesitate to express an opinion as to the cause of ulceration and perforation of the soft palate. Two causes only are likely to produce this result : syphilis and scrofula, and the former by far more frequently than the latter. If the patient be an adult who has enjoyed at least tolerable health until the present attack, there can be little doubt but that the cause is syphilis. No matter if a syphilitic history is obscure or even denied. Admitting the honesty of the patient, the primary and secondary symp- toms may have been overlooked or forgotten, and have left no traces. ' See^an article by Dr. II. J. Paul (of Broslau) on "Adhesions of the Velum Palati to the Posterior Wall of the Pharynx, following Ulcerations." Translated by Verneuil. — Arch. g^n. de m^d., 1865. 598 AFFECTIONS OF THE ORGANS OF DIGESTION. Tertiary lesions often appear years after the preceding, and when least expected. Then, too, they come isolated, without concomitant symptoms to assist the diagnosis. If the patient be young, say of 10 to 15 years of age, the chances of syphilis are less, of scrofula greater. Inquire as to the evidences of hereditary taint. When an infant, was the child affected with an eruption, coryza, etc. ? Look at the upper incisor teeth ; are they well formed or do they show ti'aces of hereditary disease? Are the corneae clear and intact? Are there cicatrices of strumous ulcers upon the neck or elsewhere? In all cases the effect of treatment is a valuable aid to diagnosis. Syphilitic ulceration yields to full doses of the iodide of potassium as if by magic. Strumous ulceration may be benefited by the same remedy, especially if combined with tonics, but it exhibits no such marked improvement within a few days. The Pharynx. Lesions similar to those occurring in the mouth are met with in the pharynx. Erythema, superficial ulcers, and deep ulcerations resulting from degeneration of gummatous deposit may be observed. The occur- rence of mucous patches of the pharynx has been noted by several author- ities, but we have never seen them in this region. Their rarity may be ascribed to the fact that the papillae of the pharyngeal mucous membrane are of extremely small size. Frequently ulcers extend into the pliaiynx from the posterior nares. The symptoms of pharyngeal syphilis are usually insignificant, except in the case of ulcers, when there may be pain, aggra- vated in the act of swallowing and especially on the ingestion of acrid or irritating substances. The posterior portion of the lateral walls of the pharynx is more often attacked than the posterior wall. Gummy tumors have been observed on tlie vault of the pharynx and on the upper partjof its posterior wall. After destroying the mucous membrane the disease may even invade the vertebrte and produce necrosis, or even iuffammation of the contents of the vertebral canal. Syphilitic ulcerations of the pluirynx are of special interest on account of the traces which they leave in the form of cicatrices, or of adhesions, which diminish the capacity of the cavity and interfere with its functions. The cicatrices seen upon the pharyngeal wall are quite characteristic. They may present a stellate appearance, or may assume the form of pro- minent bands. The cicatricial tissue is white and glistening, and may persist indefinitely, or gradually contract. In rare cases the entire soft palate is destroyed by ulceration, necrosis of the hard palate occurs, and the mouth, the nose, and the pharynx are con- verted into one enormous cavity. In milder cases, when the ulcerative process is limited to the border of tbe velum and the pharyngeal wall, ad- hesions may form, which divide the cavity of the pharynx into two distinct chambers, one communicating with the posterior nares and the other with the mouth. There may be a very narrow passage between these two cavi- TREATMENT OF LESIONS OF MOUTH AND PHARYNX. 599 ties, or they may be completely shut off from each other, respiration being carried on exclusively through the mouth. It is often very difficult to distinguish between the deep ulcerations of syphilis and those of struma. There are at least four points to be con- sidered in making a diagnosis. In syphilis other lesions are usually found. Syphilitic ulcerations follow the formation of a gummatous tumor ; in but few cases, however, on account of the very slight inconvenience occasioned by even extensive lesions, is the patient observed before complete destruc- tion of the original gummy tumor. Specific ulcers usually progress more rapidly than scrofulous u cers ; and, finally, they yield to specific treat- ment. Some observers claim that the ulcers themselves present distinctive characteristics, but this can be very rarely the case. The diagnosis must be based chiefly on the antecedents of the patient and the history of the lesion. Treatment of Lesions of the Mouth and Pharynx. The treatment of syphilitic atfections of the mouth and pharynx resolves itself into constitutional and local. For an account of the former I must refer the reader to the chapter upon the treatment of general syphilis. Suffice it at present to say that mucous patches, erythema, and the super- ficial forms of ulcers belong to the secondary stage of syphilis and require the use of mercurials in accordance with the directions given in the chapter referred to, while the deep ulcerations belong to the tertiary stage, in the treatment of wliich the iodide of potassium plays so important a part. Local treatment is of great importance. It is often surprising to see how mucous patches of the mouth and fauces will persist under the best directed internal treatment used alone, and yet how readily they will dis- appear when appro[)riate local treatment is added. Those situated upon the lips, internal surface of the cheeks, and sides of the tongue, should be touched every second or third day with a crayon of nitrate of silver or the sulphate of copper, or the acid nitrate of mercury. Another excellent application is the chloride of gold, adding just enough water to make it liquid, and applying it with a camel's-hair brush. With those upon the fauces, the walls of the pharynx, larynx, etc., I much pre- fer the spray of a saturated solution of nitrate of silver, applied by means of the atomizer represented in Fig. 120. Other forms of tlie same instrument may be obtained, in which the spray is directed upwards or downwards for the cauterization of the pos- terior nares and the larynx. These atomizers luxve been much improved and perfected by Dr. Louis F. Sass, of New York, to whom I am indebted for those in my possession. In nearly all cases of the ash-colored, excavated ulcers upon the tonsils or uvula, the stronger caustics, as nitric acid or the acid nitrate of mer- cury, must be employed. In making these latter applications, great cau- tion is required lest the acid come in contact with the sound tissues, or its fumes be inhaled; and these evils may be avoided by taking care that the 600 AFFECTIONS OF THE ORGANS OF DIGESTION. probang or glass rod which is employed be not so wet as to permit the fluid to drop from it, and by allowing the fumes to pass off before the remedy is applied. Fiff. 120. The application of caustics should, however, be deferred in cases at- tended by severe inflammation and swelling of the fauces, which must first be subdued by saline cathartics, rest, mustard pediluvia, and sometimes by leeches at the angle of the jaw. I have found the most grateful topical application under these circumstances to be a solution of tannin in glyce- rine (5j to the §j), with the addition of extract of opium if the pain be severe, which may be applied with a camel's-hair brush two or three tim^s a day. Rest should be promoted by means of sedatives, of which Dover's powder is the best. So soon as the" acute inflammation has subsided, various astringent and tonic gargles may be employed with benefit. A good one is the undiluted tincture of Cimicifuga. It should be prepared from the fresh root, as otherwise the effect is much diminished. Washes and gargles containing Labarraque's solution, chlorate of potash, the bichloride of mercury, or the oxymel of the subacetate of copper also serve an excellent purpose. Liquor. Sodae ChlorinataB 5ij-3iv Mellis I] Aquje §v 81—16 38 150 Hydrarg. Bicliloridi gr. vj Acidi Hydrochlorici gtt. xij Syrupi |j Aquce §viij 38 250 THE (ESOPHAGUS. 601 R. Potassae Chlorat. 5j 41 Infusi Lini Oj 500| M. T^. Oxymellis Cupri Subacetatis 3ij • • 601 AquEe §vj 180| M. (Langston Parker.) ^.. Acidi Sulphurosi ^ss 15 Glyceriiire §iss 55 Aquje §vj 180 M. (Mr. Shillitoe.) Either of the above washes may be used three or four times in the twenty-four hours. In fetid and phagedenic ulcerations of the throat, the following is a valuable formula : — ]^. Creasoti nix 65 Mellis ^j 38 Aquie |vij 210 M. In all syphilitic affections of the mouth and pharynx, the surgeon must insist upon the patient's abstaining from the use of tobacco, which is found in practice to be the most common cause of the pei-sistency of these lesions and of tlieir frequent return after removal. Unless this restriction be faithfully complied with, the patient should understand that little perma- nent benefit can be expected. The question is often asked whether smok- ing or chewing is the more injurious ? Tobacco in any form acts as an irritant, but in the act of smoking a partial vacuum is produced in the mouth, whereby the vessels of the mucous membrane are congested, and I am therefore inclined to think smoking the more injurious of the two habits. The CEsophagus. In an able paper by INIr. James F. West, Surgeon to the Queen's Hos- pital, Birmingham, which was published in the DuUin Quarterly Journal of Medical Science for Feb. IHGO, the probability, if not the absolute certainty, that stricture of the cesophagus may be due to syphilis was first established. The case upon which Mr. AYest's observations were chiefly founded was one of a girl aged 21, who h.ad suffered for several years from well-marked syphilitic manifestations, such as eruptions upon the skin, ash-colored ulcerations of the fauces, rheumatic pains, and syphilitic cachexia, and who was admitted into Queen's Hospital, May 18, 1858, for stricture of the frsophagus. Treatment by means of tonics, iodide of potassium, and mercurials afforded only temporary relief, and she succumbed on Sept. 2, of the same year. The following appearances were found at the post- mortem examination : " The upper portion of the oesophagus for about four iBches was much dilated ; its mucous membrane thickened, and marked by s{)Ots having the apjjearance of recent cicatrices. At this dis- tance from the upper end it was suddenly constricted, and terminated in 602 AFFECTIONS OF THE ORGANS OP DIGESTION. a narrow canal which would barely admit a No. 4 catheter. This con- stricted portion, which was about two inches and a half in length, was formed by the thickening of the mucous membrane, and by fibrous deposit in the form of bands and bridles, having very much the appearance of an old stricture of the urethra. Below this track the ossophagus continued perfectly healthy