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Full text of "Outlines of the pathology and treatment of syphilis and allied venereal diseases"

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OUTLINES 



OP THK 



PATHOLOGY AND TREATMENT 



ov 



SYPHILIS 



AND ALLIED VENEREAL DISEASES 



BT 

HERMANN VON ZEISSL, M. D. 

I^TI PWmWOB AT TBI taFBBUIrBOTAL DNIVIR*ITr OP TIIBKA 



8SC0SD SDITIOS. BEVISED 
Bt MAXIMIUAN ton ZEISSL, M. D. 

VHTAT-DOOKHT VOk SI»*»1 OP TBI SKIH AMD ITPBtUB, AT Tar UtrXRUL-ROTlb 
DHIVVMIITT OP VIIMHA 



AUTHORIZED EDITION. TSASSLATED, WITH XOTRS. 

Br H. RAPHAEL. M. D. 
Atmnmta fhtbician poh dibbaaw op OKKiro-TTHnfAKT nnoANB and rtrranLa, 

BBLUTDB HOCPITAL DOT PATtSHT OIPABTMKNT : KKMBLU NEW TOKX 

oounTT irr""" "Tiir*' btc. 




D. APPLETON AND COMPANY 
1886 



886 

vw 



• • _■ ■ 



CilPWIOHT, 1S86, 

Bt D. APPLEl'OS ASD COUPANT. 



All right* raerred. 



0^ 



PREFACE TO THE AMERICAN EDITION. 



A TREATISE on SypMlis by one who has devoted his entire 
life to the stndj of this disease, and whoee experience is the 
result of observation and treatment of upward of thirtj thon- 
sand patients in private practice and in the wards of the 
AUgemeine Krankenhaus of Vienna, needs little additional tes- 
timony to attest its value. As a clinical observer of venereal 
diseases, and as a teacher, Professor von Zeissl stood de- 
servedly high in Europe. The concise and graphic descrip- 
tion of the various forms of venereal affections, the accurate 
delineations of the different phenomena of the pathological 
lesions, the terse and detailed account of the symptomatology 
and characteristic manifestations of the various phases pre- 
sented by the different specific diseases, the conscientious 
records of results obtained, bear evidence of the scientific 
thoroughness with which the investigations were pursued, and 
therefore must serve as a valuable guide to those desiring to 
study them. The prominence given to pathology in this work 
indicates the valne placed upon it by the author as a means 
to the proper understanding of the diagnosis and treatment of 
the various venereal affections ; and if it can not be said that 
the work contains an -abundance of remedies and formnlse for 
the treatment of the different phases of the different diseases, 



iv PREFACE TO THE AMERICAN BDITIOHT. 

neither on the other hand is it overladen with polypharma- 
ceatical combinations. 

The few notes and prescriptione added by the tramktor 
will not, he hopes, be deemed snperfinons. 

H. Hapuael, 

N»w ToBK, May, 1886. 



PUEFACE TO THE SECOND EDITION. 



TnE first edition of tbia book was compoeed for the pur- 
pose of |)kcuig in tlio hands of tlic student il brief guide to 
«id him in Llio studj of Sypliilis, lUvuig been reqaeeted bj 
tnj tiitbcT to reviao the second edition, it oocmrcd to me that 
the reader would be pleaded vith it still mora if, by making It 
Its briof u poBublo, it should be as grapliic and perfect in 
the description of tlie morbid picture of venereal diEeasea aa 
pottible. 1 fiought to diminish the eizo of the book bjr omit- 
ting certain Rpedal subjects, giving greater prominence to 
ctinical dcacriptionfl. Some cliaptere, which are only theo- 
retically important, or motliodn of treatment that are only of 
historical interest, have been briefly sketched. The sj-plulitie 
•ffoetionfl of the skin were taken entirely unaltered from the 
former edition, while tlie chapters on thera})cntica of gonor- 
rh«efl, of epididymitis, of etrictarc«, of chancres and eypbilie, 
■e abo the chapter on Tisceral syphilis and hcreditaiy ^^hili»^ 
hare liecn almost entirely rewritten. Here and there parta of 
tbo fourth edition of tlie *^ I^ihrbuch fur Syphilis," lasucd by 
my fiither and myself, were ns«L Professor ron Schrottcr and 
Ftofe«$or iUauthner were so kind as to write the articles on 
sypbilttic affections of the larynx, trachea, and eye. I am 
folly aware that the book offers little that is new, but it is not 
intended that it should epread any now doctrines ; it doims 



vl PREFACE TO THE SECOND EDITION'. 

only the modest task of presenting a comprehenfiible picture 
of venereal diseases and their treattDent as briefly as poesible 
tu the practical physician, whom time will not permit to I'ead 
extensive works upon every special branch of our science. 

It only remains for me to express the hope tliat this book 
will receive the same friendly judgment as the first edition, 
and that I shall succeed in concisely reporting my father's 
ideas, and at least preserve what he created. For the words 
of our great poet find their application in science too ; 

" Was da ererbt von dcinon Tatem hast, 
Erwirb os, oiu cs zu bcsitzen." 

VoH Zeisbl. 



COKTENTS. 



nam 

iHTRODUCnOH 1 

Thk Vzsxksu. Coktaoiohs 8 

SECTION 1. 

OOSOutHtEA (trippeb) ten ere Ai. catarrh. 

Slle of Gonorrhceal Affection and Mechoniem of Gonorrha-al Infection . . IT 

Fftctora thftt luuftll; favor Oonorrhoeal Infection 18 

Gonoirfacea of the Male Urethra 19 

Pathological Alterations in the Male Urethral Canal produced b; the Gonor- 

rlueal Disease 26 

Morbid Fhenomena which occur as CO'^ffccts and Scquelffi of Urethral Gon- 

orrlusa in Men 29 

Prognosia of Gonorrhisa in the Male 30 

Propbjlaxia against GonorrbicK, and Treatment of Acute and Chronic Gonor- 

rhcea in Men 3] 

The Indirect or biternal Treatmeot of Gonorrhnea of the Male Urethra . . 42 
Catarrh of the Gtans Penis and Prepuce, Balanitis, BtdaDO-Blcnorrhaa, Bala- 

nopjorrbffia, BalanopoBtheitia 46 

Phimosis and Paraphimosis 47 

Differential Diagnosis and Treatment of Catarrh of the Glans Pt-nis and of the 

Besuiting Inflammatory Phimosis and Paraphimosis . .43 

Affections of the Lymphatic Vessels and Glonda in coDscqucncc of Gon- 

orrbcea 91 

Inflammation of the Vasa Dcfercntla and the Epididymis .52 

Treatment of loflamniBtion of the Spermatic Cord and Epidid}-mis . .06 

Chronic Hydrocele. Hernia Aquosa 68 

Inflammation of Cowper'a Glands GO 

Morbid Alterations that are produced in the Prostate by Gonorrhoea of the 

Urethra 61 

Inflammation of the Seminal Vesicles in consequence of Urethral Gonor- 

rhsa 66 

Functional Disease of the Seminal Vesicle and of the Testicle. — .^pcrniatorrhaea, 

Seminal Emissions, FoUutio Uiurna 67 



viii CONTENTS. 

Diee&ses of (}ie Bladder caused by Urethral Gonorrhcea .... 69 

Discasea of the Kidney that are produced by Urethral Gouorrhma , . 74 

Oonorrbna of the Fem&lo 78 

1. GoDorrhoea of the Vulva. 7S 

2. Gonorrhcea of the Vagina 60 

8. ComplicatioDB of Vulva- vaginal Gonorrhoea 83 

(a) DiwucB of the Gknda of Bartolini and their DucU ... 83 
(h) Inflammation and Abscese of the Lymphatic Vessels in the Labia 
Unjora and Minora, and of the Lymphatic Glands of the In- 
guinal Folds 86 

4. Urethral Gonorrhcca in the Female 68 

Gonorrbtra of the Itcctum . . , ' 8B 

Gooorrhiva of tbe Mouth and Nasal Cavities 90 

GoDOrrhira of the Eye (Opbtbalmia Oonorrhoica Blenorrhoica) . . .9*) 

Treatment of Gonorrfaa'al Opbtbalmia 92 

The EfTects or Sequela; of Gonorrhoea in general and of Urethral Gonorrhea 

in particular 93 

Gonorrhtcal RlicumatiBm 94 

Condylomata ; Vegetations ; Spitze or Moist Worts 97 

Stricture of Urethra 101 

SECTION II. 

mrt CHANCRE OR CDAKCROID. 

Action of Chancroufl Vims and DcTclopmcnt of the Soft Chancre . . 109 

Pathology of the Soft Chantro 110 

Coune, Durstiun, and Cicatrization of the Soft Chancre . ,112 

Varieties of Soft Chancre 113 

Site of the Soft Chancre IIH 

Differential Diagnosis of the Soft Cliancrc 118 

Prognosis and Treatment of the Soft Uhiincie 121 

Prophylactic Treatment 122 

Abortive Treatment 122 

Curative or Methodical Treatment 123 

Diuaaes of the Lymphatic Vessels and Gland?) (Li-mphangloitis and Adiuilis) 

in consequence of Soft Chancres 128 

Buboes originating as a Result of Soft Cliancrcs \"'i 

Site, Shape, and Size of Chancrdd Buboes l"<5 

Differential Dlagnouis and Prognosis of Buboes 137 

Treatment of Dineascs of Lymphatic Vessela produced by Chancroida . ,139 

The Treatment of Open Buboes 14 1 

IlBtale In ooowqncace of Suppurating Buboes 142 

SECTION III. 

BTPUILIS. 

General Conception 14S 

Nature and Vehicle of the Sjiphilitic Vims , . 145 



COlfTENTH. 



Tte Truimi«BiUUtj of STplillte, at Um Vttriou Waft >■ whkli QjrpUIUlo Ift- 

frdioa uuj ul:« plkoc M( 

TnuHnlHlgn of Sniltilii) tqr T>wiBftllOB.— Tfca lUlatiaii of Tatdne Ijmpli 

ta fljiiUliUo Vliui U7 

TrsiwaiiMibilit; o( iHjpbilb t» Vam-bliwdeil AnJiaale . l-IV 

Pint MaaifnlAlioa of the Actloii ol tiM Syphilitic VIrua . .NO 

AuAUnj or ihc Sjtihnilic Inillal tteI«rMiii 1)1 

fill« aail fomi of (fau Buulvrisii Iiidunilioa IIS 

Oaablacd BOvcta of tbc Syphil'lic Tlnw aiul uf tlte Cliuicrulil TiruH . . \M 

InooolatiUbr of the 8ol«rotk ni<vr 1M 

fttpilliiTiirii . DunlwD, Courve, m»1 DiBcreDtuJ DiagnuiB of tlw Sfpliilitio 

UitUI Sdciwli [nurd ChMcaoJ IM 

ITMidty of Ih* STphJLitto InlMlitni , . . lU 

ASkiIoiu at the LfiBphttic ^:n>tefli ooouioncd bj BtcinniDg Sn^hHli . . ISt 
InduMkM uut HTpcrtraphj of ibo PcrijibeRiJ Ljmpballv V«»ela ia con- 
•oquniM at flvptiiUtle iDtection ........ IAS 

TIk fVpfaiU^*-' l>'atbuda \M 

pBtbologbMl Altcrftiinn of die Bhxid of^xpliilitio P«noa* . .10? 

Inipti'raFtrtTefSjrpliilu IM 

TtaM of Eruption gf 0«dm»1 SfphDia IM 

fiO«ftUnUm of lb* 8ypbililic Fod I«t 

TU Ou^bexU pM>do«>d b; SyphlHs 174 

OoMbloMion of 8;plillia 110 

Saoenriin and Dmm» of S^iliUc Affections ...... Ill 

IkrelopncDt, OmrMi, and Duntltia of CvnalituUotut] BjphUk . .171 

Horulltfof OootUiuiloiul Sjrptillii lit 

[}«iralDpm(-iii of I.Tntpboll« Olwidtibr Swnlllnp origi&atlMg In the CoutM of 

STpbilis (lluhiplc liktdtia) K4 

KoitiU Lnkim of the 8ldn coasod b; Sjrphni* (Qr^'tlo Mmmm of tlM 

t;kib_ejpUlkk«) 1?X 

DaliBhloiiudChHUcalliiiiorSjItlillliicSUn-DlMMM .160 

I. The Brrtbnut Sjpfailiilc. Erjibmia StP^II'^i" UMitlanni «t Pnpu. 

laiuiB, Bawnl*. %ibUllie*, Sy|>bU!ti« S|>oU 180 

a. rapolor STpbillitea lU 

{<■) IxvtIcuUr, Papular SjpWIido 188 

(() &ii«l1 PapuUr Syphillih (SfphiUa FkpiilDiw Hiliarb) , . im 
(«) Tlic Pspnlaf STpUlidc^oretttiunonagjrphllidcof ikcralmaottlM 
Huub and SoIm of tbc Fbm (PaDriaila Palmarti « PktHatU), 
and STpUUUo DiSvied AffMtion ef Um Sternal Strau of 

Ibc [Ian<i> and Frvt (SypliIIls (^nm) 191 

ifi) TliP Biiuiul or MoLat Papolea, or FlM CctuljlonuU ; Papnlf* 
BuirddM ; Pimtula Faikia Ani ; FuaUlisa, Plaloa, olo, of Va- 

rloua AutbO're 196 

S, PMInlar Sr^hOIih) Siil 

fa) Tbo Acn«>-11)co Sn>1><I><I« 302 

it) Varicolla-likc Bypluliilc or Tarkuna S7pUUl>Cft .304 

fc) (Bi|wtigoSjphaliliM. ........ SM 



X OOSTENTS. 

(rf) Ecthyma Svphiliticum 209 

(_e) Rupia Sjphititica 211 

4, Nodular Sypbitide of the Skin ; Tubcra Syphilitica ; Tubcrcula Syphi- 
litica ; Syphilitic Nodes of the Cutis and of the Subcutaneoue Cellu- 
lar Tissue (Gummata); Syphiloma, according to WagDcr . . . 21!) 

The So^alled Pigment Syphilis 228 

Syphilitic AfFcetions of the Uidr 222 

Syphilitic Disease of the Nails 22S 

Syphilitic AfiFcctions of the Mucous Membrane 226 

(1) Syphilitic Erythema of ^he Mucous Membrane; Syphilitic Catnrrbal 

Inflammation ; Erythema S)^hililicum Membranie Mucosid . 226 

(2) Syphilitic Papules on the Mucous Membrane 227 

(3) The Syphilitic Node or {luniina of tlie Mucous Membrane . . 231 

Syphilis of the Mouth and Fauces 238 

Syphilitic Disease of the Tongue 238 

Syphilitic Disease of the (Esopb^us 244 

Syphilitic Disease of the Stomach and Intestines 24B 

Syphilitic AfTecIiuns of the Liver 247 

Syphilitic Affection of the Spleen 250 

Syphilitic Affection of the Pancreas and of the Salivary Glands . . SCO 

Syphilitic AScctioDB of the liarjni and Trachea 251 

Syphilitic Acute and Chronic Catarrh 262 

« Papules 258 

" Infiltrations, Gummata 254 

" Ulcers 26G 

" Perichondritis 261 

" Cicatrices 261 

" KewGro<rthB 263 

Syphilitic Affections of the Bronchi and Lungs 263 

Syphilitic Affection of the Kiilney, Suprarenal Capsule, and Bladder , 269 

Syphilitic Affections of the Testicle and Spermatic Cord . .265 

Bjpbltitic Affections of the Ovaries, Fullopian Tubes, and Uterus . . 270 

Syphilitic Affections of the Mucous Membrane of the Genital Organs of Both 

Sexes 271 

Syphilitic Affections of the Corpora Cavernosa Peui^ 27^ 

Syphilitio Affections of the Breasts 273 

^hilis of the Heart and B)ood-V easels 273 

Affecttoos of the Brain, Spinal Cord, and Peripberal Nervc:>, as a Result of 

Syphilis 274 

Syphilitic Affections of the Nose 2H0 

Syphilitic Affections of the Auditory Paii.engcs 284 

Syphilitic Affections of the Eye 2$5 

Iritis Syphilitica 285 

Affections of the Ciliary Body, the Choroid, and Vitreous Humor . . 21'0 

Inflatmnation of the Retina and Optic Nerve 29^ 

Affections of the Cornea, Conjunctiva, and of the Eyelids . . . 293 
Affections of the Orbits, Lachrymal Sac, and of the Muscles . . 294 



CONTENTS, xi 

MM 

STphilitic Affection of the Bones and thdr EoTelopea 89D 

Sn)lulitie Inflammation of the Periogteum ; PeriostiUs S7philitic« . . 297 

Ostitis SjphfUtic& 800 

CScatrintioo of Sjrphilitic Ulccra of the Donea 803 

Site «nd Effects of PerioBtitis and Ostitis 803 

Differential Diagnosis of Affections of the Bones produced bf SyphiliB . . 801 

STphilitic Affections of the Joints SU5 

Sjphilidc Affections of the Cartilages SOT 

STphilitio Affections of the Muscles, Tendons, and Sheaths of Ten- 
dons 808 

Sjphilitic Affection of the Burete 810 

Endemic Sjphilis ; Leproid or Svphlloid Disease 811 

Malignant or Galloping Sj'philis 812 

Hereditarj Syphilis 816 

Manifestations of Congenital Syphilis 819 

Macular Sjphilide in the Infant ; Erythenia Maculo-papulatum Syphiliticum 

Neonatorum 820 

Papular Syphilide in the Infant 321 

Pustular, GuminouB, and HEemorrhagic Syphilide in the Infant . . 822 

Syphilitic Affections of the Mucous Hcrobrane in the Infant .... 826 

Syphilitic Affections of the Bones and their Envelopes 826 

Affections of the Eye in consequence of Hereditary Syphilis , . 328 

Morbid Alterations of the Internal Organs resulting from Hcrcditaij 

Syphilis 829 

Diagnosis and Prognosis of Congenital Syphilis 333 

Syphilis Herediuria Tarda 334 

Treatment of Syphilis 83i 

Prophylaxis of Syphilis 337 

Treatment of the Initial Lesions of Syphilis ; the nuDtcriao Indurated Chan- 
cre ; the Indolent, Multiple, and Strumous Buboes .... 340 

Treatment of Secondary Phenomena of Syphilis 342 

(A.) Expectant Method 842 

Therapeutical Application of Iodine and Iodine-Salts against Syphilis . . 346 

(B.) Medical Treatment 846 

The Treatment of Syphilis by Vegeteble Remedies 360 

Therapeutic Use of Mercury 862 

Mercurial Preparations irhich are best adapted to be introduced into the Blood 

through the Digestive Oigans 868 

External Application of Mercury and its Preparations 368 

(a) Mercurial Inunction Treatment 308 

(6) Ilypodcrmie Mercurial Treatment of Syphilis 871 

(c) Treatment of Syphilis by Mercurial Fumigatinns .... 374 
(<f) Treatment of Syphilis nith Baths containing Mercury .- . ST6 

(«) Treatment of Syphilis by the Application of Mercurial Suppositories 
to the Mucous Membrane of the Rcctiim . . . S76 

Pathogenetic Effects which Mercury and its Preparations may produce during 

Treatment 376 



3di OONTElfTS, 

Effects of Gold- Water Treatment, Sea-Baths, and Sulphur Thermal Baths on 

Sjphilia and oil HydrargjroBis 880 

Sjphilophobia and Hercuriophobia on QTpochoDdria Hercurialis , , ., 881 

tjj'philizatioa 882 

Tteatment of some of the Local Syphilitic Affections 883 

The Nursing of the Syphilitic Child and the Treatment of Congenital 
STpbilia 388 



DfTRODUCTION. 



IxPEcnoDs discliai^es from the genital oi^;aiui of tmtli hcim, 
uid ulccntioiu on Uiuec parte, must liavobeon known in oideo 
timcfl, even in Uie remoteef antiqtiity. Tlicre \e an itllwion to 
au "DDcIean Beminal diediai^" in tUe third book of Mosca 
(LoriticQB, chap, xt), and the Banitory rcgnladona prescribed by 
Uoees hinuclf indicate conclusively tbe actiial infectioos na- 
ttiTO of «nch seminal disrhar^es. It is likewise Been, fmm the 
writings of the oM Greek and Roman phyeieiaiw, tliat thpy 
treated ulcers of the genital orgnuB which woro caused by con- 
tagiixi. 

At the end of tlie fifteenth century many pereons were at- 
tacked, a» in ai) epidemic, with morbid phenomena, eepeeially 
diieaMs of the skin, whuM origin Uio pbyncians of thotto times 
regarded an being due partinlly to telluric and partially to astral 
causes. Theee affections were supposed to originate in a gen* 
oral dctorionitiou of tlio curdiual evcrctioDB of the liody and 
the liver as bein^ the fountain of ihn dinpnAc. Not until it 
became apparent that theee diseaaee prevailed nmong the troops 
of Cbarlo6 Ylil, which occupied ISapIcd in HS)5, and occarrcd 
cfpceiaUy among those women with whom they had scxval in- 
teroouiw, did many j^ysieiiuia become oonvincd that the dis- 
eases in (jueetion originated by transjiortatioa from one pereoa 
lo another — tliis trannportation or infwticm occurring repe- 
eially during bosuaI congress, and Flarting with an affection 
of the genital orgaua. These ctrcunutanccs led Fenielina 
and Bcthcnconrt to call ttiia di&case venereah or the trfnvria-, 
and also "lues venerea." For the aamo reaM>n it waa also 
called mentulagra (from mcntulii, penis), when it attacked 
men, and pudendagra when it attacked women. At tlie time 
wben it prevailed a« a pest it received variooB oainca, haaod 
1 



S PATBOLOar ASO TNEATMEXT OF STPHJUS. 

mainly upon p^ograpliical groiiiids. The Froneh called it '* tnaJ 
do Naples" aoil "la gn»SBe viSrole"; tlio S[iaiiiani8., '" Ua bu- 
bas" (poclcft). The Uemuins anil Italians Ciiilcd it ''mal dc 
France " ; tJie Poles, Uie " Dutch, disease " ; tlie Dutch and 
English, Uic'-Spaniak"; die Oricntds, the "FreDcU"; tlie 
I'ortogaefie, the " Castilian '* ; tlio Poreiana, Hic "Turkiah"; 
and the Chineee, the ^disease of Kan ton" (Konang tang 
Trichouang). But all these diwignatione were eopplaiited by 
tho name of ayphilits wliii^hhuB bcuu universally adopted. 
This tenu ttu ^t applied to the dieeaae bj Hierooymns Fra- 
ciu4oriiv<, deriving it from a sbepbcrd by the name of '*Syphi- 
lus," whom he apoAtropbizee in an ode:, u tlie Unit to auffer 
from this diaeaee beoaoeo bo had ofiondod tlio gods. Othoro 
derive tlie mime ^yphilU from Uiv (<n>ol{ word attpx6<;, broken ; 
others, again, from llio wordi; o-lv and ^\ia. 

The bifeodonadiBcliaripM from tlie geoltal organs are called 
hi malei^ "gouorrbcea" — fliixus aive protluvium eominis, from 
4 fov^ semen, and Juitr, to ilow ; in f(;nud(.», " iluor*' ; in Ger- 
man, " Tripper." The temis blennorrlxBa and blenoorrhagia 
niiKrifltixiDt, from to ^KamK, or ^ d^firoo., mucus, and f)eu>, or 
furp^vok, were firet ublxI b)' t>wodiaur. 

We are indebted for the designation of the word "obancre^" 
tt fipplic-d to a dorc on the genital organs originating from ecx* 
aal intc-rcoune, to the French, who subetitntt-d the word chan- 
cro for cancer, which Celsne bad selected to dedgoate this dlA- 
oaw. Witli tlie won! cimoer Celsim wi^ied to describe the 
spreading, corroding, malignant character of the nicer. The 
pbysiot&ns of the thirteenth and fourteenth oenturioa selected 
tlio whpiIh "caries," "caroli," or "taruli pudendum," to dea- 
igoate such malignant contagions ulcers. 



THE TENEREAL CONTAGFONS. 



PKRXRurM WM one of tlio first ti> properly comprplicnd tho 
connection Ijclwcvn d!fi«a*c« of the genital parta and syphilis. 
He anggcfited the hv^otlieeia of the extatcDce of an nnitnol poi- 
son which he called the Tenoreal poieon. This virus, FerncliuB 
bcUerod, developed not only in tho pnmlcnt secretion of cee- 
taia tilcent of tho Rkin and mncous tncmbrano that originate 
daring goxuot inlcrconme, but alHo in thu uiuoo-pDmlent dis- 
eliiige of the inflnmcd. or oatarrhal niTectod mucous mcmbmne 
of both 80X68. From tUcBo two affeelione of tho gonital or- 
gans, FemeUiw eontendeil that the venuntal virus pisses Into 
the secretions of the body and tlicn attacl» nometiincd one or- 
gan and then a^n another. lie was therefore of the opinion 
that Eyphilis, until then stich a myAteriotu disease, resulted 
from wull-known nifections of tlie mnrous mcmhninea and of 
the stiin covering the scxiial organs, ifhich wo to-day desig- 
nate as chaucrc and goii(irrii<ra (cUp). 

The opinion that gonorrhoea and chancre were the com- 
nencement of eyphilts prevailed till the Rcoond half of the 
eighteenth c«ntnry. In the year 1767 Balfonr, an English 
surgeon, poeitivoly averted that gonorrhopa and syphilis were 
eeeentjally distinct diseases. Balfour's asMjrtinns, however, 
vcre Btoutly oppiwed by John Hnnter. wlio, in 17fi7, first 
iostitated comparisons between tho two diseases by perfonu- 
ing inoculations with the secretions of venereal catarrhal af- 
fections of the niueouB meiuhranea and of vwriereal ulcer* of 
the skin. Hunter inoculated the penis and prepuce (whose is 
not stilted) sritli pas which he derived from the nrothni of a 
patient jtrtMumaltly alTt^tcd with gtinnrrhota. As ulcers do- 
Tctojied fponi these inociiIation.i, npon which induntion of the 
tjiDphatie glands of the right groin eoon supervened, and a 
few nioQthft later alcere of the tonsils aod a nweok omptioo 



^ATUOLOQT Aim TREATMENT OF 8TPBTUS. 



bccuinc sujicraddcd, wliicb e^-mptouts of constitutional ejrphilift 
were jiritiiiptlf cured by Diercury, Ilantcr deemed the idcntitj 
of g<juvrrliiKk and chancre ;l8 vuiuplete, and cousequentlj? abo 
of ^le oontogion of gonorrli<ca and sjpliilis as concliuire. Tbe 
difference in the form of tLe iiianifc»latioiu of this oonlagion 
Uo believed to bo due otdy to the diJ^emuceB in tho anatomical 
structures upon wliicti the lesion was pnxluced. Upon the 
seorettDg maoous membmne tbe pcii.<K>n in, question produceft a 
cataniial, upui tbe gt-nend cutaut-ou8 covering an ulccmtire, 
proooB. 

Tbe first one to oppose Hunter in this matter was Ben- 
jaoiia J3cll, of Edtubujgb. lie adduced tlie following facte : 
Two yoatig persons «»riHed the skin of tlieir glaii» penis and 
prepuce wiUi a lancet, and allowed bitd of cliatfiic ilip[>cd iu 
gonorrluual matter to rumain Iu contact witb tbe scaritlcatioiis 
for forty-eigbt hours. Id one of the young men a balano-Wcn- 
Dorrhcea etuaed ; in tbo other, some of the dripping pii« gained 
V) entrance into the urethra, in conaequcnce uf which a catar- 
rhal disease developed in two dsya in tbie canal. On tbe otber 
Iiand, one of tlie eJCperimenteHi, by earryiug tbe pus of a 
veneraal ulcer of the skin of the genital oi^ane upon ■ prubo 
several niillimetrce deep into the nretbral canal produced a 
punful ulcer at thin place, which wua followed by a enppnrat< 
ing bnbo. Notwit1i«tandiug ihis and many other similar ex- 
periments, the virus of goiiorrlioail witli chancre contagion WM 
SDppoAcd to be identical till tlie tbirtietb year of the prc(>cnt 
century, when Ricord first tool: sides in tlie matter. Ity tbe 
aid of Rccaniicr's vaginal speculum, which was used very 
little by bis prcdtocasoK and coatcinporariea, lUcord disproved 
Iluntcr'B views, by the fact that venereal ulcers may ciirt 
upon Ibc mucous tnembraiie of tbe vagina and of tJio ueok of 
the utoms, and consequently tbe vaginal discharge may be 
tainted with that of the chancre. From 1S31 to 1837 he per- 
formed. 667 more inoouhtious wilh gononlm-al matter, and 
from none of tbc«e lUd any cliaucnvulocrs result. Finally^ 
Ricord proved that not infre<|nently the mattt-r that cxudca 
from the uruthra is duo to a chancre-uletT sicualcd in that 
canal, which upon inoculation produces a puHttilo from which 
a chancre will develop. 



TBB VESEUMAL CONTAOWNS. 



With these and other e::perimontal iwearcbee all apparent 
eontradiplionfi wore explnincd, and the independence of the 
gonorrhiL'al coutagium wag iuconteetaUly proved in every way, 
both an regards ita indirect an veil as ita direct effect. 

With tins progress of fidence *nd more carefully ohecrved 
clinical facta it soon becanio inxnifi^fit that not all ohaneras 
WBre follon-c!(l by gyphtlitie lesioutt. IFutiter, who, although he 
looked upon goDorrhcsa and iilcem on the genitalii ariiiing 
from Kxnal contact as the effects of one and the Bamo poison, 
ncTurthclcw maintained that not aU the ulcers on the genital 
organs are of e-ypliilitic natnre^ He <inly dc«tgiiatcd wich niccra 
on the genital organs chancre that were followed by evphilia. 
Aooordii)|^ to Hunter, the chancre vm dietiuguished from all 
other sores on tlio eoxual orgaiiB by a dense, bard, eclerotic haso 
and by elevated indurated borders (Hunterian induration). 
All otfierwUo coDBtitttted non-indurated nlcers on the genitals 
wore, in his opinion, not chancres ; tlioy vera aimplo, ordtnarr, 
non-infeetiouB nloera or secondary aypbiUtle sorea These seo- 
oodary syphilitic »ires wero said to be diNtioguifihed fmm the 
primary florpg by tlie faet that they wtronot eslIoTW, did not 
apread rapidly, produced no adenitin, were not auto-inocuhible, 
and healed rapidly. At lirst, RicorJ made no dietinctiou be- 
tween the induratt-fl and non-indurated nieeni, calling them 
both ulcerating chancres, and deeming both to be tlie effect* of 
one and the »anie vinu. He called the vinia *' chancre-poison 
or primaiy Byptiilitic poison," which in aome cases — nut, how* 
ever, in all— ih followed by ayiihiliH, and wliich, according to 
the grade and pha^e of devcloptnent, he embraced in the 
category of teeondary and tertiary affections. Gradually, 
however, bo approached the poftitinn held by Hunter, in to far 
to admit tlut only that chancre which was aitnated upon 
a bard ha«e, or left behind it a hard cicatrix, was capable of 
producing {jencral pypbilie, and pnch cliancrea he therefore 
colled '* infecting chaiK-'ro^j." The induration thns eelabtit-hod 
WIS looked upon aa a criterion of conuncneing blood-pouoD* 
ing. Tile rciiRon wliy indiimtion rc>«iiilted in one case and not 
in another, he maintained, was not due to the difference tn tliK 
character of the virus, but partly to its more or less weakened 
power to infect (vimleecencc) and partly to tlie difference of 



6 



PATHOLOGY AND TREATMENT OF SYPHILIS. 



tisene upon which it was implanted. lie regarded the Ilunte- 
rian or tUo infecting L'liaiicri> nierely a^ a cariety of eliancre-in- 
fection, nnd which i» sddicioiially distiDgimhod from the other 
variuCii's by thu faut tlial it occurs but oiice apou one aud the 
Rarno iiullviduHl during \m whole life. Finally, Ricord, like 
ilimtor, held tlmt the primary sore w&£ the eole foimtaJD of 
syplulia and denied the ability of eeoondary mauife^Utious to 
tranmait Lhc ditteasc fiXHu uuc perMjn tu aiiolher. 

This theory of ICit-ord, which has been called tlte unity or 
identilij theory, was 6ood shaken by experience, which con- 
flicted with iL It voA rei>eut«dly observed that a ]itirsoii liad 
simuHanioualy a soft and an indurated chancre ruarcacA other^ 
chat many persons had multiple couta^ious suit chancres, with- 
out being affected eubsuqucntly by syphilis, wbilo in another 
person a eioglo hard ulcer was followed by constitutional niani- 
feistattoua. Laatly, numerous confrontations of iitfected and 
infecting patients showed that the indurated ulcer was alwayg 
produced by simiUr or secondary sji'philitie ulcers of tUo per- 
son inf*>ctiog, wliile a isoft cliaiiere, attended only by local 
Byuiptomg, propagated throiigb contact only a local sore wluch 
was soft in eharactur. All thcee circumetanooB lod one of 
Rioonl'a eclwlaxx, Ltkm Basscrcdiu, in 1852, to eatabiiBli the 
propooition that the »At cliaiicre wus not a aonrcc of syphilis. 
In conjunction with Clerc, another pupil of Kicord, he pro- 
pounded a new theory, munoly, the ditcUtiy tJmortf, by wliich 
ho maintained the existeaoe of two OBSoatiaUy ditlcreut chancro- 
poiaooB — tlio Hoft and tlie indurated — both of wUicU are in- 
debted to two totally dificront contagions for their origin. 
The eof t-cbaxiero son, be maintained, was always a local diacaae, 
and waa only capable of acting i>ermcionflly upon the general 
system by eauaing suppuratiuu in tbo adjacent l^nupliatie 
glands. But the hard chancre nlwa^*8 IihI to blood- jioitiuuing 
and conadtational iymptoms. Though, to he sore, it likewise 
causes ewelling of tlie adjacent lymphatic glands, they nerer 
or very seldom paw on to i4itp]>iinition, and ibc pna they con* 
lain can not by pn)pagation pHxluce a chancre Tliia new 
theory of BaaBereau and Clerc 'wasaoon adopted by Kicord and 
Founder, and formulated in the law that each variety of chan- 
cre was only capable of propagatiiij; its own kind. 



THE VSyEBEAL COHTAOWJ/S. 



The Boft cliancro or chancroid mftv be produced bj inoca- 
latioD QpOD soQud as well as npon 6>-pliilitically ditnia^ tie- 
sues; tbo bard chancre con only be roprodnocd hy iooculatioD 
upon healthy tUeues, and nevei- upon any that is already sypbi- 
titic 

Clerc, it \& true, »ic>oecded, by iuocuUtiom with matter from 
a hnrd rUuncre, in |irtK)uciug uk^em, which be designated by 
the name of " cbancroide," and which be boUcTod to bo of a 
timilar naliira as tbo soft cbancro. lie therefore maiutauied 
tbat tbu Boft chancre waa a Ixwtard product produced by in- 
ocBhuing a syphititit! [>cn»im with an infecting chaDcre, wbioh, 
if It were once developed, was capable of propagating itwlf 
in an endleas merits, without ever aagaming tho primitive char- 
acter of an infecting chancre. 

In Jiicord's '^Le^ond eur le chancre" cases were, howereri 
voportod wliicb were supposed to prove tbat Oerc'a chancroids 
were capable of reproducing the infecting chancre and the io- 
fccttog chancre a soft chancre, even upon an indindual who ia 
p<>t f>ypbilitio. In order to &nve tbe dualism theoiy that was 
now <tpp<iivnfii/ tottering, Rollet, of Lyons, snggCBted tbe by- 
potlueis tli»t buth [Miisonti can Im trautimitted simultaneously, 
and tbo reeult of tbiii tmnRminiion iti a ** mixed " clutDcre (chan- 
cre molet), whose auto-iooculation upon tho eamt; or npon a 
^ypbilitJo ponoD would produce positive ru((ult«. IrTliile tbe 
French physicians contiuuud to entangle themselves by ono- 
sidod vieira of tbe fcoina of the sores in a labyrinth of contrar 
dictions and uamea^ other invuetigatore dccniiug the contagions 
tliat formed the basis of the ulcers to be of prime importance, 
and supported by cxperimeuts as well as by exact clinical ob- 
•ervations, were ^ood able to tbrow new Ugbt upon the action 
«f tbe soft cbancro aud of sypliitis. Tbo results of the ro- 
searches instituted by "H'allace, Waller, lioineckcr, Lindemann, 
DauicUseo, Yon Biirensprung, lliibbener, Lindwunn, Hebra 
and Hosoer, Pelizzari, H. Zcisel, and nuuiy others, together 
with our own clinical exporienco, enable us to lay down tbo 
fullouing principles : 

1. Tbe poigoDS of tbe soft chancre and of syphilis are totally 
diilcruut from each other. They have only in common tbe 
external (juality that both of them are most frequently con- 



8 



PATHOLOGY AlTD TREATMENT OF STPBIUS. 



tncted dnring scxool congretts; Ki5ncc soft clianercK, like pri- 
mary syphilitic lesions, arc more often fuund upon Uic puuital 
orgaiw of both «c.x«. 

8. The pus and tieeac d(}tntUB, disorganized hy the chancns 
infection, are the vehieW hy wliich the poison of the chanert 
is conveyed. The virus of eypliilitt is nnited eepoctatly with 
the disoi^oizod dotritus of the eyphilitic inflammatory prod- 
net, and also with ihu blood, and prulwhly willi die semen of 
gyphilitic perKjnt. Tiie experimental inoculations performed 
with the hlood of srphiUtic patients produced positive results 
in some thou^ not in all casut. Why all syphilitic parvnta 
do not beget ayphilitic children in ittill unexpklned. 

3. Pus from an abscess or tbe contents of a non-eyphilitio 
oraptiou on a syphilitic person, when tnuisuiitted to a hcnitliy 
individual, have not hitherto, in our LXpcrimeiits, produced 
ayphilis. 

4. The poifion of a soft chancre reprodaces itself, if trans- 
mitted upon a s^-philitic pereon, in tlio tame manner as in a 
healthy one. The discharges from a soft chancre sitnatod upon 
a Byphilitio individual will always produce a soft chancre only. 

5. If tlie tcorctions of a suppurating gpociBc primary lesion 
are inoculated ujton its possessor or upon another syphilitic per- 
Hon, there re^nllj? iip4>n m>me of tlit; luetic (K^'jiliiHtic) |Nitients 
80 inoculated au ulcer ; hut (his ulcer need not necessarily be a 
primary specific ulcer, because a person who is already loetic 
can not while he is still (syphilitic again acquire sypliilis. We 
maintain the correctness of the pruptnition that a primary 
syphilitic lesion, as such, can not be reproduced npon its poe- 
aoeeor. 

6. The minimnm qnantity of blood-particlcs which ie apt 
to be present in a ehaoore of a eyphilitin pcrsou ie not capaUlo 
of producing syphilis. But if svphilitic inflammatory prod- 
acto, 8Uch lui papuleg or nodules, arc made to undei^ siippum- 
tion and disorganization by implanting upon them chancroid 
vims, a pustule iiuiy !« pro<luced, and if tliis detritus Iw then 
inuculitMl upon a noti-syphititic perMni,an initial sypliihtic pri- 
mary sderosia or hard chancre will develop. 

7. Little as tliv purulent sputum of a syphilitic person when 
tnuumittod to a hcaltliy person can produce in the latter erphi- 



raS VENEREAL COSTAOWNS. 



lis, 6o littlo ^rill the pus of an abeeew or tlie oontente of a n<m- 
■pectDceniptiou fnim aeypliililie patieat produce sypliilis upon 
ft hcaltliy tndivtduul. Ouly tli« piui or die strnctnral debriti of 
the products especially belonging to Kyphilis is capable nodor 
broniiilu cucuinKtancCfl of producinp syjiliilia. The suppoei- 
liuD of tlie exIsEence of i mixed cliancro, in tbc bcdm sdvo- 
oatod bj tlic Lyons kIiooI, ve ha%-o discarded long ago. To 
be mre, we have to admit that tlie aecretion of a soft chancre, 
if tmplatilod upon a eypbililio eruption, will exercise ita de- 
stroctiTo action in the same way as n|Kia p«rfo«t]y hcatthy tia- 
6uee; btit if (he difiorg&mxation of the syphilitic eruption 
through the clioncrous virtu bos once been e^itablished, the rc- 
solting nlecr will tlicn bavo nothing in common irith the soft 
chancre. >'ow, if the \ms of art iuflaramator)' eyphilitic prod- 
net — for instance, a Bvpliilitie papule brought to the elage of 
sujiparation by irritating it with tbo secrotion of a soft chan- 
cre — ift iInpl.^uled upon a boalthy pcivon, Byj)hiHs will be pro- 
duced; while the Kime soft chancre if inoculated upon a s;,-pbi- 
litic indtvidual at any place that is nnaffected hjr aypbilitic 
iufliunmat<>ry product will occacinn a soft chanore only ; and 
this, again, if inoculated upon a healthy person, will give vim 
to a Boft chancre only, and produce no sj'pbilia. 

8. The syphilitic primary effect or IcNOU may appear in 
three fomiK : Fin^t^ a« a KU[K;riicial erosion or deep nicer with 
hard bnnlers and hanl base ; Bocond, as a hard nodule or ker- 
nel, which iu the progress of the di^aee breaks down; and, 
third, as a bard nodnic, that from its origin to its complete 
resolntion shows not the least trace of breaking down. 7'h« 
typhiiiti'e prirnartf Uvion is the Hn^t manife^tion of yfjuraly 
cofutitutional a'/pAUh. 