to its termination in the stomach. Both lungs contained tubercular deposit in different degrees of softening, with several small cavities in the upper lobe of each, one in the left apex being as large as a pigeon's egg." In reviewing this case Mr. West remarks: "We have no account of the swallowing of any caustic or irritating fluid, so that we cannot attri- bute the stricture to that cause. The presence of numerous recent cica- trices clearly indicated that ulcerations had existed in the walls of the oesophagus. The deposit in the submucous tissue was fibrous ; it was ex- actly similar in nature to that which is so well described by Dr. AVilks as characteristic of syphilitic eruption, and could not under any supposition be referred either to cancerous or tubercular degenei'ation." Mr. West' has since reported another case in which the pathological appearances were very similar, and states that Mr. Langston Parker has recently met with a case of general syphilis in private practice in which unmistakable stricture of the oesophagus existed. In reviewing this subject it appears extremely probable that Mr. West is right in his conjecture as to the cause of the stricture in the cases which have come under his observation, since we may readily admit that syphi- litic ulceration of the fauces may extend to tlie oesophagus or attack the latter as a primary affection ; and yet it is singular that this effect of syphilis has attracted so little attention from previous observers, and to the names of those authors who are (|uoted by Mr. West as silent upon the subject, I will add that of Yvaren, whose work on the Metamorphoses de la syphilis includes nearly all the obscure forms of syphilitic disease, so far as they are known. Follin,^ however, was of the opinion that some of the reported cases of stricture of the oesophagus might be attributed to syphilis, and Virchow has met with contraction of the upper portion of this tube in the post-mortem examination of a syphilitic subject.^ Some of the cases of syphilitic stricture of the oesophagus, whose advent and whose disappearance under treatment are somewhat sudden, are prob- ably spasmodic, the contraction being excited by ulceration of the mucous membrane of the canal. Organic strictures, which undoubtedly may result from syphilis, are caused by fibrous deposits in the submucous tissue, thick- ening of the mucous membrane, and by contraction of cicatrices following ulceration. Obviously, anti-syphilitic treatment can avail in cases of only the former class. The iodide of potassium seems to have given relief in one of Mr. » Dublin Q. J. M. Sc. 2 Des r6trecissem«nts de I'ocsophage, Paris, 1853, p. 30. 8 Syphilis constitutioiielle, p. 88. STOMACH AND INTESTINES. 603 West's cases, while only temporary benefit was derived from the use of mercury. In cases of organic stricture, dilatation with oesophageal bougies, com- bined with general tonic treatment, is a palliative resource. When death from inanition seems probable, in spite of rectal alimentation and of medi- cation, the question of producing a gastric fistula arises. A most interesting case of syphilitic stricture of the oesophagus occurred several years ago in the practice of Prof. F. F. Maury, of Philadelphia, in which this accomplished surgeon resorted to gastrotomy, after it had become impossible for the smallest quantity of food or the finest bougie to enter the stomach, and the patient had been kept alive for several weeks by way of the rectum. Unfortunately the operation was performed too late, and the patient died of exhaustion in fourteen hours after. The post- mortem showed a very tight stricture, entirely free from^ any evidences of cancer, just above the cardiac orifice. The patient's syphilitic antecedents had been unequivocal.^ Mr. Bryant was somewhat more fortunate in the case of a patient at Guy's Hospital upon whom he did this operation,^ life being prolonged until the fifth day. The fatal result was due to pulmonary complication, which Jullien^ believes is the most frequent cause of death in these cases. Syphilitic gummata have been found in the wall of the oesophagus, and doubtless obstruction may be caused by the growth of vertebral nodes. Habershon* refers to a specimen, in the Hunterian Museum, of a gumma- tous tumor of the liver which had produced a similar result. Stomach and Intestines. Functional disturbance of the digestive organs is not an uncommon effect of the contamination of the blood by the syphilitic virus, as shown by the loss of appetite or the occasional inordinate desire for food, and the nausea and vomiting which sometimes accompany the appearance of early secondary manifestations. The general cachexia belonging to the later stage of syphilis may also be attended by intestinal derangement. But the question is an interesting one, and one not yet, perhaps, fully solved, how far syphilis may produce, in those portions of the intestinal canal which are beyond the reach of sight, the same organic changes and their consequences which are known to exist at the outlets and more accessible portions of the same canal. Are syi)liilitic erythema, mucous patches, ulcerations, and deposits of gummy material to be found in the stomach and intestines, as in the buccal cavity? CuUerier^ believes in a form of enteritis developed in syphilitic subjects, ' Am. J. M. Sc, Phila., April, 1870. ' Habersliou on Diseases of the Abdomen, etc., 3d ed., 1878, p. 73. Quoted from the post-mortem records of Guy's Hospital. 3 Mai. ven^riennes 1879, p. 848. * Op. cit. p. 7G. ^ CuLLEKiER and Bumstead's Atlas, p. 2t)0. 60t AFFECTIONS OF THE ORGANS OF DIGESTION. which is probably not ulcerous, and " the specific nature of which cannot be doubted," and he is thus led to admit syphilitic exanthema of the in- testines. Post-mortem examinations, however, of persons dying in the early secondary stage of syphilis are rare, so that the above statement can with difficulty be verified. Moreover, enteritis supervening during this stage may be due to the improper use of mercury, or to many simple causes. Hence we must, I think, regard the existence of syphilitic erythema of the intestines as probable but not demonstrated. With regard to late syphilitic affections of the stomach and intestines our knowledge is more definite. Several cases have been reported of persons in the tertiary stage of syphilis, who have suffered from chi-onic diarrhoea that did not yield to simple treatment, and in whom post-mortem examination has revealed ulcerations of the stomach or intestines, identical in their appearance with the ulcerations of gummy deposits on other mucous surfaces. Cullerier gives such a case (op. cit., p. 317). In another instance, reported by Lancereaux (op. cit., p. 311), "The stomach was about of the normal size, but, near the pylorus and on the smaller curva- ture there wa.s an ulceration which had nearly eaten through the wall of this organ ; its edges were bevelled at the expense of the mucous mem- brane, and were fibrous and indurated ; at certain points they were of a clear grayish color, while at others they had a cicatricial appearance. No indurated ganglia in the neighborhood." Cornil gives a case of gummata of the stomach associated with similar lesions of the liver, the patient having died with pulmonary complication. The only symptoms were indigestion and pain in the epigastrium. An extraordinary case of multiple gummata of the parietal and visceral peri- toneum has been reported by Laurenzi.^ Lancereaux concludes that the intestinal canal may in rare cases be at- tacked by syi)hilis, and that " the multiple and rounded ulcerations, pene- trating to a greater or less depth and circumscribed by fibrous tissue, of which it is sometimes the seat, are probably only the sequence of gummy deposits, or, in other words, the result of the degeneration which these deposits have undergone. The simple thickening of the submucous tissue met with in some instances, and the case reported by Wagner,^ of deposits not yet ulcerated, are favorable to this view." This view is still further supported by the beneficial effect of the iodide of potassium in several of CuUerier's cases, given either in large doses in- ternally, or, when the stomach was irritable, in the form of enemata (gr. xv-lxxv ad aquai .^iv-vj). Ths symptoms of this affection present nothing peculiar to mark their origin aside from the history of tlie case and the coexistence of well-marked syphilitic lesions elsewhere. They consist only of an almost constant and obstinate diarrhoea, sometimes with bloody stools, attended with a feeling of oppression and nialaise in the abdomen, and occasionally with severe ' Gior. ital. d. mal. ven., Milano, 1871, vol. ii, p. 298. 2 Arch. d. Heilk., 1863, obs. xxix, p. 369. THE RECTUM. 605 colic. There may also be frequent eructations and vomiting of food a few hours after its ingestion ; the appetite diminishes; the patient loses in strength and in weight, and assumes a condition of general cachexia, which is observed in syphilis of other internal organs. The Rectum. Chancroids situated near the margin of the anus may give rise to a form of stricture of the rectum, which has improperly been called "syphilitic." Its true pathology was first pointed out by M. Gosselin,^ who reports twelve cases under his own observation, including three in which he was able to make a post-mortem examination. M. Gosselin's views have been confirmed by other eminent authorities^ as Mr. Holmes Coote^ and Lance- reaux.^ I have myself had several cases under my charge, in which tlie antecedents pointed in the same direction, and in which a thorough trial of mercury and iodide of potassium failed to afford the slightest relief, as they would have done if the trouble had been of syphilitic origin.* This lesion depends upon a thickening or hypertrophy of the submucous cellular tissue of the rectum, the same as is produced by chancroids of the j)repuce and labia minora in the neighborhood of their site, and which has already been described. All the cases thus far reported have occurred in women, as may readily be explained by the greater frequency of chancroids about the anus in this sex. The patients often complain merely of a frequent desire to go to stool, which is followed by a discharge of pus and sanguinolent mucus. Consti- pation, and difficult and painful defecation are present in only a few in- stances ; the majority, especially when the disease has been of long standing, suffer from constant diarrhoea. The amount of purulent discharge is ex- cessive, either with or without fecal matter at stool, or involuntai'ily during the day. Most of the patients lose flesh and strength, and suflfer from va- rious dyspeptic symptoms. In nearly all, hypertrophied and prominent folds of integument ai-e found upon the margin of the anus. The stricture is invariably found at the depth of about an inch and a half or two inches from the margin of the anus, and does not appear to vary from this posi- tion like strictures dependent upon other causes. The stricture is composed of an indurated and inextensible adventitious •leposit in the substance of the mucous membrane and the submucous cellular tissue. It is never impermeable nor so contracted as entirely to l)revent the exit of fecal matter. The muscular tissue surrounding the contracted portion is somewhat hyt)ertropliied. There is not the slightest evidence of any deposit similar to that found in gummy tumors. ' Des retrecissements syphiliticjues du rectum, Arch. g§n. de miSd., t. iv, 5«s6rie, ]>. fJ(J7. « Med. Times and Gaz., Lond., Jan. 27, 1855. » Op. cit., p. 315. * See also Bull. Soc. anat. de Paris, 2e serie, t. iv, 1859, p. 100 ; also a paper read by the author of tliia work l)efV)re tlie N. Y. Acad, of Med., April, 1864, Bull. of the Acad., vol. ii, p. 280. GOG AFFECTIONS OF THE ORGANS OF DIGESTION. The lining membrane of the dilated portion of the rectum above the stricture is denuded of its epithelium and glandular layer, giving rise to an extensive and continuous erosion for about four or five inches above the contraction, and the muscular tissue surrounding this portion is hypertro- phied. This ulcerated surface is the chief source from which is d(5rived the pus that is mingled wath the stools and flows away involuntarily. Gosselin believes that so extensive an erosion is peculiar to this class of strictures. Since the last edition of this work much has been written upon syphi- litic aflections of the rectum, but little has been added to our knowledge of the subject. The chief contribution has been by Fournier,^ who has published an elaborate brochure, of which the thesis of his student, Gode- bert, is a reca|)itulation. Fournier thinks that tertiary lesions of the anus and rectum are rare, and classifies them as ulcerating syphilides, gummous syphilides, and a third variety, wliich he calls syphilome ano-rectal. He subdivides ulcerating syphilides of the rectum into two kinds ; those which are continuous with ulcers outside the anus, and extend one or two centi- metres, more rarely three or four centimetres, within the sphincter. In one case they reached further than he could see even with the aid of the speculum ; secondly, those which are developed originally within the rec- tum, as multiple ulcerations, either in the sigmoid flexure and rectum, or confined to the latter portion of the intestine. He says that these lesions are very rare, although they are [)robably more common than is supposed, since they are seldom looked for. He has never seen gummous infiltra- tion, but it has been observed by Prof. Verneuil, and he, therefore, con- siders it another but rare cause of rectal stricture. The third lesion of syphilis, which may cause stricture of the rectum, is the one upon which Fournier lays most stress. He thinks that most of the strictures in syphi- litic persons are caused "6y an infiltration of the ano-rectal walls with a neoplasm of unknown structure, hut capable of degenerating into a fibrous tissue, the contractioti of which results in coarctation of the intestine.'"' In proof of this theory he has no facts derived from post-mortem examina- tions, but, reasoning from analogy, he concludes that since syphilis pro- duces connective tissue hyperplasia in other organs, as the testes, lungs, liver, etc., it may have a similar effect in the rectum. This theory, cer- tainly more than any other, seems to be in accord with the facts. Four- nier calls attention to the fact, that at the autopsies of subjects with old syphilitic strictures of the rectum, no ulcerations nor cicatrices can be found ; hence, he infers that the morbid changes are submucous rather than in the mucous membrane itself. He admits, however, that contrac- tions from ulceration do occur, but claims that tliey are very rare. He thinks also that chronic inflammation may have a modifying influence in the production of stricture. In this lesion the entire circumference of the rectal wall for a distance of from three to eight centimetres above the sphincter, becomes trans- • Fournier, Lesions tertiaires de I'anus et du rectum, Paris, 1875. THE RECTUM. 60*7 formed into a thickened, hard, and unequally rigid cylinder, with no trace of ulceration. AVhen the infiltration is limited to the vicinity of the anus, it is not uniformly ditfused around the circumference of the canal, but is circumscribed, forming tumor-like masses, irregularly round or flattened, which are at first covered by healthy tissue. These masses are firm and elastic, and are painless unless they become inflamed ; they are liable to erosion and ulceration. These anal lesions are curable if treated early, but if neglected they inevitably result in stricture. It is the opinion of Fournier that these lesions are more common in females than males, in the proportion of eight to one. We have given an analysis of this valuable paper in order to present clearly the views of its accomplished author. While we agree with him in the main, we are somewhat surprised that he is silent regarding the in- fluence of chancroids in producing rectal strictures. The views of Fournier concerning syphilome ano-rectal are adopted by Duplay,^ who thinks, however, that primary lesions and gummata are never the cause of rectal stricture. He says, " the cylindrical and ex- tended stricture of the rectum accompanied by thickening and induration of the walls is a constitutional affection, having, in a measure, its own proper individuality." He thinks that the irritation to which the rectum is subjected is the exciting cause. One of the most important contributions to the subject of gummy infil- tration of the rectum is contained in the report of a case by Zeissl.'^ The patient was a man who contracted syphilis in 1860, and suffered severely from it. Fourteen years later he came under Zeissl's observation, being much emaciated, and having a large fungous mass growing from the scro- tum. The slow, painless course of this lesion suggested its syphilitic nature. While under treatment for this affection the patient complained of pain in the rectum, attended by bloody and diarrhoeal discharges ; very soon a brownish-black ill-smelling mass was found protruding from the anus, which, after removal, proved to be composed of connective and elastic tissue. On digital examination a swelling the size of a walnut was discovered on the right wall of the rectum, from which a sanious pus could be expressed. Periosteal nodes were also present at this time. Zeissl quotes Virchow as saying that there is nothing absolutely specific in the formation of the infiltrations of syphilis, but that their nature is determined by their development, history, course, degeneration, etc. He concludes that the anal tumor was a syi)hilitic new growth, and tiiat it was of exceptional importance on account of its occurrence in a male patient. Barduzzi,^ an Italian, has also published a brochure on the sub- ject of syphilitic stricture of the rectum, which he thinks may be caused first by simple ulcers or the chancroid, second by the lesions of secondary syphilis, third by those of tertiary syphilis, and fourth by cancer. His ' Ddplay, Progrfes med., Paris, nov. 30, 1876. * Zeissl, Vrtljschr. Dermat. u. Syph., Wien, H. II, 1876. 8 Bakduzzi, Gioi-. ital. d. mal. veil., Milano, No. I, 1875. 608 AFFECTIONS OF THE ORGANS OF DIGESTION. paper also contains a good description of the symptomatology and some suggestive points in the diagnosis of cancerous strictures. The literature of this subject has been further increased by the publi- cation by Zap[)ula' of a case of rectal stricture, in which cure was effected by the internal use of iodide of potassium. The patient, a man 36 years of age, had gonorrhoea and an ulcer on the glans fifteen years before. Mercurial treatment was at once begun, and no lesions of syphilis subse- quently appeared. Fifteen years later he began to suffer from pains to the right of the anus and in the right tuberosity of the ischium. Very soon the symptoms of rectal stricture became well marked, and so extreme was tlie intestinal obstruction that large fecal tumors formed, and could be felt through the abdominal walls. Upon examining the rectum with the finger, smooth, elastic elevations of the mucous membrane were felt, rather in the form of folds than of condylomata or other adventitious deposits. Examination with the speculum showed the mucous membrane hypertro- phied, uniformly swollen, and slightly mammillaied. A sound could be readily introduced to a depth of eleven centimetres (four and a half inches), but there met an impassable obstruction. On a second examination there was found at a depth of four centimetres (one and six-tenths inch) a pain- less swelling the size of a hazelnut, globular, smooth and elastic, which was situated beneath the mucous membrane, and appeared not to adhere to the latter. The diagnosis lay between syphilis and cancer. Giving the patient the benefit of the doubt, he was placed upon anti-syphilitic treatment, consisting of large doses of the iodide of potassium. In the course of twelve days tlie pain disappeared, the tumor diminished in size, natural stools took place, and the patient was at last completely restored to health. According to Fournier, Guerin also obtained good results from the iodide of potassium in rectal stricture. Treatment. — It has only been exceptionally, as in Zappula's caee above given, that the potassium iodide and mercurials have had any effect in relieving stricture of the rectum. Their success, however, in these few instances should lead us to give them a trial in all. At the outset of the disease, dilatation, either alone or combined with incisions, may effect a cure ; at a later stage, they are in most cases at best palliative, and a fatal termination can only be delayed for a time by the use of sounds, tlie administration of tonics, and general hygienic means. An important modification, however, of the treatment of these stric- tures by dilatation has been successfully employed by Dr. McMasters^ of St. Francis Hospital, xSew York. The patient was a man, twenty-three years of age, who had been infected two years previous. Fifteen months ' Zappula, Ann. univ. di med., Milano, CCXIII, 1870 ; also Arch. f. Dermat. u. Ijyph. Prag., 1871, pp. 62 and 90. 2 McMasters, Treatment of syphilitic stricture of the rectum by means of pres- sure, and the local application of mercurial ointment. N. York M. J., Oct. 1876. THE LIVER. 