9. Tlw most imjwrtant data of the ejphilitio priinaiy lesion 
an the peculiar cartilaginous hardnees, whether the flyphilitic 
chaucre appoars as a nimple nodule or as a bard nicer; next, 
the indolent swelling of the lymptiatic glands that acconipuue^ 
it and the scanty suppuration. 

10. If a eyphilitii! iK-nton is inoculnted witli orrlinary pus 
or any other irrilaling tluid, ajmn an incision made witli a clean 
Tsccinating-laiicet, tlicro will eomeUmes result, in consequence 
of (Ills irritation, a syphilitic nicer. 



10 FATHOLOar AND TREATMENT OB SYPBIUa. 

11. Tliere U no cliaocroas Kj'pbiliB, no pritntry aod no ue- 
oodaiy syphilis. It is only proper to speak of diancrfr^ypbt- 
lis wbea it is desired to indicate that the chancroid poisun wu 
mixed with s^piiilitiu {x>tc»ou. The Uimteriui iudumtion niay 
indeed be looked upoa as ttie finit maoifoitstinn of 8f-phili« 
that is about to develop, but ia by do woanB to be refrardcd aa 
B primBiy evil wboiw vinu in tliu cuiirve uf uliMirplion will 
become converted into the so-called »ecoiidary evpliilitic rlnu. 

To the principlea eDUDciated onder § & wo miut add a few 
words ood also refer tbe rtuder in the cliapter on thu "Inoc- 
olability of the Indonttcd. Ulcer/' which will bo ioand far- 
ther on. 

It ijt an irrefiitablo fact tliat it is po«sible, by inoculating a 
luetic individual tvith syphilitic pus and syphihtic nlnftnlctri- 
tua, to produce piutulcs and ulcere. Xow, the qasKtioD arises, 
What Id the nutun! of th<Mt! uhrem, wliieb Ctero,for the Make of 
brevity, Htyled '^cliajicroiduK," aiid wtiat liappens if a be«lthjr 
person ia inoculated witb one of them i i3efore we answer 
Uiose qaeedons, we hare to prctui^ a few reuurks. It has 
been ascertained, through experiments made by many pliyst- 
etaDB, that even the pus from ordinary fikin-diaeafie — for in- 
stanoe, a pimple of the face — may in some' caece be oacd for 
repeated aut«-inociil»tton on healthy persons. In lhi» way the 
prinoLpIe of ttic great«r vulaerabibty of the skin of a syphi- 
litio person was partially refuted^ and wc most restrict onr- 
SoItm to tbo statement that we can obtain positive rceiilts in 
wnne cosea by inoculating healthy penuns with any kind of 
pug, but tbat sncli iuoculationg take effect more readily in 
syphilitio persMis. It is, therefore^ easy to comprehend why 
wv can HO often produce ulcers by luocuIatiDg syphilitic per- 
sona witli tile puH of a Kyphilitic emption. The question next 
arises. "What happens when we inoculate a healthy pereon with 
tnatter taken from sacb a " chaneroid " J The result may be 
of three kiudb : rinjt, the inocukitlon may not take ; or, second, 
an nicer eni^ueB wliicli rtTnaing localized ; or, third, a t^yphilitic 
primary Icedon develops, followed by consecutive general syphi- 
lis. Why on inoculation iuU wc arc unable to explain. The 
socDod and third conditionB wc consider as explicable in this 
wise : The ^philitic contagium is not chemically soluble and 



TBE VSSB&EAl CONTAQI0S3. 



11 



is Dot nniformlj' dliftriWiitod iu tlie Itltxid. Xon', if wc bear in 
nuDd Cbaiireau's experimente with vaccine lymiih, we can as- 
euino tliu foUowiug facte : That in raocioatiiig we only tnma- 
nut Ijmph aiid eucli particU-j^ of matter which accidentally con- 
tain no syphilitic virus. In this cose, if tho vaccination takca, 
we will only prodace a simple local ulcer, which does not bear 
tho oharaotora of a syphilitic priinary Iceioii. Bat if we tnne- 
tnit pns and aueh particles as do contain iiyphilitic vinis, w« 
will, in the third ease, prodnce a Bvphilitie primary lesion that 
will be followed by general, constitutioniLl itypliilis. The vac- 
ctnited sure tliui renuuiifi localized may be compared to the in- 
oealated Qtcora, which may be produced ou luetic and healtliy 
peraoDs with ordinary piu, and which may be reproduced by 
repeated inocuUtton<i. liut if It is intended to regard these 
inoculated ulcers a» soft chancres, tbcn every iuoculatul nicer 
produced with any kind of matter would hare to he oonfiidered 
M aoit chuucrcB — a fttatcmviit which wc aru not yet inclined to 
nuke. 

From what has liere been aaid, it is evident tliat we mast 
ndbcre to the duiditv doctrine of Von Biircimprunfi; and IT. 
Zefaal) and conM<:jucutly assume the existeuoe of three venereal 
pdftoos, namely, the contagium of gonorrAaa, of tho (soft) 
cAofWTv, aud of stfphilis. Wc wilt lirut diacuea the morbid pro- 
«ea>efl of gouorrticm, theu the soft chancre, and lastly syphilis. 



SECTION I. 



OOyORRJKEA (TttrPPERK VESEttEAL CATARRIT. 



The morbid proecsa knowQ sb gonorrhoea is a catarrh of 
tlie iipethral macous membrane. TrVitli tlie word eitarrlj, how- 
ever, only one %ym[tU)in — naiudy, the hj-perBtcrotory iictivity 
of tlie afFecttfO miicoiu memlireno ie bronglit into prominence. 
Every hypersecretion pregupposes the presence of a hypews* 
min. Tim hyperaiuiia, iu the vast majority of casea of gonor* 
rbflea, is very uctirc, bccuiise, as a rule, it \» the immediate con* 
BC<[uciicc of a piithological irritation. However, mucous mem- 
br&nca in general, and tlio mucoutf mcuibnuie of the male 
nrcthra in pnrticuUr, are exceedingly scnsittve to morbid ini- 
tation. Hut, ae is known, there arc also etaais-catarrlis in whiob 
the hypenemta is pasavo in cburactcr, and consequently comce 
on Tcr^' gradttatly. The immediate effect of hypcncmia is a 
wrous truDsndation into the mucosa and tbe eubmuoons mem- 
brane (a'doma of the mucosa), and an increased activity of tbe 
secretory poweruof the mncons foUicleo, which produce a clear 
BCToas fluid (oeroufi catarrh). Still another effect of the hy- 
peremia is an increased formation of epithelial eelbi and the 
production of mucus (epithelial and iihicouh catjirrh). When 
the irritation of the tissues ia veir alight an increased forma- 
tion of epithelial ccllf only w\\\ cmuc ; when it ia aomevbat 
severer but Ftill mo<lerate, the pnMltictiou of mucus becomes 
notably increanod. But tbe increased flow of mncns does not 
only emanate from tlte niwo, patuloiiB acinous glan<le, but alflO 
^m the cpiliicIiiU cttllK of ttio mucoue membrane, whose 
^ffotoplasm. becomes tranafonned into mucoos enbetanoo (mn- 
QODS metamorplioeiii) — a procedure tliat hna it£ analogy in the 
corooous tniufonuation of epidermis-cells. If a still more 



OOXOBSBfEA, VESSREXL CATASSff. 



IS 



intense irritation takes plncc, tho cpitlictutl cells will form piw- 
oeUfi either Uin>ugk endogcnoiu ccll-fonuation or nuclear lis- 
noD, aiid tlio oaWtiefi of tlio fulUcles are tiDtxl up witb a iliiid 
oontikiiiing pos-celU (ittflommatoiy and purulent catarrh). As 
A result of tlie coDtinued suppuration, many of tbe affected foK 
MoJits aro liable tu uoderf^ ulceraliou, wbicb ma^- iurulve tbe 
nibmuooiu tiasiie, and result in liniilvd defects of the mncoas 
tad sabmucons tissaoB (catarrbal ulceration). 

Now, just OS we nutj speak of a serous, opitliclial or mu- 
cous, and purulent catarrh, bo is it poeeiblo to differentiate bo- 
tween a«fin>u«, epitJirl'ml or muA^M, uidjwru^j/ fforu/rrhaa. 
The diiitJDCtioii, bowcvcTt bctwocQ tbeae forma eon oot be 
strictly maintained. In all forma of catarrhs, just tho same as 
in gonorrhiBa, more or Ie«s epithelial cells, mucous and pus 
oorpusclea may oucur together ; one or the otlier of these tliruo 
elements ma^, tiowovcr, preponderate in a gireu ca£c,an(l thus 
Wlablish the eluirocter uf tbc etwredon. 

The serous, epithelial, aiid tiiucous cAtarrhs, as r<^*nrd8 goo- 
orrhcea, are the forerunning stages of the purulent catarrh of 
gODorrhoia. The diseiwe may bo arrested at any one of tlwse 
stages by any inhibiting inHaence ; or, on the other band, tbo 
inflammatory and purulent catarrh of gonorrh«?a iu its retro- 
gnulu development may uiidcrj^) rcMoIutiun from stage to stage 
to the mncous, opitlielini, and serous form. 

If the preasore of the blood in the ca]>illari(« of tlio cator- 
rfaally uffuctc-il mucous nicnibrono becomes eo great that they 
rapturo, capillary hfflmorrha|!;e will ensue. Tho eecaped blood- 
corpuscle* cauM the purulent discharge to become bro^vD or 
black in color, and tho bleeding macoos membrane to assnme 
an inky appearance (tlie black or Kussian (*onorrho?a). 

All the phenomena deocribed aliovu which go to uuike up 
tlio anatomical eymptora complex of a catarrh in general, and 
hencse, al^o, uf the venereal kind, undei^ in tbu latter espe- 
eiolly a rapid transformatiuii, eo that the whole morbid process 
nuiB its course in a few weeks and the mucous membrane may 
again be restored to a perfectly normal condition (acute gonor- 
rtoja). Before, Wwevur, ihn umcous menibnuic agatu bfcoiucfl 
perfectly normal, it remains twusitJvo for a long time and the 
least cause may reproduce the catarrh. These rdapecs may 



14 PATHOLOGY AifD TSSATXBST OP STPElLm 



rcmr very nften, lunl (Jmir frefjticnt rcpi'tition tcml to render 
greater tlie diapositlon to contmct new catarrbal attacks; theee 
rdapKs always laat longer too. TlirougU ilib rccurrcacu of 
fre()ttcni rclupsce tlic moHiid conditiuii ts u)>t to booomo per- 
manent (chroDio gonorrfaoeo). 

Tbe views now prevailing concerning tbc genetic factors 
of gonorrhwa are not vcnr cloar. At any lato, it n an undeni- 
able fact that the dis«ia£e may 1)e transmitted from one persoQ 
to anollier. The iiiiestion, tlierefore, arises whetlier tlio trana- 
misaion can be explained by the fact tliat the morbific action 
of the Becretion of goiiorrlicea develops its irritating pro|)ertiea 
In tlie uMial manner in tbe Feoond individnal, or wliettier the 
gonorrbceal eecretion poeecBsee a peculiar epecifie power by 
virtue of whicli iL infectd. 

WJiile eonie investigatorB look npon the morbid proocas of 
gonorrhcea as a reeult of ordinary irritation of the muooua 
uicmbrauL'. others cloirn that it ia produced fuliri'ly by a con- 
fciginn, whicli is rt-pntcd to poSBCeB BOch inteiifir powrr that it 
can. act not only by indirect contact but also at a diatauce (aora 
gonorrlia>a). 

In regard to the bypotbceis, that any irritation of tbe mn- 
ooiu membninc, be it mechanical or cltemical, iB capable of 
prodnoing a nioco-pnrulctst eocrctiOD, it is a fact that liaa been 
a matter of daily oWrvation for a long tinio. Through rim- 
ple friction of the valvar mncous membrane (manuBtupratlon.), 
the frequent introdnetion of inetmments (liongien or catheters) 
into the male urethra, the impaction of calculi d^hria in the 
latter canal, tbe wearing of peK^aries in tbe vagina for a length 
of time, catarrh of tlio nmroiin mninln-aiie of tlie«o organs baa 
frequently been produced. Swediaur engendered an obKtiaate 
dificbarge from hia urethra by injecting it with aium<Hiia. 
Oemio acid, when plaeod upon a mucous membrane, will pro- 
duoe catarrh upon it ; even the vapor of the acid is capable, 
ag u well known, of causing ecrioos catarrhal irritation of tJio 
conjunctiva pa][iel>raruin et buibi and of tlio mncona niejn- 
brane of liio hirrnx and tmehca. Tlic decomposing pccretiou 
of the glans pcnix, containing aa it does ammonia, may oeca- 
son b]ennorrh<«a of the glana ponta. The deeoropo«ing men- 
atrual blood, tbe lochia, diwbarge from a cancer, a chancre iu 



GOyOBSJTfEA, YEXERKAL CATABRJI. 



15 



tlie urethra, alt ma}- iiidtitfi a hjpenecretioQ of the aivtlirul 
foIKcloR. The catarrhiU hyaline secredoii of the ntcnig, un- 
der certuin condirions, will give rise iB some men to a tuaco- 
puraleut discharge from the mucous metubnuie of tlte 
ttrcthnu 

As every catarrhiLl eccretion may become aggravated into 
an inflatnmatiou altcDdtxl by euppuration, ft was suppoecd that 
the growth of tlio lufoeting power of the secretion kept pace 
with the growth of the catarrlial prooesa till it bocumc aggm* 
\'ated into a purulent condition. Some anlhore, therefore, 
Qiaintain tlrnt tlio gonorrhccal dlschar;:^- only becomes infcctivtis 
when it ha;* become purulent ; that the serotta eocretion during 
the prodromal stuge and the mucous Becrotion during the ittngc 
of Tcaolittion, if they oontoin no piu-ccUs, poeaces no infectious 
propertiw. lu our pnictioe, howt>Tor, we have Eeen nDmcrcina 
initances where men troubled only with tlie prodromal plie- 
nomena of gonorrhoen, i. e., a prickling senration at the 
meatog m-iiiarim, where not a tracu of puB could be found 
in the urethral discharge;, infected tlieir wires and mistrcBsea. 
We have hkewiK had the experience that the fliigfat mucous 
secretion of gleet is capable of communicating a gunorrlKca] 
iliscaae. 

The facta hero produced compel ns to assume that the mor- 
bific potency of a gonorrha«l infection in not to Imi found in 
thv pufi-celLs but in a Hpccitic catalytic power of the accretion 
— i. e., in a contagion which adhereato the epithelial aa well as 
the pus celln, and which we are not able to isolate any more 
tliaa other kinds of coutngium. The hypothesis tlint an ani- 
mal or vegetable parasite (Nciseer's goDoeocciu) forms the 
bosid of a gunurrhoeal contagium has not yet been Mdafsotorily 
demonstrated. 

[This gonocooeus, which Ncisser diseovereii in 1870, he 
dalms ocean »> oonstantl}' in the jms of gonorrha>a, that he 
and other investigators were led to consider tlie vinileiicy of 
the disease aa Ix^ing due to thl« micro-organism. This propooi- 
tioQ was Hulxteqnentty confinnod by the snooeesful inoculation 
ef ft pure culture of gonococcu-s. The gooooocd are tlirstin- 
guiahed by thtir relative size, and alio by usually occurring In 
gronps of two, four, and mora couples, whoee origin may be 



16 ^ATffoioay AifD theatusnt op SYPBlUa. 

a-cognized bjr tho division of die iiriinitivo co«nm. These 
cocci are flnt ou tlio siirfacus, facing eacli otlier like ''split 
peas," and the groups formed of tvro or more coQpIes ore liko 
German roUe facing one another. This miu^ed ttuiK-ncy to 
form groups that coDsi&t of numoroiw poire of atogle cocci, 
diiatingui^hes this from other kind of cocci, which maj liapp«n 
to bo in tho urino and dis<:bargo£ from Uie eexiiul organs, aud 
wliicli likou'iMj occur In thtj furtii of diplocotxiut, but nvver 
ooDstitute eucb large groups. 

The gonococci are found in the puti, some of them free 
and otliers upon and ]>rot>ably bIku In the epithelial and pu« 
cells, bnt not in the granules. My examining a prepared eoo- 
ttOQ of the conjunctiva of an Infant afflictc^d ^-ith blenuorrhoca 
nconatonim, Ittimni proved that tlic gonociicci arc onl^ capable 
of penetrating cj-lindrical aud not tlat epithelial colU, that tfae7 
penetnto down between cpitlielial cells, but reach only tliQ 
topmot't layer of the enbmuc-o»t, iHrmctimca arnuigod aa if tbcy 
followed tho C4tpillarics of tho l^vmpliatic vcs£cld.J 

Trae, it ia now generally admitted that there muet be a 
gonorrliceal contagion, because daily ex(wriencc has shown that 
a minimum ipiautity of gtmurrlm-al dtBcharge i^ guHieieut to 
morbidly affect a normal mucous membrane, as is often tlie 
case in the production of gonorrhoi-al eoiijunctivitiR, Accord- 
ing to tho views of most experlvncod pliysicianr^, catarrhal Be- 
cretioQS of odur mucous membraneii are alra more or less c<hw 
tapous. We are, therefore, of the opinion tliat tlicre are trri- 
taiiee ait-arrhv — i-c., catarrhs that mny be produced br rmrioos 
irritant?, cliemical igente, and disorgauizctl pln-siolo^col and 
pathological secretioos, and Kiich cjitnrrlis as are produced by a 
spcciiic contagious matter, and which ghoiiid be designated aa 
purulent or viruUnt gonorrhoea. J^Ubouj!^ the irritative cfr- 
tarrb Is pre-eminent 1}- attended by a nmco-opithclial secretion, 
still one is not jnstitieO, from this property of tho secretion, in 
saying tliat its gvD(9<is is n(4 vimUint, becatuc n nmcous catarrh 
may l>e the beginning and cud of one that is Timlent. In 
regard to the prt^ogls, however, we can say that tho mucotu 
catarrh, as a rule, is irritative, and its care much easier to 
effect than the other forms. 



OOS0&BB<EA, VESSBHAL CATAHSB. 



17 



Site ef th« Qonoirlittal AffMtion aad Hcoh&aum of tho Goaor- 
rhiKBl X&fectioo. 

yenerml catAirli luostlj' aSccto the mncoue mcmbnuic of 
the g:enital orguu of 1>otb aoxos ; but it maj also be coureved 
by contiguity to tlie mncotia racmbnuie of the rectum and 
vteree, aod bj transportjitioo of the aecretioD to remote mu- 
C008 membranes — for iiistanee, tbo coDJunetiva, Venereal oa- 
tarrfa inogt frequently occim upon the muoous meml>raiie of 
the luale urctlini, and the viigina and tnitva in the female; lees 
frtMjiienlly the cervical canal of the ot«rns, and rarer Btill the 
fvniale nri'tlirii, are Involved. Wo have nuvcr had an oppor- 
tiini^ of eeeing gonorrhoea of the no«e and mouth. 

It la eaev to oonceire whv the female vagina and raira and 
tbo ghms jK-ni« gboald hj contagion beconio catarrholly ofioctod. 
Tho morbtSc matter ruudily oomoe in otmtact with the genital 
partB during coitna. Lees easy to cnmpn'bond, however, is it 
how tho morbific agent can, during copulation, exerciBe its in.* 
jluonc« apon tbc diucous membrane of the male urethra, the 
mcatns being but a narrow slit, whose lips vell-nigh dose the 
opening of the nretlira hennetically. We opine tho mwlt/ii 
operandi to be 18 follows : Tbo oxtemnl orifice of ttie male 
uputhra during the act of cuition, hy the forciUlo intrusion of 
the membmni virile (erect pcnie) into tho vagina, U mecliani- 
eally slightly opened. By the separation of the Hpe a vacnum 
oocum, and by the Inn's goveniinfj^ ancli pliiiidea] condicionB a 
portioai of tlie contagions and irritative finid that happens to 
be in the vagina i» sucked into tho urethra and eflectivelj re- 
tained there, bccaui^e during the retraction of tlio organ that 
follows the Ui» of Ihe meatus are doited agnin. That this ex* 
pbnotion is correct is proved by the following facts : Of 8uv> 
eral men who euocessiveir copulate with the eaine woman, 
tboM will not become diseased who ou account of their intense 
excitability ejaculate their eeincn when their mcmbrom virile 
has barely been introduced within the vulra. Men who break 
oS tbc act of coition l>ef<>re ejaculating the somen become 
affected soooor than those who ooraplote it nattirally yet 
(|uickly. Men who micturate imtuediat4>ly aft«r cojiiilating aro 
lev often affected than those who do not take that precaution. 

i 



18 PATBOLOOT AXD TREATMENT OP 87PEIU3. 

Tbe c^penuatic Quid during cjiLculution, and tliu urine during 
mictarttitin, seem to wa^h out tiie urethra from b«luud forward 
ID a aiiailar maDDer. 

7actan tiut oaually favor GoDorrliatal lufectioo. 

Short acts of ooition frequently repeated, and abruptly 
broken off, f&Tor gonorriircal infecdon, bot^ouso, as the orgasms 
become longer, the female genitalia become more irritated and 
incited to diechargee. Hence it tiuppeos that copulation re- 
peated at frequent intenals vk-ith a woman entering from iit«- 
lino catarrh, or one who is mcnstniatinj; often, producer eorons, 
epithelial, or mucous gonorrhoea in the male. If tbe catar- 
rhal uterine aecretioo and the racMtnuil blood, per w, irere 
capable of acting a« irritants, tbe number of nretJiral catarriis 
would be far greuttr. E%'eii healthy, loving coiijilos very often 
Khonr, after s night of immoderate indnlgeiicu in wxiial inter- 
course, the Eymptoms of commencing urethral and vagina] cip 
tarrb. 

The relative sixo of the genital oi^gans ia abio a factor that 
should be taken into confiideration here. The greater the fric- 
tion whicli the vagina munt suffer from a large membrum vi- 
rile, the more profuse and thicker will the catarrhal secretion 
be. A short, erect penis will scarcely ever bo affected by a 
uterine secretion. 

)lcn with targe meatuM^ become discaeod more eaaily and 
quickly than thoeo who have a very narrow orifice. Aurcthra 
termiiuiting in a hypoepAtlic meatus is oftener and more eas- 
ily infected than a normal one, because the gonorrhceal secre- 
tion of the vagina, in accordance witli the laws of gravitation, 
accumulates moetly upon the posterior wall of the vagina, and 
constKjiuentty the contact of tlie urethral orifice of die hypo* 
apailiac wttli the infecting and irritating matter occurs moro 
readily. 

Another factor tliat favoia gonorrliteal infection is drunk- 
cnncu, because the act of copulation when attempted by a 
pereon in an intoxicated eonditioQ will take a longer time be- 
fore terminating in ejaculation, and the meinbnim virile ia 
cotuoqucntly retained lon^r in the vagina. 

A man who has bat recently recovered from an attack of 



eONORBn<EA. VEi^EBEAL CJLTABRS. 



19 



gonorrliopft is mach more readily infected than one who iraa 
not afioctcd with the diecaeo. 

There is do peculiar cwnditiou of the hlood t)uit will ren<tcr 
ft person especiallj prone to be allected with the gonorrhceal 
contagftun. 

Ooaorrhffia of th« Hale Ur«thj«. 

We malco a distinction between eerons, mncooB, or epi- 
thelitd nnd [Minileiit cnlnrrh of the male urethm. Tlie cause, 
or circam^taocc, which in a given case produces a seroos or 
roucona catarrh ontj, and etampa it with tltat cliaracter, con- 
tfarta mainly in the pn)perty wliicli tlie niorhitic matter e?ceF- 
ctwe upon the aruthm. Upon tliat also depends the rapid 
or tardy development of the catarrh. The richer the inor- 
bi6c matter 1b iu pua tlie f[uicker will the disease ensue, 
and the more intwieo -will it be. Mucous secretion, for in- 
stance, catarrhnJ nterine discharge, or fluids entirely free from 
pus, like rocnstrnal blood, or mechanical irritation of the ttto- 
thra, 06 a mtc gi%'C rise to ecrous, epithelial, or, at tJio mnet, 
mucone ciitairh, while the pnndent di«harg©B of inflammatory 
catarrh of the urethra and vagina generally cause an iuflaniina- 
tory or purulent catarrh. 

The eerom and mucous catarrh of the male urethra is either 
inituxi or terminal. The initial catarrh soon Bubadee under 
an appropriate treatment ; nnder unfavorable eircmnstanccs, 
hoM-ever, it will merge into an inflammatory or purulent catarrh. 
The tenuinol catarrh, as a rule, assumes a protracted course, 
and u exceedingly otiHtinatc The initial sennis and mnconn 
catarrh liu^ its site in the fosaa naricularifi of the uretlira, the 
terminal catarrh in the pare mcmbranncca and proatatica. The 
secretion of the terminal scrona and mucous catarrh m frcijuent- 
Ij more opaque and glutinous than that of the initial catarrh, 
bccauK, owing to ita site in the pore proetalica, tlw tubuli proa- 
tatici arc al«o inTolrcd. The secretion of tlio proetate gland 
prodnced in conecqnence of tmnatnral and prolonged sexoal 
irritatioa, and which finds its way into the orethro, is not to 
be mistaken for the mucons dischaige of the initial Ecrous and 
macona catarrh. 

The ir^<tmmaiory catarrh uf tlie mate nretlira (urethritis 
pomlcuta, acute inflammatory gonorrhtra) runs its course In 



^ PATHOLOGY ASD TRHATMBST OF SYPBILia. 



tlie foilowiDg manner: Twenty-four or forty-cigbt hours, sel- 
dnm Inter, after an act of iiit«rcouree, tbi^ penoti fcela a slight, 
iinploiKtuit prickling n:it«.iUi>n at tlie meatus wLidi leads luiQ 
to otictar&te frequeatly. Gradually, however, the maoooa 
Diembrauti of the meatus becomes swollen uid a slight but 
clear tramlaccnt and tonadom eccrclion nukes its appearance, 
which, under the microeeope, shows mocoiis corpu^les and a 
few epitlicUiiI cells. If the jtatieut is uiade to pUfUi his urine 
into a glow vussel, tho discliarge will be Bccn to contain nnmer- 
0U6 flocculont and chrcod-liko Etructurce that swim aboQt in 
tLti urine, vrhieh u oUicru'Ifio clear. The dtKsliurge being alight, 
it therefore beconitw in!>pii>i>ated in the uieatUH, Healing it up, 
thus preventing tlie patient from micturating eanl/. It gen- 
erally reijulnM a few uiomeutd before the thickened diMUiarge 
is waslied away by the etroun of urine. These symptoms are 
met with alike in both the serooH and mucous gonorrfacea. 
In purulent gonorrhoea, however, the scene 16 soon changed. 
The tickling is tranaformcd into a burning, i<aiuful eensa- 
tioD. The muconfl membrane of the meatus ewells up bo that 
it bulges ODtwardly and the orifice bokB like the moatb of a 
££h. The secretion bccomoe more profuse, tliivkcr, and a&; 
qiiiree a greenish or yeUowish-grecn color, if at this stage of 
the diftciuie a suinll quantity of tlic unite in collec!te<l in n glan 
T066cl, it will appear opaque on account of the purulent secre- 
tion that ia mixed witli it. The puBK»>rpuKcIes swim about 
like particles of dut>t or niiinite auiuialculeti in the urine, and 
then gradually sink to the bottom of tlie veNicI because tlicir 
apocifio gravity is heavier than that of the mucous ilakee and 
epithelial cells of the mucous catnrrb and the urine itself. The 
discharge slightly colore blue litmuA-pajier red, and under the 
microacope shows predominantly pturcorpnsclea along with 
mucous and epitlieliol cclU, eonietimed also a few blood-cor- 
posclcs. Virchow \ua called attention to tlie fact that goaor- 
rliccal ptu-corpuscle« are larger than those of ordinary pus. The 
paruleut difichargo apiwars by tlie fourtli or fifth day, rarely 
not until the twelfth or fourteenth. As tbc discharge from 
the anterior part of the nrctlim gmdualty inorcoMS, the difficul- 
ties of nrination aUo increase. The patient uiietunite« either 
with a good deal of pain, the nriae coming away only in drops, 



OONOKItamA, VES UREAL OATARRB. 



SI 



or ID a tliiD, weakf and iulemiptcd elream, tiooatue the nretlimi 
owing to indainmntnry Kwelling of tlie miioous mernl^rane, is 
temporarily narrowed, and the smooth, irtriated, innBCukr fibers 
of the urethra that propel tlie stream of urine are partiallj par- 
iJvzed. Occasiouullr Wilaon's niusclo. tho epliiuctcr vesica, 
coQtractfl spAsmodically, caiusiiig inten&u etninf^ry. Tlie epon- 
gy portion of the penis, like the mucous niembmne, ia en- 
^rgod ; beiic« the orgAD is constantly io a eemi-arect conditioD, 

. thUE helps to render the urethra stilt narrower. 

IzL cases of intonso indamuiatorr gonorrlioca of tlie male 
nrcthia, gastric diaturbnnow and febrile movomcnt not infre- 
quently bwonie snperaddod. Tho former healthful appear- 
ance of tbu |xitieut dieappeara as if liy a blow, and he bceomoB 
pale and piekly-looldng. This inarkeil duprasscd condition of 
the general syeteui is not, however, due to tho effect of the 
gonorrh(Bal contagion upou tho blood, but ia the result of tlie 
eomtant pain and disturln-d sleep. The warmth of tlie bed 
causes frequent erections, and ttic swelled mucous meml»ano 
not Ijcinp Buffioicntly distensible is dragged upon by the erec- 
tions of tlic corpora cavtTnosa, pnidiicing intense pains and 
diKturlJoncc of sleep at night. M'hen the patient, deepito tho 
pain and utter e?(IiaUAtiuu, liuullr falls ai^leep, ho is not infro- 
qnently awakened by a painful cin'wiuou. 

Tho morbid phenomena here delineated persist for a longer 
or shorter period aecording to the dietary meaiSQrce and rep- 
moD the patient keeps. Under appropriate measnreB tho swell- 
ing of tite iirethnil eanol sub^des by the eighth day, and the 
dysuria markedly diminiBhcs. At the beginning or end of tho 
third week the purulent dimvliarge decreases and liecomes 
poorer in pns-oorpu-<^ck's, while tho mncous and epithelial colls 
begin to predoiiiinato. Gradually tho luuoous di»oharp;o also 
cbangee, so that only a few dm|M of mucus or muco-punilent 
diicharge ew-upes fmm hin urethra if he has not micturated for 
several hours. If the urine thnt is pas^ at this time is eol- 
loctcd in a ghuw Te#el, whitish elireddy structures (gonorrhci>al 
shrtrdfl), varying in length, are seen floating in it. If tho 
shreds are talten from the urine they will eontract Into email 
gelatinona lumpn, and microtwopirally aio seen to ho fat^ 
degenerated epithelial cells aud pufi-corpaaclos. Tlioso don- 



SS PATBQLOOr ASS> TRMATMENT OF 8YPBILTS. 



gated epitlieliul shreds may, it is trne, originate in the dnet« of 
Oon'per'B or Alory's gland; etill tWy are not to bo coneideied 
u such in all caws, eiuce tlicy may form at aiiy |>i>iiit of the 
tiretUral canal. After a wbilo, the quantity of t3iese alueds 
diininifth&i, and for iwinc time, wbcnever tltu patient urinates, 
Uiere may be bnt one ench shred in the nrine. FiniUy, tlufi 
one too diM.])pears, and in the coiir&e of eix weeks' time a gon* 
orrba-ol [>roGCM may ])C ^d to hare ruachixl its L-nd. &<) long 
ae any of those gODorrbttal hlir(.^ii if, noticeable in tlie urin^ 
the least caoae m&y again start up the morbid proccfls that iB 
so near expiring. Tiie oftcnor these rclaiieoe occur the mora 
difficolt is it to curv complct^-ly a nrethral gonorrhoea. In 
some parta uf tliu niucontt iiienibrauu of the urethra pormaneDt 
flensitiTe epots remain, attended by jieisitilfnt tlioiigh slight 
muco-pomloDt discharge. This condition is called gleet (aftcr- 
c!ap) or clironic torpid gonorrhoBa. 

Clironic nrethral gonorrlKRa mny Iwnt be descrilied as a 
penistent mncous elage in the retrognuie development of the 
dlseaaa Here the diecliarge containing mucons and epithelial 
cells is Tcry plight, and is only seen at time*, C8i>eeinlly in the 
morning, at the ueatua of the urethra, or, by squeezing the 
partB, a drop of matter is exprceeod. If the lips of the meattu 
arc not agglutinated, micturitiuD is easy, and no gCDcr«l and 
often no local diAtarbancce of eenaation are present. In eonse 
ca8C£, howcTcr, the patients complain of occasional prickling een- 
eations in the region of the fosa nanculoria or at some jwint 
of the perineal ^uut of the urethra, or, again, of gome transient 
etitchca that extend from the lattar Bjiot to the anal opening. 
These fienaations seem to bo duu to deep patliologicul altera^ 
tionii, vbtc^li, however, vary bo much tliat we are not jiuUfied 
in dcecribing them under tlie common name of '* chronic gon- 
orrhoea*'— etill leas so, as a more correct diagiUMJs would eeseo- 
tially alter the prognosis and treatment of t!ie dipcase. 

In acute gonorrlura of the urethra the dy&urla may, owing 
to the intoiuo swelling of the uretliral mucous membrane, be- 
Dome intensified into a condition of actual slrangnn,-. The 
tutgeecence of the capillaries of the mucous menibrano may 
attain nieh a degree tJiat they mptnro at various points, eome- 
timce rofiulting in severe liEemorrhogc. The blood that is 



eoyoRnn^A, tss^ereai catarsb. 



ss 



potircd out into the urethra uud coa^rnlatcfi there colore the 
purulent discharge r«ddisb-bro^^1l or even blackbh, and for 
thia reoeon it is also called AtemcrrJiagu!, iflack, and Jiuman 
gonorrfaoMi, because it is eaid to havo bcco of UDCommonly fre- 
qoeut occoncnoe amoiift the KnfiAian troops engaged ia the 
ware at the bt^noing oi tlio present centnry, oving to indi^i- 
eretioD in the diet and hy^cnic rcgimca, 

Anotlter onoommon feature of the inflammatory uretliml 
gODonhcea In the male is that the itil!ariiiu»tioQ of tbe cpitlie- 
lial tajer penetrates through the mucons membrane and the 
snhmncons tissue and inTolveB the spon^* ])or1iou of the are- 
thra, in the meshes of which, cepcciullv in thoec of the corpna 
carernoBum urcthnc, one or more painful swelUngti, varjring 
in axe from a pea to that of a lentil, form. If these peri-ure- 
thr&l intUmmatory foci fonn in pcreons who arc afflicted with 
froqooDt erections that la£t some time, the ercctiona already so 
painful become still more intense, hecaose the spon^ portion 
in which the infiltration lias tftken place not onlj can not keep 
pooD in the erections with the other portions of the erectile 
Gpongj body, but actnally hinder it from lieoomiujf erect, and 
oaiue it to carve like tlio bow of a violin. Thin kind of ereo- 
tioni has been designatinl chorda venerea (cliordcc), bcean«e 
the patients claim that thej have the eensation as if the penis 
is pn-rentcd from heooming erect by a tenso cord drawn 
through the nrethra. Now, in its erections the penis wilt be 
bcoit either downward or to one side, according as the corpna 
earomosnm or nretlira is affected. Under judicious treatment 
tbo poinfi during erections coaso in the tliirrl week, and the 
peri-urethral inlUmmatorv node« underf^ absorption. If tbe 
absorption ia incomplete, the inflammatory exudative hyper- 
trophies will remain, causing the affected spot of the ^ngy 
body to become obliterated, and daring enactions tbe mentbor 
will curve toward tlie gtrellfxl »]iot, rendering it diflicnlt of 
introdaction into the vngina during intercourse. In Ninie 
cases absottses form in tho^ peri*nrethral infiltrations, which 
nbeequentty perforate the urethra and givtf rise to tine fistn- 
Imu tracts. These abaeenea moKt fn^juently bn>uk into the 
fosBA nsTicnhiris in conficqnence of the inflammatory exuda- 
tion occnrriug in tlie buIcus coronariiifl near the freenum. 



34 PATBOLOQT AiVD TREATMBXT OF SYPBIUS. 

In clipwnic gonorrhoea tlie Oitarrlial pnjpuan may likewtBa^ 
through indiscretion id diet or oUier injurioiu measures, be- 
come aggniTiLted. The uiacoiu catarrh becomee inteosified 
into a puruleut one, or even itttoiuft to a conditJuu of croupoos 
intlniDmation. This manifetits itricif in tlic following manner: 
The patient whoee urethra is apparently almoet well eaddeuty 
b<^iiu to foci iatenac itching in the periociU region, uid thia 
BctuatioD ueoppUntcd iuafcwhonrs by violent paius. The 
inn«0QS discharge subsides almost entirely, but there is greater 
dilHculty in making water, and tlie tttreRm of arinc becomes 
thinner. If a boagic is introduced, and aft43r its rcmov^ a 
eyriuge full of water is injectwl, tha returuiiig fluid will bring 
away white menibraiious imuweii from two to tliree centimetres 
in length, conBisting of a dense bimd-likc ur cyliudrical fibrinous 
aubstanoe which haa oi-iginated by fibrinous exudation upon 
the opitbelitil layer of tbe mucous muinbRuic. Tlicitc bands 
will break abniptly on l»cing fon;ibly strvtcliod. On tlie addi* 
tjon of acetic acid tliey swell up luid^ become clear like fibrine, 
whereaa mnona becomee opaqae and coagiilalee into ahredfl on 
tlio uddilian of an acid. According to our cx|)CTiuicc, tlm mor- 
bid condition ^>enu mostly to be produced in the membranous 
port of the nrcthra in consequence of eerere irritution by strong 
injocttoDg, especially solutioue of bieldorido of mereury. 

Urethral gonorrhtea liati it^ Btartiug-[>oint in the foesa na- 
vicnlaria. Tliis ie evident from the fact tliat at tlie beginning 
of the di^eafio padonts complain of an itching Beneation, and 
later of pain in tltia regiou. But the phyucian should not 
hastily aiutume that tlie gonorrhceal proc«M tarries in the fo«m 
uavicnlaris ha long as the patient experiviice^ tickling or paio 
in this locality. In this part of the urethra the scnsoriom 
oommone of the ontlro territory of the genital organii eeems 
to center, for here tlie patient feuk all the morbid eensa- 
liotie, in whatever manner or pari of the unnary organs they 
may have been prodnced. Thus, calcnli in the bladder, affec- 
tions of the prostate, and many other irritations, prodaeed in 
the deeper parts of the urethra, are fell in tlic region of the 
foesa navimlariii. At the beginning, during the initial serooB 
or mnoou« «^tage, the oongeelion \& certainly limited to the 
anterior part of the oiethral canal ; bat after a few daya, espe- 



\. 



GCyORSBiEA, YEXEJiEAl. CATARRB. S5 

(■{ally in purulent catarrh, the congestion gradualtj' extends 
twdcvonl, &o that by the eij^bth or tentli day tlie entire mucons 
membnute of tlic p&nt jieiiilulii, antl hy the begimiiiif^ of tlie 
third week thnt of the pars tnenihniiiAcea, Is aJTccteil. The 
junction of the pars bulbosa to the pot's nieuibranacea of the 
p4jnt9, where iikuwisv a imviculor foesu funuA, and vrhcrx; a num- 
ber of aggregated fulliclcn exirt, 18 the mw.\. diflicnlt apot to cure 
— the follicular inlUmmation forming the greatc(>t obstacle 
in curiug a goitorrba-a radicully. An iuSoiumatory urctlinil 
gotwrrlia-a may be arrested at any point ui its prof;rc86, from 
the foaaa Daricularts to tho meinbnmous portion, but at this 
poiitt the diitcase in not only likely to Ijecimu markedly iiggFA- 
voted bceaose the existing follicleis that have bevn ulladcd to, 
become indamed and undergo bupiniratioti (gutiorrha-al ab- 
soowes). hut dwelling and thickening of the tisoii^tt take pUoe 
here preferably, wliiph, if produced by Btagi»K:>atarrhB, will, ao 
cording to the intensity, duration, and courae, seriously affect 
the gauorrhwul pn>cea». Uiit, fnjm exjieriwicc, we are justified 
in eaynng that certain coiti^titutiona] conditions, euch an scrofals, 
tuberculcaia, ouirnu'a. gout^ rhcumatiani, lia>morrftoi(lR, and all 
tlioae imitations which, emanating froin the rectum <intc(jtinaJ 
ffonuB) or bladder (calculi, etc.), are likely to affect the posta- 
rior jiart of the urethra, also contribute materially toward pm- 
Inn^ng a chronic catarrh of the urelbra, and make it exceed- 
ingly difficult to cure. 

Pathological Alterations in the Kale ITretliral Canal prodneed 
by the Gonorrlioeal Diwm. 