609 after the primary lesion lie complained of symptoms of rectal stricture, which were not treated, and which gradually increased for ten months. When he came under treatment his stricture, which was just within the sphincter, scarcely admitted a No. 12 bougie. After unsuccessful treatment by incisions and dilatation. Dr. McMasters introduced a piece of wood covered with flannel, saturated with mercurial ointment, and so shaped as to exactly fit the stricture. Having been retained for twenty-four hours by means of a perineal band, it was withdrawn, and, after the application of another thickness of flannel, anointed as before, it was reinserted. After daily repetition of this procedure for two weeks, the stricture was large enough to admit the index-finger, and, at the end of five weeks, its diam- eter was nearly one inch, which was subsequently increased to one inch and three-eighths. The treatment, being continuous, required confinement of the patient. For the first twenty-four hours the wooden plug caused slight discomfort, but afterwards no inconvenience was experienced. Cure was hastened by the internal use of the iodide of potassium. The Liver. The liver is attacked by syphilis more frequently than any other of the abdominal viscera. In the secondary stage congestion of the liver some- times occurs, usually associated with a cutaneous eruption. The most marked symptom is icterus^ which is of short duration and may be accom- panied by gastric disturbance and febrile reaction. There is a sense of weight or oppression in the hepatic I'egion, but seldom any pain, except perhaps on pressure. Percussion may show ■slight increase in the volume of the organ. Tliis condition, Avhich was first described by Gubler in 1853, is probably due to the extension of a catarrh from the intestine to the bile-duct. The fact that it usually accompanies a specific exanthem, simultaneously with which it often disappears, suggests the possibility of an analogous condition of the intestine. It rarely persists more than a week or two. The icterus occurring at a later period of syphilis may, of course, be due to interference with the transmission of the bile by mere congestion of the liver; more frequently it is caused by compression from a gumma or a cicatricial band. The affections of the liver observed in the later stages of syphilis are much more serious and present more decided symptoms. Three forms of tertiary syphilis of the liver are usually recognized: — 1. Chronic Interstitial Hkpatitis. 2. Gummata. 3. Amyloid Degeneration. Chronic Interstitial Hepatitis. — Clironic interstitial hepatitis may be general or partial; the former condition is rare, and cannot be distinguislied from ordinary cirrhosis. In the localized form the increase of fibrous tissue is especially marked in the capsule of Glisson at the 39 filO AFFECTIONS OF THE ORGANS OF DIGESTION. attachment of ligaments. The subsequent contraction of" the newly-formed tissue causes very striking lobulation of the organ. Upon post-mortem examination the liver is found to be united to the neighboring organs and to the diaphragm by means of ligamentous bands, whicli are so firm that it is often difhcult to remove it from its position. The external appearance is highly characteristic. Its natural contour is often lost, so that its different portions are with difficulty recognized. Its edges are uneven and fissured. Its surfaces present irregular prominences or lobes, se[)arated by furrows radiating for the most part from the sus- pensory ligament, and dense, grayish, and fibrous at the bottom. On making a section, thickened strise or septa are found to emanate from the fibrous bands upon the surface, and permeate the substance of the organ, enclosing interspaces in which the hepatic tissue is of a deeper and more yellow color than normal. Under the microscope the hepatic cells are enlarged and fatty, or they have undergone amyloid degeneration, while in the neighborhood of the septa they are commonly atrophied. The size of the liver may be moderately increased during the early vascular stage, but it is commonly diminislied at a later period, and in one case reported by Frerichs, it did not exceed that of a man's fist. The symptoms of this affection are those of ordinary cirrhosis, consisting of loss of appetite, emaciation, ascites, etc. GuMMATA Gummata are commonly found imbedded in fibrous tissue, and are usually small and multiple. They are seldom larger than a walnut, and are frequently arranged in groups. Their outline is irregular and their consistency firm. jCorniP describes the structure of a gummy tumor of the liver as follows: it consists of three portions ; a central mass, homogeneous or composed of granular matter, imbedded in which are small round cells. These cells are arranged in groups which are separated by delicate filaments of connective tissue. Around this central portion is an intermediate zone composed of fibrous tissue, which, when recent, in- closes numerous round cells; when older, the cells are scanty and fusi- form. The third or external zone consists of condensed hepatic tissue, which is filled with cells and is penetrated by fibres of connective tissue from the middle zone. In the central portion of the gumma the vessels are very small or are completely obliterated. The vessels of the periphery are large and their walls are thickened. Scattered among the new cells are small, round, highly refractive bodies, not acted upon by carmine, but deeply colored by purpurine, which Malassez^ considers peculiar to syphilis. In rare cases the gummatous deposit softens and is absorbed; still more rarely it undergoes calcific degeneration ; commonly the tumor contracts, and is transformed into fibrous tissue, in which no traces of its original layers can be found. These gummatous tumors may be distinguished from tubercular nodules ' Lemons sur la syphilis, Paris, 1879. 2 JuLLiEN, Mai. ven^rleimes, Paris, 1879. AMYLOID DEGENERATION OF THE LIVER. 611 by the fact that the latter are much smaller and more numerous. The centre of a tubercle, moreover, is soft, and perhaps puriform ; its fibrous periphery is narrower and less dense than that of a gumma. Gummy tumors can hardly be confounded with cancerous or sarcomatous tumors. The symptoms of gummata of the liver are often obscure, and the diag- nosis must be confirmed by coincident lesions. The organ may be in- creased in volume, and nodules may be detected upon its surface. Pain may be entirely absent, except on pressure, or it may be very acute : it does not radiate towards the shoulder as in other hepatic affections. Res- piration may be painful in consequence of adhesions. Unless the tumors are extremely numerous, there is no interference with the functions of the organ. In severe cases there may be icterus and gastro-intestinal disturb- ances. The stools may be clay-colored or bloody. Blood may also be expectorated, and epistaxis may occur. The spleen and the abdominal ganglia are often decih. chez Tadulte. Paris, 1874. " Weil : Ueber das Vorkomtnen des Milztumors bei frisclier Syphilis. Centralbl. f. d. med. Wissensch., Berl. No. 12, 1874. Also, Ueber das Vorkommen des Milztumors, etc. Deutsches Arch. f. klin. Med., Leipz. Bd, 13, H. 3, 1874. 3 Wevek : Ueber das Vorkommen des Milztumors, etc. Deutsches Arch. f. klin. Med., Leipz. H. 4 u. 5, 1876. GUMMATA OP THE SPLEEN. 613 state, in their monographs, that they have found it during the secondary period of incubation. Of three cases observed by the latter, in one it was found between the eighth and twelfth weeks of infection ; in another be- tween the fifth and tenth weeks after the initial lesion ; and in the third during tlie first two weeks of the secondary stage. In three of our cases it was found within a month after general invasion, and in the remainder between three and eight months. Probably it may occur at any time during the secondary period. Jullien attributes to this condition of the spleen many of the symptoms of gastric derangement as well as certain blood changes occurring in syphilitic patients. We are ignorant of the minute changes in the splenic enlargement of syphilis, but probably they consist of increase of the cell elements of the pulp with hyperemia, as suggested by Weil. In all cases of enlarged spleen thought to have a syphilitic origin, other causes must be eliminated. GuMMATA OF THE Spleen Gummata vary in size from that of a millet-seed to that of a walnut, and may be few in number or very numer- ous. Their number is usually greater when their size is small. In some cases the spleen itself is enlarged. The tumors are usually found near the trabeculaj and deeply seated, or at the periphery of the organ ; in the latter case the capsule is thickened. Recent tumors have a reddish-gray color, and are more dense and tough than the normal spleen tissue ; when old they are dry and of a yellowish-gray color. When young they are less clearly defined than at a later period, when they may become distinctly encapsulated. The vessels and the structure of the organ in the neighbor- hood of the tumors are more or less destroyed. Cicatricial contraction, especially in the capsule, subsequently occurs. The spleen has several times been found adherent to the diaphragm in consequence of peritonitis from irritation by gummy tum.ors. We know little of the symptomatology of this affection. Enlargement of the spleen is sometimes demonstrable, and in some cases, when the tumors are superficial, inflammation of the capsule and localized peritonitis occur. In the cases hitherto observed the lesion has generally been accompanied by similar affections of other viscera, and the patients have suffered from cachexia or marasmus. According to Biiumler, Beer thinks that, besides gummata, syphilis causes in the spleen a diffuse cellular infiltration of the arterial sheaths, and certain characteristic deposits, which are as follows : " They are paler than the normal tissue, from which they do not project at all, but merge diffusely into the surrounding spleen tissue; contain but little blood and few cells, and in the centre consist of a finely granular material in which a few cells and nuclei are embedded." 614 affections of the organs of digestion. Pancreas. Upon this subject Lancereaux remarks: "Cases showing syphilitic changes in the pancreas are extremely rare. In a patient who died under the care of Prof. Rostan fourteen years after having contracted a chancre, there was found, besides multiple gummata of the muscles, a gummy tumor of the mammary region, and two others in the pancreas.^ All these tumors, subjected to microscopic examination by Verneuil and Robin, appeared to be composed of similar elements. I, myself, in several cases of visceral syphilis, have found this organ firm, indurated, and sclerosed, so that we cannot deny that the pancreas, like most of the viscera, is subject to the diflPuse and circumscribed lesions of syphilis." ' Bull. Soc. aiiat. de Paris, 1855, p. 26. THE NOSE. 615 CHAPTER XVII. AFFECTIONS OF THE ORGANS OF RESPIRATION. The Nose. The pituitary membrane may be the seat of erythema, superficial ulcer- ations, and mucous patches, which giv^e rise to symptoms resembling those of an ordinary catarrli. Sometimes an ulcer may be seen just within the nasal orifice, surrounded by swollen mucous membrane, and rendering the alai nasi tender upon pressure. Plugs of inspissated mucus, mixed with blood and pus, which obstruct the passages, are from time to time dis- charged. The nasal secretion is more abundant and more purulent when ulcerations or mucous patches exist. In the absence of other lesions of s}i)hilis, upon the skin or elsewhere, the character of the nasal affections may be suspected only because of their persistence and of their rapid dis- appearance under specific treatment. In the more advanced stages of syphilis, deeper ulcers appear, which originate in gummatous infiltration of the submucous tissue and gradually involve the cartilaginous and osseous textures; or the latter structures may be the first attacked, and the mucous membrane become implicated secondarily. On account of the serious deformity resulting from destruc- tion of the framework of the nose, the importance of recognizing these lesions at an early period is very great. Their progress is usually very slow and insidious, so much so that necrosis may occur before the patient is conscious of any serious trouble. The ulcerative process may [)erforate the septum or the floor of the nasal cavity, or it may extend into the pharynx. Again, it may find its way along the Eustachian tube and even penetrate the cranial cavity, involving the meninges; more commonly, however, the membrana tympani becomes ruptured and a purulent dis- charge takes place tlirough the external auditory canal. Deafness may ensue from obliteration of the Eustachian tube by a cicatrix. The disease has been known to pass up the lachrymal canal, involving the lachrymal bone and even the eye. Respiration through the nose may be interfered with by hy[)ertropliy of the mucous membrane, by the formation of adhesions between ulcerating surfaces in process of repair, or by the contraction of cicatrices. The voice becomes nasal ; the sense of smell may be impaired or lost, even whea the terminal filaments of the olfactory nerve are not involved; the discharge, in cases of necrosis, is extremely fetid and may contain frag- ments of bone. When necrosis of tlie nasal bones occurs, the bridge of 616 AFFECTIONS OP THE ORGANS OF RESPIRATION. the nose becomes depressed and its tip elevated ; when the cartilages are destroyed, the tip of the nose is depressed and flattened. Tlie portions of bone spared by the destructive process become thickened and eburnated, and are often separated superiorly so as to form a longitudinal furiow running along the dorsum of the nose. According to Virchow,^ this ten- dency to eburnation and thickening of the osseous tissue is not confined to the part first affected, but may extend to the bones composing the base of the skull. Treatment of Lesions of the Nose. The earlier syphilitic affections of the nasal passages readily yield to the internal administration of mercurials, and rarely require topical appli- cations. In tertiary affections, iodide of potassium, preparations of iron, the mineral acids, cod-liver oil, and other tonics must frequently be em- ployed either, alternately or in combination, and for a long period, in order to afford permanent relief to the disgusting and distressing symp- toms. As a general rule, however, the iodide of potassium in large doses, together with the cautious use of mercurial inunction, will suffice to effect a cure. The most efficacious local treatment consists in mer- curial fumigations, which may be administered by means of the ordi- nary mercurial vapor bath, provided the general health of the patient be not too much reduced ; but a more convenient method is to evaporate a sufficient quantity of calomel, the bisulphuret or binoxide of mercury from a metallic plate heated over a spirit lamp, directing the fumes into the nostrils by means of a tunnel of paper or other convenient material. Blood- Avarm injections of salt and water (5J ad Oj), diluted chlorinated soda (one part to twelve or twenty of water), and weak solutions of nitrate of silver or chloride of zinc, by means of a syringe, or with Thudichum's apparatus, will also be of much service. 1 most frequently employ a strong solution of chlorate of potash. It must be recollected that the discharge' will still continue as long as there are any necrosed portions of bone or cartilage to come away. Patients and even physicians are too apt to despair of the success of treatment in consequence of forgetting this fact. Before making any of the above applications, the nasal passages should be thoroughly cleaned by the use of Thudichum's apparatus, or, better still, by a douche directed from behind forwards. The Larynx. Before the invention of the laryngoscope, knowledge of the syphilitic affections of the larynx was derived chiefly from the study of post-mortem appearances. Reasoning by analogy, it was the custom to infer the exist- ence of laryngeal lesions corresponding with those manifested on parts 1 Ueber dcr Natur der constitutionellen Syphilis. THE LARYNX. 617 within the reach of visual examination.^ Thus all syphilitic diseases of the larynx were believed to be propagated from those occurring primarily in the pharynx, and they were thought to follow the same laws, regarding their time and mode of development, as the dermal lesions of syphilis- Modern research has shown these theories to be erroneous. AVe know that the larynx maybe the seat of syphilitic lesions independently of manifesta- tions in the pharynx, although these regions are usually involved at the same time. Moreover, the laryngeal lesions are so erratic as regards the time of their appearance, and so modified by their situation that their arbitrary division into secondary and tertiary is impracticable. It is desirable, however, in order to obtain a clear idea of these affections, to adopt some system of classification. Provided it be borne in mind that they refer to the depth and extent of the lesions rather than to the time of their occur- rence, it may be as well to retain the terms secondary and tertiary. Among secondary or superjicial lesions, therefore, may be included: 1. Erythema. 2. Superjicial ulcerations. 3. Mucous patches. ■1. Chronic injiammation tcith hypertrophy of the mucous mem- hrane. Vegetations. Tertiary or deep lesions comprise : 1. Deep ulcerations. 2. Gummy tumors. 3. Perichondritis and Chondritis. 4. Caries and Necrosis. With regard to laryngeal syphilis in general it seems to be true that the more remote a lesion is from the entrance to the larynx the more serious will be its consequences, and that the subjective symptoms of a lesion are by no means commensurate with its gravity. For instance, a superficial ulcer may be complicated by an acute oedema so general and so excessive as to threaten life ; on the other hand, a destructive process may have gone on to a considerable degree while the patient is in ignorance of his con- dition. The invasion of the larynx by syphilis is usually very insidious, and the subsequent course of the lesions is chronic and devoid of pain. Gerhardt and Roth'' express the opinion that the parts of the vocal organ- ism most often in contact during the performance of its function are more frequently attacked by syphilis. Hence the vocal cords and the arytenoids are the most susceptible regions. There are certain symptoms, some of them common to many of the lesions of laryngeal syphilis, which deserve special attention. Spontaneous pain is very rare. It is considered an indication of the invasion of fibrous or cartilaginous tissues. Pain in the ear and, when the lesion is unilateral, • Dance ; Eruptions syph. du larynx. Th^se do Paris, 1864. 2 Uebor sypli. Krankheiten des Kehlkopfes, Arch. f. path. Anat., etc., Berl. H. xxi, 1861. 618 AFFECTIONS OF THE ORGANS OF RESPIRATION. in the ear corresponding to the affected side, is spoken of by Jullien* as a symptom in many cases, although not peculiar to syphilitic disease of the larynx. Cough is also an extremely rare symptom, and exj)ectoration, if present, is scanty, mucous or muco-purulent. The sputa may be tinged with blood from an ulcerative lesion or from ruptured capillaries. In cases of caries or necrosis they may contain fragments of cartilage or bone. In the latter condition also the breatli is likely to have a fetid odor. Alteration in the volume and quality of the voice may be very slight even in severe lesions. Frequently the voice becomes hoarse or assumes a character called by the French " crapuleuse." Sometimes it is reduced to an almost inaudible whisper. Dysphagia is quite infrequent except in very advanced stages of disease, or when the epiglottis is attacked. Dyspnoea may supervene in cotisequence of stenosis due to various causes, chief of which are oedema, growths which invade tlie air-passages, or occlude tliem by pressure from without, and cicatricial contractions. Probably spasm may be an occasional and temporary cause of dyspnoea. Oedema may occur with any lesion of syphilis. The sub-mucous effusion may take place rapidly, in which case the danger to life is imminent, or it may be gradual. In the latter case the patient may accommodate himself to a very considerable diminution in the calibre of the larynx. The dis- appearance of an acute ojdema is usually proportionately rapid, while a slowly-formed effusion may persist for a long time. Among new growths which may cause stenosis of the larynx, are to be included vegetations, hypertrophy of the mucous membrane following chronic inflammation, gummy tumors and exostoses. The most intractable cases of stenosis are those due to gradual contraction of cicatrices. This unfortunate result usually follows only the deep ulcerations of the later stages of syphilis. Superficial ulceration may involve quite extensive sui-faces, producing complete aphonia and other pronounced subjective symptoms, yet a cure may be obtained with entire restoration of the functions of the larynx. It is in these cases of stenosis from cicatricial contraction that the operation of tracheotomy is sometimes necessitated. The experience of Krishaber,'' however, authorizes confident delay of surgical means of relief, even in the presence of alarming dyspnoea from other causes, the energetic use of spe- cific remedies, especially by the hypodermic method, having been promptly efficacious in many instances. The larynx may also be occluded by the formation of f\\lse membrane between the vocal cords. This is rather a rare cause of stenosis. Ellsberg,' in an article published in 1874, stated that in about 270 cases of laryngeal syphilis he had met with this condition six times. It may result fl'om ' Mai. vSnerieimos, p. 835. 2 Contribution a I'etude des troubles resp. dans les laryiigopathies sypli. Gaz. liebd. 1878, Nos. 45^7. ^ Syphilitic membranoid occlusion of the rima glottidis. Am. .J. Syph. and Derm., N. Y., Jan. 1874. THE LARYNX. 