Dnring the life of the patient it is not possible to eee 
tUrougliont tlii^ whole extent ut the urethra, witJi the unaided 
eye, the niorbitl allcratioiis of the mucoos membnne of the 
nratbra. lilxaniinHtions on the cadaver seldom offer in op- 
porttmity of studyiitig tlu; morbid alterationii of the urethral 
mncoiiB membrane; and the ricws of most reliable invcHtiga- 
tora, baaed upon poat-mortem reeearch^ refer more to atush 
morbid IcKioaa wliich have ongiDated in vonecqnencc of a 
protracted chronic gonorHu^a Uian to alterations resulting 
from the actite form of the diseaae. The few case* of gonor- 
rbtsal diseafe which we had an opportunity of investigating 



S6 PATBOIOGT AXJ) TSSATUBifT OF BYPSIUS. 

post-mort4ini, before tlm iiiTecttun of llie nretlira li«d entirely 
disappeared, taught us tliat it au\y occanoiu sncb morbid 
cliaiiges ns we are acciistonied to find in catarriis of other ma- 
oouK uicmbrancB. The pathological alterations of gonorrhcea 
of tlio ragiuol mnrauK loviDlinme in the acute stage, or blra- 
□orrbagio afoction of tlic conjunctiva palpebraram et bulbi, 
will form the traeet repreeentation of the lesions resulting from 
the dieeaso under consideration. We find there rcdncee and 
swolUng of tho mncoue uipniUntne, sotnctimes granulations, 
and not infrequently eroti^iuuH, whicli bleed easily. In re- 
gard to the gonorrlitpiU diseluir^, in tJie acute stage of tbe 
disease, proliferation of the epithelial evils and tnnsformatioa 
of tbe epitbelium'Cella into pus-corpuBcle^ ta.1ce place, while in 
the toqiid «tage epithelial cells uudurgo fatty degeneration 
and hyaline cells nboimd. Kokitanjiky exprcspr* liiniBelf tlios: 
"The catarrhal intlammation of the uretliral mncous mem* 
bnuio has a tendency to run a clironic courae. It ifi eitbor 
uuifonnly di^Lribiitcd over the entire tin-'tbra, or fioinctimea 
from the beginning, at other titnee later in its course, is limited 
to one or moro Bpota. These inSamcil spots are found at any 
part 09 far u the pro«tatic portion, but mett fr^t^Uhj at t/*<i 
JotM naviculariiy and near lAf buHmu portion of 0*4 vre- 
tAra. Tliey are recognized by tbeir dark~red color and the 
afwdling ofths mueoiu membrane ; Kometimcs, especially in tlie 
fu8M]iaviculA]ie.r(MTiarkablc enlargement of M^fntMVUfj^^ofufls 
and puruU'iiL collecliona are observed. At the Mine time the 
corpus spongloeiom urctlirte, at the places incntiontrd, in its 
inoennost Inycr— «t times, indeed, throughont its entire length 
—is Bwcllc4l, and its uifshes dimiuiahed in size, and conae- 
qnently contiiins Icsh blood. At these places an nnyielding 
swelling, produced in the manner described, is readily per- 
ceived along the urethral cauaL Tlte longer the inffHmmation 
laH$, ospccinlty vhen its intoosity it frt'qttcntly (u/yravatcd^ 
the less likely is it to get well entirely ; it is more apt to tcs<- 
mioata in thiekcuing of the mucotu membrane, or strictaies." 
EJigel is unable to my a great deal positively regarding the 
diseases of the urethral mucous ineuibrnDC, becao^ in must 
cases it is imposjdhlo to distinguish on ac-uLo inflammation 
of the DTOthra from tbe clironic rariety. Xeitb«r produces 



^ 



OONORSnaCA, VBy'SREAL CATARRK 



97 



morbid Ic^'ioos that arc readily perceived or bclon^^ to tfacm 
■peCLolly, and whicli ore aot likuly to be met with in a condition 
c^ apparent hoaltli. And tlio disclutrgc which in inflamniatioo 
of otiier parU afFords definite proof, is generally only limited 
Id unonnt in uivtbritiii — oft«n, indeed, it is greatly di1iite<d, 
changed, or waslied awny by (lie current of tlie urine, and in 
rare instancce only is tbere any thick, purulent secretion. 

The iirethmt mucous mcmhraiie generally l>cc«tuius tliick- 
cnod, rough, luid ilry in chrtinic genorrhiiai. Occ.i«ioiialIy tliere 
have been found in the r^on of the bnib, less frecpiently in the 
navicular fnesa, epreadin": uloera, one ueiitiinctro long, witli 
tlatf projcctini; sliruddy cdg<» and nncvcn buH'-s fiurrounding 
the entire circomfereuce of the urethra, etudded vitli condyio- 
nio-lilto cxcrceccncce (camncuUe) and bridica of muooos mem- 
brane (Engcl). They originate from the □Iccntion of the 
follicles found at those points, and in healing fonn orhite 
yielding ur lum-yielding cicatrioea, according to the deptli to 
which llie ulcers have penetrated. In the foe»a nnpicaloria 
tbie ulcerative proceee may jierforate the uretlira, and a fistula 
may result, through vluch urine euaipes daring the act of 
micturition. To W able to diagnosticate a gonorrbccAl ulcer in 
the living ttubject, pure water slioutd he injected several times 
in meco»Jon into the orethni. if pas, mncufl, blood-corpus 
cles, and especially Btmctoral dlHritua, come away after each in* 
^tion, it is certain Uiat an ulcer ia prmcnt. Sonmtiinca a 
bougie introdnocd into the urethra cauMe» intent pain in poM- 
ing over the alccraled epot. Id some case^ we found the ducts 
of Oowper'a glands dilated to euch a degree that they allowed 
the paaage of tine probce. 

In the last decade the mori)id lesions of the urethra, rcanlt- 
ing from vanous diseases, have been studied by direct ocular 
inspection. 

Dc^timieaux, as far hacl: as 1S53, usod a coiuplieated in- 
rtruinent for that purpose, which has einoe bi>eii euiuiidunibly 
improved by several mrgeonii. The simplest a]>parBtns was 
invented by Griinfold. His instrument consists of an endo> 
BCopic tulH: and a concave mirror onlinarily used in ]ur\'ngo- 
•copic exarainationn. Gas, petroleum, or sunlight may be 
made available for illumination. 



28 t'ATaOLOOY ASD TREATXEST OF B7PUILIS. 

TIic " cndtwwope," i*o wartnly rrfommcndiMl and employed 
by Griinfeld, U simply an endoscopic tube. It consista of a 
cyliudrical metillic or Uanl-rubbcr tube, whose ocalar und is 
diluted like a futiuci, its inner rarfoce blackened, and ita 
Tieceral cud open and polififaed smoothly. This tube ie in- 
trodnc-ed br the aid of a condactor, and it upt only eervee the 
parpose of enabling tbc ph^-sicitin to obtain a view of the nre- 
thra, but also of applying reuicdiea to it. 

Great tact and pniuttcal skill in the uee of boiimk and 
catheU-re will btdp one to tniiploy the endo»C(jj>e inicetie«full_jr. 
The inetniuient is introrluced amted with the conductor, pn«bed 
into the deepest part of the urethra, when the conductor may 
be witlxlrawn ; the urethral tturfarcK may tlien be clcanned of 
mucus, discharges, etc., either by a plug of cotton-wool upon a 
wire, or by a stream of water from u loiig-nozzled syringe. 

Three things are to bo noted, according to Griinfeld, in 
making examinations by the aid of IhourvthroFOOpo: 1. The 
fuonel, i. e., tho^iape under which the urethral mucom mem- 
brane presents itself, wherein the larger end of the funnel lie* 
centigooas to tbc iiitoroal }M>rdcr of the tube, and the narrow 
end U directed towanl the smaller lamen of the urt'thra; 2. 
The central figure, i.e., the apex of tlie funnel corresponding 
to the point in the center of the field of rifion, wbieh is occa* 
woncd by the urethral walU meeting at a point; and, 3. The 
, urethral wallti, the color and ihickneaa of the muoons mem* 
brane, the conditioD of its vascular arrangement, its reflex 
Mmnibility, etc 

Griinfcid dietinguislics the following forms of acnte gonor 
rhoea: 1. Urethritis blcnnorrhoim; 2. ('rt'thriliKnivnihninaccu; 
3, Urctttritia sinipleA ; 4. I'rethritia^n'anulofa ; 5. Urethritis 
trachomatosa; and, G. Uretlmtis phlyctscnuloM or horpetica. 
In ujythritit hUnnorrhot'^a the field of vinon Vi profusely cov. 
©red with pue. The funnel form is absent, the central figure 
is irregutarly int]ent«d, or a single spot is seen from which 
two or tlin.>e indentations rndiate. Tlie swollen mucous mem- 
brane that bulges up into the tumon of the tube is unifomilj 
livid in color, and presents defects of refleelion eorreiiponding 
te the punctated losses of anbstance. The cdgeof the tube pro- 
duces in the thickened mncona membrane n temporary groorod 



QONO&RamA, VEUBBEAL CATABBH. 



29 



impreesion, nmJ tlib inm-uiu metubrane lilccds on tbu etiglitvi^t 
pveBtire. In uretfiritis mcmimtiiatvay Oruufcld found tlm 
morbid procces limited to a certain part, to wliicli tlie poa 
tirmljr adhered, tLo removal of which eaosed bleeding. Paral- 
Ld with Uifi a:iid of the urethra govor&l gray or gmyish-whito 
Strips of exudation were found Hnnly :idhering upon tho mu- 
cons inombrane. In vrdftriti/i ginipltxn there m often present 
odIj a bTpersemic condition. Where the nincoua mcmbraao 
ii Mimewhat more twollon, it will lie found wore reddened, 
and eovcnJ bleeding i>oiittH will al^ be detectetl. In MnthrltU 
ffranulftna a sinall quantity of tnnco-pns is found in the middle 
of tli« lield of viMou, reeeinbllug the point of the central ilg- 
me, the funnel is short, the center tignre oval and slightly 
flhorter, the reflex iireguliiriy triangular, the mncooa mcni- 
brane of a unifonn Tvlvuty rctlness, n-itli a few solituiy punc- 
tate elovationa. The mocouit niotabranc, in tJie majority of 
caeee, acquires a certain dcgreo of rigidity, as mar be per- 
oeivod from tlto gaping of tho walla at thu ct;iitral figure. In 
eoino cafies QrUufeld observed a purely granular trachomatoufi 
BwelUng. In the form? of urethritis attended bj ulcerations, 
VMiAriiU pM>/^t(pnuhsti or /nvpeilxiy OrQnfeld fonnd a few 
ffnndl circular oleere which attracted attention by their color 
and shar[)ly detiued edges.* 

Korbid PbenomcniL vhich occur as Co^ffeds and Seqaola of 
Urethral Goaorrbcea In Meo. 

In genorrlta*al dii^4>aso of tlie male OR-thra, eertaiii morbid 
alterations often coexist which have tlieir site beyond the ter- 
ritory of tho urotlira and its adjacent ports, and which may 
he regarded as tho co-cflFcet« of tho orothral di&ease, while 
the propagation of tlie disease may give rise to certain mor- 
Ud lesions in cqntigQous or adjacent organs or parts of or< 
gana. Among tho coM^ffects we may mention balanitis, affcc- 
tioaa of the lymphatic vvmcIs uf the peats, inflammation of 



"If IbeMndcal doircj Turllicr infumiBiion upon llti* imlijcet, bft !■ r^frnvd 
l*lkewvrictir<;rQDf<;M,"Th<>Emlc<w»]K in DUowMof tho ttlnddor mkH' ■■lhr«," 
pobliitud tn the " Ihoulidir riilmrtic^" uuJ to OriiiifcH'ii tnukllM, " Tlic Bmlo. 
saople XuBlnctUtt ot iho tJmtan,'' in our work on " i^jphilU," founb nliUon. 



so PATSOLOGr AXJ> TBEAT21EXT OF SYPmilA 

tlie inguinal Ivmplmtic glands, coudvloaiata (warts), and cer- 
tiun rbcumatoid allcctioufi of tlio juinta, sbcatLs of muEclea^ 
and buns. 

Of the diseases wliich extend by contiguity from the 
Tirotlirn to adjacent organs, wo may mention affection* of 
Cowpor'fl glaud, of Iho epididymia, jiroatate, blailder, ore- 
ten:, aud kiiliieyB. Alorfover, tlie morbid tesiinnti prcxlueed by 
lireilinil gcinorrliCM, when tliey supervene npon n severe fonn 
of the disease, are generally coDeidcrcd as accompanying 
plieoouiena of tbe di»ea)te; while tlioite leMons produced by 
gouorrha'H of the male urethra and coining on funtiie time after 
tile nretbritis was apparently cured (strictures of the nretlm^ 
prostatic and vesical diseases), arc dc^ribcd ti scijucIfq. 

Fro^Qosifl of Qoaortli<ea in tho Kale. 

Gonorrhooa of tlio male uretlira affords a less fnvoniblo 

prognoeifi than gonorrha^n of the female nrethra and vagina — a 
fact that might be inferred, even after leaving oot of consid- 
eration certain oo-effecta which natunJIj can not oecnr at a]l ia 
the female, but which in iirldition seem to bo due to a higher 
function of the cpitlicliHl colle of the male urethral tract that 
liaa not yet been fatbomed. To foretell the dnration and 
course of a male urethral gonorrboM is a dillicnit problem. 
Experience has only taught us so far that, when a mucous 
gonorrhcea has retatncil this diameter for several days after 
oxposnre to Infection, it will under an iippropriiitu treatment 
disappear sooner than a purulent gonorrhcpa. This prcsump- 
tion of a speedy cure becomes almoet a certainty when the 
female who eonmiunlotted the dliicaite to the patient suffers 
only from a mucous catirrh of the genital organs, or when tlie 
dlwase In the man can bo ascribed to t)te temporary irrita- 
tive influence of the mcnstrnnl flow in the woman. The first 
inflammatory goDorrbccal urethritis of a person is generally 
severer and more obstinate tlian the following once of the same 
ohanieter. Tlie shorter the intervals between the first inflam- 
matory gonorrhota and thoac following, the milder will the lat- 
ter be. The greater the Bwclling and the cvereion of the lips 
of the meatus^ the more severe iJic diveasc may be expected 
to run. Iliemorrbagps, peri-urcthral iuilammatory cxadutioos, 



QOSORRBIEA, V£X£S£AL CATABRB. 



31 



infiltrations intoone of the spongj- bodice, affect tbe prognoeie 
anfavorBblj. Tlio licaling of ulccratioDB takes a long time, and 
eveD a mucous catarrh of tbe cteupor part of tlio urctbraJ canal 
ia very slow in getting well. A croupous gonorrhea causes 
ehrioking and contraction of tbe affected part tlirougbout its 
vrbole extent. Lastly, bfomorrhoidal conditions, Bcroptiulosle, 
and enpeciaJly pulmonary tubercuUwift, tend to delay tlie cure 
of a gonorrh(pa in tlie male fur a long wbiLe. 

Prophylaxli af^ainst OonorrhaBa, and Treatmeat of Acuta and 
QLTOuio GonorrlicDa in Ken. 

Up to the present day wo have not succeeded in finding a 
medicinal agent by the use of which, before or immediately 
after sexual interetturw, a gonorrlunol infcctiun nuy be pre- 
vented. According to Diday's and our own cjcp<srience, injec- 
tions with a solution of potash considerably diluted, or with 
Bligbtly acidulated preparations, indeed even with pore water, 
directly after coitus, have a decidedly irritating effect; we 
would therefore leeommend that sneh injections be not need 
till the membrnra virile has been cooled off in a topical Iwith of 
cold water. TUq bcftt security against contracting the diseafie 
is affonled by the ose of the eondom, made of varioag sub- 
stxnees, ditch ta the intestines of »hcep, figb-biiidders, and 
India-rubber. Giving to the freqnoticy with whiL-li theso 
envelopes hurst, they can not be relied upon a« a xiire protec- 
tion. As propliylactie ineiuinrcs which may po«*«ibIy prevent 
the origin of the disease, tlie act of coition ehould be accom- 
pliafaed as quickly ae poesiblo, and tihould not ))u repeated at 
short ialcrvaU; the individual f^honld abr^tain from hnt'ing in- 
tercouree witli meuEtniating women or those euffcring from 
bdiial dtadiai^ee, and finally ho should urinate directly after 
oopalfttioQ and wash or bathe the penie in water. 

Inefiiciont as our measurea are to prevent a gonorrhoea, eo 
liltle are we at present alile to abort the disease by treatment-. 
Injections of caustic preparntions — for mstanee, elrong eolutione 
of nitrate of silver (1 gramme to 30 of water [= gr, xvj to 
5j]) before the inllauiumtion has begun to develop, as recom- 
mended hy Kieord— may prove positively injurious to tbe 
patieiit and never afford any benefit. Indeed, all kinds of 



33 PATBOLOQY ASV TREATMKNT OF HTPmUS. 



L>aaBtic iojcctfoDs arc ayX to prodace slougliiiig of (lie nrctliral 
iitncou.1 muiubi'SDe, iiillainmation of tlie neck of tlie bladder 
and of the prostate gland, liffiinorrhage from the urethra, and 
tUe diM>ade wliicli the plivMciaD soiiglit tu iiip in llie bud wiQ 
be vastly prutrdctiil and a^ravaled. In n'gurd lo large doees 
of babamic remedies udTninintcrcd inkmallv, vrith the object 
of aborting tbc di^-asc, we hold that they merely give riee to 
ttevLTt* diguKtive dUttsrbaiicus without exercising an j beneficial 
cScct« whatever. 

Hence we are only able to rceommend a methoditai treat- 
ment of nrcthral gunorrlioea corresponding to the intcneity and 
tbc Btago of tho disease. The more intense the intlatnniatoiy 
phenomena aud the dieebargo, the milder shonld t)ie treatment 
be ; tlie mihier the inflammatory symptoms, die more energetJe, 
but not too energetic may the treatment be. If the treatment 
adopted conei&te iu the introduction uf romedieftand medicated 
insLrumeuta into tlie urethra, it ia called the dirtH method ; bne 
if a cure is attempted by tlie action of romedie» through the 
digestive and respiratory organa, it is known as the indirect 
method. 

It is of the Dtmo^t importance to tpgnlate the diet and 
rcpmen of the patk-nt. Whether the jwtient Buffers from aa 
acute or chronic gonorrha-a, he should l>a prohibitod from 
drinking beer, wine of all kinde, champagne, and i>oda-water. 
In sensitive individuals these beverages may occftsioa dysoria, 
bleeding, and other symptoms denoting aggravation ; these nn- 
favorahle coin plications arc likely to mpevrono in gonorrha>a, 
oven without any special canaee. The patient should likewit^e 
\x protiibitcd from mine; af)j>.'ira^iii, celery, and all other arti- 
clea of diet which t^tiinulate the urinary organs or caui?e erotic 
■ensationg. Active cxerciae, such as nmning, riding, fencing, 
pU)-iog billiarda, etc, nhoiild be pmhibit«--d, and as a measiue 
of precaution tlie jnticnt t«tioiitd lie advif<ed to wear a ffDSpcnaory 
bondage with thijch-etra^M^ Siwponn>ry bandages with elaetica 
which prcEa upon the urethra are injurious aud should not be 
used. 

NotwithHtimdiiig these precnutioDB, the patient is not safe 
from an attack of infliunmntion of iho epididvniia He is, of 
cuutve, tu abstain ab^lutely front sexual inter(M)urae ; a stnglo 



OOXOBSRfSA, VENEREAL CATAB&H. 



33 



indnlgCDcc at ttits time i» likely to pmilaro the inottt injnnaiiH 
remits, and a simple gonoirho^ maj beooiiie gravely oompli- 
«ated. Tlio boet driuk U, after all, puru water; at Uio moetf 
IcmoHAdo in qimntitics only sufficiout to <)iicuch tbo thirst may 
be allowed. DiureLice are directly injurious, la regard to 
lu« food, the patient should be kept on a spare diet, consifiting 
if poasiblo cxclmivolj of vegetables, milk, light toil nnd mild 
e>offee, choeolate, Boups, and stewed ripe fruit. If meat has 
to be permitted, it nhonld only be in eraall quantity and at 
oooDtime. The patient should eat nothing late in the erening 
or shortly before retirinff, in order to avoid geoiinal emisMona. 
Were the g<morrh<i?al patient* to Bubject them«jlve«t to Uie 
aboTe^dewribed diet and rentaio strictly at rest, and in addi- 
tion make daily applicatioiu nf cold water for several hours to 
the genital organs and perinajntn, mo«t cawa nf gonorrheea 
would get loetl toU/nnyotir or »ix iceeis iiithont injections or 
intcnul medicine, or at tlic most with the aid of very little 
medicine. 

Jf the ]>atient, in the course of an acute or chrooio gonor- 
rbfsa, ta obliged to uriuato fruqucutly, or if blood is ejected 
with the b«t few drops of the urine, no injection should be 
made into the urethra oor any balsamic remedies adminiBt^rcd 
internally. The froqucnt iselmrin and the diachar^ of blood 
from tbo nrotlira or bladder art! bi'Rt relie\'ed by the applica- 
tion of hot fomentations to tlie re^on of the bladder and over 
the penia and perinieiim, by the introdnclion of suppositoriea 
of belladonna or morphine into the rec'tmii, or the internal use 
of both these remedied or of extract of eannabi:* indiea. Iron 
and ergotine may be employed if the hfemorrbage continues 
or is Bevere. For tliia purpose we prescribe : 

B Extmct b«IUi]<niDic (or tnorpli. iour.\ 010 1= itr». Jm.]; 
Butrri de cacao, q. a. ; 
nU ft. anpposttor. parra No. 10. 
& TliTvo mipiM>ntori<», weU oiled, u> be introdao«J dnily Into Um 



B Ext. noDabia iodicn; 

EiL aomin. hjroMuin., UO'SOdra. v]; 
8!»wh»f. alb«, 8-00 Igra. xlvyjj 
liiv. in Omia Ko. X. 
8, Ooo powder t« b« lakes tfirj four h«an. 



84 PATUOLOOY AXD TRKATMbW'T OF SVPSILrS. 

B Lkiaoria ferii Msquiclilor. eoIuU, 1-SO [gr. xxlij]; 
A^oa dM(i!^ lOO-OO ( | III, J IJ. 3 ij] ; 
Bvr. rubi iilwu, 20-00 I § M., 3)17]; 
S. Oo9 tabltvpoonful ervrj liour in water, 

Q C*rboaatb fern wccbaroL ; 
ErBOtlnl pur, U TOO [^r. xvj] ; 
Smcbkr. oltm, 8-00 [gr, xli^UjJ; 
Dir. In dmis Ko. 10. 
8. Foar pi>wd«» to l>o t«k«a Oailj. 

In very intenBC d.rsuri* and wry paiufal erectioHB, the hy- 
podiMiuic iajecdon of murpbia Julu tbe ])eria}ei]n] will afford 
prompt relief. 

[For the control of the ardor nriniie, olkalifis, nich as acetate 
of potofih, with spirit of uitri duldla and caiaphor-water, vanj be 
given, diluted in vrater, erery tliree or foar honra. 

ia the acute ata^, whuu the cbordee ia very screre, rm 
injection of cocaine Iwfore going to ^>ed, and aootber vhoa 
tlw patient h attacked by it in the lURht, have roDdarod tiie 
beet rsBults. In aonie ci»w tlie cocaine answered adniinbly 
when all other a^centa foiled.] 

No favorable eSeeta are derived from the internal adDiin- 
istration of camphor. If the bleeding from the bladder does 
not cease under this tn-atuieiit, cold-watur applieationa should 
Iw Bubstitntcd for tbe hot fomentations ; but the former should 
be discontinued if they aggravate the paina on mictaridoiL. 
If no dyauria Ixj present, and the penis ia not ranch swollen, 
injectdona may lie ordere<l at once, but if painful urination or 
paio in the testicle enane, the injections must be immediately 
diacontiuned, aud the remediee above recommended for the 
dyauria, or tlie mi-a^irus to lie duscrilied iu the treatment of 
epididymitis, may be resorted to. AVlien no great amount of 
swelling of the i^enla, in cousequeuee of the inflammation of 
tlie ureUica, is prcHont, injections may 1>o begun. But the 
romodiee to be injected mnst not bo too strong or too con- 
centrated ; they abould Imve no esdiarotie action, iiotiun^ more 
than on astringent effect, li the injections employed are of 
the proper strength, the pain from which the patient suffered 
dnring uriiudon often subaidea in from two to three days, and 
the discharge of pus aJw dimlnislies, while stronger injeotions 



OOyORBff(SA, VBSBREAt. CATARBB. 



%% 



qniclcljr iijfigravato the paitiR, tlic penis booomoa swoUen, fre- 
i]aent aoid painfol urination and bleeding eneue^ and Lbe patient 
is Tendered more nusenible than ever. A» han tieen nmiarked 
above, better rtsnlta arc o!(taine<l from mild astringent injeo- 
tiooft, emploved at proper periods and in a proper manner, 
than from luij other measures. And yet uuui}' objectioius hare 
been urged against nring tliem. l'h« mocst serivos are that 
\\y the injections the ooDtagioOd dit<«bai^ ia forced farther 
backward into the deeper parte of the urethra, and the io- 
flammation is cooeeqtiontlj driven into the tcetce aad bladder ; 
fortliermore, tliut astringent or eauslio injections accompli^ 
nothing more than Bpwmodic contraction of the uphinotcr rou«- 
cte of the bladder. Now, the contagion can not be forced 
badtward, becawie the injected fluid oo»^iktefi the dituyhnrge, 
and in that way destroys its infecting pmpertie*. Tlie wcond 
objection i^ refuted by a thousand-fold experience, which prerea 
that the majority of Btricturt» of the urethra are due to thoM 
morbid cliangw in the inucone membrane, resulting from per- 
Bifltent and Tiolentgonorrhowd" inflammation alone. Wc hare 
found stricturca in [wtiimts who for years had suffered from 
gonorrho^ and enhmitted to no treatment at aU. The grouud- 
leaeness of the statement that injcctionB may hare mich an 
tnjarioas efiect uix)ii the diecaso of ttie urethra as to caufio the 
dcstractioD of the epiihehal cells of the mucous membrnne, 
eoagnlate the protecting mucus, and corrode the euperticial 
layon of the new, imperfectly eolidiliGd connective tifisne, 
ia proved by reeulta obtained in the treatment of gonorrhcca) 
disease of the eye, vaffina, vulva, and rectum. H we do not 
advocate the abortive method by the aid of caustic agents, and 
eonoentratcd astringent remedies (nay, more, we even urge that 
the greatest caution he exercised in the local treatment with 
astringent preparationB), it is not because of the bad effects we 
fear the injections will have upon the mucous membrane, hut 
on account of totally diffi-rt-ut circumstances. If a large quan- 
tity of even the mildcet fluid is injected into tlie nrethral canal, 
eontracted through intlammntion, the mucous membrane of that 
canal will be severely otretchcd or oven torn, Purthermore, 
the senativencaa of the male nrethral mncooB membrane, as 
eomptJed with otlier mucous membranes, aliould not be lost 



36 PATB0L0S7 AND TffBATMS.VT OF STPOILIS. 

tight of. The niucitui) mfiiibraiio of even a lic&lthy uroLhni la 
markedly irritated by tfao mere injection of pure cold water. 
Ueooo an inflamed uretbrul canal r&tjuirw to be tiundled witfa 
tlie iitinuet gentleness. 

Tlie injections arc best made with an air-tight bat cosy-act- 
ing syringe, nuuJe either of hard rnbber or tin. Glan eyringm 
ore too fragile a.ncl flt>ldum i)f uniform caliber. It ohoulil ter- 
minate in a short, blunt, and emootb end. A» air forced into 
tbe urethra is apt to produce spasm of the bladder, erery porti- 
clu uf air ethoulil tlicruforu Ix- expelled from the nyriuge. This 
is bciit accomplished by turning the nozzle upward and push- 
ing the piston home till the liquid flows out. The amount of 
HiiiJ that may be injected into titu uretfant should be in pro- 
portion to the length and lumen of that camU. The injection 
may bo made with tlic patient in any position, but it is best 
done when ho is standing. Tlio physician gnmpa the exposed 
glan^ ])cnig between the thumb, indos, and middle finger of 
tbo left band ; applies closely to the meatus tlie end of the 
vyriugv, held between tlie index and middle fingers of bin right 
hand, while with tlie thumb, ineerted in tbe ring uf tlie pietoo, 
he slowly presses it home. In patients aSeeted with hypoepa* 
dias, and who soiuctiuies have several openings situated behind 
each otliei^-of wliich only the laRt is likely to Kiad into tbe 
uit^iluH, while tlie rest terminate blindly — the penis has to be 
tHifited upon itH oxih, bo Uuit the meatus, which is aituabed upon 
its andor enrface, i» made to af^Mau* u]>on its upper eurface, 
and tho syringe ib placed npon it almost perpendicularly. The 
first Eyringefnl may be allowed to come away directly after 
being injcetod for the piurpoee of wafihing away tlie disebatgo 
that has accomolatod in the canal, and tlicn a second injectioQ 
slionld be made and retained for a few momenta by compreU' 
iii^ tbe Iip» tif tlie meatus as the syringe is being withdrawn. 
If thv lluid is retained too long, tbe mcatm nrinarius is pulled 
and (li.<itcnded too much, and may become greatly irritated. The 
more slowly tl»e fluid is forcetl into tlie urethra the more deeply 
will it penetrate. Injections repeated too often arc injurious; 
not often enough, are of little use. We recommend from four 
to six injectioos daily. For the purpose of ascertaining tho 
progress of tbe urethral ailcction, and to modify its treatment 



OOffORkntSA^ VBySREAI. CATAKRtr. 



87 



accordingly, tbo injected flnid ehould bo allowed to fHovr into 
a glius vGEsel from time to tiuie, and the amount of mucus, 
epit}iellal Cells, pns, Wood-corpascleii, fibrinous masies, and 
stnictnral di^tritDs it contains, rill afiord the phydcian all in- 
dicatlcma Docuesar/ for tliat pm^xxit?. If tbo dysuna ia aggra- 
vatcd by tlie injections, tliey niuiit be suspended until tlie 
spurn and pain in nriuating are enUrely gone. Intense cbordoe 
aud utTcrc uretliral lui-niorrhagt: likewise oontraindicate tlie 
continuation of injix-tiontt. In rcgnrd to tlio fluid that Hbuuld 
be injected, ve luire been in the babit of u^ing for mauj jears 
* weak eolntion of ponnanganat*; of i>oUi«Ii. We begin witU 
OK'S of [wnnaiiifiuuitc tu 200 gratnmca {gr. ^ to J vjas.] of 
wal«r, and gradually increase the fitrength of the solution, if 
tlie 9eQsttivcnct«3 of ttie urethra permits, to O'Ol tgre. }], in the 
same quantity of wator. Owing to tho rcadiDOM witb which 
It is docompo«>(i, a eutHcioiit quantity of the medidne, to last 
hro or lIirL* days duIv, Klionld \w. prttwrilwd. In a great many 
<u«s we succeeded witb tliis remedy in subjugnting a pnmlont 
e»tarrh in a very few days, Jf the dbcharge has already bo- 
eome mucoan, we lure recounte to tlie unud aeiringont retne- 
dies, such as alum and sulphate of zinc. Of alum, 5KX) to 
S6(KK) [Siv to 5 viij] of water is tolerated ; of Hulpliate of zinc 
or of cadmiani, from 0-^ to O'^O in 200 grammcti [gra. 5 to tf 
in 5 TJ**] "f watvr may bo used. AVe generally employ tho 
following fommla : 

5 Alomin.crodi, 5-00l3iv]; 
Solph. siDd, D*I[0(KTa, vi|J); 
A(liiA doMO., SfiO-UO 1 1 vi^). 
i. Tit lio (i^Mb.**! foar to Atq timcB dailjr. 

If tbe mucous membrane is very seositiTe the acetates are 
preferable. They oiay be u«ed tu stronger dowx. We geo- 
orally order — 

B Aoct, itinrL, O'SO [grs. vvj\ ; 
Aqtm iIm^., UO-OU | $ v]. 

' MOtatc of alum, in the following manner: 

B Alnmio. cnid), I'AO [^n». xxig]; 
Aci<I. wdic oonci-at., I-OO {Rn. ztj]; 
Aqua (Iwrtil.. 80000 [ J vJm.]. 



t& PATHOLOar AXJO TREATMEiVT OF SVPSIL/S. 

B AlamiiL crndl ; 

AwL plotubl basio., iki I-OO [gra, xvj] ; 
Aqua deetU^ 20000 ( ; vjw.). 

If tJic morbid senBltiTeDew of the urethra has entirely dis- 
appeared and a weaJfeocd couditioti uf the muci)ti» membrane 
of Uiie orgau ia Bupixjswl to cxiirt, nlnni in oombination with 
tannic acid liliuuld be tried. We order the following combina- 
tioD: 

B Alnm «nidl, 1 -00 [gn. xyJJ ; 
Tiuuun pari, O-EO [pra. Tiy] ; 
Aqttt duoli)., SOO'OO [ 3 trJH.1, 

If the inueo-purulenl diHc1i.argi> does not p«>n'e])tihlir dirain- 
iab aftiT u^itig tlivsc injections, it mKj be advi^ble to res<Ht 
ia addition to the indirect treatment and to eniploj both 
methods. 

If circunittcrilwd inliItnition» are present in tlio corpora 
cavemoisa, we order cold water to be applied, and cauae the 
infiltratod places to he rubbed with the following ointment : 

9 ExtrooL bdlndonnn, l-OO [grt. xvj] ; 
Vug. hydrary., 10-00 [ 3 i^n.], 
W. Fl nng. a. A lump us big as a pea to bo rubbed in upon tba io- 

filtrntcd iftit. 

Aa w>OD BB flnctoatioD is detected, the abeoces ehouM bo 
opened, in order to avoid the occnrronco of urethral fistolie. 

In Uio treatment of tboee diaeasee of the male urethra tliat 
have been collectively called ehronic ffonorr/iaa, the phj-wcian 
mnat first ascertain the morbid alteration of the nrcthra that 
kcepR up the discharge. Tfaew morbid alterationa may be a 
markedly relaxed condition of the mucous membrane and 
pnssire dilatation of the follicles, gODorrli(jcal absceefiM and 
granular eroaions, cn)U[WUB iuflammation, beginning or already 
deTe]oi>cd strictures, and the grannlar and tiachoinatoos con- 
ditions described by Gr&nfeld. Tboee practicing endoecopy 
may by that means aaocrtain the character of the lesion ; up 
to the preeeat date, however, wo have not seen any brilliant 
roniltB follow the tri::atnicut can-ied out by means of tlie ondo- 
Boopie tube. Thoee who do not practice it ahould examine the 
oriae which the patient is iuatructed to paM in a glam roeeet, 



eOJFO&MB(BA^ VSSSSBAl. CATARRn. 



39 



and tiio injected fluid after it oofDCS ont from tlie nrctbra. 
To make tLc cxaniiuatioo still mors complete, a bougie or 
sound, enfiici^Dtl/ large in caJibcr, should be pufscd iuto tJie 
urcthrBL ; and, taking into eonndcratioa all Uio (arcain&taDoee 
pr«MDt, the phyBician will bo able, per inducttonem et escdu- 
eionem, to diagiioeo the autoal coodition of the canal. If he 
hu diagno«od tho prcMoce of gonorrh«?fll ulcerations, lie 
should endeavor to prevent tho formation of bridle cicatriees 
hj Lho daily itilroduetiou of sound:; for a lon^; vrhile, and after 
each pasaage of the Koiind Hime astringent Bbonld bo injected 
into the nretlira. In »uch cases we order nitrate of eitver, 
with or without campliur, u in the following formulis : 

S Argont nitric., 020 U fr50 [gn. iU to vij)] ; 
Aqu degtiJ., SOO-OO 1 1 vjas.] ; 
Cunpb. iDttfiiL gam. arab. subactn 0-10 [gr. li]. U. 

B I*i«|' fcrri •osqnichlor. pululi, gtt, x ; 
Aq. (Itwtil., SOO-OO [ I \JM.]. ii. 

If we sutipeet the exiftt^nce erf grannlatiomi in the nrethral 
rana), we nso somo inmlublo snlt or oxide, in the hope of 
CBuaing them to Bkrink ; for infitance : 

9 Uagiat UnDoth, aootolO-l>0{3iTto vifj]; 
Ai. desHL, 300-00 1 1 *jH- U. 

8 Zinci sulpbu ; 

PInmW aouL, U 1-00 [(tr*. xtJ); 
Aqu dortil, 20000 [ I vJM.]. U. 
B Zinci ealph., 0-BO [gn. Tiy) ; 
Ziod drill., I'AO [gn. xxiijj-, 
Aqoa dett, 20000 [ I v^\. 
H. Ifust he veil abakea before tuutg. 

If these injections achieve no good result, n boagie, dipped 
in mueihgD aeminum cydoiiionim, or guui-aratiic, and after- 
ward in powdered binuuth, mav Iw passed into tlie urethra 
bejrond the grsmiilationn. An the greater part of tho powder 
is apt to be rubbed oU daring the introdnction of the bougie 
into the nreihro, and but little reacliea the dI»caH(»l part, it is 
preferable to introduw) thi; ri-ni«'<lics in a wlid fnmi. mixed 
with gani-arabic and rt>IIc4l otit into long pencil like boDg^es. 
When oiled, thcee arc ineerted into tlie nrctlini and pimbud 
hj tho aid of a bougie iuto the membranous |K>rtion where tho 



40 PATilOLOGY ANH T&ISATMSKT OP SYPBJUS. 

(Itfieaiie is most tikelj to be located. The reraedies rocom* 
mctided above may be prepared fur tbii» purpose ia tL« fol- 
lowiag manner : 

9 ZiDci Bul|tb,, O-SO [gn. iyj; 

Butjrldc cocao <|. ft. ut f. L>iidUi ureltirdca Icaoca longitmliao 
(lollicu Ni>. X. 

One of tbeee sticks, liavlng been pasbed Ento Uie deeper 
part of tbe urotbni, should be retained there by comprcBsing' 
the Ii|>i) of the mcatiu; it will mou melt, and exercise its 
healing properties upon tho aSectcd parts, llie patieot sboold 
be told tfaat^ the first time be nrioatee after tiie introdnctioD of 
one of these medicated boogie?, he is likcl_v to pass a <ew 
drops of blood. Good results arc often obtained in cliroDtc 
^norrlioea b/ the introduction of ^teel &ouiide of the largeet 
Bze postiible into thu iirctlira. In resorting to the 111% of 
gonuds for the piir]x)(« of curing thi^ disease, the physician 
shwuld exercise tlie utmost care, because the forcible introduc- 
tion of hurd solid inatnuucutri niay readily produce falMi pa»- 
wgoK and tlte patient be ecriouidy injured. GeDerally it \» quite 
difficult to pBEs the instrumeut through tbe prostatic portioa 
of the arcthra. To jiass tliis ]urt witli the greatest caw it ie 
necessary to depress tlie hiuidle of tlie instrument till it Uee be- 
tween tlie paticnt'6 tbighti. The first few times tbe instni- 
mcDt is introduced it generally canseA scTcro pains, and the 
operataou should tlierefore be carried ont with the utmost gcn- 
tleoeBS, and with the patient iu u horizunlul pixtitiou. After 
all, a cure will only be achieved by tlie use of the suuuda and 
injoetions of OK'tringont uicdieiiic when there is no urethral 
apasm prexeDt. To i^ubju^ate thii^ eaudition, the patient should 
apply warm fomentatious to tbe bladder and jteuiK, and medi- 
cated bt^ugies containing morphia or extract of belladonna 0-01 
(gr. ^) should be pushed into the nrethra. After the eipasm 
has completely buliHidcd, the use of the sound and injections 
nui,y l)e ot-ain ruHimed. 

[Of all the injectiona that have been recoimnended — and 
I have given them all a thorough trial, both in my clinic and 
private practice— I found none so effieocieDS as sulphate of 
Bine and bclUdonua, and now tue it alnwet exdnsively : 



eOXOEBUfSA, V£N£SEAl CATASBff. 41 

B Zinoinilpb.: 

£xt. beltadoana, U 0-W = gn. x ; 
Glycerloe, flO-00= SIJ; 
A^n». 200-00 - S Tjw. 
IL S. For Iqjeotkin. 

Kecently Dr. Bryant has proposed tlie irrigation of the 
urctliral canal with a solution of coriwive eotpltiaatej 1 to 
40,000 parbi of water. Ifure tliau llircc jcont ago I cndcar- 
ored to cnre a miiuber of cases of g<»iiOrrliaia by allowing 
miotu solutions to flow into tlie uretlira from a fonutain- 
•Triogo through a catheter, but I found thG method troii- 
bloeome, withoat deriving mi e<[xni\ amount of benotit 
from iE. 

In protracttHl ais^ in which the di>(>])er porCii of the urethra 
aro involrcd, and (tie acnto iRtlaminatory evrnptonui liavo en- 
tirclj- Butfciided, I cauM dc«p urethral iujectiong to be made 
with a long-nozxle syringu, or uoe Mitchell's cietlifatcd lioii- 
gies. The latter, however, pre not alwa^n toleiated, for the/ 
act as foreign bodi(», and the paiu tliey occasion docs not Hub- 
adc till the nurlled ingrediuntA of which thcj are composed 
have been ejected. In these cases I have very often succeeded 
in efivcttng a cnre by making applications of a two-pur-cout. 
eobtiun of nitrate of ulvcr ttirongh an endoscopic tube witli 
a fine brush. Having first aficertatued tlie exact location of 
the affected part by means of conical probce, the tube h in- 
verted, poshed iu eo far that its internal end touches the di»- 
cosed part, and then the eolutJon is applied.] 