619 superficial ulceration and, on the contrary, has been observed in conjunc- tion with destruction of the cartilages and other late lesions. The process appears to begin usually at the anterior commissure, leaving a passage for the air posteriorly. It may take place in a reverse direction, or an aper- ture may be left in the middle of the rima glottidis, or along the edge of the vocal cord. This condition is also described by Sommerbrodt,^ who, with Elsberg, recommends the use of the galvano-cautery in relieving the dyspnoea, and adds that complete restoration of the voice must not be ex- pected. The fact that in many cases of stenosis the obstacle to inspiration is greater than to expiration lias been noticed by several observers. Let us now consider the special lesions which may occur in the larjnx in the course of syphilis. Erythema Erythema of the larynx, unless it be very acute and at- tended by oedema, may be so slight as to attract no attention, the only symptoms being slight huskiness of the voice and moderate catarrh. No doubt it occurs during early skin eruptions, and it is frequently developed at more advanced stages, either independently or in connection with deep laryngeal lesions. There may be nothing in the appearance of the affec- tion to distinguish it from a simple catarrh. It occurs either in patches, which give the mucous membrane a mottled appearance, or it may be limited to certain regions, or it may be diffuse, the lining of the larynx having a uniform dusky-red hue. There may be superficial erosions of the mucous membrane. The vascularity of the affected parts is much increased, the bloodvessels often presenting the appearance referred to by Krishaber and Mauriac^as " arborisation." When the epiglottis particiiiates in the affection and in the concomitant oedema, it may be much tumefied and assumes a bilobed shape. Superficial Ulceratioxs The superficial ulcerations observed in laryngeal syphilis involve only the mucous membrane and, according to Baumler,^ usually begin in mucous follicles at the posterior commissure. They may affect phonation to some extent, but are generally very sluggish, persisting with sliglit change for an indefinite period. Their margins are well-defined, quite regular, and very slightly elevated above the surround- ing level. The. surface of the ulcers is usually concealed by a layer of tenacious secretion. Frequently general erythema of the mucous mem- brane coexists.. These early ulcerations, wliose appearance is quite differ- ent from that of ulcers occurring at a later period, may be confounded with incipient tubercular ulcers. They are not so likely as are the late ulcera- tions to be mistaken for cancerous disease. The following points of dis- tinction may be found of service. The ulcers of phthisis begin in the ventricular bands and are usually i)aler than tliose of syphilis. They are • Bexl. klin. Wchnschr. Apr. 1, 1878. 2 Des laryngopathios syph. pendant les premidres ishases du la sypliilis. Paris, 1870. 3 Ziemssen's Encycl. vol. iii, p. 20G. 620 AFFECTIONS OF THE ORGANS OF RESPIRATION. bathed in a copious, muco-purulent secretion. There is decided swelling and oedema of the arytenoids, while the mucous membrane elsewhere is anamiic. The course of phthisical ulcers is more rapid and painful, and pulmonary sym[)toms coexist or are soon manifested. Whistler^ observes that in syphilis the voice is rough and rasping, while in phthisis it is whis- pering and moist, suggesting the presence of excessive secretion. The absence of ulceration in the mouth, the blanched appearance of the palate and fauces, Avhile the pharynx may be congested, are indicative of the tubercular character of laryngeal ulceration. Symmetry in the position and outline of syphilitic ulcers is considered characteristic by some autho- rities. Mucous Patches Great diversity of opinion has prevailed, even since a method of inspecting the larynx during life has been provided, regarding the frequency of mucous patches. Pierre Terras'^ considers them very rare, having found them in only one instance among nearly one hundred cases of syphilis. Krishaberand Mauriac, on the contiary, found ten casesof '■'■plaques nmqueiises" in fourteen of laryngeal syphilis, the former observer discover- ing them only on the vocal cords. Whistler states that he has met with twenty-four cases of this lesion among eighty-eight of syphilis in its secondary stage. In his experience the time of its occurrence varied from one and a half to twelve months after primary infection. In all cases mucous patches of the mouth or genitals coexisted ; in seven cases papular or papulo-squamous eruptions were found, in one case associated with a roseola. In one case, six weeks after infection, the indurated cicatrix of a chancre was still present. Enlarged glands and alopecia occurred in many instances. In ten cases the epiglottis was the seat of the lesion and in ten the vocal cords ; in four cases the arytenoids, in two the inter-ary- tenoid fold, in two the ventricular band, and in one the glosso-epiglottic fold. When seated on parts ex})Osed to irritation, either in respiration ot in phonation, mucous patches of the larynx are prominent with ragged margins, forming what are known as condylomata ; in other regions they are flatter and the ulceration is more sharply cut. Their surface is covered by a scanty, viscid secretion. The removal of this film exposes a red, excoriated surface in striking contrast with the paler hue of the surround- ing mucous membrane. Sometimes the centre of a patch is slightly de- pressed, its borders remaining prominent. Besides the ulcerated form of mucous patch we also meet with the opaline patch, according to Whistler, mon; often on the epiglottis and on the arytenoids. In these lesions the epithelium is thickened and still adherent, the deeper tissues being infil- trated with new cells. Tlie opalescent appearance is attributed by Cor- niP to minute collections of pus amidst the epithelial cells. ' The early manifestations of syphilis in tlie larynx. Med. Times and Gaz., Lond., 1878, Nos. 1473-74-75-80-84. 2 De la laryngite syph. Paris, 1872. ^ Progres med., Par., Aug. 10, 1878. THE LARYNX. 621 Chronic Inflammation Chronic inflammation of the larynx is an intermediate lesion ; it may follow an early catarrh, or may not appear until three or four years after infection. The color of the mucous mem- brane is decidedly darker than in the early erythemas, although Whistler affirms that it never deserves the name " coppery," which has been ap- plied to it by some authors. The affection is very persistent and com- monly leads to thickening or hypertrophy of the mucous membrane, which, according to Krishaber is the only one of the early lesions which does not disappear spontaneously. This thickening is quite different from the oede- ma occurring with an erythema, in which the mucous membrane has a puffy appearance. The thickening of the cords may be so great as to require operative interference for the relief of the dyspnoea. A remarkable instance of this condition has been reported, in which tracheotomy was done four times during a period of five years.^ Associated with this con- dition chronic ulcers are almost always found. These ulcers have ragged and thickened edges ; frequently vegetations spring from them, which may reach a considerable size, even to the degree of producing aphonia and of impeding respiration. The vocal cords, which are thickened and rough, are very often the seat of these ulcers. The ventricular bands may be so swollen as to overlap the cords. The vegetations, which may grow from the margins of an ulcer or from other portions of the mucous membrane, are often difficult to distinguish from simple polypoid growths. Their favorite seat is at the insertion of the inferior vocal cords. Ferras states that they may appear in the ventricles of the larynx, where natural papillfE are scanty. The history of the case, or even the empirical use of specific treatment, may sometimes be required to determine their character. Deep Ulcerations Deep ulcerations, occurring in the later stages of syphilis, may form by extension from the pharynx or by degeneration of gummatous deposit. The epiglottis may be entirely destroyed by the ulcerative process. Next in order of frequency the aryteno-epiglottic ligaments are attacked, then the superior vocal cords, and more rarely the true cords. The ulcerations, especially those of gummy tumors, are very irregular and indurated. Frequently, vegetations, like those occurring in connection with the ulcers described in the preceding section, accompany tliese deep ulcerations. Extensive regions may be destroyed in a chronic and insidious manner, irreparable injury being done. These ulcerations can hardly be confounded with those of tubercular origin, which are smaller, more numei'ous, and more superficial. The lardaceous base and the general appearance of the lesions, in connection with cicatrices of previous ulceration, suggest their specific character. They are much more likely to be mistaken for malignant disease. In cancer the tonsils and the sub- maxillary glands are. at an early period, the seat of infiltration. Pain, often extreme, is distinctive of cancer, while the syphilitic lesion makes much flower progress and is generally painless, until the tissues have • Tr. Clin. Soc. Lond., vol. x, 1877. 622 AFFECTIONS OF THE ORGANS OF RESPIRATION. been extensively destroyed. In most cases of syphilis, moreover, there is a clear history of infection, and traces of former lesions may be dis- covered in the mouth or pharynx, or in other regions of the body. Gummy Tumors Gummy tumors of the larynx are much more com- mon than has been supposed. Two forms of gummatous deposit are de- scribed by Simyan :^ a cii'cumscribed variety of a grayish-red color, and a ditFuse infiltration which has a yellowish color. Virchow describes gummy tumors of the larynx as extremely vascular nodules, of softer con- sistence than those developed in other regions, which gradually ulcerate and penetrate the deeper tissues. The lesion is often single, and may attain a very large size ; freciuently the tumors are small and multiple, and may be limited to the mucous and sub-mucous tissues. The deposit some- times undergoes absorption, but more frequently it degenerates, forming the deep, ragged ulcers already described, which may involve the frame- work of the larynx and produce permanent deformity. The epiglottis and the arytenoids are most often involved, but any of the laryngeal car- tilao-es may suffer. A fatal termination may ensue in the course of these lesions from impediment to respiration, due to the size of the tumor or to an acute oedema of the larynx. A single case of death from hemorrliage has been recorded by Tiirck. PEPaCHONDRiTis Perichondritis is generally the result of the exten- sion of an inflammatory or ulcerative process from the mucous and sub- mucous tissues. The cartilage itself may be involved. Pain, of a marked character, is a common symptom of this lesion, and the parts are sensitive to external pressure. Crepitation on paljjation of the cartilage is referred to by Jullien^ and others as a sign of its invasion. Oedema of the soft parts, and deformity from the structural changes in the affected cartilage are frequently observed. The epiglottis and the arytenoid cartilages are most often involved, more rarely the cricoid. They may be entirely dc= stroyed. Caries Caries, or true necrosis, in cases where ossification of the cartilage has taken place, is a common sequel of the invasion of the peri- chondrium by inflammation or gummatous ulceration. It is always a very late accident, and frequently induces structural changes in the larynx which cannot be remedied. An instance of its occurrence six years after infection has been reported by Lamalleree.^ Two small abscesses formed on the anterior aspect of the neck at the level of the cricoid cartilage. They soon opened, and, several years later, pieces of necrosed bone were discharged through the fistulous tracks. Fragments of sequestrum may be expectorated, or may lodge in the air-passages and cause alarming or ' Syphilis laryiigee tertiaire. These de Paris, 1877. 2 Mai. v^neriennes, Paris, 1879. 3 Ann. d. mal. de I'oreille et du larynx, Par. 1878, Vol. IV., No. 5. THE TRACHEA. 623 even fatal dyspnoea. The occurrence of phlegmonous inflammation in the parts surrounding the larynx, secondary to the invasion and death of the cartilage, has been made the subject of a special paper by Mauriac.^ Syphilitic aphonia, occurring at an early period, without appreciable lesions, was originally described by Diday before the use of the laryngo- scope became general. There can be little doubt that the condition was really due to lesions which could not be discovered with the impei'fect methods of exploration at his command. Simyan and Paget^ describe a paralysis of the vocal cords, which has been observed in the later stages of syphilis. It is always unilateral, and affects the left cord more often than the right. Simyan gives the details of a case, communicated by Libermann, of complete aphonia due to this condition, which appeared eight years after infection. It resisted every kind of treatment, until its specific character was suspected, when the use of hypodermic injections of mercury was begun. The affection then yielded, and the voice was gradually restored. The Trachea. The trachea may be the seat of lesions similar to those occurring in the larynx. Vierling^ concludes from the observation of forty-six cases that early syphilitic lesions are rare ; the most common are ulcerative processes, which lead to stenosis by contraction of the resulting cicatrices. The wall of the trachea may be perforated and an abscess be formed externally. Usually the larynx, trachea, and bronchi are involved at the same time. In sixteen out of the forty-six cases the larynx was spared. Cough, purulent expectoration, and dyspnoea, which may be intermittent, are the prominent symptoms of tracheal syphilis. Stenosis is most likely to occur just above the bifurcation of the trachea, and is always a serious if not a fatal sequel of deep ulceration. Accoi'ding to Gerhardt, stenosis of the trachea may be distinguished from that of the larynx by the absence of depression of the larynx during convulsive inspiration. The trachea above the ulceration is often dilated, and the structure of the cartilages may be clianged or destroyed. Thus in addition to the stenosis caused by cicatricial contraction, the ingress of air may be impeded by collapse ot the trachea at each act of inspiration. It is an interesting fact that stricture of the air-passages consequent upon the cicatrization of a syphilitic ulcer may cause death from dyspnoea, so that specific remedies may in reality hasten a fatal termination just so far as they exert a beneficial influence upon the local disease. Two inter- esting cases of this descri[)tion are given in the Annuaire de la syphilis (annee 1858, p. 324). ' Sur les laryngopathies sypli. graves compliqu6es de plilegmon pcri-laryiigien, Paris, 1876. 2 Deitparalysies du larynx. These de Paris, 1877. 3 Deutsches Arch. f. klin. Med., Leipz., April 16, 1878. 624 AFFECTIONS OF THE ORGANS OF RESPIRATION. In the first, reported by Moissenet, the stricture was situated just above the bifurcation of tlie trachea. The lining membrane at this point pre- sented a honeycomb appearance, and the cartilages were more or less clianged in their structure and destroyed ; indeed, four of the rings had entirely disappeared and were replaced by flexible tissue ; hence, in addi- tion to the diminution in the calibre of the tube, its walls collapsed at each act of inspiration and added to the difficulty in the ingress of the air. The patient had been taking mercurials and iodide of potassium which only aggravated her symptoms. Tracheotomy Avas performed without benefit, since the larynx was unaff'ected and the obstruction was below the artificial opening. Death was caused by asphyxia. The following is a summary of the second case, reported by M. Demar- quay:— The patient, aged 3(5, entered a maison de sante, Oct. 25, 1858, with all the symptoms of oedema of the glottis. He seemed to be threatened with suffocation ; his respiration was noisy and painful ; he had had a cough for two months with slight expectoration ; his sputa resembled those of laryngeal phthisis ; and he had lost much flesh. For a fortnight his symptoms had been very intense. The lungs were found to be sound ; and as the patient had liad ulcers upon the penis twelve years before, fol- lowed six years afterwards by ulceration and perforation of the soft palate, iodide of potassium was ordered. Under this treatment he continued to improve for a month ; but on Nov. 25th he was suddenly seized with such extreme dyspnoea that M. Demanjuay thought it best to perform ti'acheo- tomy. The operation was of no benefit and death soon ensued. At the autopsy, the larynx was found to be perfectly healthy, with the exception of a small cicatrix between the two arytenoid cartilages ; but the trachea was found to be abruptly contracted opposite its eleventh ring, at which point its circumference measured only 28 millimetres. This stricture involved the left side of the trachea and was formed of cicatricial tissue in which six rings of the tube were twisted on themselves and frac^ tured. Below the stricture the bronchi were dilated, and their longitu- dinal muscular fibres hypertrophied. The lungs were healthy, and free from tubercles. Treatment op Lesions of the Larynx and Trachea. Treatment, except in the advanced stages of laryngeal syphilis, gives prompt and permanent results. The use of the " mixed" treatment is in all cases indispensable, and, when cacliexia exists, it should be combined with various tonics. Local treatment may be of service in hastening reparation, although Krishaber believes that it is not essential, except in the case of vegetations or of liypertrophy of the mucous membrane. For these conditions he uses cliromic acid and the galvano-cautery. Acid nitrate of mercury, chloride of zinc, or nitrate of silver in solutions of appropriate strength may be applied to ulcerations. Astringent sprays, preferably a solution of sulphate of zinc, sedative insufflations, such as THE BRONCHI. 625 iodoform, and inhalations, as of the compound tincture of benzoin, are useful palliatives. When (edema threatens, counter-irritation externally is indicated, and for its relief scarification of tlie mucous membrane may be required. Cohen^ speaks of the oedema wliich sometimes results from the use of large doses of iodide of potash, and the consequent necessity of closely watching the eflcct of the drug. Spasm may be quieted with bromide of potassium, and opiates may be required in the rare cases of extreme pain. Fetor of the breath may be relieved by the use of deter- gents and disinfectants in the form of sprays or gargles. For the stenosis following ulceration dilatation with bougies has been resorted to with results not fully satisfactory ; when the contraction becomes extreme tra- cheotomy is the only resource. The opei-ation is rarely required for other conditions which cause laryngeal obstruction. The tracheal lesions of syphilis, especially those which may result in stenosis, are much more serious tJian similar lesions of the larynx. Although they are equally amenable to constitutional treatment, the tracheal lesions are usually be- yond the reach of surgical intervention. In all cases of syphilis of the air-passages, and especially of the larynx, particular attention should be given to abstinence from tobacco and alcohol, and the avoidance of exces- sive use of the vocal organs. The Broxchi. The bronchi may be the seat of syphilitic ulceration and consequent stricture. In the case of Marguerite Rudloff, reported by Yirchow, " the right bronchus was contracted at its bifurcation and above tliat jioint ; a section of it presented the form of a triangle ; its diameter measured a quarter of an inch, while that of the left bronchus measured half an inch. The left bronchus was contracted to a still greater extent near its bifurcation, but only for the distance of a quarter of an inch, and was adlierent at this point to the normal oesophagus through the intervention of a thick and tendinous mass of tissue. Tlie right bronchus was the seat of thickening and contraction whicli extended for a short distance into its brandies, which further on were reddened iqion their internal surface and dilated. Several larger dilatations of the bronchi were found in tlie inferior lobe of tlie lung which was otlierwise healthy; and at thes<^ points tlie pul- monary tubes were filled with mucus and surrounded by condensed tissue which extended as far as the pleura." Yirchow concludes from this and another case of which he gives an analysis, that "we must admit the existence of syphilitic ulceration and stricture of the bronchi similar to the same lesions of the larynx, and must also concede that syphilitic bronchitis may give rise to chronic pneumonia, in the same manner as laryngeal idcerations cause extensive induration of the cellular tissue of the neck. I have often seen in constitutional syi»hilis, ' Diseases of the Throat and Nasal Passages. Phila., 1879. 40 ^26 AFFECTIONS OF THE ORGANS OF RESPIRATION. limited star-shaped cicatrices of the pleura and the sequela? of pleurisy, in consequence of the above-mentioned changes."