The nso of cool sitz-batliH is of mnterial wrvice when 
ooabined with the local treatment. In some cases it is ntiefiil 
to eombino the local with the intenml treatmout hy moanfl of 
the ethereal-liolsamic remedies, especially 'in tboae cases in 
wliieli the local nieasnrea already recommeiidod have been 
fBitlifally tried without accomplishing any good rcanlta, par- 
ticnlarty if no coutraiudicatiMUH, such oa digestive disturbances, 
are present Lastly, attention sbonld be paid to the poasibhs 
presence of haemorrhoids, hyperarinla of the rectum, irritation 
of tliie organ by aacoridi^ unieinia, ecrofuhi, etc. These re- 
quire appropriate troatmcnt before & succc&eful result con be 
attained in obstinate oaaes of chronic gonorrhoea. 



43 PATHOLOOY AND TREATMENT OF SYPSIUS. 



The Indirect or Internal Treatment of Qmon-hcea of tbe Kale 

ITrethra. 

Tbo indirect or internal treatment consists in tlic omploj- 
ment uf oeitaiu r<>mt>die>«, wliich when introdnced into tbe sj&- 
tem aro in greater part excreiod bj the kidneyB, then puss 
with the nrino through tlio unuary apparatus, and exercise in 
tliid luann&r a curative effect upon tlie dittcoscd mnoons nieiii- 
hnuie. This also explains the reason wh}r these remediw are 
onl}- effective in gonorrhoea of tlie miJe and feinalu nrethnt, 
and not in gonorrhuia of tlie vugina and uterine canal, and 
have little or no curatire properties in gonorrhoea of the evee 
and rectum. Tliese r«medic» may lie introduced into the sys- 
tem either lim»ugh the digeHtive or the n«piratory oi^ns — 
poHubly nlflo by a prolonged application npon tho integument. 
Among theac aru tJio following rcmedioa : Copaiba, haleam of 
Pern and Tola, tnrpcntin^ cnbeba, ol. amtal. fiara, the so- 
called wood-oil, or gurgon bakam, and, lastly, certain prepara* 
tions of matico. 

Up to the present time baUam of copaiba has remained the 
favorite remedy. lU unpleasant taste, however, is a great 
hindrance to in« administration, and many wap Iiave been de- 
mised of disguising iL The beet is by inclosing it in gelatiae 
capsules ; each cagisnle QEiially contains from six to seven drops 
of copaiba (capniles de Motlie:) et de Itaquin). Otlicre giro 
balsam of copaiba in aromatic tinctnre, or 'm the furiii uf pills 
(copaihine Mige of the Freueh). If it is desired to administer 
it in its purity, it should he ordered to he taken three or four 
times daily, fifteen to twenty drops cai^h time, OQ a lump of 
sugar, or in some liquor prepared as follows : 



U. 



B Tinct. aroTnut. aold., BKIO [Slv]; 

LtftLuim iv>|iiubft, 50-00 1 jml, ^'n]. 
8. FiftccD to twcDl)r drops to b« token foar times dailf. 



For the purpose of administering it in pilla, it is beat com- 
bined with magncuQ. Thus we order : 

B Bftb. oopolba, lOOO [ 3 ^. T»i)|: 

Ua)t. xM. q. B. at iona. pit iwd^., 0-30 [^gn. t], 
8i SU to eigtit pilla M be ukeo four lioicB daiijF. 



GOXO&RUiSA, VENEBSAL CATAS&B. 



13 



Or, the baleam of copaiha, uiadu tu pUk and wrappod ia 
vrax, u b tlie fciUawlug funiiula : 

9 CcnDiiJbiisfiiMOiv]; 

Pulv. mtgnea. q. «. ut fl. ntiMM plltil. formest piloL 
puntL, 0*80 [gn. v], cunsp. pulv, cudcm. 
8. Kigbt }iillK to tw taieu tbroe tiuM iluil^. 

[Tlie following arc exc«tloDt (onuulse for admiui&tcriog oo- 
|)Aika in cmuliiitimi iir pilU Tlioee combuiACiom aru better 
tuleniretl »o<l ]«»« olijwtiunnble on aooonnt of tkeir dtsagree- 
ablo taste, niid very officacious : 

B Copub«,30-00BjJ; 
Li<i. poUaan, 4-00 = 3]; 
En. gl^ojrrrbizs, 15-OU = ^ M.; 
8pU wlhwb oitrwi, 30 00 = Jj; 
OI«i gnalUierlw, g\x. xvj. 
Uix the cOfMilM and Uie Kquor potama u*] th« cxt of liqnorioA and 
q>iriu of nitn finl aopanMlr, Bad tbeu add i)i« other iu^ntdiMits. 

Bl a UbleipooDfuI afl«r eaoh meaL 

B CopBilw, 60-00 = 3 U ; 
UagB««. c«rb<., 300 = 3 m.; 
OL Dtenthffi pip., gtt. xi ; 
Ptilv. oabcbtD i 

BUniutb lubnitralU, U COOfl = ! Q. 
M. To be divided io pUb of 0-9 i^n, v eacb, and coated willi Risar. 

Id tbie pKecriptioo tbo cubebe serres aa a stomacluc; the 
alkali and tlie bisioutb are also good anti-djrspeptic remedies.] 

Balaam of Tola ia met with in oomnicrce as on hupiBBated, 
mliious sabetnnce, wliicli, Ix-forv iL^iiig, utiut be disBolvecl in 
Rpirits of wiuo. It has no tiiipleaAaiit tOHte, hut as a remedy 
k Inferior to tlie other resinoidii u-seil in Uie care of thia 
disense. 

The black Perunan baUam is administered in the same 
iBiDDcr, aiid til Himilar diiscts but U seldom uaed, on account of 
poeiegsing tittle medicinal virtue. 

Tlic therapeutic properties of oil of turpentine are alraoet 
aa great as Uiotso of bdKatii of copuiUi, but tliia oil ia even 
more unpleasant than an; of tlie remedies already epckcu of. 



44 rATROlOOY A2fD TBEATUEST OF SYPBILtS. 

It is best adniiiiutorod in pill furm, geaorally combincJ Mith 
UD ostriDgeut or iron : 

Zlnd nJpbM pari ; 

Tcrubinth. lurioi^, IS t 00 [grK. xvj] ; 

Pulv, rad, rtunliio) t{. «. 
H. Ut ft. pil. No. 80, cou«p. pulr. ctnDumatui. 
S. One pill thro« times dail;. 

B Fcrri sulph.. S-OOfgivl; 

T«rabiDth, iaricia, 2*00 [pn. xxsj] ; 

Pu]». Ijcopod. q, 8. ti. f, pil. pond., 0-20 [gra. lij], oonsp. pnilT. 
ciDiuiniomi. 
El Five plllt Ui 1h) ukea tbroe or futir tlinM a dAjr, 

Cubebs, piper ciiudatum, may be administered ettlier in 
powder or pill form ; for tlie latter, tlie ethereal extract or 
freahly powdered berry ia well adapted. The following for^ 
mnbe may bo used : 

9 Pitlr. pip»r cubeMn roKwnt., 20'00[Sm^ 3ir]; 
Bftcchar. lacCia, 0-00 [3 if]. 
U. 8. Dirido in dosn oqnole Na IS. To b« put In c&pniU-s, ood 
talcen in forty-eight hours. 

B Pulr. piper oabebic reoenL, 30*OOtS**^ 3i'1: 
Kxt janlper ; 

SjT. ilmplM, ftt, 50-00 f !j«!., 9W]. 
U. 8. To be tokvn ia twoDt;^-four tioan. 

If a cnrc is to bo nchicved by raeaju of cnbebs, tbe patient 
will have to take from 13-00 to 15-00 grammca [3iiJ88.to Siv] 
of tlio remedy iu twciity-four boure. 

Crrimault, of Parin, \w\& introdncod tbu use of the fu-callcd 
matieo capsules. They conlain an ethereal oil, prepared from 
the leaves of tlic drug mn.tico, piper uigtietifoliutu or clonga- 
tum, extract of cubebs, and ba]«um of copiuba. We ncT«r 
succeeded in effecting a enre by the admiuigtration of matico- 
oil alone, bat we did with nutico cap«ulc«. The latter «j« 
preferable to Uio copniba capsules, in eo far m tliey are better 
tolerated, owing probably to the oil of matico, vrhieh secnu to 
act as R storaachie. Of these matico capsules, from nine to fif- 
teen shonld be taken daily. Tlie so-called " injection v^tal,^ 
made of matico, and known nnder tliat name in commerce 
cootabs ethereal oil of matico and snlpbate of copper. 



OOHORRBCSA, VSNBRSAl CATARRH. 



45 



Now, experience bu sliowa that nmiij pereons Eoffer ixam 
vomiting and diurlKca iw the reoult of the iutonial iidinii)i]ttra< 
tion of the aDtibloiiDorrha'a-bakaiuie reinodicii, and io others a 
prolonged lue of these remedies will occasion chronic goBlrio 
and iDteetinal catarrlL But the iujurioua uflecu produced upon 
the digestive organs are nut the oul^' eviU ocouiioiied hy them. 
In 80036 patients tiiey also give ri»c to a pcculiur cniptlon of 
the skin. Attended bj* gastric and fehrile distorbaneee, grouptt 
of pale, wlicul-like cnipttous develop uhout the wriBt^ hi{>- 
jointe, and eepecially on tlic fuc'O. Tbcj roeciuhlc nottlo-rash 
vet)- clo^y, and, hke the latU^r, eauae severe burning and itch- 
ing, especially when the patients get wanu in bed. This aSec- 
tion of the ekin id called urticaria balaamieay and, o\V'ing to ite 
resemblance to ruseola ?^-plulitica, vtaa until quite rccentty re- 
garded by some phjgidans — Ctuenave, for instance— as proof 
that gotiorrh(8a was tlio initial disease of eyphilis. That thia 
assertion i» incorrect ie proved by the fact tliat tho eniptiuu 
disappeare aa soon aa the use of the remedy in discontinued. 

It is also anerted that the ethereal-balsam ic remedies exer- 
cise an injuHom eSect upon the kidneys, iu coniie'jueitce of 
which Dright'a disease ia said to rwolL Kow, if to the urine of 
a person who Bcveral htMu-s previouKly had tiikcn cubcbH, co- 
paiba, or tnrjxsntuio-oil, i^ome Atrong mineral acid is added, an 
opalescent, gelatinous sediment is precipitated which might be 
readily mi^takeu for ooaguhited ulbumcn, but it tH diittingiiiKhcd 
from the latter by thu fact tliut it a^in becomee soluble on boil- 
ing, or on the addition of alcohol, carltonate of potash, or am- 
moouL The rcscorchoe of Bcrzclius and Johnson have shown 
that the constituent elements of the balsamic remedies wq an 
ethereal oil and a resiuoni) acid. The experinionta of Dre. 
Weikftrt and H. ZeiBsI have proved that the precipitate above 
alluded to is not due to the ethereal oil. Consequently, we can 
explain ita prochiction by the following tlieory : The resinouti 
acids are the tcIucIcs ooutnining tho curative principles ; In tho 
intestinea or blood they combine with the potash or the soda 
and form a soluble rei<inoiiK »oap in the excreted nrino — a reiln* 
Old potash or soda. If to snch urine a stronger acirl than the 
resinoQS acid id added, for iunlaiiro, nitric acid, tht- rcainons 
acid that is insoluble in water lit precipitated as a whitish e«di- 



46 PATUOLOOY ASD TREATMSHT OF STPBTUS. 

raenL Pruf. IT. Zei^ and Dr. Weikart nonglit to mako 
therapeutical luic of tliu traiiKfonuation which tlic rwinoos acid 
trndergoee in tbe utine, by administering resinous add alone or 
resinous eoop to patients eTtfiering^from gocorrhoni. Aod they 
actuftllj eaeccoded by this means in reducing the blennorrhoic 
disclmrge to tbv least possible quantity, and by a prolonged nn 
of tlie remedy id euppreaaing it entirely. But no Beditnent, 
or at tlie most a feeble whitisli cloudincfs, was seen in the 
nriDc ; to produce even that, la.rgo quantities of tlie dm^ had 
to 1)6 adwiiuetcred. Hence it ^enut th:il the rminous adds, 
iu their natunJ combiuutiou with the ethereal oils, pass out 
in the urine more quickly thaji isolated pure or saponified rae- 
inoufl acids. It can not be maintained, however, that the 
ediercal oils of the baltuuns mentioned here arc cxcretwl from 
tlie system without producing any effect, bccaiiee clinical ex* 
perience has shown that, when introdaoed into tbe system 
by inhalation, they accomplish eomc good results in urethritis 
and pyelitis. Dr. Brcmond, Jr., cloiuu to have oblaiood better 
effects from turpentine-vapor hathti than from iuhalationa. 

Catarrh of the Olans Penis and Prepace, ^u^ftnit^^^^ BaUoo* 
Blennorrhcea, Baknopjorrhtea, Balanopoatheitia, 

The sebaccouB glands, glandiilm Tyitoiiii, tiituated in the 
fD6«a gkndis and on the inner surface of the prcpncc, secrete 
so lai^ a qnantity of sebum in some peiK>ns tliat it nndergOM 
dooompodtion — especially when allowed to aceumuliiie, and in 
those whotse !iabits are uncleanly — and irritates the parta. 
These become inflfimcd and produce a profnse dischai^. This 
follicular liypMsocretion may be prodnced by friction of the 
secreting eurfac^ — for instance, in mastnrbators (especiallj 
when tlie preputial orifice is constricted) — by ^norrhoml pns, 
or chancroos diHchargco, warts, syphilitic initial indurations, 
syphilitic mucons patches or cmptionn on the gluns penis and 
mucous membrane lining the prepuce, and epithelial carttinomo. 

Catorrlial disease of the glans and prepuce manifeste it«elf 
by an itching sensation which giros rise to erections. Gradu- 
ally the tickling seoflation boeomee transformed into a painful 
feeling. The ghma and tho prepnc« become (edematous ; tbo 
external surface of tho latter becomes red and erysipeUtons ; a 



OOirORRB<EA, VENEREAL CATAHBE. 47 

profnse duchnrge wells up from t]>e prcpntitil oi-iflce wliicb 
hen tUo odor of boiled carpcntcrVgliio. WLeri nuglected, 
enxiom and oven alcera originaU! vn thu inner Hurface of tite 
prepuce Bnd on ttie gliuis penia ; the discliarge becomes greea- 
\Ai va color and purulent (p_vorrha>a). Tlie l^'inpliatic veawU^ 
sitnah-U on thu durauiu of llio [wim, tho supvriiciul and deep 
ioguinal ^laude bccouic ludomed ; phimcMis aud paraphtmods 
may result ; indeed, it ia oven poeeiblc, cepociaUy whcu a clian- 
ere is present on tho inner surface of the prepaco, that tho 
latter, as veil m tlie gUum, will, in eonsoqueuce of conatADt 
jH-eeenre or conetriction, boromo ganj^nous. Condylomata 
aud Tugvtatioog ore another result of caturi'h of the propuco 
and g1an« pcniK. In extreme oases balanitiit, wlica asKoeiat«d 
with phimoftiK, may terminate in limited or extensive Rynechia 
between the glaim ami prepare, renilering ^xiial intercourse 
exceedingly painful in consequence of the traction between 
the porta 

Phlmosit and ParapluiBorii. 

"Under the term " phimosis " we nnderriiind an ahrionnal 
Qfitriclion of tho prcpncu to tmch an extent aa to make it iin- 
poBstbld to expoee tlie glans fnlly. In Mine oasea the prepuce 
can only be retracted enfficiently to cxp<Me the tip of the g^an^ 
penis. Tho caiwe of phimo«i« ia tho dii^roportion between the 
size of the prepuce and that of the glans penis. This kind of 
phiniwia is called tfwjurmry, in eontradietiuetion fmm the per- 
mtuieiU or eongenifai- \A\imoM». The Iiitler condition is due to 
the ptractoro of the prepuce, wliich, being too long, forme a 
funnet-liku cap over the gtantt ; the preputial oriitee is there- 
fore narrower tlian in pepBons in whom tlii« fiinnel-Hke cover- 
ing ia aborterand more widely expanded. Again, if the fne- 
num extends ap to the urethral oritice, it is difficult to retract 
tlic prepuce, and if force ia used tho fnenum will Ikj dragged 
backward and tlie glans penis downward ; the former ia often 
torn and the wound bleede. Such long and narrow prepucce 
are ttsaally trtTcr«ed by lar^ varioose veins, whoeo comprce- 
non during tho ozietcnco of a balanitis will often occasion 
oedema. 

If a phimotie jnepuce is forcibly retracted over the glans 



48 PATEOLOOY AXD T&SATXSST Ot 3TPMILJS. 

peiuA, llierQ reoolts the condition known u puaphimosis. The 
preputial opening that is now drawn backvrard behind the 
oonwA gUodu coDstrioU it und caudO) it to swell n\k. Tlio n- 
tum flow of liluud from the glaiu is impeded, wliile the BQp- 
pl}- ts not retarded. In rtmsequence of this, the glans swells 
Bttll more ; a serous exudation takes place in that port of the 
prepace antvrior tu tliv cuu-^tricting point, whereby a semi- 
Innar swelling fonns on tlic lower border of the corona glan* 
dis, which ov^lapa the constncting- point — a condition that 
hu bem called the " Spitnieb collar.'' Under nnfaTorable cir- 
cametaocea the constricted part« may even become gaDgrenons. 

Differeattal DiagnotiB and Treatment of Catairli of the Olau 

Feoifl and of the recalting Infiamm&torj Fhistoiii and Fat^ 

phimoBUL 

Balanitis ^^-ith ooeTUting pbimoeia maj be mistaken for 
gonorrhccft of tlie nrethm. The diagnosis can only Ins based 
upon the conree of the discoEe. Tbo cnwiong upon the glans 
peuifl and internal snrface of tUo prvpuce produced by bala- 
■litis aoinotimes are not easy to distinguish from mperlicial 
cluncroidfi, initial syphilitic leeioos, and their consecutive phe> 
nomena. Tbo chancroid ulcere, owing to their great tendency 
to inoculate^ giro rise to numerous deuj), tJiarply outlined small 
fiorui ; thus we oftt-u have folhcnlar utccratiotte in tho fossa 
glandis, and deep ulcers occaaonally on the fnenuuL Id casee 
complicated with phimo^ia the cxisteucc of chancroids or 
chancres can only be aficcrtaincd by inoculation and tho coorso 
of the disease. If the discharge exuding from the preputial 
orifice is mixed with chancrous vims, tho inoculation!) will 
produoe pnstoles after a longer or shorter period of incubation, 
acconling to the nature of tho virus, and (he puetiilos exhibit 
n tendency to mn into ulcerationR. Undtjr appr<ipriale treat- 
ment simple erosions heal in a few dnys, sometime!* even in a 
few hours. They are distinguished from syphilitic initial Ifr 
Riooa by the total abM!n<*e of indunition or parchment-like hard- 
Dem beneath them, while erosions which have ari.<tcn from ex- 
conations of the efflorescencee of roeoola syphilitica are aooom- 
panied by i^pot£ on tlie body, indolent glandular ewellings, etc. 

Id mild foniis of balano-blcunorrhoea, frequent cleansing 



eOJfORBStEA, VEXEBEAL CATARRS. 



49 



of the glans and prepuce, nod keeping tlie«e parte from coming 
iu eoiiUu--t with oacli othur by intorpoaing bite of elcan muslin, 
or II tliia Ujer of cottou-H'ooL, will »ii£ve to effu>ct a cure. Tlie 
profuse secretion may be quickly suppressed by the application 
oi a strong leud-lotion four or tive times a day, or an injection 
of nitrate of silver 0-10 or (yiQ to 50*00 [1} to S^ gre. to J jss. 
of water]. After the injection, oomprcENOEi dipped in the soln* 
tlon may bo applied between the gkni? anil prvptico. If it ie 
sttspoeted tiiat there on: cruxions or ulcers on the glaus and 
internal snifaoe of the prepuce, a long stick of nitrate of silver 
Bhould tw iusert4.-d under the prepaoe, and by & rapid move- 
mont the glam aud prcpncc are to be cauterized. In addition, 
tho injections with tlic above preparation Bhonld be continnod. 
If tho febrile pheoomena, the paiii and i;wetling, arc severe, 
and gangrenous slooghing is apprehended, Uie jKitiuut will have 
to go to bod ; the penis thoald be kept elevated, or lixed on 
the abdomen, and ico applied to it. H tho danger from gan- 
grme does not abate, the cotu^trieted prepuce should he Bptit, 
or circnnicised. The hitter, in our opinion, is the more appro- 
[uiBle trcfatnicDt 

Splitting of the prepack may lie done in two ways. Either 
bdlJi luyers of the akin are divided at oticc in the median 
line or the internal layer alone, the nmcoDs meuihninc, ie in- 
oittid. The tin>t mctliod, u'liich wc resort to in coiigcniliJ as 
irall OS in ue<{uircd iuflauimatory phimoeia of nxMlerate de^;ree 
(where the prcpitoe is not very long), coQeiBta in retracting the 
foreskin aa mucli as powible to tho corona glnndis, and pa^ng 
n ghwved director beneath the prcpacc. Upon thi* one blade 
of a straight ecissora is posfied, and both laiueUie are divided at 
once in the median line of tJie doraum <if the [wniit to an ex- 
tent of about one to one and .i half centinictxc TIm3 slight 
hieniorrhage that follows is arrested by a few stitches inserted 
in the lipa of the wound, and lead-n*ater dreaaiuga are applied 
to the paita 

The aeeoiKl method we employ in tboee cascfl of a^ravated 
congenital phimetiis in which markedly dilated veins onasto- 
moae in tho fureitkin. The pn-'puco is retraotod m mach as 
poedble, to that the margin of its inner layer is expoecd, and 
it is then snipped vrilh a delicate pair of ecissor» to the e:ctont 



50 PATUOLOGT AKI> TREATMENT OF STPBIUS. 



of two to four millimotres. Tbls iuciiiion allows tLu foreskin 
to bo rctractud a little nion;, aiid ati additJutuil portion of the 
inner la^er can now be exposed. With the points of the sdflsora 
the first incision it extended, snipping the mucous nienibrano 
oaljr- tittle l),v little, a» tliu prt;piico itfiL-lf is twing rotituitcd grad- 
1I&II; over the glaiia penis Ull the Utter i» finnllj entirely ex- 
poaod. After thia hii^ been accomplished tlio hleedinj^ ia 
nrroetcd, cold water dressing* ore applied to the glane, and the 
]>rcpuce is restored to ira normal position. Fresh pledgets of 
liutjn or cotton-wool must be inserttid eeveral times daily till 
the incised wonnd ha« completely cicatri?^. 

Circumci&iou is indicated in thoge cases in which, in oonso- 
qnenoe of the aooumuktion of ichorous discharges, (Esngrene of 
thefore8lcni,orofthegInn8,orofhatIiisimniinGiil,orliaKalready 
commenced. The operation is performed rb follows: Anas* 
BtBtant holds the pculs of the patient (who lies on his back) in 
his left lumd, and with tlie thumb aiid forcfliij^T of hie right 
hand draws buck the forcekin as far as possible toward the co- 
rona. The operator then inserts a grooved director between 
the )>repnce acid ^Luik, oseurcs hitnacU by sweeping the gluu 
with tbo instrument tliat it did not pasa into tbo urothrt, c«r- 
riea it in the median line on the dorsum of tho glane with the 
grooved eiirfaco facing iipward m far as (be foaaa, aiid divides 
both Uiyers of the skin cither with a Bciseors or aehiup-pOTnted 
biBtonry up to the fossa glaiidis. The flaps of tlut skin rosnlt- 
ing from the incision are amputated by the aid of a cnrrcd 
pair of BcissoiSf with its concave surface directed toward tlie 
gtans, following the course of the corona to the fnenom. taking 
care not to injure the corpora ca%-emoaa or divide the arterial 
branches coursing in the fnenum. It in nccctbuuy to jiregcrvc 
the fncniun, bceauae aa a resnlt of \\& diviraon the integument 
of the puuis l«ac» \\» point of fixation, and tlio nun^ins of the 
wonnd are Ijable to become displaced. Bleeding Teasels shotild 
be tied or twisted ; the slight bleeding, however, is generally 
■nested by sewing up the wound. The operation may also he 
performed with the aid of Esmareh's bondage. Adhesions be- 
tween the glans and prepuce should bo divided with tlie 8ci»- 
AomL [This oiKratiun may l>o rendered perfectly painless by 
the osc of cocaine, either by injecting a foor-peiHjent solution 



GONOSRHOiA, VS.VFRKAl CATARRH. 

of the uoriote i>f ciocaine BUbcutanM>iul/ or nmpl^ bnuhing 
the ekin and macone meiubnuK! of tbo proptic« « number of 
tinwa with it. Ja about tivo or ten minutes the ekin "niU be 
found to have lost all eengibility, when it mtiy be amputated 
and Uie 6tiU:hea inserted without causinj^ the patient any pain.] 
Faniphitnoela oaUa for tlie reduction of tbu cutu.tri(!t(>d 
^ana as soon as possible. Tliis operation may be carried out 
in the following manner : The phyeician places both hi» 
tfanmba apon the glaiisof tlio patient, then--by com presiding it 
laterally and at the eamc time pressing it Ijackwanl, while with 
his index-lingcra above and the middle fingere beiow the penis 
he endeavors to push the prepulial vTclt forward over the co- 
rona glandis. If it ho no longer poeBible to roplaco the foro- 
skin, the con&trictinf; wolt xhouhl Iki divided with a eharp- 
potnted bistoury upon a grooved director inserted beneath the 
ring in the ni(>dian Hue of the dorsum of th« penis, after which 
tho prepuce may bo brought down to ita normal p.isition. If 
tbo poraphimoaid, however, has already existed for ecrerat 
days, it will lie irapoiwible to reduce the displaced prepuce; 
it will lliou bo neeefieary to dirido tho coUar-liko welt with 
two cinnilar and parallel incisioua, and, sparing the corpora 
Cavernosa, tite Htrip of comttrictiog baud may be dissected out 
from the welt alluded to. Tlie edges of the wound should be 
united with eutores. 

Afieotions of the Lymphatic VesKla aud Olanda in oiniieqaeitc« 
of OoaorrhtBa. 

Acute and chronic urethral gonorrluiM occiuiionally give 
rlie t* inflanimatorj- swelling of the lymphatic Teaeela of tho 
dorenm of the penis and of the lymphatic glands of the groin. 
Tlie inflammation of the lymphatic veas^ manifests itself by 
000 or two Rinooth or nodular corda, as thick aa tho quill of a 
raved, mnninf: fnim (he foiwa plandis to the mouB Toneris, and 
by a linear (edematous, erythematous ewelUng of tho ekin. 
FraaBore on the affocted tracts, or pinching up a fold in the 
ikiii, orasea taarked pain. Owing to the swelling of theeo 
tyraphatte veeseU, the paiu during erections is also aggravat- 
ed, and for that reason tlie organ is frequently inirvc<t toward 
the pubia. Under appropriate treatment inflammation of the 



£2 PATBOlOOr AKJ) TBEATMBUT OF aYPSlUB, 

l^nupliatic vomclft as a result uf gonorrhaiL disappcan in the 
coareo of twelve or foarteen d&js. 

The IjmphatiQ glands of the inguuml r^oii ore lees fre- 
quently affected in coD<»equcucc of gonorrbcva than tlie Ijrm- 
pbatic Tcs&cU. In tbd majority of caeefi rvsolutioo takee jdaoe 
in tiieee inflamed ingoiiial frlands; but, iii debilitated pereons, 
or tboeo atBioted with the tuberouloiiR or ecrof nlouscacliexia, the 
glunda will uodorgo suppuration. The treatment of intiammar 
tioD of the lyiDphatie Teaaels and glaiids, iii moet casesy is Um- 
ittxl to the applte-atjon of cooling liitions, siuco mipparatioD sel- 
dom ensues. In intense iiittammation of the Ivmpltatic vessels, 
iuunctloos of uug. hydrurg., in quantities of about the size of a 
pea twice dail/ in the course of the ailoctcd ruaitt:I,are of great 
heneSt. 

luflamiaatioa of the Yosa Seferentia and the Epididfmia. 

Tho mo6t fpttjuent sequela produood bj nrethml gonorrhn?a 
in the male is indaiumutiou of one of the vaea deferentia 
and epididymis Like pliaiyngeal catarrh of the mtioonB 
mcmhraiiei traveling downward and attacking the larmx. 
trachea, and bronchi, so the catarriiul aSectlon of the prus- 
tntio portion of the urethra not infreqnuntlj extenda to the 
vana dcfuroiitia and epidiJytni?. The affection of these or- 
gans, consequently, is not to be looked upon as a metastaaia, 
i.e., as a leap of the catarrliol affection from the orethnl 
tract to tho testis, but it originates through contiguity — in 
other wortlri, the catarrhal process travels on from ocll lo coll, 
and as soon as Jt has reached the vicinity of Uie caput galliua- 
ginia — which nsoalty occurs in tlio third week of a gonorrhoea! 
disease — there is a jKiBsIbility of the affection of a Ta« deforena 
with its eorreaponding epidiilymis. It is a womier that the 
parts mentioned do not become affected in all cases of catu^ 
rhal inflammation of tlie prostatic urethra, and, furthermore, 
tluit even in the mo^t pronnnnced caHce of inflammation of the 
epididymis the simultaneous implication of the vas deferens is 
not always apparent This last condition, after all, has its 
analogy in the |>iithugi:ny of bulNx« tlut underpj mnjlution, 
and which originate, in the majority of casos without any ap- 
parent inflammation of the lymphatic vossela. Aa a rale, how- 



aowoRsn<EA, venereal catarrh. 



E13 



erer, in epidid^iuitie in ooneeqaenoo of goaorrlifea, tbere ta 
fuTiml au inflimmaturv tUickerilng of tliu ann-«pot»iiug viw 
deferens or spcmiatic cord, and seldom is a vas df ferons af- 
fected witliout tiie ooincident disease of the epididjinis. 

In iuflamiuutorr affeetioiis of tlio wm <hf>.Tcm the patients 
complain of eeverc piiiis in tint v-icinily of llic abdomioal ring, 
throttgb -whicli the afi«Kited 8i}ermatic cord possea into the in- 
gniniU canal. The pain gpokcn of becomes aggravated on 
toucbing the cord, t))o tatter l>ciiig readily felt sa a dense, 
liArd, ronnd utrinfc, like n gofw^e^iuill. The luoao connective 
tiRKnc of tho tunica vngiiialn (■umiiiniiitt and the adjacent s^h- 
cutaneous connective tissue of the scrotum become infiltrated 
vitb ecrum, and swollen. General di^turbancee of the extern 
BOon aapeirene; Ah in epididymitis the patientin oompUin of 
cliilliness and a feeling of heariuess in die head; the poise 
bemmes quickened, the tempcratrire of the ekin elevated. Isoi 
inftvt{nently nausea, and even roinitiug oomo on; usually an 
ohetinate constipation is present (circumscribed peritonitis). 
In nire cubcs etti>piiniliou of the thickened Bperinatic cord may 
follow. 

Tbo aubjccf ive Pvinptoine of epiduit/mUU usaally oome on 
mddenly. The patients claim to have felt at the beginning 
of the disoase • sensation ae if a drop of hot Uquid had dropped 
into the affected ecrotum. !Joon after the affected testis aj)- 
poara to tbeni In have Itocntno iiiiirlce<]ly heavier and walking 
if irksome. During the first three dap the diBcaeetl epididymis 
is felt as a donghy nia«s at the inferior part of the posterior 
•crotal wall. On the third or fourth day the nwelliiig of the 
epididyniti becomes mora tenjte, and the organ n«iially deacoads 
atill lower. In this mfinncr a tWTsdng of the axis nf tlic testi- 
cle n])on \\a traoBver^ diameter (aJcea place. We have likewise 
bad the opp(»rtuuity of confirming Dr. Bergb's oLecrvatioti, 
uunuly, that in eome cascR a twinting of the iixis of the tcfiticlu 
Dpon it6 longitudinal diameter takea ptaoe, the epididymis ap- 
pearing at ^e anterior instead of at the posterior border of 
tbe testis. Tn the progress of the disease the testis it^tlf 
nrdls up, eometimett attaining the size of a tlst ; tbe increase 
iu siae, however, is not due to swelling of tbe parenchyma of 
the testicle, bnt to serous effusion Into tlic tnnica ragiualis 



M PATnOLOOT AX/} TREATXEXT OP SYPUIUS, 



propria (acute hydrocele). Fioallj, tUero also occoib a •eroiu 
ialUtration into llie looae cellular tissue of tbe scrotal iiitcga- 
mciit ; iu wriuklcd become cfiaccU, and it ac<j[uirc£ a brigbt- 
red color (erythma glabrntn). Tlic6« phonomoaa indicate that 
Uie opJdidyiJiitiii has attained ita height, in wliicti condition it 
usually reiniiiiw for live or six dnm On tlio tenth dn^- of llw 
diaeaso, resolution be^us, oshcrcd in bj febrile exacerbation, 
and the effiuion into the subscrotal councL<tii-e tissue and into 
the tunica Taginalis propria begins to be absorbed. The sab* 
jective and objective nirniptoms gradually diBappear, so that 
the diseaiW gcueraUy tcrmiuat** bjr tlic iK^iiiuiu;? of tlio thirti 
week, leaving no trace behind it, save a painless hardness qf 
tite fjndidi/iiiii ccnaequent upon liypertropliy of its oonnectiiro 
tJBBue. TluB hoi-dnuKi gcncnJly doit> not interfere iritb tlie 
functions of the tecticle; occasionally it is liable to cauM ■ 
temporary and even permanent impotence. In many gnre 
oases of inflammatiou of tlie epididymis and of tlie vae deferens 
the eemcn tindergoeB morbid changes to encfa a degree as to be- 
come bloody when pollutioud ensue (tipeniiatorrhoca crnenta). 
lu cases of bloody ecnicn, the spermatozoa generally are totally 
absent. Occasionally, even after the termination of an ©pidid- 
ymitin, tlie sumen fur Bome time lias a rusty color, dno to tlia 
admixtnrc of blood. Atrophy of ilie tceticle as a result of 
epididymitis blennorrhagia we have seldom seen, and then only 
in tlia-ie csmsi in which Fnct(''« compressed bandage was ap- 
plied too energetically and for too long a time. 

In very rare cases a cheesy degeneration and necrotic dis- 
organizatiou tulic pliure in tlio dlsoaBed cpidid)-mis, or in tbe 
fturruunding tiaues, withont any coexisting tuberculous in tho 
lungs, proHtate plaiid, or kidneys. Chce«y foci form, break 
through tiie tunica vaginalis and scrotal integumeot, and dis- 
cbarge erumbling, choosy pus. The borders of the perfort- 
tion» in tlie scrotal integument then become agglutinated di- 
rectly with the exposed tunica albuginea, from which cxtGneivo 
exuberations of connective tl<wue arc occasionally protruded, 
oonstitntlng a " fungiiH ]>en!gnns." Wcndclin isaw an cpidi<ly- 
mltJs originate in a patient with chrome urethritis, which be- 
came associated with marked swelling of the funiculus and 
aeoondary peripheral intlamniution, attacking the peritouteum, 



QOKORRB<EA, VEySBEAL CATAREB. 



ftO 



going (11) to ATI ]>pti ration &ni] perforation of Oie blatlder and 
rectum. Tiie ca^ ternjinated fatally; no autojM)^, howevur, 
was iiudc. 

Another eqaallj rare rosalt of cpldidymilm U tiriiralffia, 
whose site can not be more expliciti^r described tbaa that it 
is in tbe ooureo of the j^udcodul plexus of ncrvui. Tliis 
tortoree Uie pationbi to hucIi a diqi^roo tliataomo of tbcni, as 
reported by MicbaelK demand tbc operation of cutration. 
Tbo mofit fnsjucnt evil cffi.'cU of cpididrtoitlit aro tho oocu- 
malation of fluid in tho sac of tbo tunisa x'ugiualis propria, 
known bj tiio name of *' hydrocele cliroiiica." 

IiitLuiimatiuii of tbe ppeniutic cord and of tlie epididymis 
ID eonsoc^nono* uf uretliral poiiorriioea is genorally nnilat«nd. 
One epididymis is as often uffectt-d as tlio other, but uut lM>th 
NmulLaneonsly. The dimoMi in one gent^ralty coinw entirely 
to an end before tbo other h attacked, and in such cases the 
left teeiis is always the one firat afTcL'ted. 

Although cpididymltU toruiiuatoi favorably in most casea^ 
BtiU in eonie fistiilie form in the ecmtnm, and etdll moro often 
B permanent accnmnlation of scrum in tbe tunica propria en* 
■aes. Vio hare, monxiTcr, ob»TTcd that pon^trnti %vho hare 
■oiEcred from repeated attacks of epididymitifi blennorrhogicA, 
if ther Etub^eqncotly acquire syptulis, readily become affected 
with albu»:iD)ns eypbilitica. 

The following painful Iceion of the testis may be mistukon 
for a b^iiuiiug epididymitiH : There are certain iudividuaht 
wbfi on tiecoining sexually excited, and without baring an 
emission of gemen, suffer such intonao paio in the testicle at tho 
■lightect tOQcli, and even witbiiat touching it, that tbo pain 
wili canw tbcm to faint The absence of swelling in tbe ras 
deferens and in the corresponding epididymis, the statement 
of the preceding excitement, and. lastly, tho exceedingly favor- 
able cfft^ wliicb the application of cold ooinprfcHaca prcidoces 
in a few minutes, will &liow conclnsivety the tmo natore of 
the complaint. 

An epididymitifi in crrptorcbids may be mistaken for her- 
nia <ff swelling of the inguinal glands. But tbe abeenoe of the 
testkle from the Bcrotom will gnide the physician to a correct 
diagooeiB. Tlie differential diagnosis between blcnnorrboic 



56 PATHOLOGY AXV TREATUBST OF SYPBILIS. 

epididymitis ind an opididjiiiis rceultiog from srpliilU will be 
elucidated la tlie sectioa on syphilitic difiease of the testicle. 

t'iuttUy, we wirfi to say a word ooneeniing an exceedingly 
rare morbid alt^mtiwn of the testicle, wliicli Von Focretcr has 
deeeribod uitdc-r the name of ehrouie opididyiuitia termiualin^ 
in atheromat<>Ufi di^^vuoration, and which may readily W nilg- 
takeii for gonorrhoeiU epididynutii!;. Id thU lenos the testicle 
onlargefl gradually, without any febrile phenomena, and tlte 
paiu in not Kevere. Sabtte<piently, tlie {win dixapiwara entirely, 
while the enlargement remains fitatloiiary, and tliu only cliauge 
noticeable in the testicle \& that it becomes doughy. If such a 
tcetifl ia cxotuiuixl after deatli au atlieromatoos snbetance coa- 
taining numerous crystals of cliolcsterioc and li<jaid dro{)e of 
oil may be pressed out of it. 

Treatment of Inflammatioa of the Spenoatio Cord and Spi- 

didyiDU. 

Tho treatment of ioflonuiiation of the spermatic cord and 
opididyiiiis does not vary very much. The main indication is 
to alleviate the pain, and to limit tlie infiaminnlion and ita effects 
ait much as possible, '^o liavc eeen the pain iD0»t quickly 
8abjiij];ati>d by tho a}>plicatii)U of Horand's (Lyons) drceeing, 
which we have inodilied. The ilre^tiiiig conciiidii of three parM : 
(1) a Hufliciently thick layer of wadding ; (2) a sqnire piece of 
India-robber cloth; and (8) a muaUn Kospensoiy. The latter 
has a trimigutar, elightly CDiicavu Blmpe, and at its iipptT mar- 
^n a hole is tnit, through wliicli the penis ia passed. Ite npjwr 
comeiB are provided with two long banda, or, better etilU a 
l>ult may lu used, witli u buckle fur the purpot« of eocoriD^ 
it around the abdomen. At ild lower angle two ihigh-etnps 
or baade are fastened, which may be tied either to the bncklee 
of the belt or dratm through tlio bonds paAsing around the al>- 
doraon, and tied to them. Tho lateral borders of tlie suspen- 
eory aro incised, and each cut is. provided with two short tapes. 
The apparatus is best applied when tlie patient is in tho rocnm- 
bent powtitui. The patient draws up the genital organs as 
high as possible against the symphysis pubta ; the entire scrotum 
is then oorered witli a layer of wadding ; tht_> B^uaro piece of 
India-nibbcr cloth with a circular liulc near itis npiter border 



QOKOSRnaiA, VENEREAL CATASBff. 