^ The prognosis in syphilitic ulceration of the air-passages is exceedingly unfavorable. Tiie iodide of potassium, mercurials, nourishing diet, and tonics may, in some eases, afford relief, while in others they prove ineffi- cacious, or, in a few instances, as already remarked, may hasten a fatal termination by inducing cicatrization of the ulcer and consequent con- traction and strichu-e. Carmichael believed that the ulcerative process was maintained by the transit of the air, and that tlie best method of cure was the early performance of tracheotomy. These views have not, how- ever, been confirmed by recent surgeons, who resort to tiiis operation only in cases of impending suffocation, and even then, since the stricture may be seated below the artificial opening, if for no other reason, the prospect of affording relief is very dubious. The Lungs. Lancereaux describes an interstitial pneumonia due to syphilis, and also gummy tumors of the lungs. Interstitial Pneumonia — " The seat of this change is variable ; some- times it occupies the superior or middle lobe ; at other times it is limited to the inferior lobe ; whence we may conclude that it may invade almost indiscriminately the different portions of the lungs, without, however, ac- quiring a very considerable extent. The affected portion of the paren- chyma is firm, hard, elastic, resistant to pressure, friable, impermeable to air, and, therefore, non-crepitant." Numerous yellowish points have been observed in the condensed mass, which under the microscope were found to be composed of granular nuclei and numerous molecular granules, con- tained in a fibrous network. This form of pneumonia may generally be distinguished by the small extent of the tissues affected, since it rarely involves an entire lobe, or at times it is disseminated at various points. ' Gummy Tumors — " Their number is variable, sometimes single, but generally multiple, rarely exceeding six or eight. They appear as tumors of a grayish or yellowish-white color, somewhat rounded, of the size of a pea, almond, or large nut, at first of a firm, slightly elastic consistency, and afterwards rather soft and cheesy at the centre. Deposited in the midst of the parenchymatous network, these tumors are generally sur- rounded by an indurated, fibrous, and grayish tissue, which forms a kind of cyst, and is of importance in the diagnosis. Upon the surface of a section of one of these tumors, this cyst or zone is perfectly distinct from the central nodule ; the former is resistant under the finger, evidently tra- versed by vessels, and is made up of j)erfectly developed fibrous tissue ; the latter is friable, little or not at all vascular, formed of nuclear elements or imperfect cells, which are more or less granular, and which belong to the group of elements of connective tissue." Secondary degeneration of 1 Op. cit., p. 154. THE LUNGS. G27 the deposit subsequently commences at the centre and extends to the periphery, and tlie granulo-fatty debris may be absorbed or are evacuated through the bronchi, leaving a cavity which is lined by the fibrous zone. Such cavities are capable of cicatrization, resulting in depressions and scars upon the surface of the lungs, which have often been mistaken for those of tubercle. Both this form and the one before described are often attended Avith dry pleurisy, followed by membranous adhesions to the costal walls. The most important recent investigations of the pulmonary lesions of syphilis are those of Drs. Greenfield, Goodhart, Green, Gowers, Pye- 8mith,and Mahomed, published in the Transactions of the London Patho- loyical Society for the year 1877. The main conclusion of these observers is that syphilis produces fibroid changes in the lung, especially at the base and in the middle and lower lobes, with the formation of nodules of a new small cell-growth ; in other words, granulation tissue. These fibroid de- posits may consist of large firm bands or of masses of greater or less size. The gummy nodules are prone to gangrene, and their vascularity in their early stage explains the haemoptysis observed in syphilitic subjects. All observers admit that the minute appearances are not always clearly defined, since both tubercular and syphilitic phthisis are accompanied by chronic inflammatory changes essentially similar. There is, however, a radical diffei'ence between the two diseases, which is rendered more prominent by their clinical features; in the former we find, coexisting with the fibroid masses, tubercles, which have a tendency to cheesy degeneration, while in syphilitic piithisis there coexist small cell-infiltrations, which have a tendency to necrosis. The microscopic appearances of the syphilitic lesion are given by Dr. Goodhart as follows : There is thickening of the bronchial septa and of the coats of the vessels, and dilatation of the bronchi. The fibrous septa are in places crowded with small cells and nuclei, which project into the lung tissue between the alveolar walls which they distend. The alveoli, in consequence, become contracted and are ultimately oblite- rated, leaving a fibro-nucleated tissue containing vessels of moderate size. Degenerative changes appear to be going on in the central parts. "In one patch of more ra{)id cell growth the central cells were softening down into cavities without any previous formation of fibrous tissue." The thickening observed in the outer coats of the arteries, and perhaps also in their inner coats, was not out of proportion to the general thickening which had taken place in the bronchial septa and around all of the tissues contained in them. Dr. Goodhart states that in some cases of old lung disease, tubercular grains were found in various parts. He says: "But while I do not wish to detract from such an occurrence any of the weight which it may be thought to have against the disease which was found along with it being essentially syphilitic, yet, on the other iiand, it must in justice be remarked that the presence of such grains in the lungs is no positive evidence of their tubercular (as we understand that term) nature. And'even if they were tubercles, they may quite possibly have arisen in the chronic inflammatory changes whicli resulted from the syphilis; and G28 AFFECTIONS OF THE 0RGAN8 OF RESPIRATION. thougli tubercles were found in tlie lungs in six cases, yet none of these were prominently tubercular, but, on the other hand, fibrous." He there- fore concludes that, " with the large proportion of cases of fibroid disease of all the cashes of chronic lung disease which occurred in syphilis, there can, I think, be very little doubt that syphilis and fibrous change go together in the lung as elsewhere." As to tlie natui-e of the fibroid lung disease, whetiier it is at all specific or only a i'orm of inflammation, tuber- cular or otherwise, modified by the syphilitic virus, he says : " On this point I tiiink there can be very little hesitation in arriving at a decision. I can see no ditference in any of the sjiecimens that I exhibit between those I suppose due to syphilis and the more chronic forms of tubercular phthisis, chronic pneumonia, and miners' phthisis ; all of these are histo- loo-ically concerned with a nuclear growth in the interstices of the lungs. They are indeed but varying forms of inflammation, but, unless we think to find a specific corpuscle in syi)hilis, the close similarity of the growths which occur in it to those of other diseases was but to be expected, since the range of variation in the arrangement of cells and tissue and in the form of cells is, so far as we know, most limited." Although he believes that the changes are characteristic of syi)hilis, he can determine no histo- logical distinction. •' Fibroid degeneration of the lungs due to syphilis diflers from chronic pneumonia and that state of solidity which arises after contraction of the lung from old pleurisy, in that it is generally less evenly spread over the lobe than they ; it is nodular rather than diff"use, and is symmetrical and not unilateral ; it differs from miners' phthisis in wanting the extreme amount of dilatation of the tubes and possessing more solidity from fTi-euter cell growth. Many of the patches of disease look, it is true, not unlike red or gray hepatization, but they are more tough, generally less granular, and often somewhat translucent." The clinical features of syphilitic affections of the lungs have been carefully studied by Fournier, Rollett, and Frey. Fournier' thinks that syphilis affects the lungs in two ways: first, by the development of it:r specific lesions — gummata, etc. ; second, by producing changes such as occur in any cachexia. The lesions, which seldom occur before the tertiary period, are divided by Fournier into two classes: 1, simple hyperplasia; 2, gummous infiltration. Syphilitic hyperjdasia of the lung is similar to that of the liver. The septa of the lung are thickened and the alveoli consequently narrowed. The epithelial lining is secondarily involved. Fournier regards the process as really an interstitial pneumonia, which results in the formation of nodular masses. In recent cases the pleura over the nodules is white and glistening ; in old cases stellar depressions of the membrane are found. Gummata of the lungs resemble those of other organs. There may be a single tumor, and the lesions rarely exceed six or eight in number, in this respect differing from tubercles, which are very numerous. They are usually superficial and occupy the lower lobes. They degenerate from the centre, leaving a cavity with white, hard, and fibrous walls. Fournier ' FocENiEK, Gaz. hebd. de med., Paris, Nos. 48, 49, 51, 1875. THE LUNGS. 629 enumerates five anatomical points of distinction between gumma and tubercle of the lungs : 1. Situation — tubercle involves the upper lobe of each lung; gumma, one lung to a limited degree. 2. Number — gummata are few and solitary; tubercles become confluent. 3. Gummata are larger, and are never miliary. 4. Color — gummata are white or yellow, never transparent like miliary tubercle. 5. Consistency — the structure of the gumma is more uniform, and if it breaks down its capsule prevents the degeneration from being complete. Syphilitic lesions of the lungs may attain quite a large size, with very obscure symptoms. There may be some disturbance of respiration and slight cough with scanty expectoration. Physical signs are absent, unless the lesion be very superficial and circumscribed. The dyspna-a gradually increases, but is never very intense, the cough becomes more severe and spasmodic, the expectoration is free and muco-purulent, and haemoptysis may occur. The symptoms are in fact similar to those of ordinary phthisis. Fournier recognizes three varieties of syphilitic affections of the lungs : the latent, in wliich the lesions are circumscribed, cause no symptoms, and are not detected until after death ; in the second variety there is merely slight disturbance of respiration without any disorder of the general condition, the symptoms being those of limited induration or of a cavity ; the third is a severe form, [)resenting all the features of phthisis. The prognosis depends upon the extent of the lesions and their amenability to treatment. That cure may be effected has been proved by the post-mortem discovery of the traces of gummous deposits which have been reabsorbed. The gradual disappearance of the physical signs of induration, with im- provement in the general condition, as a result of treatment, is often observed. The remarkable degree to which subjects of these lesions some- times retain their flesh and strength should always excite suspicion of syphilis. It is the opinion of Fournier that, however grave and extensive the lesions may be, the disease will yield to specific treatment. The views of Rollet^ are of interest chiefly by reason of their contrast with those of Fournier. RoUet thinks that syphilis of the lungs is indi- cated by pronounced dyspnoea or even orthopnoea, besides a sense of ojipression or pain on deep inspiration. The cough is at first dry or ac- companied by bloody sputa. Percussion shows a sharply de{in<'-d region of dulness over the middle lobes, particularly on the anterior and lateral portions. Auscultation gives at first diminished respiratory sounds, and finally the usual signs of phthisis. He alludes to the statement of Gran- didier, that in twenty-seven cases the affection involved the middle lol)e of the riglit lung, and adds that conclusions should not be drawn without confirmation of the fact. He admits the diagnostic value of tlie fact that the upper lobes generally escape. The history of the case is of the greatest importance, and the coexistence of syphilitic lesions, the absence of a jihthisical tend