57 



tbroQgh irhidi tbc jxmub its ]>a££cd u next pinccd upoti the 
wwldiiig-, witli tbe ((I'^eey surface dircctt-d toward it, and upon 
tliat tlic triimgatar ]Mec(> of nni^liii. I-'iimllj, tlic btiU is buckled, 
or the bcllr-baiid nllnded to \s tiol around tlie wiu'itt; next, the 
thigh4tn[» or thigli-tapce aro made fa^t to the bolt or bcUjr- 
bnnd ; and, lastly, cite tapes at the eidtxuts aro tied over the 
doretuD of thv ]ieni8 a« tiglitlj an p«iM(iUe. Ry tli« aid of this 
appHTntna tbe ecrotnni can be raiifed up nearlv to tbe eynipby- 
Bi«, and tlie paiiu diiiappear ultiiobt iiiiiiicdiatelv aftur it ik a\> 
plied, enabling tlie patient to puniue IiIk calling. The epidid' 
ymitts is gpnerally cured in about eight or ten days. If not, 
tiic apparati» may be retained for a longer period. Should 
tbo cpididytnitiii be tx>nipli«>tod with au acute hydrocele or in- 
flammation of the Fpennatic cord, the apparntuB alone will not 
be Bufficiont to relievo the paia. If tbc pains are not relieved, 
or the patient has fever, ho will have to go to bed, and the 
serotnm ehould be su^>nded in a towel ae high a£ possible, or 
elevated by a pillow rolled up and plaoed between the thi^is. 
Cold or cooling lutionu may tlien bo applied to the inllamod 
testicle. No ie*vcoId applications alioujd \\a made, esixvinlly 
fa tabercnloQK penu)ni^ in whom liwrnopt^iiiit has been known 
to occur under this treatment. Some authors aliio claim to 
have seen gangrene of the Bcrotnm produced by tbe applica- 
tioa of icv. Compresflcn dipped in cold water or in lead-water 
are amply safiicient, I'or the relief of the pain, ung. bclla- 
doDDtv, oompOBed of extr. belladonna 5*00 (3 iv) and ung. 
litliai^g. 20"00 ( 3 t), may lie rubbed in iii>on tlie scrotum. No 
mercurial ointoicut i^houM Itc uppHtKl upon the Hcrotuni, for it 
k apt to occaaiou a viulent cczematous eruption and iutenae 
pain. If the pain is rory great, morphia may bo injected sub- 
cuianeoiwly in tbe inguinal region. It is of the utmost im- 
portauoo in the trentmeut of epididymitis that the patient 
abcmUl have daily m^venient of his bowels. It is nearcely 
noeOKory to nay tlint, upon tbc onset of an epididymitis injec- 
tions into the urethra and tlie inlvmal admiiiieitration of bal- 
aainio remedies mu»t lie Iniim^liiitfly diH-onlimK^l. 

There is another roctliod rt'cummended by Dr. Friclte, of 
Hamburg, for the purpose of canning the absorption of the 
cfluded Suid into the tunica, vaginulio. Thin ooumBte of etrap- 



58 PATEOLOQY AifD TBBAT^EKT OF 8TPBIUS, 

ping the ecrotum with strips of adhesive pliifetcr. The Ktrip« 
gbonld be lialf a metre (19 iuclieaj lo Icugtli and uigbt to ten 
miUiuietrcs (a1>out an iucli) iu widtli. Bcfon; xtmpping tlie 
Berotam it and tlio pubis eliould be (thavcd. The physiciui 
now pnslios the sound tcgtis up toward its iu^lunl ling* al- 
lowing the patient or an asaifitant to hold it there. He next 
gnups the discaeod testicle in his left hand, brings the long- 
est diameter of the Ecrotum in u iine with the longest diomo- 
ter of the uilected ttBtia, tlien encircles the upper part of the 
scrotum -willi a i«trip of lulliesiTe plaster. Eat-li titihsecjuent 
strip of planter u nisde to ovorlap the prccediog one like diin- 
gles OD a roof. Throe or four loiigitudiual stripe arc laid upon 
the scrotum from side to side, and these are Eecnred hy a few 
more circular strips. Tliis dressing sliould onlj lie applied 
tight uiuiugh to retain ito hold upon the partit. ]n three or 
foar da>'s it is generally eo loose as to refjnire to he replaced 
by anotber. It is now many years since we aliaadoiiod strap- 
ping tlie tcaticic, Ix-cuu^e its cmj)loYinvnt not infiuqaeotly 
produoce tbo fijoaptoms of siiock, i. c, reflex paralyda of tlw 
Tflficular netres, especially the epianclmic, tlirough euddeii and 
violent disturbance of the ]>artd, and er^n gangrene of the 
scrotum in some eases followed. 

In ease? of ("innimKcriU'd nciite hvdrorele excellent results 
were often obtained from punctures with, a sharp-pointed bis- 
tonry. AbeoeesM of tbo epididymis ahoiild be treated la ae- 
conlance with the general niles of Kirgen,-. Tlie hyiwrtrctpby 
of the connecdve tismo in the vicinity of tlie head of the epi- 
didymis obstinately resists all kinds of treatment, both local 
and genvral ; tttill. in Aiinc cases we have ohtaitied good results 
from the intenrd admioifitration of the prcparatioiusuf iodine. 

Chronic Hydrocele. Hernia Aq.aoa^ 

Wlten tlio HLTOuii o£fu£ion which i^ poured out in the coureo 
cf an acute inflammation of the testicle, between the two lay- 
ore of the tunica vaginalis propria, is not absorbed after the in- 
flsminntorr phenomena have suicided, or, worse »till, more and 
more cjlueion conliouea to form» there reeults n painless on- 
largGCoent of the scrotum and distention of tlie tunica vaginalis 
propria, wtiieh has been called ohrouiu hydrocele, or hernia 



OOXORSUfEA, VESEltEAL CATASEn. 



59 



aqnoea, in contrad'u^lirirtiou to acuto liydrocelo. The tumor 
111*7 attain tlic &t2e of a goose-ef^, & mui's tist, or even a 
ehild'a head, according to the quantity of the fluid tbat acco- 
mnbtiis in tbc sac. The testicle is nln-svi; found located in the 
lower and poetorior part of the di^luudvd tiiuicu vngiaalis. 
The Ouid oontHined in Uie latt&r m clear and watery, and gen- 
erally contains a large <|iiunt.ity nf snltx and nlbuminoid?, prob- 
ably albo tlio eo-ca!led tibrogenou* Hulistanco (Vircliow). Ad a 
reemlt of injury, tsucb as hlows^ aqueezing, and the like, haimor- 
rhage readily occurs into the tunica va^DoIis, whereby the 
acroua fluid beoomes bloody (hmamtoeele). Wben the liydio- 
cele lasta for a long while, excreiieenccs not infrci|iit-nlly fonn 
open the parietal or visceral layer of tlie sac. Theee become 
ooaveited citlier into a fatty or cartilftginoos substance, eoou 
drop olT and full into the hydrocclic duid (free or floatiiig boUicH 
of the tunica vajcinalis). Sometimes tlte tunica vaf^nalia on- 
dorgocn eueh a hyperplastic tliickeniug tliat it becomes ti-aii^- 
formed into a leathery or cartilaginoos callosity. This ooudi- 
tion U nanally aisociated witli the partial uniou of the two Iay> 
ci». Sach adhcsioDB may give ri^e to tlio fonnation of biloeu- 
lor or roultilocnlar cavitiea. Wo obtain positive pr(M>f of the 
preeence of Unid in tlie tunica vaglnalijt if, on examining the 
ecmtiiin with a light, it is found to bo transparcut, and flue- 
tnatioo it< felt m it. In li:i>inatocele the M;nituni, when ex- 
amiiiod by the help of a eandle-Iiglit, w less or not at all trans- 
parent. Before tapping a liydi-ocele, the absence of a hernia 
rouEt bo estalilislifd beyond all douhL Pcnnancnt preaeare 
by the effuaed fluid may reralt In atrophy of the tcflticlo and 
of the crcmaster muBcle. 

Id a fc^v ran; cuacs wc Iwvc enececdcd, by amply tapping 
the tmiica vaginalis, in curing chronic hydrocele. The beet re- 
mits are obtained h; injecting iodine into the cavity after the 
tappiug, thereby setting ap an adhesive iuflaiumation wliicli 
TCSOIts in a union of both layers of the mombnmo. Or I^^>re 
Bolution may lie uimkI, the furmnla of which la a& fallows : 

3 lodi. pnri. S-oOfgW]; 
£«li. iodaU, tO-Oti I Dviy]; 
AqnadeMil., 10000[5ili, 3U«-I- 
Or*>)Bal p4rta of ir. iodiuo aad spirlu of trios mtij be awd. 



CO PATUOLOGY Ay'D TSEATMENT OF SYPBIUa. 

In lliooe csHec in wbicli the tnniea vnginnlLt ha? prohnbljr 
iiDtiergonu a condition of Rclcrosi?, no injection of iodiuG sJiould 
he maile. lieeause, owing to ibe lack of vascular supply lo the 
tusues, not only is a union of tlje opposing surface* not to be 
cxpGctud, but Hlaughing of tbe tosticlc nmj bu broaght about. 
In Riicb ciLVH we mcoinmcnd the radicoJ operation for hydro- 
cele nnder strictly antiseptic conditions. 

[Taricfus other remedies luivc been u»o<l, as injecSons into 
the tunica vnginaliB, for the cure of liydriK^le. Carbolic acid 
hu been employed here with excellent reealts. The follow- 
ing is the foTTuulu for it : 

U Acid viirbul. cTf^UL, lOporlii; 
Gljourino, 90 parUt U. 

Of cliis eolutlon four to uix grammes ( 3 j to 3 j'ss.) are injected 
after the effusion Ilos been drawn off with a trocar and cauula. 
I liave succeeded admirably iu exciting stitlicient inllamtnatory 
Action in the opposing eurfaccM of tlie sac by introducing throa^ 
the tnK'ar some crystals of red oxide of mercury on a tliin^ 
niuiKtuiicd whulebonc rod dirvctly after tliu Lydroiwle was 
tapped. But a certain perocutage of failuree \ril] result inm 
tlic UM) of any preparation, the only reliable metliod Iwing the 
radical cure proposed by Vulkioaiiii, aud moditivd by Berg- 
maan, of i3erUn.J 

Inflammatiftn of C««p«T*s Olasdi, 

In very rare oases tlie iuflamumtory prowsg citonds from 
tlie bulbous and mombranous jiurts to Ibo excrt-toiy duota of 
Cover's g!and&. Ttio disease of the glands can only be as- 
sumed to lie present with certainty when the connective tisrae 
fmrrounding tliem ih also involved. In tbiit case tlicre originates, 
between the scrotum and anne, on the right or left eudc of tlie 
raphe, a more or less circumscribed swelling, which is pain- 
ful at the Klightv«>t touclu Micturition it. somewhat diflioolL 
Under appropriate treatment the swelling disappcore entirely 
in ten or twelve days ; in very rare caees it terminates in sop- 
punitioii, oiH-'iiiiig externally or bnreting into the urethra. As 
soon AS ttuctuation can l>a detected the abeceie should bo 
opetied in order to prevent it from ropturing into the urethra. 



GONORRHfSA, VENEREAL CATARRB. 



61 



Korbid Alterations that are prodaced in the Prostate by Oonor- 
Th(Ba of the Urethra. 

Contrarj' to tlic ^icwB that were formerlj entertainod re- 
ganliiig (liu iiimetuxe of (he pruMtatc glaud, it U now known 
tocxinfiist in greitvr part of miuculiirtiialwlaiicc (B|>liinc'tur vcsicfe 
extetniu) and of a nuinber of tubukr glancU in addition to 
glandular etructure. The excretory- ductK uf tlio pttwtate, like 
the follicles of tbe fossa iiavieidaris of the uretlim, arc liable 
to botxime diseased tbrongb the propagation of the gonarrlioeftl 
duschai^ to tliu duopur parte of tliu urethra. Here, too, we 
distinguisli a eerotui, muetms^ and purulent catarrli. An a rulo, 
the severity of the catarrhal disease of tbe proiitate corresponds 
to tbo intouit; of the cataniud affection of thti uietbra. 

The MroH9 and muAJW* caXarrh of the prostate is generally 
the resalt of an inveterate gouorrhoaa which the patient )xm 
neglected. It m:uiifest8 itself by a drop of ttinaduua, albu- 
minoid matter appearing ecveral times daily, nnattcndcd with 
pain, at the meatuii, producing a dirty-grayish spot upon tlw 
liDen, and rendering tlie spots etiH as if HtarcLed. These spon- 
ttueoDfi discharges are most prubably duo to tbe occaftintud con- 
tractions of the muscular tiwue of the prustato ; bnt tbe press- 
are caused by the passage of ^eces during tbe act of defecation 
doubtless alao pro^iels the disdtarge forward. Owing to tlie 
capillary engorgement which takes place in the prostutic por* 
tjou of the urethra, the patient is tronbted with dribbling of 
oriiie at the end of each net uf micturition. The e4:rouH and 
macous pruetatic catarrh may remain in this condition for 
muy years. Shoitld the patient indulge in exceases in Jiaccho 
ti F«4i<w, dysoria, (cDesmtt&, and ischuria will soon become 
usociated with tins liarmless complaiiiL If tbe catarrh per- 
sists fOT a long time, tbe excretory ductd of t!ie prostate will 
become dilated, and in time the discharge becomes ingpisBatcd, 
lud ooncretiona form in the crypts of the gland. Gradually 
the mucous menibrauc of the neck of tlie bkdder aUo becometi 
attacked by catirrli, and, a^a result^ we then have frequently 
recarring spasmodic contractions of the neck of the bladder. 
The permatenco of (bis niuitcubir activity leads to hypertropbic 
derclopousut of the mtLKular elumciil of tlie proetate. Chrooie 



63 PATBOLOOr AHD TREATMBXT OF SYPBIU^ 



prosialie raitaiTli, Iioirercr, 15 manifefilcd not onljr by difficulty 
in urinating, but aUo by febrile paroxysms, especially Tcbea it 
is compHtAted lAitJi stricture of tbo urethra. 

PuridcTU prost^itic catarrh orijrin»to« from the propsgatioD 
of the acuta purulent urethral gouorrliipa to the prtwtate, w 
alao from injurieg of the ghnid (the iQtrodtietion of catheters, 
bougie-i, tinpacdoa of calculi). A? & retiuU of one or another 
kind of iiritatin^ causes, a serous traneudatioQ of tbo rahmbcous 
tiwnie of tLie ])ni«lato and an exaggerated amount of Becretion 
in the glandular part of the organ {scrons glandular catarrh) are 
produced. During the time that these lesions are derelopiug- in 
tliu prostate tlio sccretiou of punilont matter in the urethra dies 
out, and the only discharge that tlicn appears at the tneatns 10 
tliat from the prostate gland — a etic-ky and tcnacions fhiid 
Gndnally email ooUectioas of pna form in the gland, corr^ 
Bpouding to the number of the excretory dncte affected. Pri- 
marf ditfuiie sapporation of the proatate occurs only in thoee 
caees which are traumatic in their origin. So long aA the cede- 
matoas swelling of the proetate ie not very intense, the pa»- 
oorpusolcs originating in tlie cr^'pts hecome mixed with tbo 
normal secretion of the gland and form with it n gluey, yel- 
lowish-green fluid. In progresfiive suppuration the cavities of 
the gland gradually become filled with puK and dilated, next 
Bome of the glandular spaces coalesce and tlie entire pnwtate 
is then permeate<l hy lai^ cavities. These snaall nbiceesefl 
break im tlie tenth day after the onset nf the prostatitis, and, 
as a rule, rupture into the urethra. Tlie pua tnnncle its way 
into the rectum only in those caacs in which aoppurative inflam- 
mations Imvo occurred ropcat<>ilIy, and especially when, insti- 
gated by traumatic causes. Tbe miiMiular part of the pros- 
tate gaffers do pathological alteration ; it is only in a constant 
Btttc of contraction, thereby expelling the Bocretion, and cauaee 
tencsmofi of the neck of the bladder and tbe anns. 

Patients Buffering from prcttatitis are troubled on the one 
hand with difficntty in defecation, and, on the other, from fe»- 
qaont deans to urinate, l-'or the purpose of expelling the 
Diine forcibly, the patientn, taking a deep inRpiration, endeavor 
to compress Uie bladder by (he action of the dtaphmgm and 
the pressure of the abdominal walls. Tlirough the action of 



GONOn&HaSA, TEiVEUEAl CATARRH. 



dft 



the IcTBtor'ant mn»cle, however, the prostate is e1evat«d and 
compieased against the sviuphyau pubu, thiis causing iitill moru 
oomproSEioi) of tbe nrctlira that is already tuurowni, niid en- 
tirely prerenting the How of the nritie. Not till the patient, 
compldLely eihauated, becomea totally poAsiTe, and entirely 
MtAdA Straining, will the urino flow in drop« or ia a very thin 
Rtreun varioti^ly ehaped, cansing a violent bunung ecn^ation 
in tlie urethra. Like patients Bufftsring from Htoue, thoee suf- 
fering from prostatic dit<«i»e seek, hy pulling or manipalat- 
iug the penis, to ease tho flow uf the urine. The introduc- 
tion of a calbuter or sound U quite difficult, and luch in- 
giriiMientff only will pas as hare a large curvt. Juttt at the 
moment when it i» neeesflory to depress the handle of the sound 
for tlie pur]Kise of patttdng it into tlie hiadder, tbe 1)eak is often 
tunn.ll to one aide or tlie other, because tlio nretlini, in conse- 
c|Qi*uce of the unequal eular^ment of the prostate, has devi- 
aled fruui itA normal position, and the instrument is twisted 
to tlio right or left, according as the right or left lobe is more 
swollen. When the central part of the proetate is swollen it 
is entirely impoaeiblo to iutrodiiee an instrument into the blad- 
der, or this can only be done by force. By a digital csaraiuo- 
tioD per rootum, the anterior wall of the gut is fonnd to bo 
balged out l>y a jKiinful tumor. This painful condition of 
prostatitis gt^neniily hu^ from live to eiglit day& Prostatitis 
tennlnates either in gradual aluinrptinn of tlie swelling or in 
mppnration. Tlio latter is generally Ufihercd in by ft-Jtrite 
mopement^ indird even a chill may occur. TIio moment tbe 
pna is evacuated tlie patient feels relieved. TTe have never 
ttxn. inBltration of urin« and fistiilie following prostatitis. 
When the absoesa bursts into the rectum, fecal masses may find 
tluy'r way into the cavity of the abace-ss, causing grave compli- 
cations, such as gangrene and pyn^niia. If the abscess opens 
into the rectum or urethra, the dieeaac will almost always ter- 
minat« unfavorably. 

Serou.1 and mucous catarrh of the prostate may bo mistaken 
for a condition of this organ that has boon called prottator- 
Man. tu oonaeqnenee of eoxaal excitement, unaccompanied 
by ejaculation, tlie prostate may pour out its secretiou ; tlie 
patient beootnee aware of this by finding a drop of sticky albu- 



0« PATBOIOOT ASD TSEAT3iB2fT OF STPBIUS. 

minoas floid npoD hig linen, and bv the moistnro of the lips of 
die meatofu At tlie same lluu be BuiTunt fruiu pain in the 
])eriaeal port of the urethn daring micturition. 

Strictlj Apeakiiig, prutitatorrhcca ia no patholc^cal ocm- 
dition, and of little consexjueuce to the general sjtrttm. Chta- 
liloiui, however, make vcrjr cxtciutivc luc of it, destgiiatiiig it 
08 i^-nnaturriia)a for dishooost porpoeea. 

Ill very rare casee exteuaJTe infiltnttioii occnra in one of tiie 
iachio-reccal epaces, as a rwalt of Drethnl gODorrhiv^. This 
faiiklen the parient from walking, standing, defecating ; indeed, 
01*60 l}iBg on tho affected Bide is irksome, but luicturition and 
tho introduction of a catheter am not prereuttid. On intro- 
ducing the index-finger into tlie rectum, llie pbrtiiciui discoT- 
eni oo u^ne Ride, but never xt the anterior wall of the rectum, a 
very sensitive swelling, which sabsequcnlljr majr become aV 
Borbed. In most cai»», however, it uDdcrgocffKiippuratioD, and 
the pus is evacuated into the rectnm, a condition liable to re- 
sult in rectal fistula. To prevent this perforation of the rec- 
tum, an early iuciiiion elioiild Ixj made tlu-ough the akin over 
the affected ischio- rectal space. 

In tlio vast inajont>' of cases of inflammation and swelliog 
of the prostate, resolutioD takes place. The more intense the 
paiiu arc in the ]>erina:um, and the greater the swelling of the 
gland, the greater is the probability that it will snppurato. In 
cousequence of tho sDppur.ition, a large part of die gland b 
.not itifrequently deeitroyetl. In scrofuluiia and tiibenmlooB 
pereons an unfavorable termination of tho prostatitis may bs 
anticipated. Opening of the prostatic abscess upon the peri- 
neum seems to occur only in tliuKo cnfies in which the tissues 
surrouDding the gland are affected more than it» t<troma. The 
irritative condition of the prostate may, in some cases, extend 
to Olio of the nt-jumal vy*iV/p« or Ugfid^*, and thereby prodoeo 
tpcrmatorrfioa, or inllammation of tlieeo organs. Chntnic 
prostatitis — i. e;, eerotia or mucona prostatic catarrh — is at- 
tended by little danger, but in the aged may occoitiou jrroeiatie 
hijfpertrophy. 

The tirst duty of the physician is to relieve the difficulty 
in micturition and the violent pains tlmt radiate toward tho 
periiifciim, unus, and penis. This is clTucte^l by tlic application 




GONORRBiBA, VESEREAL CATARRH. 



m 



of tnxm cataploanu, 1«pid nu-batlis, and narcotics ftdminifl- 
tered internally and locallv. Accordingly, wo order tweuty 
drops of tiDctore of cannabis indica ovory tbroe hours, on a 
lamp of sugar, ur helladonim i;up)H><iitoriuA, if tliu ruotum tol- 
erates thom. Tf ttie jKiin is ('otilitied Ui one spiit in the peri- 
Dsuiu, and the dyenria is not very severe, cold compreeees 
may W applied, and the following ointment rubbed in upon 
tbe perinaiuni : 

9 Extract. UlLud., 1^0 [gra. xyjj ; 

Cor. nenpol. [nDK. bydrarg.], lO'OOfJij, 3^}]. 
U. Ft. aag. 

The rectum ehould be cvuctiatcd daily, citlior by tho ad- 
ministration of caAtoroil or by incauii of uticmas of olive or 
castor oil. In order to keep open tlio ciuulI for the paonge of 
the urine, a N61aloii cfltbet«r should be inBcrtcd and retained 
in the uretlira niitil tbo twolliiig sub^dea or tbe abwxM 
burets; For the purpixte of allaying the tliimt, we rooom- 
mend weak lemonade or sweetened water acidulated witb add. 
Ualleri [anjtuatic aulpburic ac!d]. The diet should conajst of 
Ivottu, milk, etewe<l fruit, icocreain, and the like. Abecesees 
and tirtuUp are to be treated in accordance witb tbo rulcH of 
general sorgery. For ttic hyjwrtrojtliy uf the gland tliat re- 
mains, the physician is nnabte to devise any remedy. In 
chronic catarrhal prostatitis, benefit may be derived from tlio 
iotemal odminietration of tincL furri chloridi, and tbo mineml 
wat«rs, such aa Franzonsbad, Gieaebiibel, Itobitech, Preblau, 
KisfflDgen, Setter^ Lalintschowitz, and others. Should an ob- 
etiuatc mucoa« diecltarge fmni tbc urethra romaiu after tbo 
iDflammatory phenomena liavo disappearod, we advise the pa- 
tient to take the following pills : 

« lodurcli ftrrrl. l-OO fgr*. itJ]; 
Spirit. lon-Wntb,, 0'5n [gw, viiJ] ; 
Kit. ^ntUniu q. r, ft. bolu. flermeDtitr tales Ko. 10. 
8. Om piQ U> be ub«B three tim<a a ity. 

[Id acute prostatitis, as in affections of tbo oigaDB in tbie 

ncinity generally, I Itare often Kucceoded in aborting the dift- 

eaae by the application of live or lux leeches to the pennteum, 

or at the margins of the anus, and, when the disease has boeomc 

6 



(16 PATEOIOGT jUID TREATMENT OF SYPBrUS. 

clironic, one or more blieture over tlie perinieam vill almont 
alirajs liavc a Imjtpy effect] 

iBflanautioD of tiie Seminal Tetiolei in oonMqnoBc* «f TTrathnl 

GonorrhcBa. 

The oc^culns seminalis may be dcecribed ab the starting- 
point from which the inflammatory disease of the urethra and 
of the neck of the bladder attacks the organs that secrete 
and conduct the ecmen. It is even more difBcnlt to de- 
scribe fully the pathological condition of tlie inBammatory 
process hi the BCininol vesicle than that of the prodate. "Wo 
can only draw certain inferences from appearances fuund in 
tlie cadaver as to the nature of the disease. The experi- 
enced physician will be able, on examinatioa with the ^An^ 
in Uiu ructuui, to detect, in pronounced ca»es, tntlAnuuation 
of the eeminal veacle. The latter is aitnated on the posterior 
surface of the bladder, directly l»ebind the prostate, and, when 
intlauicd, will oe^uine the form of on oblong oval, painful and 
hot swelling, having a doughy feel. The subjective eetuatioiu 
in intl&miiiation of the seminal veeicle differ bat little from 
tho»e in proetatitis. There is but one symptom that belongs 
exclusively to the disease under cousideratiou, namely, tho 
erections are wfil-nigh eonslant^ and »o painful tu U> con^ti- 
taUpriapivm. According to the observotionB of LoUemand, 
Goawlin, and Pitlia, involuntary Eemiual emiasions occur, at- 
tended by burning pains, the f^emen oetwiionally being red 
from an admixture of blood (red poUutiong), or yellow from 
pus. In the intervaU between the involuntary emiaeionK, dis- 
charges from the uretlira contnitiiiig xporwatozoa mixed with 
blood or pus also take place. A contintied fever l)ecome8 sn* 
jicnidded very cm-ly to this local phenomenon. In coaee of 
intcnHc indaiinnntion the eeminal vesicle may become trans- 
formed into a veritable pua-rcoeptacle, which gradually empties 
itself into the urethra, or ruptures [H)«tcriorIy into tlie rectum. 
Aa a result of suppuration, the seminal vesicle may disapptar i 
fniir^j/ or bewme ciliteraitfl. I f the diseoM OBGumoe a chronic 
character, tho aeminal vesicie muy mKlergo indvraiion, cale{ti- 
eation, and o$9\^txition. In tnberenlons persons tlie cxudatioD 
in and around the veeicle may undergo caafoua degenerotion. 



GOyORRIKEA, VeHBREAL CATARRH. 



67 



Tlie result of gnive diseaso of botli seiumal raeJctes fa sexual 
impotence. There arc no epecial rBinedies that Ran be resorted 
to ia the treatrcent of itiflmnmatioQ of these oi^ane, and those 
tlint have beeu foimd efficacions xa the treatmeDt of prostatitis 
wUl, ia general, also auevrer hero. 

Fonotioiul DlMaae of tlu Bsnlud TadAle sad of tlifl TMtlcla,— 
BpermatorrhtBa, Stninal RmiMiom fdlattd ]>iurna. 

The opinion prcruts, not only among tuynien hut also among 
medical men, tltat spermatorrhoea ia of very freqnent oconrretico ; 
but, aecordinj? to our observation, it u (juito the rcvci-Eo. The 
diaeaae ocours Ices frequently in coneoqucnco of the exleosioa 
of goflonlicca than from eexnal eKoeeseSf onanism, etc. Id 
mo6t of the eases, the raorl)id condition whicli ti looked upon 
as spermatorrfaii'n is really due to a oonBtant discharge from 
dw pm^tate (pmotatorrliuia). 

Through excessive indnlgciice and nnnatnnd pratiiicaHoa 
of Munuri intermuree the secretory and excretorj' seminal or- 
gana are kept in a constant state of irritation, gradually pro- 
dncing exhaoBtion. atrojihy and paralysis of tlio muwular ap- 
parntua a]>pertainiog lo them. The beginning of tiio disease 
mauifeatA itself by a rapid discha)^ of somen whenever the 
loaM excitement of the gem'tal oi^ns occurs, the erections, 
however, beinp short induration and incomplete. Gmdualty 
the ojacutatiou of eemcn takes place even witliout any erotic 
Uioogbts or voldptnous sensations. While at firRt tlic emis^ione 
only occur at night, perliA^ig several times in one night (pollnti- 
onea noctHnKe), later on thoy take plaeo even in the waking 
hoora, with the penis perfectly relaxed, withoat any orotie 
thongbts — iwmetiraes, indeed, attended by unpleaamt feelinga. 
The least p^ycliieal excitement, the most insignificant distnrb- 
anoe of tbe genital organs indeed the ordinary act of niictti- 
rition and defecation, are KuSlcieiit at times to produce an 
ejaculation of fiemen. IT^nder these cirenmstancc^ ihirt fluid 
gradoally loses ita consistency, becomes watery, and resembles 
an albuminous iK-en-lii>ii mixed with viscid mocns; the i^per- 
nuttOKOQ constantly diminish in nnmbers. i'lnally, it is not 
ejaculated, but oozes out from the urethra. This couetant 
loae of seminal fluid produces a remarkable mental and ph^'si- 



GS eATBOLOQT jUID T£EJLTMSlfT OE 8YPBIU3. 

oal Gxhftustion of tbe pttiont. In some cuob, marked pev- 
(•hical diitlurlmucAJB, spinal di8ea}t(.>d, aud paraljsla, may grad- 
aall^' SQiKjn'eiie. Tbe urtim of tlietio patioots j& geaerallj tur- 
bid and cloady, and Iitu the odor of frw-lily-ground bone, due 
to ito being mixed with semen. Kotwithsiandiug the great 
t(M8 of the aemiual fluid, toma of the patlcnti are Bi^ U> be 
capable of procreation ; in most cases, however, prolonged 
spermatorrhcea prodnces impotence. 

The treatment of spcrruatorrhtua is not satisfactonr. Th'S 
efforts of tli« pbpifiau am limited to measnroe that will pre- 
vent all mental and psyclucal iuHuenced which directly or indi* 
ntctly irritate the genital organs, aud which will brucc ap tlto 
drooping epirits of the patient. For the purpose of prevent- 
ing the aeniimil emitiaioas the patient should keep coul, live 
Qjwn a nutritioiu but unstimalating diett moderately indulge 
in light wines, take cool bathe and frictioiiH, eold doneboe to the 
periuiBum, and clyetters of colil «'utcr, niL'tliodieal uae of tlte 
cold-water eurc, or seorbathK. Ilypoeluiiidriac patients should 
be urged to take exoroiee, trj- country air, bo aa to become in- 
vigorated in every potuible way. We admiui^ter internally, 
agaiust the freijueut omiasioDS : 

9 Lnpallnl pari, 0-&0 [gnkvilj]; 
CaiDpboro, 010 fgr.jM.]; 
Saochar. nlbo., 900 [gr*- "xU]. 

U. Ft. pU. No. X. S. Tvro pilU to I'd t^ikcn during tbo da;, and 
Ofttt <tiri'cil)> before going to bed. 

Or we prescribe : 

B Curb, (crrl tM^bu,, S-OV {^/f. mQ]; 
Cunpliora, 0-SO[gnUj]; 
Pulv. Mcalo cor. ; 
Sacclisr. albiu U 5-00 IdirJ. 
if. Div. ia do*. Kq\iali« No. X7. S. TbrM or four powdvrs to b* 
taVco Ati\j. 

If the erections are incomplete, or premature ejaculation of 
the Hcmcn taken place, iron and qninine will Ih; found bene' 
tidal, and may be pre^iibed in the following manner: 

B Tr. ferri acet ether., S*00 [gra. xxzy] ; 
Tr. cort. cliiote tidos, 60-00 (S jw.. 3ivJ. 
U. fl. One teaspooDful to be takes four tiraoe daily ia aireet«n«< 
wabu-. 



QOfrORRU(SA, V£A'£R£AL CATABBH. Bfl 

We also ufle the following : 

Q Ertr. i)i]uda!, 2000 [ g «,, g It) ; 
Fiulpfa. ferri p«ri, 2-00 [grj, zixt)); 
PnlT. corf, ciniuimoin., S-OO [gn. zzi\)]. 
Ill FL pU. No. CXX. S. Tin pUta u> bo UUn dailj' tiro or tUre« 



In ttHM enes in wbleti the erections and ejaculations do 
not take place at alt, jet tlio semen flows connumtly, we use : 

Q Acid, plioaph. <l[l. ; 

Sal|i!i. qoinino, d£ 2-00 [p*. xxxij]; 
Cwnphon, O'SO [pt. Tiu[; 

£xt. ouonrilln, <\.». at liont pti. |M)ad.,0i5 [gr*. EJn.]. 
B. Fosr or tin pUle ta b« taken tbno ttmoa dailj. 

Bromide of potas^iiim may nXm be proscribed in tliesB easw. 
We geuerallj order hall of the following mixtoro, to bo token 
morning and evening : 

B Kiilil>r»mflt., 6'00[3lv]; 

Aqaa dostil., lOOOOfjiiJ. 3ii«^]; 
tijr. eon. anrunt-, 12-00 [ 3 i|j]. K. 

Loculljr, we adWao the om of the following measures: 
Wax bongiee {lOjuie a dtituur/) ti> I* ititrodui^wl and kept in 
the nretUn, injections of tanno-gljccrine into the nrctlira 
(0-50 [gnt. viij] of tamiic acid and 200-00 [ % vj, 3y, 3j] of 
glycerine), the injection of a weak (solution of oil of cam- 
phor (IJ to 2 grsmnieo [gm. xxiij to xxxij] of camphor to 20 
grammes [ 3 vj, 3ij] of olive-oil) into the deeper parts of tlie 
uratlira tlmnigh a soft catheter, faradization of the genital or- 
gans, and the introdiictioD of a cool steel eoond. little or no 
benefit ia derived from cauterizing the deeper parts of the 
orethrs with nitrate of silver, as pecmnmended by LallcmaQd, 
irhlle the danger atteuding thin pruuedure t& considerable. 

SiBCflses of the Bladder caucd by Urethral Qooonhsa, 

Tbc bladder, as a nUe, only becomes affected, as a reoolt of 
gODorrboea, in thoeo eases in which ihe disease has already tn- 
volvod the prostatic part of the urethra. At the boginnifig 
the disease generally attacks the neck of the bladder only ; 
gradually, however, tlie fundus is also alTeeted. The disease 



PATUOLOar AJ{J> TBt'ArMENT OF SYPJIIUS, 



of the neck of tlie liladder has an acote character, while tliat 
of the funduB i^ chrciiiic. Heuce wo dUtinguUh au acute and 
a chronic catarrh of the bladder. 

Aoute eaUxrrh of the blad4<r rntnifestti iteelf by cvidcncee of 
intenae hvpeneinia and a niodt'mte amount of eecretion of mucus, 
the chronic fonn Ivy a pi'ofiK^o disebarge of catairhi)! sccrotioii. 
So long aa the catarrhal di^easa is limited to the neck of the 
liladder, the pulieat^ cv^tiipliun uf fruqn^nt di-tiire to arbmte 
and to defecato. If (he jxitient endeavors to relieve himself, 
he only sacceeds^ under the most dlstreeeing pains, in pasang 
u few drojw of ooni-ciitnitcd add or nentnij urine. After the 
last of the nrinc hne been voided, one or more drops of blood 
as a mle follow. The urine ia generally clear; on cooling, 
however, a evdiiricnt fomiH, whlcli coulaiuii defiqiiamated epi- 
tliolium-celb, mucus, sometinicft nko blood and puA-corpa5- 
cle8. The discharge fmm the uruthral mucous luembrane is 
then reduced, to u niiiiinuini. A digitid examination per loc- 
tuui, in inodt caece, canses an unbeai-ahle pain in the rcfnnn of 
the proetalc, and the introduction of a catheter m usually im- 
powiblo, bccauiKS the neck of the bladder, in conscqnenoo of 
tlie Bpasinodio conlraetioii, ih impassable. Altlioagh febrile 
phenomena are present in all case-s of di!«;swe of the neck of the 
bladder, novortbcless, cot all of the patients are compelled to 
rauahi in bed ; but If the tenesmus increases to a condition of 
ischuria, riolent febrile nymptomn, preceded by a nevore dull, 
will ensue. If not relieved promptly, the ischuria may catisa 
raptore of the bladder and mwniia. 

When properly managed, the acute phenomena will bo re- 
liored in from eight to twelve <laya. The infliiinmatory afle©- 
tiou of the neck of the bladder, however, not infrequently 
extends to the cvTctoty dncU of the prostate and vaaa defer- 
cntia. A permanent hjpertcmia of tbo coilicnlns ecminaliB 
remains, and as a result the patient, at each ejaculation, feels 
as if a hot needle were thnist through his porinicnm. Acute 
eyatiUa may rolapee from the elightost canao, in whicli case a 
permanent hypertrophy of the apex of the trip;onuiii Lien- 
t«>dii (/« ImMe wMicaUof Ajnvgsai) not infrequently develops, 
causing difficnlticg in voiding the urine and ojacntating the 
semen. 



QONOSRUaSA, V£yEREAl CATARUE. 



71 



Tbo extension of tbo inflammatory disease of the iirctlira 
to tlie ueck of the Uladtler is proiiuil»Kl or ocauloned "by vari- 
oiu influences. Cliief among these are a liberal indnlgenoe 
Id ft^BBli, nnformentcd beer, unfcnui-iitct) winv, oliampa^e, 
and Boda-watcr. In addiLioii, iujiri-tiuux lui^ikitlfullv uod vio- 
lently', or too often uiado, ur of too b'trong (>>olntioiif% majr lead 
to the development of acute pntarrb of tiie neck of lite blad- 
der. It i« very ofti-u cKX-a^ioiitd by tbu vioteut um: of euundfl 
and catlietera, and by the impaction of calculi. Lastly, an 
acnte vesical catarrli may also be produced by the use of can- 
tbaridcs. 

If acntc veeicai catarrh is not carefnily treated, 8till more, 
if tiie injnrionji intliieneoH oontinno, encli as tlie nretlinil injec- 
tiona, tbe introdactioa of eatliot^rs or sounds, or tbo internal 
uae of faolfiamic remedies, a chrouie ivitu'al catarrh, or gonor- 
rbcea of tbe bbulder, will Iw jirodiurtni. In uIU persons, who, 
as is veil knoim, not infrequently soSier from prostatic hy- 
pertrophy, and in spinal paralyeig, a chronic Teeical catarrh will 
readily be prriduccd undtT tbe pcruicnous intlacnct^ that have 
l>een mentioned. In chronic f^atarrb of the bladder, febrile 
pbcnomena and pain appear only at times. T}ie latter cotun'ata 
not CHily of annoying calU to nrinato often, but pains aJto dart 
toward the meatus. The urine ib cloudy and oj'aipie, becauae 
it oontains a nutAlilu (|naiitity of puu and nnuTontt curpneclue, 
blood-coagnla, epitlielial celLs, and a large amount of ealts, 
phoBpfaatee, urates, etc. It emit^ an ammoniacal odor, and re- 
acts alkaline Tbe alkaline condition i& occasioned by the mn- 
cos from the bladder, which acts as a ferment, and as a oon- 
wqacncc carhonnte of ainmouia develops from tlie urine while 
still in that vi6cu», and tbi« salt in its tnm causes ndditional 
irritation. L'ndcr unfavorable couditionfi the catarrhal secre- 
tion in the tiLicUlcr tuny attiiiti kiuOi ii dt'gn-e that largo lumpH 
of mncns, pus, and blood are discharged every time urine is 
voided. Tbe sediment Lccomett teoacions and ropy, an alter- 
ation produced by the action of the carbonate of ammonia of 
the nnnc upon the mucutt and pus. 

Chronic vcKieal catarrh gives rise to more important patho- 
logical alterations tlian tbe acute variety. It ivault« in hyper- 
trophy of the luuBCtikr coat of the bladder {la ve«ei« d oolvmu)^ 



73 PATBOLOQY AND TREATMENT OF STPBIUS. 



mth Bi'mnltoiieoTiB thicken! iig of the mncoos membrane, aud 
iu coiiBcquenc« of these leaiona paraijeis of the viitcun may 
folluw. Onidaiiltj tlic nrcti-rE, ihv pclvce, and eroQ tiie kid- 
ncjB may become di^caecd . TIte mactiB, pna, and hlood-ooegtila 
that numun in tlie hiadder iiiuv ecrrc im tlio etarting-iioint for 
tiie forinatioD of calcali. P'lnally, 6iip[>uratioii and ulccratiou 
of the bladder may take place, and hence it is readily under- 
fttood how chronic calarrh may tenninato in dentil, either di- 
rectly or by retention of arine, and tirieiniA. 

Diseaee of the hladdor is tho mwX mHous oranpltcation 
of oretbral gonorrhoea. It lias a teitdoiicy to relapse and 
to become permanent. So long as tho vesical affoction is 
limited to ih» mucous membrane of tlio neclc the prof^noeis 
ia (ttill favorable, but if tli« diMeaHe hut extendml u> the fun- 
dus of tlie bladder the physician should be guarded in hb 
pro^osis. 

Wliun tilt' nt^c'k of the l>kddi'r only in nltc-ctod, tho itinin 
dnty of iJie physician wili be to relieve the veeical epaan and 
the painful micturition. Thia is beet achieved by the removal 
of all causM, diecontiiiuanee of the injectioiiit, ar>d of the in- 
ternal adminiatratioD of tlie bal^mic remedies that had boeti 
employed in tho treatment of the gonoirhoea. For tbe porpoeo 
of allaying tho vesical tenesmas, there is nothing better than 
tlie local and internal employment of the anti-«j)aiimodie and 
narcotic remedies. Core dionJd be taken, however, in the une 
of the latter to prewut oonstijration. AVe have wed for a 
long time, widi great iHiiieflt to the patient, e<juul pouta of in- 
foaioD of horba Ilemiai-iiei and chenopodinin ninbrosioidea, of 
which two or threu cnpfuk. sweetened with milk and sugar, 
idunild be taken daily. This infiuion Iikh the additional advan- 
tage of dilating the cooccotnitcd mine in tliu bladder without 
canaiDg diureusL 

Id cutfc ihtit remedy affords no relief to the repeal teoeemui, 
Ibu fullon-ing prepoiationB may be need : 

1^ Rztr. wm. hfOW-iKmi ; 

Extr. rannsbb ii)dk«, U 0-50 {^a. Ti|j] ; 

Sacobsr. alba, 8-00 [gra. x]nij|. 
U. Div.iapolr. No. XX. 
6. One poKdcr to b« taken vttrj three booTs, 



aOXOBBB(SA, VBXEBEAl CATABRff. 73 

B Oamphoni; 

KxU rauDaltis iudioa, AiL 0*60 [gra. viij); 

Sacchar. albo, 3*00 |grB. ilvijj. 
M. Div. in doi. Kn. So. X. 
R. Oat! pitwilcr to Im lakeu ever; two or tJirco banra. 

If tlKse narcotics also fail to pve relief, suppoaltoiiee of 
belladonna, poiitaiiiiiig O-OI [gr. J j of the extract,* gliotild bo 
resorted to. In |)atieiit8 wlio do Dot gufEcr from cooatipation, 
sappotiitories eoDtainiog morphia, in (juantities eimtlar to that 
of tlie liellatloDna, or b^'jKxIenmV injection of moq>1iine in tlie 
perinseiim, waj lie employed. In the majority of cases warm 
sitz and ordinary baths, aud the application of flauneU dipped 
iu hot water, wrung out, aiid upjiHcd u%-er the bladder, aifun] 
considerable relief. The diet of the patient shonld consist 
only of fionp and milk. Sweetened water, to wliich a few 
drape of acid Halluri [aromatic eulphnric acid], or diluted milk 
of almonda, is tlio best drink for him. Formerly, it was cus- 
tonuuj to use, in acute catarrh of the bladder, oleofpnons mixt- 
nrcB and decoctions of linseed with syrnpiw Diaoodii ; in oar 
opinion, however, the decocHoti eonlaiiis but a slight amoant 
of tineeed-oil, and of this very little ie cxcretcil with the tiriae 
and finds it« way into the bUddcr. 

If retention of urine baa occurred, tlie bladder nhould Ix) 
eracnatcd by the aid of a soft catlirter. In eases in whicli the 
effiuiioQ of blood from the cnpilkrioe of the neck of the blad- 
der coutinu«», tr. fern chlorid., adminiBtered internally, will 
be foond beneficial. [Nothing Berve« the piirpose so well here 
aa blistering the pennieiim. When all other remedies Lave 
failed, one or two bli^era applied upon the perinieum not 
only am»tod the bleeding, but gave prompt relief to the veai- 
eal tenesmus.] 

In chronic vesical catarrh the physician will be called upon 
to evacniit« the urine and the ropy eecretion several timea 
daily, and to diminish the secretion of mueos ta much aa po«- 
eible. AVith this object iu view, tlie patient should be allowed 
to drink water plentifully ; aim mineral waters containing iron, 
such OS Marienbad, Franzen«had, Giefshubler, Ottoquelle, Ho- 

* [I htrc found Ihii qumntlr; cDtlret; iufluffidont— boli ■ gnin •; lc«f t \taog 



T4 PATHOIOOY ASD TREATMENT OF 8YPBIU3. 

hitscher^ Lnhatscliowitzer, WildungeD, etc. la addition astriu- 
genta, sucti as alum, tannic &cid, ur docuct. foUoruiii ura* orsi, 
kIiouIi) Ik,' umhI, u in tli« ftillowing fonnula;, fortiio piirpoeoof 
arreeting the eecretioD of niQcaa hy the oiuooos membnae of 
the bladder : 

jj F»l. ntTD ofbl, ao-oo 1 5 «■. 3 i»lj 

C»i|ua c <i. ai. u). conitu. |icr ) Ip. sab. flnen ooot.; 

A.Mii: Fliir. c^)rL nur., 10-OU [d vli)]; 
Slct ill iiifiino fcrrids |>or \ bgr. vnso cUutao. 
Uoiiit, SWIK) [ 2 ix, 3 vj|. 
AdJu: Syr. lUitiw. 30-00 ( |j]. 
U. S. tlolf & teaoupfU to ba taken over; three lioura. 

B Glyoerini pun, «0-«0 [ 3 s«., 3 ItJ; 
Tftuuiui [mri, W5U Jew. viij); 
A<|. defctlL. 50 0(1 [ S,|«».. 9 iTj; 
t^jr. oooniilia ppin.. 15'(KI[|m], 
II. S. To be lakeii in tweaty^fuur lioom 

We opo iinahlo to ray aiijtliing In favor of tlie mo of limo- 
water or tor-water, or of a solutlou of corrosive sublimato, 
iu thiti cuin|ilaiut. 

i( the muco-puruleut evcretion of the vesical mucotu ineni- 
brane does uot ditniniiiti from the use of tlto mineral waten 
and astringent remedies, it will be ucccssarr to remove mcchani- 
call/ tliu eecrvtiou and urinary sediment that ^taguaU; in tho 
bladder. For tliis purpose, we cordially n^commcnd the pro- 
cednre eng^ated and published by Drs. Briinner and II. von 
ZeLt<»l, of tilling ihfi bladder M'ith U^uida by hvdr'jntatic pn;e»- 
uro M-itliout tho aid of a catheter. If tho bladder doea not 
CTDCTiatd it6 contents epontaoeoiLBlj, a catheter huving a lai^ 
eje abotUd be introduced, and tho organ should be carefully 
washed out with some weak antiseptic pn.'])aration, uttcli as u 
solDtioa of earbolic acid or tho like. For the purpose of conn- 
terioting the alkaline condition of the urine, wo give intenially 
potaa. cldor., 0-50 [gra. vUj], per diein. In aohitioii, witli veiy 
good ranlL 

Diaeaaes of the Kidney that are prodaoed by Urethral Ocoorrhcnt. 

No morbid conditions that originate in conscqnonoo of 
gonorrhcG* of tho nrothm escape the notioo of the physician 



0OXORRIIOIA, VENEREAL CATAJtRS. 



75 



BO often u tlioev tbitt dwulop in Uic ttidacy^ Tbo gcoeau of 
theae kiJney Iceions was but imperfectly knovra to withm a 
eofluporatively reci'Qt period. Many ]>LyaicittiiH ascribed tlie 
dUeCBOS of tlic kidney thit complicntod gonorrlitpn excliiMvoty 
to tlie large doses of tlie r^^iuoitg diurclics wliicli the putionbi 
tuok. Oo tliQ citlibr liiuid, ('lutiiiet and Rayt;r iiiaiiituin Oiat 
neitber the rc«inons remedies nor tlie diuretica aRriii exert any 
uufnvoralilo effect upon the kidueys. Still, we hare proof 
tliat eveti ntnall diweH (UitM*, (K-'caKitmally, tm-morrbagti and 
ecchymoee* of the neck of tlie bladder. From tluH point tlie 
hy|)cr»-uiia urny extend along the mncon» membrane of the 
tmcterit and pelves of tlie kidtiej-s to the papiUiL^ and Uie 
etniiffht renal tnbules, and prodocu witliiit tlie latter catarrhal 
proUfemtion of Uie cella. Now, it is easy to perceire how 
A catarrh of the bladder, merely by cxtcn&toQ, may occauon 
dise&M In the kidney, dooc irritation of the nock of the blad- 
dor not infreqnently occure even in gonorrlireal nretliritis 
treated without any balsamic remedies. Furtlier, bccaaso 
lUifl cooxUting catarrhal affection of tho etmight tnbnlcs of 
the kidneyR, occAaioiied pcrli.-ips idiopatliically, ifi acoompa- 
niod by albnmiDun'a, ibe roeinoua remedied vcro duiTKod with 
having cnut^ the nephritis. It is all the more easy to make 
tliiB oiiKlake, tiecaiue it is poosible, even in lioalthy kidnoya, 
after tho use of copaiba, cubebs, etc., in large doees, to pro- 
ducv for aoveral davit au opacity of frosh urine by the add!- 
tkm of (ttmng mineral addx, vliich ia remarkably like that 
canned hy the presence of albumen. Tliis opaque sediment, 
}iawBver, is uoi albumen, but the rcAinous snlwtance precipitated 
by the acid. But, even if the opaqne sediment proves to be 
ftlbnnwD, the leaion can only be rcganled aa a catorrlial ne- 
phritis dceqiiainativo, and not ditluw nephritis. Now, it ie a 
wctlod fact that tlie kidne^t!, in most cuks, are not attacked 
by aente gonorrha-i, even if the latter extends to the proe- 
tato and bladder, and tltat it only produces a catarrli of tbo 
•trvigfat renal tubnlee when it faaa cid^tcd for a long time and 
involved the bliirhlcr. We have only been able to demonstrate 
in the cadaver the prcdcuce of puppiiralion in one or btith kid- 
neys in tlioae caww in which bad etrictnres had already formed 
M a raault of gonorrhoja, followed by hypertrophy or nlcora*- 



76 PATffOLOer AXJ> TUEATMEXT OF 3TPB2US. 

tinns of tJie prostate, wntli or witlioat [mrulent catarrh of the 
blikdder. Inflammatioti of tf»e pdv*s qftJu: kidneys, in coiup- 
qucnoc of gouorrtia>u, occura more often than Is sapposed. 
Tbu ilittjpiiwis of tliis oondition is hssed npon tho presenoo of 
febrile moremeiit analogous to ioterraittent fever, of anamoant 
of albumen in tlie urine eomtspoudiugl^r greater thau tlie piut 
in it, tlio microscopical dcmontitration of ptw-corpasclcs, and 
irrogalar pavem«nt epitUelium of the renal pelvia. The urine 
in pjolitis has an acid roacUon, bdng directlj the rorcrse of 
the ocjoditiun tliat appcrtaini^ to catarrh of the bladder that has 
existed for n long time. Tho patients complain mostly of a 
dull pain in the region of the l;idut>y, and tbe organ iuclf is 
eaneitive on pressure. 

In mwL cases the patient oomplains — if not at 6ret, at any 
rate later in tho course of the caUirrUal n^j^ritU — of u dull, 
somctimca of a Tioleitt pain in one or both InnilKir regions, 
wlilcli becomes aggravated Mt tlie ^ligbte^t touch, and usually 
c&teutls downward along the cour»L' of tlte uretere. Not lu* 
fivquently the di«vaii(t mumfv(tl« itwlf by mor» or loM «CToro 
febrile movemout The urine in euch cases is markedly di- 
mintelicd at fiivt; later, iu most imitancct, it i» incn:ai>ed, and 
is generally of a pale-yellow color. Aa a rule, it contains a 
moderate amount of albumen; but, notwithstanding the pre^ 
once of albumen, tlio specific gni\ity is lower thoa nonnal. 
After standing for eonie time the urine deposits a sediment, 
in whieh tho epithelial cells of tlie aretei^ and bladder, along 
with nmciia and pus-corpnscles, hyaline castR, cytiDdrical epi* 
thctium, nnd oecasiouaily 6brine casta are found. The urine 
reacts eiiglitly aeid, but, if the disease perBtet& for a long time, 
it will become alkaline, owing to tho decompcNition of tfae salts 
of the urine in the bUdder. "We then find tlie well-known cof- 
tin-lid-like cryi^s of tlie triple phospliatcs ; sometimea blood* 
oorpUBcIes are alBO preeent. The condition of the cxtravaftated 
blood will Acrre to show whether the blood that 'm mixed with 
the urine originates in tlio bladder or in the kidnera. Blood 
coming from tho ureters gonerally forms clots, shaped like casts 
of tiicso tubes. In hemorrhage from the bladder the blood 
is not intimately mixed with the urine, and the urine that ia 
voided at first is only slightly red in color, but that vaided later 




aONOSRHtSA, VEXHSeAL CATARRH. 



11 



becomes as inteneelr red ae if it were pure blood. In biemor 
rbigo irotD tlie Idduej tlie blood is thoronghlv mixvtj with tbo 
urine, and the latter hoe a anifonu color from tbo be^DDing to 
the end of iiiieturitiun. Fur llie (JiirpuM) of aiwcrtiuuiug defi- 
oitoly the preswitce of blood-corpiiwlw in the nrint; in slight 
renal hfemorrbagva, the arrue should be subjected to tho potash 
test, which eoiutiBtfl in boiling *oiue of it in a test-tube, adding 
a few dropA of a M>tutiun of cuuBtic potash, and tliui boiling 
it again. The eolation pnx^pitatcs tlio pbo«^hatc», carrying 
diL' coloring<inattcr of the blood with them, and the Bediinont 
\s thereby colored red. 

The couree of a renal catarrh occasioned by gonorrhaift ia 
ttHiftilj rapid and farorable. The prognosU depends npoa the 
inteod^ of the primary diMasc. If the reaical catarrh is ic- 
tense and ponilent, there is dtager that the catarrlial nephritis 
will become ^nppumtive. 

Renal catarrh, duo to gonorrbcca of the bladder, gcnendly 
dlBappeers when the primary disease disappears, ncneo tlie 
treatment of the reside and renal oatnrrh mnst go lutnd in 
band. Itep;arding the therapentica of the disease of the blad- 
dt!r, we refer tlie reader to wliat tian already been csaid above. 
The patient should avmd everything that ia liable to prodaca 
marked fluxiuu to the kidney, especially food and drink eea* 
Honed with muoh salt, and also all kiud» of dturctic& Cold 
water, weak lemonade, and milk of almond.i arc hc«t suited for 
drinks, and milk and milk-diet a^ food. f^liniuUting the ekiii 
bj means of hut LuthH is e«pocially Ufvful. The following may 
U) employed for the purjioeu of arroeting Uie tccrction of the 
mucv-pua: 

B Tnaniol pari. 1-00 [grs. avj]; 
Cuaphom, 0-50 [grs. viij) ; 
Swxiuir. xIbt^ S'OO [9iv]. 
It. Dtv. IttdoseNo. IG. 
8. Four powder* to tw lalwa ddlj. 

g, nijrc«rli)l pari, 10-00 [ S oa.. 3lv]; 
Tanntni pari, 1*0& [i^. xvj] : 
A<]iia <k»Iil., 10000 L S iv< 3 U^-l* 
8. To bo lak«n daring Uio dof. 

In profnso renal hiemorrhago we admiiuster tr. ferri mur. 
In very obsUnata bleeding and pcmiAtent Inmbar pain, cold 



7A PATnOLOOY ASJ} TRBATStBNT OF SYPUIUS. 

ctiiupruaaoa abonltl he appIiiHl bi botli renal n-gions. Tbo 
treattucnt of the pyelitis consifits in the internal Administration 
of tannic acid iii the maimer described abovo. [In renal 
hemorrhage, aail olra in pvclitis, I cad heartily recommend 
the use of dry cnp£ over the luiubor region as often as may he 
deemed necoesary. From twenty to forty cupe may be applied 
and repeated. It lias rendere<l me excHlent i^errice wlien 
other much-vaunted remedies failed.] Dittel obtained very 
good reeolts from tho inhalition of the othereal balsamie 
remedies. 

QoQorrboea of the F«male. 

We dietingnish (1) gonorrhcea of the vulva, (2) of the va- 
gina, (3) of the Titen», aiid (4) of the urethra. 

Tho most fre<iiient form is raginal gonorrhoea, next is 
vulvar and uterine, and the rareet is the urethral fonn. IJeo- 
alty several iiarts of the geni to-urinary mucous membrano are 
aflcctcd ut tho futnio time. Vaginal gonorrhcea ia very often 
associated with valvar or uterine, nretliral with vulvar or va^- 
nid, vaginal ^rith nrcthnd and ntcrino gonorrlm^a. Tho en- 
tire gomto^urinary tract id very seldom attacked in t<Ao by gon- 
orrhoeal dleeaae. 

The cause* of gonorriicea in tlie female arc infection, ex- 
ceesivo sexmil intercourse, and mechanical and ehomiCQl irrita- 
tion of tlie mucous membrane. ConRtitntioual diseasee, raoh 
BB chloronia, serofnla, BTpliilts, and similar blood d}i<cn»n, ir- 
regularities of meuBtniation, abortions and difficult confine^ 
mcnts, neoplasms, and surgical operations, may aim occasion a 
mucous catarrh (ir ju'olong one that lias originated In some 
other manner. 

1. OoNOKnnmA. OP TUB VrLVA. 

Two kinda of vulvar catarrh mav be eoid to occur: aa 
idicpatAie variety and oae that has been produced by propa- 
gation from adjacent part*. Idiopntliic vulvar cutarrh origi- 
nstee mostly iti confte(|uenec of onanism, but may aUo \t& cauEied 
by tlie gonorrhceal discharge of men. Vulvar catarrh originat- 
ing through propagation n«nlu from the action of vaginal or 
nrethnd diaohaige of wocoen a£Fect«d with gononiiceA, or it ac- 



OOHOBRa(SA. VENEREAL CATARRH. 



79 



corapttnioB wft ehaneres and eypbilitic affei'tioiw eitrwtod on 
the vulva. 

The {latlioli^cnl leeioD ocituists either of a hy|)envtnia of 
the affected macoos raombraiie or its cnawqnent effect (eeroDS, 
mooom, or epithelial catarrh), or the follicles are iiiSamed and 
bGoomo (illed with puD (viilvitU piiruluuta). Vulvar cutairh be* 
gioa fritli Acnsnal itcJiing, n'birh cIiangM to a burning sensation. 
If anjr part of the mtiroitH tneinhraiie lit denuded of epitbe- 
Uunt, or oxcoriationB aiid erosioua such as usually occur on the 
labia majora and minora at the fonrchctte are preocnt, the pe> 
tieote will sutler eevcrc ]>ain during micturition. ]f the diiteasc 
becomoe aggravated the parts of the vulva, provided with looee 
ooDDeetive Utfue, beeomo swollen. The nymphte become en- 
Urged to three and fonr fold their »zc, and, as a conse<|nenee, 
project in front of the labia inajora and are BtrangaUtcd by 
them. In milder forms of the disease — eurons, mncone, or 
epILholial catarrh — the discharge from the vulva is slight, 
mucoid, and tenanioiLt. In puniletit vulvitis it is considerable 
in quantity, thick like cream, and yellon-islt-green in color, 
emits a peculiar, fetid odor, irritatefi the adjacent mucotta 
nrnnbrane, and pitxhicwi erythema of the skin in the genito- 
crural and inguinal fold^. Warts and condylomata are some 
of the most frt*<iuent effects of vulvar goDtirrhtua. 

iljld CAMM get well soon, if tlio dtwnscd parts arc washed 
several times daily, and the sound parts are protected by com- 
preaaeB of ninslin or wadding. If the inflammation of tho 
tuncoTtt membrane is iot«D»c, compresses, dipped in cold water 
and fpe<inpntly changed, sbonid bo ordered, and pledgeta of 
lint, dippetl in a aoliition of lead or of zinc, placed between 

labia majom. 

B Ext. SMornl iplnmb. ocaU], 500 [Sir} ; 
Aqiu ilcitil.. 200-00 [ S vj. 3 V, 3jJ, 
U. S. Fur «xt«rDa) o»e. 

Q 'tAikiA mar., JI'OO fitra. rxs^); 

AqM d«tU., 200-tiO [ 5 vj, 3 T, 3JI. 
K. 8. For axt«rnal u>e. 



Excoriations that exhibit no tendenc}' to cicatrize may be 
touched witli tlie solid nitrate of silver. 



80 PATB0L067 AND TRSATitE^fT OF BYflUUa. 



2. QOKOESIICEA OP TBB TaOOTA. 

We dtoingiUBh a terxnis, mucrms, or rpitJulSal, and a puru. 
lent catarrh (kolpitifl), aooording to the eererilj of the inflam- 
matioD. 

EvoTT raginiil gonoirlKca U'-girut by an nmlefined Eensadtm, 
BOmetbing between dcktiri^ and pain. In the eeroiia and luu- 
0008 catarrh, the vagina ia only «li<<litly eciiaJlivu, especially at 
the bo^Dniog of tbc morbid proocee. In kolpitis the burning 
BensatiOD is moro marked \ tho iutr>:Klucti0n of the lin^^r or of 
a vaginal speoulmn jpves riee to unbearable \mn. Miclnritioo 
also Cannes more or leee pain in vaginal gonorrhcra. The dis- 
charge of a raijeoOB gonorrLoia of the vagina \a tbin, whilieh, 
like macuB, or yellowish ; thti diticharge of the punilent variety 
is thick, Uke cream, and has a yellowisb-green color. The dis- 
charge of both rarietiee has an acid reaction, in contradiatioc- 
tioD to the discharge from tlte inflamed inucoua mviulinuie of 
the urethra, and of the cervix nteri, which reacts alkaline. 
Tbia acid rcatrtion eeema to bo due to the fact that the vir^nal 
vulvo-Taginal mucous membrane f umiahca a euujguui-Uko Mcrc- 
tion containing a fatty acid, while tho folhclcs of the oenrica] 
l>ortion of the uterus furuiab a mucoue itccretion. Examined 
with the aid of a microscope, the discharge of a vagioaL gooor- 
rbtea is found to contain iuucoub oorpusclea, a few pufrcorpofr- 
ctcs, cost-oS epithelium cells, and now and then a few blood- 
globulcfi. 

In attempting to make a digital oxaiuination during the 
initial etago of tho disease, tlio vaginal orifioe is fonnd to be 
ooDtract«Ml and the temperature of the canal incroaecd. Its 
mucoiia membrane in felt to lie either soft and smooth, or 
rough and dry. On examining with a iipeculum a vagina that 
is affected with gonorrilCBa, the mncoue mcnibnuie. afUT the 
di^harge tliat has aonunnlated at the mouth of tlie speculum 
has been wiped away with some cotton on a wbalcbono rod, fa 
found to be swollen, dotted with red spots, bore and there ex- 
coriated, and turgid with blood. Occaeioiially the anterior 
part of the va^na especially ia studded with minute gronala- 
tionis which have originated through swelling of the folliclca 
and of tho papilhv of the mucous membrane. In prt^mmt 



aONORRlKBA, VBNERBAL CATARRH. 



81 



women tlicse ^ninulHttoDs att&in an cnormom size (vnginiti« or 
(Uytritifi papalo&a). As it u not po^ble to tue the speculum in 
joDOg girts, we enoceedcd rer)- well, in eomo casoe, in ligUtiug 
up and examining tliu vajpna hy tltu aid of Griinfold'e ura- 
tlinU endoecope. 

Qonorrhuial diecue of tho vagrinn generally begins at the 
lower third of cbo c&nol and gmdiially extonda to tho fornix, 
imle«U, flotDctiiDos to tlie cerrical canal of tho uterus. Tbo 
genoml condition is bnt idightly aiEocted by a mucous gonor- 
riicea. The purulent form, on tho contrary, is attended, eepo- 
ciallj' at the beglnuing, by fevor, lu^tudo, lo^ of appetito, 
hack-Acbe, Ticarious nienstniation, and otlier funt-tioual diKturU 
aaaes, oo account of which the patients acquire a cliloro-ansemio 
appearance. The local duturbanooi coniiigt of «rytbeiaatouti 
rednrfv) of the extenial ourfooos of tlie genital orgatm, faa»od 
by the discharge from the va^na flowing over them. The 
duration of a vaginal gonorrliiuiL dvjH-ndK uixin the habits of 
tlie patient, certain couHtitutional coiiditionN, and tlio manner 
of treatment A purulent gonorrhcea, in womon who aro 
otlierviae bttiltliy, can be cunnl in about fourteen days, pro- 
vided menstruation doee not interrupt tlic treatment and the 
core, which it is apt to do, experience having ehown that it 
trill start tho diwaso anew, after it waa entirely checked. 
If tlio treatment of an acute vaginal gonorrh<cn is abandoned 
loo early, and tbo woman indnlgtw in »cxual inlorcoursOj the 
int1.immation either relapses or tbo catarrhnl hs-jiorseerctioD 
bocome* pennanont {chronic vatjitud ffonnrrhmi). Uowever, 
eren a vaginal gonorrbiKa wliich, at its inception, was of the 
catarrlia] muooos fonn, may, throngli unfavorable circuni- 
stances, especially antemia and frequent and irregular menstma- 
tloo, beoomo protmctwl ami diflBcult to cure (f^ucorrfuxa). The 
dischaiige from chronic catarrli is almost colorless, more macous 
than purulent As a result of tbu chronic process, and still 
inoro from the astringent liqiiidis need against it, tliu mucous 
noiBbnine becomes hypcrtrophied, loses its velvety appeaianoe, 
feeU rough and dry, like tanned leather (xcro&is t'Of/irwe), and 
eauos a grating noise when a speculum is introduced. 

For the purpose of curing a va^nal gonorrbcea, the woman, 
above all thingx, must pmctioc tlie utmost cleanliness. In 



8S PATUOLOOY ASD TREATMEUT OF SYPmUB, 

ouu of iDtcnse Bwellinn; of the inuoous meiubratie, cold oom- 
preaaeft, toaX eitz-lntU^ or the cold-wutcr vaginal doadie, hj 
mewB of the fountain-fiyritigo, shoold be employed. After 
the inflammatorr swelling has pubaidod, and the hTpeieeiui- 
tivcness bos (limiDishcd, niincrul lutringcnts, luid, if theee fail, 
vegetable ai^ngcots aud tonic Jloid^ muy be iujectcd into the 
va^ua. Ttttse inJectioiiB may bo laucli etron^r tbuu tlioee iiBed 
iu lyvtltnU gouorrhuBU in uieu- We prescribe the following : 

U Alnmerodl, lU-00[3>vit)]; 
Aqnk dcstil., 800-00 [ : xtJ]. 
M. B. For ttxtoroal oiw. 

Q Curiio. <|u«rcas or radio, rntimh., 50*00 lljn., STi^]; 
Coqua oum sijua, 1000-00 1 1 xxi\|J uik|uo ud rotoaflot 
500-00 [ ! XTJJ cola. 
U. S. For eitvruol use. 

B ancisolplL, 5'00l3ivj; 
Atitux dcatU,, 600-00 \ % tvj]; 
U. & For cxtcnuJ uso. 

Q Tr. rnUDhiiD or oateohn, SO-00 [ S ju., DviU]; 
Aqua dMUI., 600-00 [ |xvJJ; 
Aloro. cmdi, fl-OO [3iv], 
U. S. For external aso. 

3 TimDini pari, 6-00 [£>lv}; 
Glycerin!, 60-00 [ S }«&, aTiiJli 
Aqna destil., 600-00 [ $ xvj]. 
U. 8. For eiteroal oae. 

These preparatiooB mnst be ofied bj tito patients at Icort 
three Umce daily. They may be injected into the vagina with 
a aterine or foniitain syringe. By the aid of the P{>eculuni the 
niuse or the phyaician will be better able to apply the rcmcdieB 
to the discued {daoes. After the injections the y&ginal walb 
should be wiped aB dry u possible with oottoii-wool, and, for 
the purpose of keeping tbem apart, the vagina slioald be tam- 
[wntKl witli jiledgvts of cliarpie, dipped in the astringeDt lo- 
tions. The»e ehonld be changed every two hours, otberwias 
the blennorrhoic eecrction with which they beoome ntanted 
will undergo deeompotiitioii and irritate the maoous memhrana. 
If the pludgeta of lint have iitringa atuurhed to thein it will be 
quite easy to remove them from the vagina. 



lOKOnSBfEA, VEy^REAL QATASRn. 83 

If tHc dischargo, notwithstanding Iho frwincrrt employment 
of the iDJeotioita, doee Dot cease — as is osoally the case, espe- 
dally ia elytritJa papnloaa — ■ specaloin ehonld be hiCroduoed 
into the Tap;iiia, and, aft«r cleansing it of secrotioDs, the ma- 
conn nienihrane should he pautemed with llie soh'd stick of 
nitmio of silver, making circnhtr sweeps witli it as the spoco- 
iDm h bein^ gradaally withdrawn. The yigina ehciuld be 
immeduitely tainpoucd with dry absorbent cotton, but t}iia 
most be removetl !n a few hours, and tbe injertiong again 
mad. It is necessary to repeat these canterizatjona of the va- 
gina etcry two or three days, and, failing to aecompHsh a cure 
in this way, plalgctit of lint, dipped in a solution of alum or 
of bismuth, should be inserted and allowed to remain for two 
or three hours, and tluTU followed by iajections. [tiuite re- 
cently a solution of bichloride of mcrcnry (i part to 5,000 or 
10,000 of water) haa been used with e:tcellent restalta.] 

8. COSCPLICATIONS OP" Vct-VCt-VAOrSAI, QOKOKSIKEA. 
(a) Diseases of Oui OlufiJs of BarUAini ojid their Duett. 

We distin^iah (1) dieeaee of the f^land and of the oon- 
nectiTe tisnte nuroanding it, and (3) diacam of the duct itself. 
The firet lesion i» better knovm and oftcncr cornea under treat- 
ment Both originate utiually from the extension of the vul- 
var inllammntion to tho wnlU of the excretory ducts and the 
gland itself. The disease, however, may also lie produeod by 
masturbation, since ahsceseui of the gland and of the labiee 
have been met with in virgins. Both affoctiona gonoraUy 00- 
cur onilaterally. 

Jn^ammation. oftjie ghind is ushered in by febrile move- 
mont and constantly incrpjising pain in the affected labiam, 
which swelb np immensely. In die course of six or eight 
days a periglandular abscesa forma, which finally buntta on the 
corface of tho mucoua membrane of the labitim, or, in rare 
cases, a gangrenous condition ensues, producing an intenaely 
fetid discharge. 

If^liammatiim of ths ercretory duett mna cither an aoate 
or chronic conise ; hut oven an acute inflammation canaes only 
& moderate d^ree of pain, is unattended by fever, and does 



Bi PATffOLOQr AND TEEATMEXT OF SFPfflUA 



not give riw to any culargcment of tho labiam. A Umaeloos^ 
luucouB, eoiaetimiM uIhu jmruleiit (IiBcIiar)^ dows constantlj 
from tho excretory dantit, a cunditiuu tlut L<t liable to become 
chroinc. If tlie dUciiai^ can not escape readily, tlio duct will 
bucotne distended, ampulla-lilEe, to ita utmoBt capacity, awl 
then some of the matter will be pourod out periodically, or the 
bolgiog diverticulum tlmt projccto ou tho inner surface of the 
affected labiom undergoes euppunition and ruptures. 

I'erigUndular abeceeees occur more frequently than abecou 
of the diverticulum or of tJie excretory ducte. AbeoesBoa d 
the excretory duct arc more superficial than the porigUndolar 
ones. Tlicy aro not uo painful, burat and cicatrize sooner 
than the latter. The walls of the glaitdulor abscess are nn* 
even, shaggy, markedly red, and bleed readily. The walls of 
the diverticuluiu are siiiooth and gl'iBteuiiig. Catarrh of the 
excretory ducta in very obstinate, and often resiitts all kiiuLt of 
treatment. 

Swelling and aheoess of tho glands of Bartolini may readily 
be mistaken for Iiernui labialvh The latter ie genaally lo- 
cated in the central purt of tlie hibium uiajus, and from that 
point it turns to ttie side of the Yogiua in the direction of the 
taber ischii, and, with a finger in that canal, the dircctitni of 
the tumor is readily followed. The diagnosis may bo oetab- 
lifihed beyond a doubt by examining the intcnial abdominal 
ring and by pepcuasing tlie tumor. 

The other morbid altorattona of the labia which nrc liable 
to be luistalcfi) fur in^aromation and ab«icee« of the glanda of 
Bartolini are atheroma(«ut nnd other ft/Ktic tumon of the 
labia. 

There is a diaease of the labia, that occurs very rardy in 
Europe, and which consists in an enormous hy perlrophy of 
one or both labia. This i& known under the name of depkam- 
tianU araium pttjendmn. In the early stages of the disease 
tlie diagnosis may be establislied by tlio presence of a local, 
persisting, or freqacntly recurring eiyeipelaa. In oonscqncnce 
of this erysipelas tho &o<aIlcd lymphatic ^sdema, as is well 
known, devclope, and after a while eairecs the elcphantiotio hy- 
pertrophy of the labia. lu tho further counw of tho disease, 
that funn which haa been tiitliurto doscribcd aa elophantiasla 



eOJfOSRBfSA, YSNEREAh CATARRH. 



8S 



g^altra pntlanrlaniin may develop into Uio Tartetv to whtcli lios 
be^n ap])ti(Mi tli« tenti eUpha'ntitui* arabujnyuMtut, on aocouDt 
of tbe glaniliiliir appearuncE! of the affected parts of the skin, 
and the deep-brown color of the epidermiB. 

lu regard to tLe tlicr&peuttca uf the dUcaM, we wiiih to 
irmko the following oljwrvatioiw : 

If tlio gland IB affected, tbe patient, in tlie licginning of 
the disease, must keep perfectly quiet, and c»iM ahonld bo 
a]ipLied. W1il*d ^ofteuiug tokcB pkico, the compressM slionld 
be roDowed lees often, bo that the,r may beconse warm and 
BOt as cal-ipIiiKma, and the ewoUiii^ hiiined a» early ms pmcti- 
cable, anil, if possible, exteninlly, lo prevent tlie lip« of the 
wound from being infected by the vulvar or vognnoJ diecharge. 
In catarrhal disea^ of the cxeietorv ducts, cool eitz-liatlu and 
pledgets of iniuliii dip|>eil iu aHtnnguiit solutionn, nucli an tan- 
nic add, xinc, or copper, laid upon the gland, have been fonnd 
Dsefnl. A divertipntiim that ia in danger of underj^oing sup- 
poratiun Hhoiihl Ihj slit open mid tuucliud with liujur eaUKtic 
<nico daily. Non-Buppurating diverticula of long atanding 
•huidd likewi^ be slit open, and a weak Bolntion of nitrate of 
rflTcr (0-U) [gr. HI *« water IWO'OO [ 5 iij, Sviij]), should then 
bo injected throngh tlie cnt by meana of an Anell'a syringe. 

(&) /ntfammatitM and AbtCMs qf M« Lijmphadc VetatU in 
tfis Jjiihia Majora and Minora, and ^ th* Lifnipfiaiic 
OUtnda of th« Imj»%iud Foida. 

These IcKions occnr specially in enppnntion of one of the 
glands of BartolinL They are due to iJie name patliological 
ooadition, aud deveK>p iu the came manner aa intlammation 
of other lymphatic veHsels and synipathetie buboes (see AfTeo- 
tions of the Lymphatic Vessels and trknda in oonsequeoce of 
Soft Chancre). 

8. I'tEBIXG GoKUKKHtEA AKD FTS UOGT FbB()DBKT CoUPLICi.- 

tiok: Erobions aso Gr-usulations of the Ob Uteri. 

Uterine gonorrhoea occurs vwry rarely aa an idiopathic dia- 
«we. As a nilo, it a caused by propagation of the morbid 
proeeas from tho ragina. For tliat reason the cer\-icul cotuil 
Alone is found afrec{c<l in most cases, aud tlic body of the 



g6 PATB0L06T ASP TBSATMBUT OF STPmua. 

uteniH bticomm involved uul^ wlwu the disease Uoa existed for 
a long time. 

GoDorrhtxa of tbe cetrical can&i nunifesta itMilf partljr hj 
mibjeotive and parti/ by objoc(a*'e sjiuptoms. The sobjoetive 
complniute van : Dull, unpleasant Kbtuattons, omauating from 
tlie pelvic cavity and ra^Jiatirtg toward thv lutiiliar re^on, fre- 
quent desire to micturate, and a gencnU feeling of diecomfori. 
The objiMjtivo Bymptoms oljeerved in an exataination with a 
vaginal speculum are aa follows; A f^latinous, coUodion-like, 
ropy disdiar^e oozes frarn tlie mouth of tlie utcrusu Thiit is 
exorutc'il from tbo follidcK lying between the plicn pahuutiB 
of the ccrricul canal, tenaciously adlicrce to the socrcting sur- 
faces, and reacts alkaline. During prt>guancy it appears in 
chutwy flakes. Thiit dl&cliarge oontxlai the pcwttfrinr lip of tlie 
cervix, and, in conwKiuenoe, it often becomes etrcaked with 
bloody erosioDfi. U terinc gonorrhoea aeldom disappeais entirely ; 
geiicnilly it merj^ into a tJinmic catarrli, bocauau, oa has beoa 
learned tliroiigli oxperienpc, tJte mnoons membrane of the oer- 
vix uteri, of all the genital mucous membranes, has tlie great- 
est toudenoy to bc<'/>tne aflt-ctcd with chnmic <-jilarrh. lu con- 
saqnenoe of this chronic catarrh the follicles foimd there grow 
and bccomo dilated into polypoid growths, which sometimes 
protrude through the o« utwri, become straugiittited luid drop 
oil (uvula Nabotlii). Should the morbid procuss involve the 
covity of the ntcnis, irrpgnlar ineuKtmation will etisue, It will 
becooio dilated, the secretions tliat hare Rrmmnlatod within 
become dcconijxiAod, and oooauon the Ho-called pby«ometrB — 
L e., aociimalalion of air within the uteriiie ca%-ity. Wlien the 
catarrh b:ui existed for a long while, the muooiu niembnina 
undergoes vanoiu morbid changes. It is traversed by vaiican 
vessels, studded with cdchymotic and discolored {Mgmonted 
spots; tho ciliated epithelium is destroyed, the glands at the 
OS cxcroto fat and hyaline matter instead of normal macna^ 
and become converted into cysta ; many of tlicm when grouped 
together develop into polypi. Tbe walls of tlie otcnu beoune 
thickened ; prolapaos and displacement of the oTgaa maj* takd 
place. If tho catarrh has extended to the Fallopian tube, rto- 
rility will either be tbe result, or the fecundated ovam nmuins 
iu the vicinity of the os iutemiuUf and givaa rise to placenta 



eONOBSn<SA, veitbbbal cata^bh. 



St 



pnBTtft (Schroder). Infectif>n with gonorrhival Tinui may oo- 
CObIod eren metritis and parametritii!!. The digestive organa 
and UiQ nutrition become nnfavorabLy affected od acooimt of 
these lesions, and fuiictional diatorbanoes of the Dtcnui ensue. 
The appetite is diminiehod, Yomiting occora frcMjocntlj, gastric 
catmrlt etieuoe, foUowed hy pai^ve dilatation of tlie etomacli. 
Tltc patients )>ccotno emaciated and anaemic. 

in r^iird to the qacfition of the infecting property of the 
uterine diachit^ we coiacide, from personal experience, mtb 
the opiniouB of Cooper and Ktoonl, that it will product* gonor- 
rhiVA in men, but of a nitldor form. It will do this e^pocioJIy 
when it iH profuae in t|i)autity and conlalue many pus-eella, 
when the woman nc^lcct^ to keep her genital organs clean, and 
wbbii iiitcrcom«L> Lt ropenled at ^lort intcrvabt with pRtvionnte 
■riliir. Thi« coiuliliou may obtain iiioro frequently in ilUeit 
intcroonrse tlian among sedate marritxl wuplcs, and will abo 
BCTTo to explain those ca«» in which a woman anAering from 
uterine diseB«e will communicate gonorrhn'a to stnngon wbo 
socooeded in infringing upon the riglitfi of the huBband, while 
the latter escapee infection. 

Ka u n^utt of uterine calatrb, leas frcqnontly uf Mnrcre> 
protracted ra^al catarrh, nnall orosiond occur on tlie cerrix 
a&d soBietimee (et=peciaily in coexieting eyphilie) in the cem- 
Cll oonaL The coaJcflccncc of many of those cromons will 
fonn bu^ bleeding Bpots which are de^itntc of opitholinm- 
cells. After tlio cjqjuUion of the glands of Nabothi the ero- 
doiM in the cervical cannl may become oonrcrtcd into excavated 
minute iileent, that henl by the formation of ^t, grayitth-wliite 
dcatriceg. Not infrequently ffranrtlai-umti, which vary in siM 
ittnn & millet-fleed to that of a lentil, and which bleeil readily, 
furm upon the eroded snrfaoes. Ilennig regards Uicm as vaa- 
cnlar papillie of the mooons membrane that hare not yet cic^ 
trizod, or as new growthe, which have epning from tbo gronn- 
lar proUfcratioa of the papillip. In conscxjncnce of thoe 
eroaions and granulations disturb&nccfi in the nerves of the e«x- 
nal organs of the female, which manifest tlicmsclvca in hyster 
ieol oonvuldons and the like, aocm to be produced. 

So long as itiUnnUDatory phenomena in and about the ntorofl 
exist, sexual intercourse must be etrictly interdicted, complete 



88 PATBOIOOY A.XJ) TREATMENT OF S7BBIUS. 

rest should be enjoined, the di«t restricted, and cold applicii- 
UoM made uvor the abdomen nud eacruni, fa*e myvcmont of 
the bowels piocured, and whatever va^nal and uterine dJa- 
L'liafgu IB {ireeent slioiild t>«! carefullj rt-iiioreii bv iiijeutioos of 
tepid warm water. If the iiillanimalor^' phutiomeiia havo al- 
ready disappeared, the cervical caiial tiboiild be canterixed two 
or three time« a week witli the ttolid nitrite of silver, at Oie 
liimic tJmc cuoliug idtz-ljutbii pni^nbcd. iiud iht uterine doudie 
employed. No injectionij of nitrate of idtver abould be made 
into the uterine cavity, becaufiO wo have Been rioleut nterine 
colic and even intiamiuation of the uterus and of tlie ovaries 
produced by them. Healing of the eroeions and gnuinktionB 
cttn oDiy be achieved by pcrd^tent and zealous trcatmcut of 
th© primary catarrhal diiicaflo of tlie vagina or uterus. W© 
have seen ext-vllent results from jtenciling the eroded aurfacea 
with a solution of nitrate of silver or coppor. The imperfoct 
digestion and afieijuiluUou, thi! auicmia and ehlorosie, must be 
improved by llie adminiittratton of f.'ood food, touiea, aucb 
aa iron, wine, miuend waters, and buth», and a retudenoe in 
the country. 

4. UttBrmUL GoSOEIUKEA IX TDK FEJtiUi 

Although the pathological lesions which are produced by 
urethral gonorrhcra are the Kamu in tlie female ab iu the maJo, 
still it is uot BO dangeroiia nor ia it apt to asflttme such a pro- 
tractod charartcr in the former as in the latter. Tbia ie owing 
to the fact that the urethra of the female 18 shorter, fewer 
adjacent organs arc so intimately connc<rted with it, it does not 
participato in erections ns in the iniilv, and, beuig nioro ex- 
posed, it is more scweeJUle to the applifalion of remedlea. 

The diaewie manlfe^ta ftaeU in tbo same manner as in the 
male, by a tickling seuKslion at Iho meatn?, which «ion changes 
to a real pain, and ia aggravated by nrinatiug. The mtiet eig- 
nificant symptom ta tlie presence of a mucoid or muco-punilcnt 
discharge, which can Ik; preased out of the nrethra by running 
tlio fin^ over it in tlic vagina from U^iind forward. This 
diflcfaajge ehonld not be mistaken for tlie mucoid or pum- 
lent discharge of the iDliamed mucous folUcK^s which occur 
in tho crypt« on both sides of the female urethra, This fol- 



00yO£S3<EJ, TESEBEAL CATARSB. 



SD 



ticalitis can be cureJ in & few da^ g ti,v Xlw ose of astringent 
roaiediea. 

Atnoug tlie acciJuntii which may be axeociatcd with a female 
orethral gmiorrtin^ dy^nria is the tnoet fivquent, because, ow- 
bip; to the elKirtiKiNi uf Uic urethra, the neck of the bladder is 
more nfteu iuvolved tlian in tJiu nulc. Ilieniorrhagc in gODOr- 
rhffia of the fcnialc urethra, occure rery »cI(iom, uiid in very 
Rligbt. Intl&iuiiution of the inguinal glands is exceedingly 
nue, bnt warts and condylomata arc remarkably frequent r«- 
snltH of the diawBC under eonadcration. 

TliL> Irt^tinent of nrethral gonorrba?a in the female i« almost 
idtiilicul with that of the male. In women who n-ill not submit 
10 injectjonjs cooling bntbs and tlie internal adininistratton of 
the etliercal balsamic remediOB should be nnlereil. lu olietinaltj 
chronic nrelhnil goiiorrlMBA the fjnidiial introduction of tho 
solid stick of argent, nitnitia once into the urctlira has accom- 
pltalied a cnro in many cnfice. 

OonoTThoea of the Eectora. 

Gonorrlitpa of the rectum is a very rare diwase- It may 
b« pmdnced iu cither sex by direct contagion, as in aDnaturai 
wxnal interconnu3 (jiederastyX o"" V ^^^^ **^ cleauline««i, tho 
discharge from gononrhoa of the genital organs mnning down 
to and euiniug iu ountact with tlie mncoua membrane of the 
rectom. Ileooe thin diacnoe is met with more frequently in 
women tlian in men, the cause just mentioned exorcising ita 
effects with greater facility in the former. Tho skin of tho 
perinieum and around tho nnns in euch eaaee is, ad a rule, 
erythematouB and oxcoriatcd. If folds of mueoua membrane, 
in oowequenoe of hiemnrriioidR, protrude from tho anus, tho 
parlf will become infected with still greater facility by the 
diBchaige from the genital organs. 

The diicfaarge from the rectum i* pre^iminently purulent, 
haji a diaagTBGable odor, and not infrequently is mixed with 
blood. It flows continiiounly, and in especially ]>rofuM bef(nQ 
defecation and aflcr the cx|nilinon of ilatog. it prodncrs ex- 
oori&tions and fi^rnires in the folds of the anna, e!4|>eciully io 
thoae ca6e« in which infection has resulted from jiodenisty. In 
rectal gouorrbum tho patients suffer from pains only during 



f 



90 PATU0L0Q7 AND TREATMENT OP SrpmLrS. 

defecation. During tlie intervals tbey complain onlj of a 
constant biiroing or itching in tlie anus, and s frequent desire 
to go to stooL In tlu) most pronounced caaix the mucoiu mem- 
bnuie of tlic anal upvrtiiro In nddciitHl and fiwoUen. 

yfe liav« never uict \f-ith a caev of chronic rectal goDorrboaa 
reeoltiDi; from contagion, and it i^ prohahic that tbc diachnigo 
from other dlBeasM occnrriug in this region, each as bseuior- 
rhoidal tuiuoiB, eypbilitio uiuist papulee, or ohronic oozemo, 
has been mititakeu for tliat of gonorrha» of tbc rectum. 
"Warte and condylomata arc the moat disaftrecablo effects of 
reetal gonorrhoea, for especially the latter may attain to such 
dimenmoDS n» to interfere ii'ith defecsition. 

The iK^tment of gonorrbnen of the rectum coiuusts of rest, 
general bath^ or protmcted ailz-liaihs, and injections of wtit«r 
into the rectum ; iJie movement of the tiowcU being prevented 
by a. restricted diet, and- the adniinistratioa of opiates (and 
when that couditioD has been attained tbc rectum should be 
iniinediatcly M-ashod oat with clyfvteni of wutcr). For the 
purpose of diecktog the secretion of pne, a oae-pcr-ccnt eola- 
tion of tannic acid or of alum ahould he injected into the gut 
Id the intervals bctireea tlie lujectionft pledgets of lint dipped 
in the come solutiou ehoold be inserted into the anal aperture. 
Excrtriations or fiasurug should be toadied with the nitrate of 
Bilvor stick. 

QonorrhcBa of the Mouth and Ulasal Caritiet. 

■We have never, either in hospital or pri\-ate practice, met 
with a caae of gonorrhcea of either of these cavities, though it 
lit BMerlod in some of the older works that tlio disease occurs 
in both ecJtes, the mucoua miTinbrane of the Qtwe and mouth 
being affected in the came manner as the conjunctiva. 

ChmozihiBa of the Eye. (Ophthalmia Chnuffdioioa Blennor* 

rholca.) 

B^r Doteui Dr. H<Kk. o(TI«n. 

The term ophthalmia blcnnorrhoica is applied to a disease 
of the conjunctiva of the eye, in which there oocura a profoso 
discharge of muco-punilent matter, attended by increased 
htchiymation, int«!uae awelling, and rodaeBS of the mucous 



aOSOBRff(SA^ rEKBBEAl. CATARPB. 



SI 



mcuibranc, proliieriitioD of the papillary bodies, and aometimcit 
ootnal ecchyiDOfiis ; in addition a eorioiu inflammatory ewclling 
of the eyelids auil Iho adjacent iut^tmoiitd may occur, aiid, 
in aom* eaaea, affection of tlie eyeliali tUelf, rcttiilUog in kera- 
titis and panophthalmitis. 

The diseafic begina with Byiiiplomfl of a severe eatarrli, 

cU within a fciw days reachM ita Iteiglit. At this point it 
^iiwenta the following morWd pictnre: The eyelids, edperlally 
tlie Dpper one, are evrollen to the eixe of a child's fist, and the 
intcgamcnt of the U<U and lUat surrounding them ia reddened^ 
tense, hot, and n^dirniiituuii. Thu upjior lid uvcrlnp tlic luwur, 
its cilia are agglutinated to one another and to the skin of the 
kmer lid by tliick, ycllowiith matter, some of which has dried 
and formed cmsls. If after thu roniovol of the cruE'tH an at- 
tempt IE made to raise the upper lid with the fingers, a qoAti- 
tity of yoliowiiib matter gnshoa out, the lid becomes everted, 
and the intensely ewollcn conjunctival mucous mombntne 
bnlges out. In the tar^l porli; tlie conjunctival oennoctiTo tls- 
sno is seen to t)e of a doep-nxl color and intciuieiy ewollcn, the 
papiltffi congested to such a degree as to give it a velvety or 
warty apjicarance ; KOmetimea the latter niuy be sctm with the 
naked eye as uiinnte excrcMKnces, between and npoa which 
a grayiab-ycllow matter has accumulated, which oocafiionally 
■oUdificB and anjiiircH the character of a false membrane. If 
the Uda are eeparated by the aid of an eye-epeculum, the ocular 
conjunctiva, the curuucte, and the aemi-limar fold ore Men to 
be rod, thickened, and uneven, the former ewollcn and forming 
arooud tlie cornea an a;dcmHloU9, transparent Sotid or livid 
wall Uko a pium)>et, under which the cornea ia buried, its cen* 
tral port only bviug visible. Generally the ])aticnt also Boffers 
from febrile moremeut. 

Of the causes of gonorrh'eal ophthalmia it ie only neoeaeuy 
to mention hero the direct transportation of gonorriiccal matter 
to the ooujunetiva by the fingers of the patient and of the in- 
fection of the sound eye witli tho discharge from the dtKcnsed 
eye. Some aathors, Xeisecr among otlieis, also claim to have 
found microoood in the diacluu^ of eyes affeetod with blen- 
ikoiThma. 

Ophthalmia blennoTrhoica runs an acute conrae; it goner- 



92 PATBOIOOT ASr> TRBATMBKT OF 8TPBIJ.I3. 

oltj readies ita end in tliree or fonr weeks. Altlioiigli in some 
cues tlio diticaM; rum a most violent couise, attaining its high* 
eet intengity in tliirtj-eix or fortj-ciglit houra, resulting in 
ulceration and perforation of the cornea, yet in otlicn* the eymp- 
toiiifl art! verj- mild and sluirer in tbeir progrefiB, and tba difiWiin 
yicldd much mure readily to appropriate treetment. Hence a 
completo reHUfitio ad inU^um is olwervud only in the milder 
clafis of caeee. It La true tJint even in the severer c\w& a care 
will be aeliioved, bat always witli more or Usa innrked cioatri- 
zation of tlie cornea, anterior i^ecliia, partial oonteal Btapliy- 
loiua, and cataract Often, however, it results Id complete 
plitLisU conuiffi, paQopbthalinitln with coiuuijuent atrophy of 
the eye-hull). Sometimes proliferation of the papiUie remains 
after a blennorrhtea, a condition which, in 8ome cases, U ob- 
aerred even during the progn«8 of the diitcafic, ^hoagh in otLciB 
not imtil it has run its ouone. (Chronic hlunnorrhceo, trachoma, 
conjunctivitis gnuiuloea.) 

Treatment of OooorrhcDal Ophtli&Imift. 

(1) Immediately after the conjunctiva has been iofocted 
with gonorrhoeal matter it gliould be washed thoroughly with 
Bomo antiseptic preparation, euch aa a fivo-per-oont solution of 
natr. benzoic, or a two-ptrr-cent solution of horacic acid, or, for 
want of either, with pure water, or with a two-per-ocnt eolation 
of argent nitric, for the purpose of cheeking the action of the 
infecting matter. 

(2) At the beginning of the diseaea the patient slioaM bo 
put on a strictly antiphlogistic diet, and the eye should be re- 
peatedly wiished M'lth the antiseptic solutions jost mentioned. 
In contractions of Uic pupil, atropine (0*10 [gr. \V\ to water, 
30-00 [ 5 f]) in Bolntion ehonld be dropped into the eye. 

(3) If the hlennorrhoic process isrery intense, the first care 
of tlic ph^'i-siciaii sliould ho to protect tlio sound eye from in- 
fection witli the gonorrboeal matter by bandaging it carefully 
and keeping the patient in n proper position (in this caaa be 
will be compelled to stay in bed). 

(4) ZoaJoua cleansing of the eye with oold wator or antisep- 
tic lotions, application of ice, local abstraction of blood during 
exacetbationa, laxatives, and cooling drinks and low diet ahould 



OONOBRUQSA, VK^iE&EAL CATARRH. 



93 



be strictiv enforced. Should Uie clieinotUii of llie coiijunctira 
and tlio BwelUng of tho oyelids be vprj- grest, tLe Gxternal eau- 
thoa niuiit bo divided; Uie lower lid, n-liiclt is iiuw released, 
majr then Iw everted h^' meaiie of Gaillanrit niare, and the 
liaamorrbage tliat followit niay W allowed to go on for a little 
while. 

The nioKt important port of tlic tiuitment of the eye, how* 
ever, is the tuis of catutics. It ootuaKte of the introduction of 
a Bolutioii of nitrate of silver (two to four per cent) ur of tho 
aolid stick, compoaod of nitrata of silver and iiitrate of potash 
(equal parts, or ono of the fomior to two of the latttr) fused 
together. Tho enti}^ poipfbrai conjunctiva should bo peu- 
eiiod with ono of thoM agents onco every twcoty-four hours, 
the e3cces4 of the eaogtic, neutralized with a eolntton of salt 
and the ehluride uf silver, wluuh tlius foniis, washed awuj with 
water. 

In cases of iDtonec turgescence of tho patpehml eonjunetira 
and iu chenUMsie of the oculai' coujimcttva great betictit will he 
derived from scarificatioDa of the membrane, the tensioa of 
the swollen ttMtucs and the Rtatu uf lite circulation being tliero- 
b^ rchcred. Should the cornea become opaque, or nicent fomi 
OQ it, atnjpiii iu aoliitioa tnuet be dropped into tho e,ve ^rcral 
titnea a daj, liut not simultaucouidy with tlie caustic. In iui- 
pending j>crforatioQ of the cornea, or when the perforatioit 
haa ulu-ady tJiken place with iU coDsequent cSect^ iu prolapsna 
of the iris, etc., the treatment indicated for these coaditiona 
muat he resorted to. 

The Effects or SM^acls of Gonerrluw Is general aad of Urethral 
OononluBa in particular. 

By the tenn efleetu or gequclie of gonorrhoea we uudor- 
etand morbid leaiona whicli generally remain a long while 
after tljediwaae that lias produced tJiemhaii diiup^K^ared. Tlie«e 
moriiid iwiouM are such aa are exclusively prtMhicwl by gonor- 
rhtE* in tho orethra itself and beyond ita sphere. To these 
belong gonorrhii*aI g"iut or rheuiontism, and etriciure of the 
un-'tbra and itit etfectii. Again, tliey constitute those morbid 
prooeseee which originate partly from any kind of gonorrhoea, 
but especially in ooneequcnce of the irritation of Hvo gooor- 



M PATBOlOer AND TREATMEST OF STPmUS. 

rtifBal fUscIiar^ upon tlio adjacent intcgamoDt and mnootis 
metnbrent!. These molade oondy lomaU. 

a«noiTlu»al Bbeuutim. 

Gonorrlicpal rbeumatism or gout iu one of tbo rarcei 
complicatioHFi of gotiurrlia^a in Wtli sexes. WriU-n; on the 
subject arc not yet agreed. In regard to its nature and con* 
DC«tiou witli tlic gonorrhaal dieea^e, mme maintain thai it 
is purely an accidental atnijflicatiot*. Otlicnt, again, say tliat 
every pby&iolc^cal and p&tbologtcal procees in the genital 
organs of both wxce may light up rhenmntiam, nod therefore 
call it "genital rheHtnatism," "NVenj t!ii« the paw, rlicnmatic 
affections would \» inach more frequent iu the female ; but, 
on the contrary, gonorrh(t>al rlieiunattHni only oocutb in the 
Iatt*r, when attacked by gonorrhoa of the orethra— one of 
the rurest gonorrhffial affections in women. The so-called old- 
Btyle unictRts clainiod tliat gfniorrlHPal riieuiiiatism h a riiea- 
matic diathetic disease, that lias originatM in consequence of 
the abeorption of the gonorrhccal virus, which they compare to 
tltc rhcnmiitie pains occurring in oypIiiliH. Other writ(>n) arc of 
the opinion that the gonorrhceal procesB gives rise to a chloro- 
ansBtnic oonftitiott of the entire system that leads to leaofu at 
nutrition, pmdnccs peculiar socondaiy diueoBos of tbo scrooa 
membranes, the ecrotum, joints, synovial eacs, etc. It ahoald 
Dot b« forgotten that rltcomatic dieeascs not only occur in 
catarrhal aScctione of the arcthra occasioned by non-vimlcnt 
agents, but &leo in thot« produced by mechanical csoeea. 
llenoa gonorrhceal rbeutiiatism would not be bo exceedingly 
rare if there were such a condition as a blennorriioic diatbe* 
sis; and, in addition, preputial, ^-alvar, and vaginal gonorrhcea 
should likeu'iiie be cipable of c:iuf>ing rlit^iunatoid disease. 
This, Iiowcrer, is not tlie case. In atxty-two cases of gonor- 
rhost, Foumier obserred only one case of rheumatism, and even 
this is too high a num1>er, when it in remembered that many 
caeoa of gonorrhoea get well without tbo aid of a physician. 
"We agree, therefore, witli Foumier, that rhetimatism originat- 
ing from un-'tlinil gonorriuea is occimioned lci« by the blen- 
norrhagia than by the individiud pathological condition of the 
urethra, an im'tciion of it, like the occasional prodaction of 



QONO&HUaSA, V£N£BEAL OATASSB. 



m 



afticalar iuflamniaiioQa Vy ihii iotrotluction of a catheter or 
soand into the nretlira. Ilence, only oertnin personn are at- 
tKlced b}' goiioirlKjeal rlienniaCimi, and are ailticted by it as 
often u they contract a goiioirlKva. 

We have only met with muscular and articular rliuuinii- 
tiatn ; never wit^ rfaeiunatic intiajntnations of the Bynoria) 
meiubnincs or of the p«rioeteiiin, nor with rheumatic aSeo- 
tions of the sciatic ncn-ce. The knee-joint watt moet fro- 
<Iiteait)y affected; still, any other joint iu the liody ie likely to 
eoffer. One joint cnly, m a rvU, is attceked at a time. 

Id eomo caeca the rlieunrntic affeotioD is noticeable at the 
Tery bepnning of tbo urethral gonorrhcNU In many eosce, 
however, the rhuuniatism does not a]>pcar until the nretbral 
diaeue hw beootnc torptil. Gonurrhciuil rhfutnattitni originates 
■Dddenly. The joint was perfectly well a few lioiire before the 
attack came on. If the arthritic riieumati«iu appeared almoitt 
inmaIunef>UKly with a ]mrulent gonorrhcBO, the infhimmation 
of the joint nnll develop very rapidly and cause marked ewell- 
Ing of the Hoft parts which eiuronnil the jobt. Thotc kinda 
of joinmfTcctions keep pace with the gonorrhcea, and, like it, 
diaappev nndcr judicious trcatuicnt in about ttix or eight 
vccks. But if the joint-diitcaM appears after the gonorrhosa 
has existed several weekflt the former will then develop lea 
rapidly, and, like the urethral disease, aasumo a clironic, pro- 
tracted character that oUtinatdy rc^ieU tlie mo»t appropriate 
trMttoent. 

Chronic, like acute gonorrhfBal articular rhcumatisoL, ia 
nnhcrod in by febrile phenomena ; in the ncnte joint-afFoction 
they arc, however, much more violeot. In the acute disoase, 
the fever as a rule sahsldee in about six or eight days. If the 
articular diaeaae does not asfoine a favorable courBe, the fever 
will remain, though at a lower degree. In chronic gonorriicml 
rheumatJHn, the fever, It is true, la»ta longw, hut it iji less 
severe. Il, bon'evcr, rise* just w in the acute articnlar rhen- 
nutism, whenever an exaoerbation of the articular affection 
tiku place. 

No exudation into the cap^ulu of the joint can bo detect- 
ed ifi all cOAB ; bnt in some an actual liydrarthroeis of con- 
ridenble dinHnuions with characteristic fluctuatioQ dovelopa. 



LJ 



■ : j'-'int. a< a 

;.■ ca-c-. ! "W- 

. The aSi-r.-.l 

'1.1.' llJlSt lIll'Vi.'- 

. .. .:.-l ill till' cavity 

■!-s III' alw>rlii'(|. 

- L-i;. Iimvevfr — fi ir 

-■■■■. iif tlio (.■xnda- 

.■■:--.!ar dropsy, liy- 

." MoiitHHTlia^ifus. 

■;■■■, -.M-'ls. Snnif very 

:?;i:n;iti(iii nf fritimr- 

:i riio joints. A tiit;il 

-1.-. lA-curs uftoiRT than 

I-.'- iiieiitiuued. (Joiior- 

frrer — i. t'., it dous iint 

!'.v Hi'vcr si'trii it at- 

V::i' artit'idiir dist'a.-c 

..;! discliar'i't.', uvitliLT 

:::uv iiMtipL'd tliat 

-.: .^'-.ii' Miilv wIk'ii tlu' 

-".11. ill <£.'iii'nil. i.-; 

^ :'-.:lly tlnir iinniial 

■-.lally ill tlic iuu'L'- 

■■ cri-riiiati's ill tin- 

■ -.y vaiisf di-atli liv 

.^t till' sairn.' k'lijjrh 

, :'.iifr-jiiiiit dins imt 

■iv!ili-ji'iiits ; diM-a-i' 

■«. -v.ot'i- ijiiiclily than 

■■-case ni the jiijiits 

• ' ':!S and in Madly 

.■.;r. 

-, -t and !iniiphh>- 

- :A Iccchi'.-; ti) The 

■■ Tpliia will lie re- 

,-. tiic felirile I'ln!- 



60K0RBB<BA, VBNFSffAL CATARRH. JT 

ranneiu are reiy Iiigli, tlie patient fabould be aabjccted to » 
strict diet, cool or aciduloiuf drinkis onljr allowul, auil a dailjr 
moTemeot of the bowels secured. If bydrarihroeifl bae formed, 
cold or worm applications skoald be made, witb or withoat 
aamMHiia, 60-00 [5 JM'. 3iv] to water 100000 [Oij], acoording 
to the ooiigeeti76 condition of tho orticnlAT swelling. When 
DO influmuAtoiy rednees is present, iodine, or some of its cora- 
ponnds, liJce tlie following, may be need iomUjr : 

3 loduroti pliimbl; 

Eit. tK-ILwlonna, U KOO [3iTl;. 
Cnff-litharg., 10000 [Siij, 3ij, 3ij]; 
Ujik< el«ini il- >• at tint tmplostr. taoll«> 
B. To bft spnud upon a pi««« of cUamoJs-leatJior or muslin, of the 
Ihlntimn of thv blodfl of a kuUV, and laid ujioii thu uffuutv^ jviut. 

In bjdruthrosiB of the knee wo bave occaAioaaUy aoen good 
iwoltB ^m tbe use of a oompreas^bnndage, made of pUeter of 
Paris, fttarcb, or water-glass. In other cases a plaster oompoeed 
of giim-aninioitinc mid acctum tsoilla: U l)cnotimU In ctusea of 
chronic hydrarthrosis, good results are 6ometime« derived from 
the (iulpbnr tlicriual hutli& Tbe treatment of snppnratioa of 
the joiiite, of fiatola), necrosis, etc., bt-long* to the doaiain of 
flurgery. The existing gouorrb<ea mmt be treated witb appro* 
priato l»eal and iutenuU reiniHlit'H. Coiifttitutionol diseoMM, of 
whatever nataro, sach aa serofiila, tuberculoaia, Bypliilie, eto., 
demand careful and special attention. 

Gondylomata ; Vegetations ; Spitze or Moist Warta 

One of the most frequent morbid clianges that are met with 
in oonscqueiicti of goimrrbota, in both eexes, ie the formation 
of warts, or caulillower-like growths, on the genital organs and 
their vicinity — on placee where pus, Bcburn, or gonorrlio^ 
diacUargc is allowed to remain for some time, and, owing 
lo its dceompoeing effectn. tlie tntegnment or mTicooa mem- 
brane becomes ao irritated and macerated that tlie epithelial 
layer is deetrojed. On tlieee places hyalino gnnulei, of the 
size of a ptn^s bead, form, which gradnalty aeeiinie the shape 
of a cone or oocV's comb, roeembling more or leea a dendritio 
Tcgetating growth. After these vegetations have attained a 
oertalu size tbey grow very rapidly. The less the ports on 
7 



PATBOLOOY ASD TRBATMBifT OF aTPIUlIS. 



wliicli thceo caaliflovrcr excrescences grow &re clcansod, the 
more quicklj- and aboDdauUv Uigbo v^tatiog excnscuQoes 
will K|)rout, Ute more proftue and Huccaleot tliej viU be, and 
tlie mare readil)- will tbejr bleed. Tbe cleaner and drier the 
parts oD which these warte are situated arc kept, the more 
(juicJdy will tlio^u that alruidy exitit sUriuIc, and tho less Iikelj 
are now ones to sprout. If one of those excreeoOQOOs is oat off 
at its base, two bleeding points may be noticed on the cat sor- 
faee, one of which oorreepcndB to the entoriug, the other to thu 
omorf^ing capillar7 vceseL 

UiBtogcneticallj regarded, two directly oppodto views pre- 
vail in roferunoc to tliie ]»!Joi|. AVliile Rome writers look opon 
the growth as a hypertrophic prolifewtiou of tho t«gnmcDtai7 
papilla, others hold that tJie origin of coiulyUiiiia iB mainly doe 
to an exuberant growtli of the cells of the rete Halpighii, at 
the expense of the t«gumentary papilW, whose cells spread 
their prolongations not only upward but aI«o downward, like 
& cook's comb, forcing their way in between the papilhu. Tbe 
epidermal cells have a very sligbt tendency to ander|;o a cor- 
neous change, and even tho uppcnnost layers retain the auccn- 
leut condition of the Malpighian cells. The whole ta covered 
by a very thin oomeoua layer. Ko nervoos filamenta have yet 
been detected in the exuberant growth epoken of. 

Warts or condylomata are meet frequently met with upon 
the gUns penis, especially in the fossa coronaria, on the corona, 
00 the foreskin, cepccially its internal ormncous membrane; 
on the fnenntum, on the large and Biuall labia, in the urethn 
and vagina, on the oe uteri, at tlie lower part uf ^Ub netnm, 
OQ the navel, on tbe skin of the genital organs generally^ and 
in tho neighborhood of these organs. If the condylomata are 
ditaated ujxin tbe iutegament or mucoua membrane of the eo- 
rona glandis or prepuce, in a person with pbimoats, tliey will 
be reddened and eoftenod like raw ileiih, owing to ttie fomvn- 
taticm Uiey arc conetautly subjected to. If they are dtoated 
upon exposed places they will be dry, oomeotu, ycUowiah or 
whitiiih in color. The vegetations that are situated npon the 
mnoouB mcuibnulo uf tbe vagina arc eo briUJu that they lire 
often broken off by the introduction of tlie epeculam. 

Condylomata a^ume u ditfcrent shape according to their 



QONORRHCEA, VENEREAL CATARRH. 99 

Iooiti<m. If the warty pfpowth is compressed between two 
oppodng sarfaees, the Bo^alled eoek**ooml>-liko vegetation will 
originate. 1/ tbe condyloma is anbjcctod to pre«eure from 
ftbove, the excresoraoe will gradually be flattened nnd iiK«nino 
the form of a mn«hroom. Ou places where tliu growtti inay 
fradjF develop, linear pednnciilated, rtrawberry-, mulbt-rry-, or 
canliilowcr-liko cxcTeecenoes will originate. If many hucH 
growths are in clone jnxtaposition, they will mntually comprni 
one anotlter, and acquirtt smooth snrfaees, whicli are eeparated 
by naiTow finsnrcd, and form cln^ten mmilar to the blossoma 
of thyme ; hence the old writere called them acrothymion, or 
thymoa. Tbeee warty etlloreeoeDcee caoec a good deal of me- 
ehaaical otstraction, and, moreover, owinj; to the alteration 
which they ondei^ in their otirse, exorcise an aofavorablo 
infloence opon the general Ry^tein. ThiiH, they may occlude 
the prcpatial opening and the mcattu nrinarius, preventiDg the 
remoml of the smegma from beooatb the forwildu, (he Jiuw of 
the nrine, and the ejaeulatiou uf the (semeiL lu a idmilar man- 
ner the female vretltral meatus and the vulvar aperture may 
become occluded by pointed condylomata, and mietnrition and 
coitus ma.j likewi«e bo rcudcred ditticult )iy the growth of 
huge condylomata aroimd the anas, in both sexes, defecaUoo 
may become very dilhcult and painful. Thoeo condylomatu 
that are sitnntod upon plucce where they are subjected to oon- 
tinaal friction or preesure readilj become gangrenous. Urdi- 
nary condylomata may he mistaken for epitliolial c&rcinoma, 
for the caullHower tumor of CUrk on the oe nteii, and for tbo 
Sat Fpccific condylonuita. The manner of development, the 
ooorec, the attendant phenomena, the result of tlie treatment 
that has been rceortol to, will aid tlie physician io forming n 
oorroct diagnoeia. It i» very easy to mistake vegotatioue for 
the flat syphilitic oondylomatji, for both kind^ may be met with 
at the flame time. 

Eicperienoe aa well as experiment has proved that condy* 
lomata arc transroiMlble by direct contact 

Ooodylomata posecBtt rcmiirkohle powcnt of rcprmluction : 
oos iboot mny be cot off, and Uvo otliers will grow in itn ptaoo. 
The small warts, not bigger than a millet^eed, and sprouting 
close to each other, are the moat difficult to got rid of. 



100 PATSOLOQT AND TRBATMSST OB 3TPEILI8. 

Pedunculated u'arU may be removed witti Cuo])er*!i mn£8ors> 
or tied and allowed to fall off. When the watts are cutoff, 
enough mother-tifisne sLould be taken away with tliem. The 
wounds ebould be moistened wilii a eolutiou of feTTum cblo- 
ridam, to cbccli the bleeding and prevent tlw future growth 
of tbe coadylomata. The local application of a solution of 
cblofide of iron h cepoouilly useful in large aggregated ooody- 
lomata ; tbo astringent aetion of tbe iron contracts tbem, and 
prcTcnt« bloedtng if they are enbeequently cut off. Tincture 
of iodiiie itcts in a eimtlar manner, but far leas effectively. 
The concentrated acidg very 8etdom answered oorexpoctationfl. 
Solutions of oorroHtvo sublluiate in epirittt of witi^ or in sul- 
pburic ether, 0-5 [grs. viij] to 5000 [ 5 j^ 3'^i rendered 
much better sonrico. Plenlc's paste acts more intensely than 
tbe solution of mercury ; it may be prepared iu the follow* 
ing manner: 

B Sublim. corro«.; 
Alum cmdi; 
Oartwo. plomtri ; 
Oampharffi ; 
Spirit, riui; 

AcL-ti viui, M 6-00 OirJ, 
U. S. For external aw. 

Tbe precipitate is applied to the warta with o eamelVhair 
brash. Flenk's pi&ete, bowever, is apt to produce unplcoeant 
effects, such us inteuee <odcuia and mercurial gtoiuatitiK. 

Tbe hard, dotted warts are raidily removed by the use of 
arsenioas acid or iodide of areenio mixed with mtircurial oint- 
ment. For this purpose we prescribe : 

^ Aotili anenico^ 0-30 [pra ^}] ; 
Uii||.hjdrBrg^B'00[3iT]; 
U. PL oug. 

B Arsenic. lodal., OSfl rRnL ig]; 
Cuff. hjiiw^ , 8-00 1 3 i»J ; 
U. Ft. omg. 

A lump of salve, of (he size of a lentil, is applied to the 
varta aereral times a day upon some wadding, jioistr cccroi' 
ing oondylomata are sometimea made to sbtink by dusting thein 



OOyORRSfBA, VBUEREAL OATARRB. lOl 

wifh paherised alam, calomvl, oxidfi of iron, enlphate of iroo, 
tnd nvin-powder. If the prepnco is phimofiod, it mast bo 
split or impQtated, in order to expoee ttie ctnulyloma. Laifp 
Iggragttioos of wurts on the labia are mnet appropriately -treated 
hj ligation or i>vith the galraDi^cauti^ry, or the therni(M»nterf 
of Pac]ueliD. lu tyinf^ oondjlomala, not oioro than one root 
flhould be embraced in eacli ligatttrv, Iwcause the tjiug of xaany 
large aggn^ted clusters of excmceDcet Iuik, in (tome inKtanccs, 
produced tetanux aud terminated to death. Dut, whatever 
method be Hokcted for the rcmoval of otHidvlomata, cleanlinesa 
sod keeping tlio parts drv elmnld sltrayu Ik; unforced. Gold 
applicatiooe done, constantly and properly made, faavecaiiMd 
the regctation to fall off in caiace that have resiflted repeated 
caotoriiatioRs and exciiiione. 

StriotoTM of th* Urethra. 

Ono of the most froqnont Bcqnolfo of orcthral fronorrhopa 
in the male is Etrictnre of the tirethra. Tlie contraction may 
take place at tiny part of the uppthia, nave in the ppostatic port 
tiou. An olwtnietion to the [laeeage of a catheter or iound 
only fornu in the proetatic portion of tlie nrethni when tlw 
prmtateT from intlanmiBtionf liypertropbj, or swelling, has be* 
come BO large that It comppe«»ee the lunien of the nrethra from 
without inward. W« may clmwify Btrictnres in the other parts 
of the orcthra, according to IMttel, a« fipaetic, inflnmmatonr, 
and oif^ic varietiee. Rj the term ajxutie Btnctnres we iin- 
dentaad tzaaeient ooostrictions of the lumen of the nrethra, 
oeeafHwed by qiaauodic contractinne of tliu moscular appanitva 
of that canaL Odq can eoaily convince himself of the exifttcnoc 
of each a stricture by attempting to introduce a larpe eound. 
It will be grasped and held tight »t oonie point, bnt by patiently 
watting, mfminiog from exercising the least presmre with the 
tnstrnmcnt, and altowin;; it to lie quietly for a while in the 
nretlira, it will soon, ahnoist of its own accord, slip into the 
bladder. Some verr gooil Riirgpone deny the existence of this 
form of strictnrc of the un^tlinu 5Iany prominent nuthoia, 
however, ench as tleroarch, Dnnireiclier, Albert, Ilniiter, and 
othere, maintain with justice that this form of vrcthral coin- 
tnotioiu docs occur. Tbo spasm mostly affects the muecnlar 



109 PATHOLoar and tseatmbst or stpbius. 

tissue sum)uu(lliig tlie nienibnuioiis {wrtiun of tlie iiretlira, the 
traiMvcnio porinei profandus iQiit«1e; in other iogtancaB dm 
Hpaeui attacks die urethra at varioos points and oocuIonaUy 
may becume so intent that it is not po^sihle to witbdmw the 
MXincI, whieli !» already partially in the urctliro, giving one the 
impression tliat it is tinnly held there. 

Transient Btricturee duo to epasmodic coDtrocUons of the 
urethra maiiifwt thcinKclvcs hv llic patient hcinfc attacked by 
ft Buddon dcaro to imnat<:, after lui%-iug cni]>ti«l the bladdur a 
little while before witlioot any difficulty. Tbe nrine, after 
much precsure, piiin, and a burning sensation, comes avav in 
drops, or is expelled epaeniodically (dy^uria), or it can not be 
voided at all (ischuria). These strictures may oecur even in 
pcrsuiLS u'ho never audered from gonorriioea, after having Itad 
their feet wet, or after indulging too much iu iin|K!rfectly 
fermented or still fermenting drinka, new beer, etc. These 
Bytnptotus, howerer, almost always accompany organic strict- 
xae& of the urethra. In regard to the ttv-atmeut of this condi- 
tion much benulit trill Ik: derived from iH-lladumia «upposito- 
rics, moist warm applications and warm eilK-ballis twice daily. 
In addition, the patient uiuet abttuiu absolutely from the use of 
all kinda of driak that are liable to irritate the bladd(v, each u 
champagne, cider, new bcor, and frc«h wine. In regard to the 
tnfiaTnmatory Btrictures we will say bricHy tliat they are pro- 
doeod by thickening and swelling of the muoiiuH membranoL 
These utrieturee develojt in cousoquence of gonorrhcea, or after 
opGTRtions on tlie rectum or on tlie extenuJ genital organs in 
the female. 

Tlie arganir. stricturea of tlie urethra may very properly be 
divided, ait propo«ed by T>itt«l, into two chief groups. One 
main group ia oorasioned by proliferation of the connective 
tiesne, the otiier by the development of a etructuro heterolo- 
gous to the tiaeuea of the urethra. AVe will only speak here 
of the firet form, that form which occnra so frequently aa a 
TCBult of gonorrhoua. Dittol briefly calls tbi« kind of urethral 
stiictnre, when it is in a state of oxuberation, calloos stricturo; 
when in a state of shrinking, atrophic stricture. Tbe eymp- 
totns of organic stricture of the urethra arc as follows : The 
stream oi nrine becomca thinner and changes its direction. 



QONORSn(EA, YBJiEBBAL CATARRH. 



103 



Simple division of the stream of urine is of no patbo^nomonir 
TiJao, and in incwt insUnceH is o('ca«ioued by tlie agglutination 
of tb« meatus with nincuA. Ilie bladder is never entirelj^ 
emptied of its conteots, and in consequence tliereof tbo patient 
is coinptrlled to urinate oftcncr. Tliat part of ttte urutbrB be- 
hind tlie gtrioture is often dilated like a divcrticHluin, and, if 
tbc etrictore lasts for a long while, rupture of the nrethra may 
oc«Dr, terminating in inliltration of urine and tbtulom opea> 
ings behind the stricture lu long-etuiidiug stricture of tho 
iiKthra, catarrh of tbo bladder will develop, and may be fol- 
lowed by pyelitis, Dephritifi, and death. 

In K^iud to the fonn of the stricture, it ia Rufficicnt to ny 
that it Tarie6 very much. It may bo a gharply defined pro- 
jection, or only a ridge gtrctehed directly across the lumen of 
the tirethra ; ur, again, a reuititiii);, hypertropliic circular liand. 
SoaetimcB caruncle-like granulations form ; and, finally, the 
contractions, in some cases, are produced by angular deviation 
of the urethra from its normnl courae, in coosequence of cir- 
cumecribod lateral atrophy of the connective tissue surrouuding 
the urethra. 

Strictnres in the niembraQOUs portion often occur from the 
cicatrisation of gonorrhoea! ulcere that have burrowed and nn- 
dcrminod tho mucons membrane. In like manner. adheflJTO 
inflammatiouB may give rLjo to strictarea in tlie urethra. 

Strictures are most frequently found in tbo membraootu 
portion or in tho antoHor part of tho pondulona portioa Oo- 
caaionally two and even throe fitrietureu are fount! liehiud each 
other. 

For the purpose of diagnosing a etricture, the physician, in 
the first place, should get a view of tlie stream of urine, the 
patleot being required to urinate in hio presence. A perfectly 
clear stream of urine, which does not det>oat any sediment, 
excludes a Bevere stricture. The patient ehoald not be allowed 
to urinate directly before it ia projxised to examine him with 
iDstrumcnt«. The oxamioatioD is bcgt conducted with the 
patient lying on his back, while the physician stands at hia 
left side. Having wanned and oiled the sound (which should 
be as Urge as will enter tho meatus), and retracted the fore- 
^in, the phyueian, holding tho penis between the thiimb, in* 



104 PATHOL007 AHD TBEATMSHT OF STPBJlia. 

dcx, and middle fingers of luH left luind, uid the InatnmiMittie- 
tweeo tlie tbnmb and index-tiiigerof his right hand, inserts tb« 
imrtniment into the meatos^ the little finger of his right hand 
rrating a|)OU tho lx>dv of the {laticDt for eiip|K>rt, thus oiford- 
ing the hand rvst and nxority. Tn this waj lie f^ides the 
instranient as it paeeee into the bladder. The penis is drami 
up oa the eonnd more than the in^trmueiit ie poshed into tho 
urethra. If an ob^traetion is encoantcrcd, the next 8^uLUe^ 
sized sound tihould be tried ; and if a number eight fiound doc* 
not piiss, it will be better to resort to Eoglish gnm-elastio OT 
conical bougies. No metallic inetromonts atoallor than nmnber 
eight fibould be used, on account of Uie iinjierfoct fioneation 
which tlic^ tranHmit to the fingen, and the risk of making a 
falee po£flage with them. Conical chi^tic inftnimcnts without 
bulbe are not worthy of recoiiimondutioQ, beeauBo they easily 
become imprisoucd in some of the dilated follicles and caott 
irritation. If no sound can be paoie*! throngh the etrictaro, an 
attempt should be made to paas an English ehiBtic catheter ; and 
if (his too fails, it will be necessary to rvmri to the luc of fili- 
form bougiw. In thin case it will be well to try the proccdurB 
recommended by II. von Zeisel, which coneistfi in tilling the 
□rothta with filiform bougies well oiled^ and poshed clear down 
to the strietoro, and then a trial ehoiiM bo made carefully with 
one after auotlier to poas it through the etrictiuie. One of 
them will then mirely go tlirougli. Hanog succeeded in pafia- 
ing the inetruraent at last through tho entire length of the 
uietlmi, it will tlieu le ueceseary to map out tho proper conrae 
of treatment to be pursued. There are three methods of treat- 
ment, namely, slow or gradual dilatation, rapid dilatation, and 
diviniou of the stricture. 

We only practice gr»lnal ditutntion and divitdou of the 
atrictnre from without inward. We will firat speak of the 
gradual dilaUUion. If the stricture is so email as to permit 
only a tilifonn bougie to be paeeed, a catgnt hotigie ebould be 
inserted, and allowed to remain in tlio nivthra until it has be- 
come distended to ita utmost cftpaeity. lU during tJiis time 
(half an hour to on hour), no anplceeant cr^ptoms hare been 
produoed,an effort shoidd be made to pass a fine Engltsb gnm- 
elastio bougie. If we have finally Enccoodod in passing tliia 



0ON0£Sa<EA, rSNffRSAl CATASHB. 



instramcDt, no further trial? stiould 1)e matlo at the tune ; but 
tlie next day another effort may Iw made* oommeooiog with 
the «izo loft off on the previoue day, and tftenrard ming 
larger bovgiM gndaaHy. Having finally Buoceoded in pweing 
through a tbin guin-ela£tic catheter, it Bhoiild lie luft In the 
bladder, oiul tied in fur tweaty^foiir honrs, if no uiipleaxant 
offocta are prodacod. In this way dilatation h acoornplished 
inn«h more nipidly ; on the next day a laiger ini-trnment may 
be iDtrodnced, and so on, till the uretUn aduute the largMU 
BUGod Boond. If a catheter ia retained in the urethra, tlie urine 
abonld be drawn off every three honrs, or as bood a^ iwlinria 
oomes on. Should sjmptoiiu vi uurvous irritation, urethral 
fever, or other onpleasant signs manifest tbetnaelvcB, it will be 
DMMttary to remove the instmnients immediately. In regard 
to the BXTtiptoma of irritation produced by the iutrodaction of 
an instnuncnt into the bladder, we have the following obeerva. 
tion to make : Some persons do not tolerate the paadng of an 
uutrameot into the urethra even if they have no Btrictnnj 
whatever. A littlo while after tlio inHtromeait is inserted they 
are seized with a ohill, followed by high fever, violent bead* 
ache, or at least a aonaation of discomfort in the lieiul. Theae 
plwDomoDA generally soon disappear entirely ; in aome cases, 
however, thuy often reappear, eometiinen hiMiog aereral wedn, 
till tlie patient eitliur lH?comes habituated to the panage nf the 
Bound, or luut been ctircd of his etrictore. This violent irrita- 
tion, which Dittel calU dcttoub reaction, may be allayed by 
amall doeea of nwrphiue, a<tininistorcd from half an hour to 
two boors lieforc nfing the inetninient. Shonlil thie fail, and 
the nervous phenomena come on with equal severity after each 
attempt at dilatation, the gradual dilatation of the stricture will 
have to be abandoned and estemal un-throtomy performed. 
If the nrethra has been injnred dnring the introdnetion of an 
inittmmenf, a similar state of resetion, which Dittel oallfl norgi- 
eal fever, ia Uable to ensue. Tlio laner in reality differi* only 
from the nervous teactkm by the fact that the parienta did not 
suffer from any phi?nomena of irritation during the pre>'{oua 
dilatationfl. The phenomena of irritation are, however, moat 
violent when the kidneys and bladder are seriously diseased at 
the same timo. Thia affords ns a guide in treatment. If the 



106 PATB0L0Q7 AXD TREATUBUT OP STPBIUS. 

introduction of an iiistnitnuit into the urctlun h tolcratvcl, it 
ma^ be allowed to Tcioaio in it a long time. If reaction takes 
pluco, or tlie patient is already advanced in life, we will Lave 
to bo content with kc«ijing the instrument in the urethra for 
a short tinic ontj, from tivo minotce to half an hour, and to 
introduce it only every other day, Jt ie absolutely iieoe»- 
«aij, before bugiiming the treatuieut of a stricture, to moke a 
careful microecopieal and chemical examination of the ariD& 
Pyelonejihritie, for instance, is liable to become aggravatod so 
rapidly, even If the dilatation U practiced with the utmost 
care, tliat death eimuea in a very fow dajii. Ilence we praotioe 
external nretlirotomy — the ^o-caJ1cd bmtUmniire—m pttieDtB 
who do not tolerate the dilatation of the Btrictnre with inetm- 
mentft. Gradual dilatation, to be auooesefnt, requires a year's 
aftei^trcatmcat, i. c, the constant iDtroduction of instrumeuta. 
If this is dieoontinued, even for a short time, the stricture con* 
tracts again, and the treatment must be reuewod. 

TV c will doscribo tlio two methods of dirisioo of a urethral 
stricture, viz., dlnaion of the stricture from without inward 
and from within outward— urcthrotomia externa ct inteniL 
The division of the stricture from witltout inward is now p«v 
formod in ttiose cases iii wliieh the stricture is so tij^t that 
even the fiiK<st filiform Xmngie C!in not be pa-^Rcd, or in tltose 
in which febrile or ncn'oug reaction ensues wbcnovcr a dilating 
instntmeDt is introduced. For the details of this operation, 
we refer the reiitler to the spocial work* on mirgery. We have 
obtained excellent ruttdts from tlie hontonnii-rc. AVe have 
discarded entirely internal urethrotomy and rapid dilataUcoi. 
Both methods, it \a true, relievo the patient from hie Btrictnre 
very quickly, but tbcy cxpoiK: him to tho great dan^r of inSU 
trntioD of urine, and, like the harmlcte gradual diUtation, ro- 
qtiire a long aftoi^treatmenU The dimgeroas character of this 
operation, and tho fact that strictures after having been dindcid 
TVhim in a£ Eevero a form as before the operation, if no after- 
treatment is carried out, and that a certain degree of porviooB- 
neas of the urethra is always ])refitippo6ed to exist for tho pur- 
pose of admitting the nccoesary ini^tnimonts, arc tlie reaaons 
why we never perform this operation. 

[By injecting a syriogeful of olivooil into the nrethra, so 



QONORRBKBA, VBSSRBAL CATASltB. 



107 



u to (lialenil U fully, Che pasengc of tbo bougie will often bo 
nutcrially inoilitated. Soiiietlmra iojcctiona of icc-wotcr have 
■erred a vei^ usefal purpo«o liy cauniug cuulracticu of tlio tin- 
gorged tlMDce, and Uiuit rendering tlie Ktrit^tared parU per- 
meidile to a bougie or catheter. In tlii»cx>nnectiuii, I would 
idd that in retcotioa of arine comiug od suddenly, iu coiue- 
quenoo of cngorgcmeut of tliv tifeues following a dcl>ancb, 
coltite, or exposure to cold, a hot bath, with a fall dose of mor- 
plkinis adtniui^tcred iutcrually, has often aceompliahed excellent 
rB8i]lt& When tlioso romcdits fail, it will be necessaiy to 
ancsthetixe the patieut for the porpo&e of Introdacang a calbe- 
ter to draw off his urine. If time perioits, 1 often soeoeed, by 
blistering tho pcritucuoi, in reducing the engorgement of the 
strictnrcd port of the urethra to such a degree that bougies or 
catheters piufi with comparative eai>e. Mr. Tevan, of London, 
roeorts to loeching tho pcrioatani for tho Kune purpoee. 

Id regard to intt^mal urethmtoiiiy, in proiwrly eeleeted 
eaaea the operation will tie of tJgnal benelit, CRixwiaity when 
time IB an element to ba considered. Where the tnetbod of di- 
lating a stricture with souudH or bougies requires many montha, 
iatcmal nictlirotoniy will achieve the aaniQ result in as man^ 
weeka ; iliougb, to he eiire, the after-treattneut with aouuda can 
Dot be di&penaed with after thiu opeiBtioo any more than in onjr 
other method.} 



SECTION IL 



SOFT CHANCRE OR CUAXCSOW. 



Tnc term *' chancre " hae generally t^ccn applied to an nicer 
the origin of which has long been ascribed to a conta^ooF epo- 
ctfic matter, wtuch was LU^olf reproduced in the nicer. 

Up to the prewnt time wo have not enceecdcd io cetablieh- 
ing fl clear, scientific, and comprchensiTc d(.'finition of that nicer 
which ia commonly called (stjft) clisncre. 

"We know no more regarding tlie contagiong element which 
is capable of giving rise to eoft ch:LQcre9 than we do of the na- 
ture of contagions in general. The conception of the contagion 
la ao ahetraot tmt. We only know that, if a minininm quantity 
of tlie disclmrge &om such an nicer comes in contact with tiv* 
ing cntis or moooos membrane, it wUl produce in a fihort time 
at that place an ulcer aualogona to the poruiit-ulccr, and from 
this fact we conclude that the dischai^ poeBOGSes conti^Siow 
propertiee. 

Uninjured epidemiia and epithelinm-celb are a protection 
against the action of the ohancre-vinut. Thefc ia no spedal 
congenital predii^iKWiitton or aueceptihility to the action of thfi 
chancre-poisoii, neither is tliere any particular immunity or 
freedom from it. All warm-blooded animals arc msccptible 
to tlic action of the chancrous virus. The effect of the poison 
of tlic itoft cliancre is said to he nuirkcillv increaMid when a 
difference exists in the superiority of the race l>ctwccn the 
infected and infecting. Newly-bom children and nmslings 
roBiet infection by a chancroid lc«a tlum adnlts, poedbly be- 
cause their cutis is more richly enpplicd with blood-vcesela- 
Different tissneeare also differently uffect«d by the contagion. 
Xhoa, the virtafl aprends more rapidly in boee, apongy tissnea, 



SOFT CBASOBE OB GEAJfCSOTD, 



109 



ricli in blood aiid Ij-inpliatic rcssrlti, tLau in teitnrcs that 
are poor in vaacular sapplj. The submucona, eaboataneoQs, 
uid interstitial connectiTe tiasuee are very eusccptibto to tlio 
inTasioii of tho eliuicro>pouoii- On the muooos mcmbtanc the 
chancroid tUcen aro gononUly smaller than on tho oommon 
iatcgtuueot. The chauuroiu poison never attscks eorons and 
fibrous tJ»eiiM, and very rarely those of a cartiliiginoiig natoro. 
8ome parts of the skin afford the rirus a mora favorable Boit 
than crthera. Larger chaucroiut ulcers will form moro rapidly 
upon the inner Bor&oee of the tluglm tlian u|K>n the »Vin of 
the intercostal spaces or upper extremities, and open tlie skin 
of tlie hypoulioudri^ quicker than upon the hkteral earfacea of 
tlie thorax. Active local disturliances of the circulation of tho 
akin — bypenemia. stasis, oedcmatona awcUing, and especially a 
tendency to purulent iutiltratiou — favor the do^tructiro action 
of the cbaucroos poidoii. 

Action of Chaacroiu Vims and Development of the Soft Chancre. 

If chancroDB matter in some way gets ondcr the epidermis 
cr fipithelial ceU-layer, a bri^t-red spot about the eizo of a 
lentQ aukoB its appearance at the point of insertion in from 
twelve to twenty-four hours. By the next day this spot be- 
comes raiaed, and fnmu a kernel futrnnmded l>y a red areola- 
On tho third day the kernel is transformed into a pustule^ 
the araola spreads in extent corresponding to the growth of 
the pustule, aiHl the skin wittuu tins areoU is hard to the feel. 
It is sensitive and painful wlicn pressed upon witli the finger. 
On the filth or sixth day the pustule collapses and dries up, 
forming a crust, and the red areola beeomen ninaller. On re- 
moving the cnist> a circular, deep, ur iihallow ulcer, with aharp, 
undermined bordum, is brought to view, whose bottom is cov- 
ered with a layer of grayish matter. 

Tho soft chancre dcvoLope on tho mucous membrane in a 
Bimikr manner, but hero the puitutes biuet much earlier. If 
tho chaQemua matter penetrated itito a Bebacoous follicle, an 
Bone or fnmnele-Uke piiAtulo will form, wliieh also becomes 
transformed in from twelve to twonty-foor hours into an ulcer. 
Excoriations and flssurett lieeomo transformed by contact wJtb 
obancroos matter directly into ulcers without the intervention 



110 PATUOLOQT ASD TREATMEiTT OF STPStUS. 

of the postTilar stage Tlie nlccre, however, are not round, but 
shaped like the excoiiationa or fasana, being mostly gaping 
ind iiT^nlar. 

Multijile chaneroida, originnlly circular, loa}* codoece and 
tlicn fonn one cliaucroid irregukr in sliape and form. 

Th» cbimcn>iut ulcer enlargw proportionallj in depth uid 
cinmnifctx^nvc, but, whon fiDaU}' it b^uis to hral, tlie earface 
of tlie Bore granulates, and a disposition to cicatnxation ia 
manifested, tjouietimes tlie marina of tlie cUauc^ruidn do not 
mark the limit of tho a(,-tion of the clmncrone oontagioo. If a 
chancrauB ulcer is cat throngh, the iround soon becomes on 
infected eore, tlie chancroid spreading and inrolring the outiro 
iociuoD. 

The chancroiie nicer emanates from the inHammatory altera* 
tion of the tissaes, by which the affected etnictarc« b«eonM 
dieovguiised, passing throngh the conditions of fatty degcnna- 
tion, softening or doliqucwence (trn>f<'eu/<tr dieinUgration), or 
the layer of tlxeuc tiiut is attacked by necroeis fomu a diph- 
theritic membranous ilongh, wliich by excesnvc enppnration 
is subsequently detached and cast off. From the very begin- 
ning of titu utneratiTe proceai au active iiitlnnimAtory pbu>tic 
cxmdidon In the form of a aligbtJy hard swelling becomee 
manifcs*. This proves microecopically to be papillary cell- 
iuilltniliou, and caiuea the delimitatioa or the doniarkatioa of 
the chancroid. 

Pathology of the Soft Chancre. 

Ia tiie soft chancre, as in every other kind of Buppnrating 
eore, a distinction may be made between the baee and edges of 
the nicer. The trondtion between the border and bottom may 
be Tciy sharp. Clecrs vhoeo b«0OB are on a level with their 
edges are called snperficial or fist chancroids : they rosembte 
more or less lardaceooa, yelluwiiih excoriations. 

The baite of the nicer ie uneven ; it has a jugged appear- 
ance, like worm-eaten wood. This nneven appearnoce \n dne 
to the fact that some portions of the tissue attacked in tha 
nkcrative ptoccfti reaiat tlie slonghing action more than others. 
The Borhwo of thu chancroid nr^tally has a yellowish or 
lardaoeons appearance produced by the fatty degeneration or 



r 



SOFT CBASCBE OR OBASCROllK 



111 



molecular dkintc^tton of tho ti^ue-clomente. Sometimes 
we find upon die surface of lliu sore a wluttfili-gra^- or fi^reenitdi 
oostiag, if it contaiiu ativ coloring-matter of tlio liluod, nmi- 
lar to the peeado-membraDo of diplillieritin of tlie fttices, and, 
liku till) latter, idLeriog tenacioosly to the etnicture bcm-atli. 
Such cbancraidit uro called dipfdhcrttic cluuicruiilft. Thojr 
originate from intense infiltration of thu connective tiiu^iic of tJto 
tail chancre with newly foraiod cclU, wliicU compnida the cap- 
iDarice of tlic cutis or miicoua membrooo and intcrfon: with 
tbcir nutrition. Tbc diphthoritic Inycr is uccroecd tifisuc in tlie 
fonn of a slough. This slough, when ihc sore \a about to hual, 
bnuTOnnded b/ a tibfiure — t!io su-calltHl lino of (leinai'kalion, 
wlucfa bleeds slightly, and iH a remit of the iutlainiTiatory re- 
lOtton that has taken place in the oat«kirta of tliu dead uiateriaL 
The matter that forms from tJiis inflammation accumulates 
between the eoand tiwuo and the olough, and finally is thrown 
off. A diphtheritic chancroid generally canses greater de- 
strudiuu of tutKUCd. 

Id many caeca the base of the ulcer exists only for a very 
brief time, as in a wtft cliancre tbat perforates tlic fnciium or 
labia minora. Tlioflc piirtjj which before the perforation formed 
the borders of tho chancroid, afterward coostitnte ita base. 

Tbc baae of the sore fumi&hce a secretion which consists 
partly of molcottlar mAttor, fatty dcgcacratod tissuiMl^critDe, 
and partly of pus-corpuscles in which generally eomo blood- 
globolcs are mixed. In places provided with numoroua »)ba- 
oeooB glands, the diechoi)^ will beoome mixed with rancid 
aebnm, and acquire a most offensiye odor, as in chancroids of 
the fossa ooranaria. 

The anatomical process of healing is as follows : Deep in 
the tisanes ou which tbc diancroid is located a marked <legrcc 
of development of tho veeeels takes place. These markedly 
rascnlar tiesnee are the germioattng soil of granulations or mi- 
nnto wart& Thece granulations may develop «pari»gly or in 
largo nombcrs. Those which sprout in a normal manner form 
a velvety coveriog which i« gradually transformed into cica- 
tricial tjasoft. In some cases the granulations proliferate so 
abundantly tluit the bottom of tho soro liscs above its edges 
(nloos elevatnm, fungontio, frambasoidoa). 



112 PATBOIOOT ASP TREATMENT OP STPSfUS. 

The mu;gtiis of tbc chaocroid, in most cases, are thickened 
aod svolleo, becaiue the papiUie of the cati£ ioTolved are infil- 
trated with cells. The cells that bare aocamulated here, how- 
ever, d^entcrate ns rapidlv aa tluMic at tlic bottom of the Aore; 
hence also is sees tbo markedly dentated and undemuDed cqd- 
ditian. ^VllCu healing hi'^na, the margina of tlic ulcer hooomo 
adberBot to the baee by tlie growth of graiiulatioDfi, and then 
they become level with iL As a reeult of the stimulated eo- 
lorgement of the cntis-papiUie, a taarked proliferation of the 
epidormie begins, which goc* on to^i'ard the centop of the ul- 
cer. Cicatrization of the chaucrous ul<*r will progreaa rapidly 
or slowly, aeeording to the character of ite edges. The less 
they are andeimiacd, the smoother and (latter they are, the 
Booner may they be expected to cicatrize. Hyperwmia and 
anemia of the borders delay cicatrixation. If the granulatioiu 
under the edges of the ulcer sprout np too profasely, the mar- 
giuB will become raised tip and everted to each a degree as to 
form a wall around it From oxoce&ive plasticity of the ccllu* 
lar infiltration, this wall may become calloiia, eo that the diao* 
cruid ulcer actiuircs a hard ring around if (annular chancroos 
nicer). Outwardly, the borders of the ulcer, so long aa tbe 
dcstmctivo procciee gooe ou, are Eoiroondcd by a red hypene- 
mic zone. With the eubeidenoo of tliis h>i>cnoraiaT the do- 
etmctive process al^o subsides, and tlien the granalationa bc^^ 
to grow beneath the undormined margins. Tlie acute irone 
abuts against ap]iarcDtly nonnal tissue — wo Bay apparently do]> 
iiialf bucauiie it is iinpoceible to know liow exteoQsively the ti»- 
snea around a soft cltancre are morbidly altered by the oloer- 
atire process. 

Cooiae, Duration, and dcatrixatlon of the Soft Chancre. 

The destructive prooeaa jn a eoft chancre variee coneider- 
ably as K^;&rds duration. lu one catio ito progress i^ rapid, in 
another it is very slow. Tn one caao the nicer barely attains 
tbc size of a leutU, in another it becomes remarkably large. 
^{ow, the niperficial nufocc of tbe papillary layer is b«rely 
destroyed (flat chancroid) ; and again not only the entire thick- 
neRR of the cutis is perforated, but even the eulieutaneons and 
submucous tissue is iuvglved in the deetnictive procefis> whore- 



aOFT CHANCRE OR CHANCROID. 



313 



by sometimes entire organs, (nioh aa tlie gliuif*, nretlim, orlnbia, 
HTO doetrojod. Tlie toiidcnc7 to gaogreuoos eapparntioii is not 
dae to anj specially speciBc iufectious clianicter of tli« dis- 
cbarge, but t^> a |)ecuUar idiosyncrasy of tli« iudividtml affected, 
altlioagb it can not bo deniud thiit in ncrufulous and tubercu- 
lous persoQH, and tho»e enifering from hunger and want, a eoft 
cboncrc, aa a rule, ViHU grofr to larger proporlioiui than m 
healtliy ladividualn. The dcjitli to whicL tbu vlniK uf a soft 
chancre, by infecting, may i>cuetrate into the tiseaes, and the 
pna oocitoinod in the discharge from &n infecting chancroid, 
fieem to oxcrcisc grcator iatluunco upon the doetructivo pro- 
cess than, the condition of the patient. But, in addition to the 
habits of the individual, local and external influences muat bo 
taken into conaidc ration. Tlie pne tliat \a allowed to remain 
too long a time upon Miu siirfaeu of the cliauemiil uot ouly acta 
«8 an irritant and is dct^tructice to the gronnlationg, but it also 
infoctfl tho parts In it*; ricinity. Arterial and venous havmor- 
rhage at tho sito of tlio sore favors the toudeucy to further ul- 
ceration. Mechanical injury of the Gore, auch as tearing and 
rubbing, chemical Irritation from improper remedies, soiling 
with phyeioU^c-al (iecretions and pathological excretions, exer> 
ci«e almilftr onfavorable influences. 

In thoiio cases in wlucU none of these injurious inflnoncce 
obtain, the d€«tmctivo process generally \as^ from four to five 
weekd, and cicatrization requires abont foorteen days more. 
The infectious property of tltc treated or untnatcd ciiancroid 
duuinishee gradually as tho granulatioos form on its periphery. 
The cicatrix alone does not till np the space formed by the Ums 
of substance; the nicer diminishes in addition through the re- 
traction of the skin. The shaUovor tho nicer, tlie lem marked 
will the sear be. For s time tho fresh sear is hyponemic, diaeol- 
ored, and tdJghtly rosiKtant ; after a while, however, it beoomea 
pale and supple. The tiear of a soft ch ancre, as a rule, does 
not break open again. 

Tarietiei of Soft ChaQcre; 

An erethistic and an atonic chancroid arc distingniehed oo- 
cording to the degree of the indammatory irritation of the 
tiniie involved iu the supporction. In the former there is a 



114 PATHOLOGY AJfD TBEATitSST OF STPmilS. 



marked inflammatury eondition of the eurroimding parte; in 
tlio liiUer, tlii< iiitlunimatory reaction U alwent, the discbarge is 
slight ftiiJ tliin, tlie granulations grow very hIowIv, are drj, 
gnuralar, aod bleed eaaily. 

If tt uiorc intense degree of iiiflaainiatorjr phenomena ap- 
pear in this vicinity of a eoft chancre of tlie skin, nn crj-niiwla- 
tons e\relUng wiU eomie. Ilowever, intense inflamoiaHon may 
give nm to etasis, by which not only tlie p«te inTolved in tlie 
ulocratlvo procofie bwc<mio necronxl^ but also the parte adjacent. 
These varieties are called gangrenous chancroids, and tUie des- 
ignation 18 cfii>ecially applicable to tboftc with black elougha, in 
contnidUtinction to t!io*o that are covered \ntb a yplbiwriBh- 
whito i)6tJudo-mombninou6 diphtheritic coating (called by Wal^ 
laoe ■ufoflrs wiVA wMiti gan/fremma slought). 

If molecular ncci-o^is comefl on with uniisnal iiitcniuty, and 
if it progreeses vith nicU rapidity as to destroT a comparatively 
large section of tissncs in a few boons, n-e liav« to deal with 
a variety of soft chancre that has long been known an the coi^ 
roding ot phagedenic chancroid. But even in this kind several 
vurieties are rL-cognizcd, sudi as tlic phagcdenfMliplitlicritic, tlio 
simple j}/iaged<itic, and the scrpi^ino-phagedinic cliancroida. 
The tinit occurs when one of the Ia}'em of elonghed tiaeuo forms 
a laidiiccous i«jcudo-incmbnuie tJiat adheres finnly to the cur- 
face of the ulcer, i'bagedciiic sores sro called simple when . 
they spread uniformly in wary direction, and the KrpiginoDS 
forms are tbo«o which, white spreiuling in one direction, form 
grannlations in nnotber. lu regard to the Borpiginous-phor 
gedonic chancroid, we again digiiugnisb a faUo and a true ser^ 
ptgiuous Tarioty. The lintt kind fipreadt; only downward 
towiinl tlie depending partn of the organ aifected, and is due 
to a want of cleanliness ; the second generally extends upward. 
The false serpiginous fonn really dL-iicuds ujtun repeated auto- 
inoonlatiwi. In these cases the initial chancroid is alwnys 
situated at tlio highest point, while the newly formed sores 
occur at tlio lower and depending points. This kind of appar- 
ently eerjn^Dous soft chniicro is generally seen in the fossa 
corona gUndts and on tlie Imier surfacee of the labia majora. 

The simple plugcdcnio chancroid occurs far more £r»- 
quently than the serpiginotaa variety. 



SOFT CBANGRB OR dTANOROID. 



IIB 



Fh&godfDDiL 18 ftppiirentlj entirely duo to tbu oonditba of 
the systotn, for thceo forms of eoft chancre arc found especUlty 
in weak and depravt^l individuals. Tlic uiodc of life of tlicfio 
individoalH is nnothor veiy froqoont wiaee. The abuso of epi^ 
ituoii3 liquore IB an ceiyoeifllly potent factor wliioh w-enis to 
favor tlio produclioQ of tlio pha^Ieuic; condition ; hcneo 
Iticord asdntned the existence of an nlciig oniupbagodiBBieiiui. 
Active mercurial treatineut, coexiating scrofula, tubercoloda, 
or auieniia — in sliort, all the influeiict's wliitrh ti^tid to tmdeiv 
mine the ajstent, particnlarly favor the production of the plui> 
pwleuic coudition. The long dHrafion of the eoft chancre, aud 
the c<iually long |>oreiBteDoe of tlio infecting property of its 
Bocrution, are murkod peculiari^es of this form of the disease. 

Sit« «f the S«ft Chaiura. 

A chancroid may occnr on any part of tho human inter- 
ment and mucous membrane that can be reached by contact. 
However, sinw most soft chancre* arc acquired through ecsoal 
intercourse, it is easy to comprehend why tho majority of thom 
mUBt t)iv.nr upon the genitA) oi^na of both E)exe«. But there 
are also other places of the human body upon which chancroids 
arc often mot with, though not, however, aa often as on tho 
genital organa. Thnn, injuries on tlie fingora of phyaicians and 
midwifes constitute points of insertion of the chancrons virng. 
^Vet>4lu^Bea affected with chancres on the genital organa will 
carry the infecting poimn to the moist nipplea if tliey rub Uie 
latter with tlieir fingers which have been soiled with the dift- 
cbargo from the aore. In those given to the practice of 
eodomy, the eoft chancre may form upon tlie Hpa, the tongue, 
mucom mcmlirano of the rectum, etc, Komemns fiiMB have 
OOltTineed us that the statement which Kicord made long ago, 
to the effect that the head wae 'proof against tho soft chancre, 
is incorrect. Chancroids dischai^^tng profosely are apt in un- 
cleanly poKona to produce, by auto-inoculation^ multiple soft 
diancres. The exporiracnts of sypliilization liavc stiown that 
hnndrodfi of aoft chancres may be produced in tlic same person. 

Any part of the integameut of the penia from the free 
border of tiie prepuce to the roons veneris may afford a aite 
for a soft chancre. The prepuce, however, is the part that is 



lie PATIIOLOQY AlfD TBEATMSST OF SYPUJUS. 

moet fre<^uet)tly attacked, eepeciftlly iu anterior or free margin, 
its inner durfaoe, tlic {ntnuiu, tlie corona glondis, and less fro 
quentl^- the (ixtcmoJ meatna of tbo urctlin ; but tliu ecrottim is 
aleo occasionalljr the Bit« of the eoft ciianore. 

In tbo female the eoft cbancro is tnoet freqncDtlj met with 
upon tlie labia iimjora aod minora, on tlie poeterior Tuginal 
eomtiuf»ure, and at the vulvar oriticc, more rarely iti the vofnna 
and vaginaJ portion of tbo utorus. lu unclean women, sufler- 
ing from soft chancres on tbo genital organs with profuse dis- 
charge, the matter coming in contact with excoriations around 
the anuB will c<Mivert the lattvr into cbaucroida. 

Tbo peculiarity, Htuatii>n, aud fimctional activi^ of the 
tieauea, epoken of here, on wliich a soft chaucre is apt to occur, 
exercise a greater or l(»wcr tb^^rou of influotico upon the devel- 
opment and course of tlie chancrous sore, 

CbaucroidB of the prepuce ore very utHtinatc and difficult 
to cure, becaaso tka foreskin io frequently strutcbcd in lis 
movemcDtd over the pcois, aud tbo eore in i)revcnted from heal- 
ing. In addition, it i» apt to become aoited hy the orine and 
the glandular echaccous secretion. In congenital phimoeis, or 
that a<^(|uirvd from temporary ewelliug of tlie prepuce, the 
preputial chancroid is even more frmjncntlj and more mark- 
edly (!xpt)t<«d t*i niL-cbanicil and clK*iiiic:il injuriua. Soft 
chaucre*^ of tlie mucous memltrane of the prepuce usually be- 
come complicated iritli catarrli of tlie glaiu^ and of the pre- 
puce. Propmial cLancroidB often give rise to chaucroida on 
tlio glana tJirougli infection by contact. In caeca of marked 
eontraction of the preputial opening, fiuch a degree of diKturb- 
ance of the circulation occurs as to produou pmgrene of the 
foretkia and glana. Impending gangrene of the prepuce mani- 
foota itself in the following manner: The patieot complains of 
severe pain in the affected part, the prepuce iweUs enormoualy, 
becomes red, has a high temperature, and a foul-amellingi^ 
purulent diwhargo flow^ from the preputial oritlce. If the 
impending dangerous condition is not qniekly Bubjngated by 
appropriate truilment cue or more blue spots appear on the 
external eiirfaco of the prepuce. In a few houra tlify become 
transformed into a black gangrenous plough, whicli after a 
while \i caet off. Tlie gangrene cither limita itself to one or 



SOFT CHANCRE OR CHASCROID. 



ni 



seren] points on the foreskin, nn opening forms, thron^h 
which the f!;1ao« ponia, till now iiiiprieooeU in the propntial 
pouch, is laid haru; or the gangroriu tilonglw awav the entiro 
prepace, attacke the glauB itself, and destroys the gn-ater 
put of it. If the arteria dorsalis penis is coiroded hj- ihu 
Bloating proecria, dangerous hiftuorrliogo uuijr tsupeirene, as 
ligature of the Tossot involved in thtv gangrenoufi' prooete 
atmrMt always prOTOS futile. 

Chuictoid^ of the franum arc situated either on one or 
both Bid««, or on tlio margin of this rocmhrane. Jn the two 
former eonditiotis, perforation almost alwaye takea place. The 
pcrfomlcd spot, as ii rule:, cinatrix^m very fd<iwly and very rarely. 
In most cases, the bridge of the skin that has remained intact 
breaks down, oft^u eauHing t^^rioiut lui!Nuiri'h»gi> fntin tlie nrto- 
ritl turigs that nm along the fn« mnrgin of the frtenum, that 
is difficnlt to arrest. Usnally, the frenom is entirely destroyed, 
and an uIcit result*, that extendi* from thi- jxitnt of attaehmwit 
of the fneniiiii, near lliu f(»««a ci>r4>nuria, to the urethral orilirp, 
and &oni this point it may eiren encroach upon and attack tbo 
macouH niemliranc of tlio nretlira. 8oft rliatirmt at the mar- 
gin of tlte fr^nnm spread rerjr quickly in the loose connective 
tissue existing between the two lameUte of that part ; may 
lay bare tlio urethra, and even perforate it. They are the 
mo«t frequent cau&e of ewcUiug of the inguinal lympluitio 
^anda. 

A chancroid may occur on any part of tbo glanspenin. In 
coexisting contraction of the preputial oritlce, chaiicrona hnpres- 
iriotw will result on the mucous layer of the preptino ; and when 
cicatrization ensues, the foreskin may hooomo firmly united to 
the glaos. In tlio shallow pits or crypto which are found on 
the donom of tlie glaiiii peniit, and which are the nidtmentK of 
the BBbaceons follicles that exist here in the emhrj'onal state, 
ttdi chancres assume the shape of follicular ulcers. Superficial 
chancroids cicatrize very quickly. If the chimcrous dertrac- 
tiTe pniooei pcnetratca into the corpns cavemoaum glanditsand 
aBBiitue» a phagedenic character, it may destroy such a large 
portion of the glans, owing to the s[K>ngy and Tabular nature 
of the tJBmeBy at to remit in actual mutilation of the oi^on. 
In coiueqDeneo of the exceedingly thin layer of the subcata- 



118 VATaOtOQY AiTD TRBATMEST OF STPEILI3, 

neons connective tissue^ the cicatrization of sncb chancroids 
progreflsea vcrj- slowly. 

Chaucroidft of the easttrmal metUw urinariut are ributed 
eitlivr upon ono or lioth Upe, and thence taaj spread into the 
urethra. After cicatrization b&s takeu phK>e, the oetiiuQ ex- 
ternum urethra (the orilice) acquires k fuDoel eliapo. TVe hard 
never, citlicr dnring the life of Uio patient or at the aQtop«y, 
miit with chancroids tlmt have originated witliiu tiie utetlm 
heliind tlie foeaa navicuUris. 

The namcroug eehaccous glands oxieting in the foesa eoro- 
naria glandU become diseased from the action of the ehancrotu 
poiacHif and aasnme the fumi of acne-like tuberclea. These are 
transfonneil into ulcers of the axe of a millet-eeed, and majr 
surround the entire foyta coponaria, like a string of pearls. Fl- 
natlv, m'cu tlui tiouiid ]>art« Iictu'CCD the ulcunt are deotroyod, 
and they then ooeJesco into ono uloemting groove. I£ such a 
folliouhur nicer spreads to and attacks the sabcntaneoas con* 
necdro tiisno uf the dui«uiu of the penis, a fistulous track from 
the foeaa corenaria to the moos veneris will rc^lt. 

In the female, eoft chnucree at the posterior commiasaro 
readilj become phagedenic or gangrenona, because the phifdo- 
logica] secretion and pathological excretions produced in tbo 
utenis and vagina, as veU as the nriuo, are liable to accumulalo 
there. As a rale, clianeroids on the its uteri iiru nut tliMpoM.'d 
to attack the deeper tisencK ; Deverthelfss, nurkvd loss of sut^ 
stance and serious luemorrhage have been observed. 

3)if ercDtial DIognoiLs of the Soft Chancr& 

The eoft chancre may be mistaken for herpes on the geni- 
tal urgiuiN for all ordinary eore, the iultial lesion of syphilis, 
and tlic caiicer-nlccr. 

It 19 only poeeible to mistake a chancroid for hirf>t4 on the 
gcuital orgiuis during its initial pustuhu-Etage. The didtinctive 
featarcs of the two are as follows : Tbo herpes vesicles gener- 
ally appear in groujis; soft cluincres commonly only one at a 
time. The foniicr are hurety as big ai! a pin's head ; the lat- 
ter, as a rule, are krger. A group of herpes veeidoa has ooe 
common, ei^-tlieinatons red base ; eack soft chancre is sur- 
rounded by a marked, slightly infiltrated red zone that is pcr^ 



SOfT CBJjrCSE OR CSJiSOROID. 



119 



ceptiWc to till! touch. The lierpw vmirlcn may cxwt for sev- 
eral dajrs befon; bnretiog ; tbu cltancrous pasttdo breaks in t«a 
or twelve hours after it bos nude its appearuiOG, The raptured 
hcri)ce vesicle* dry up, without iinderffoing ulceration, foroiing 
a ttiin orbicular scaIo corrc«pondiag to tlic old vehicle. After 
the bursting of the ehancr«-pu«tulc, a lose of eubetaoco eiuiuos 
that bag a tcndcncr to fpread. A chuuoroid alu-ayt; luavce a 
deproBood cicatrix alter it which laet^ for a varinbte period ; 
berpw leave cicatrices tliat are vi^iblt) but a few day% uud 
indifiliuclly depn^med or di«!olon?d. Heriiea of Uhi guiital 
orgua, in ino^t caae^, is an hubitual di«eafie, which oiay come 
OD without or loug after aexail iiitercDursc. Tiie pustule of 
a Boft chancre begins about twenty-four houni after a suapl- 
ciouft cohablutioD or hifection with chuncrous dJacharge. 

Laccraiionx and cxcoriaiiontf origiuutiuj^ after sexiuU iutor- 
coureu may, from neglect of cIoatiliQeai or improper treatmont, 
■SHime aD alcerating cluracter, and then be mistaken for 
ehanctoua ulourm. The coureo of those sores, or inoculation 
perfermod n-itk their Mcrction, will quickly dispel alt doubt. 
Ordinary nkera bed readily eoongb vhcn kept clean and 
properly managed; and a poatale prodnccd by inoculadoa 
uritb tboir eeeretion eoou dries np and heals. 

The inwit im|)Ortarit |M>int ia reference to the proffno*i« 
is the d^erential diagnoth between a soft cliaucre and the 
initial ^pAilitie uleer. Tlie syphJlide initial lesion rests 
open a marked, aliarply deSned («lliihir infiltration, which 
bcant no relation to tlie Nliglit ulceiatiou and suppuration. 
The soft chancrous ulcer is seated upon a base that hns become 
somewhat n-eii^taut in conautiuence of th» aiictivc intlanuuatory 
psticoBa. Tlie initial lesion of syphilis, when grasped between 
the thumb and index-finger, ehows the consistence, n»8(anc6t 
and elasticity of fibroids and vnchomliYimata. Ttic i!oft chan- 
cre, pinched up in a fokl between the thumb and foreSnger, 
will bare at the most an cedematous or doughy feeling. Only 
tardy or repeatedly cauterized soft chancres, situated in the 
aniens eoronse glandia and genito-emral fold, 6ometime« occa- 
eion a temporary induralad inflammation of the oounectivc 
tiasne that may be mistaken for tlie hard consistence and eUs- 
tio resistanoe characteristic of the syphilitie tissue induration. 



laO PATSOLOGT AXD TttEATMS.VT OF STPBlUa. 



In tbc m>ii dumcn: tlic infliuumatory iiitlumtion diAappean 
eponCiuicoujsl^' iu a cumi>arstiveJy abort time, and ia not at- 
tended by bard, indolent svrelliiig of tlie Ijmphatice. Tbc 
Hyphiiitir iiift'cting nicer is dilltin<,'^Ii^^KKi by iu bypcrplastic 
ndveotitiouB Btrocture; tbo soft cLuucro \a pi-e-omjueacly s 
destrucdvo process. Tbe eypbilitic priumt^- luKion, hji b rule, 
derelopH very bluu'ly, luid, uftt-r a protracted iuctibntioti period, 
tite soft cliancre api>eiLrs witbin a fe\r boors or days after in- 
tercouiw. tha ulcvratirig proceM in Uie initiid Icoion of i^bi- 
lid attac{» layer after layer of tbe indnrnted depout, the 
necrotic proceea proceeding from witbout inward, oviog to 
tbe iDtonau cuUular iufiltrutioa. Tbc cajiillariui in Uiu part 
tbun l)Gcome ooclnded, aitd the up7>eni)oet btyer of ttie neo- 
plastic formation die» for want of a blood-eupply ; conse- 
quently, tbc diacbargc from tiii» legion Is very eli^UL Tbo 
ulcerative process of tbe soft cbancrc proceeds rapidly, «0Dsti- 
tutiog a purulent dieeolution of tbe tiaeuee ; bence the dis- 
claim is (juite profuse. Primary Bypbilitic Uuiioiis rufieiubliiig 
eroeionft oecajsiunaDy cicatrize ao rapidly tbat they entirely ea- 
cape observation ; in tbe soft cbaucre encli m]>id cicatxizatioos 
uever oiscor. Tbe i^car of a aypliilitic sore i^ bard to the feel, 
because tbe hyperplastic deposit remains for a long time ; tlie 
near of a soft cbanfTre uever l)ecomea bard. The cicatrix of a 
primary aypliilitic chancre often Imrakii oj)cn again ; that of a 
•oft duDcre hardly ever. The cellular infiltration of a ejpbi- 
litie primary b-sion, aftt;r Ixiinj; al«60rlH--d, may reappear after 
a long while witliout the recurrence of iufet^tiou (rvpuUulatJoik 
of the syphilidc initial acleroaia); iu tbe soft chancro luieb a 
condition never takes place. In tbu ciciitrized eypluliti&nau- 
terian indaratioD, deep depreeaiona origioato, u a result of 
atrophy ; in tbe ecar of the local venereal dwncroid, mch do- 
preasions arc never observed. Indolent awelling of (be iytn- 
pliatic glands and diseased oMidition of the lytnpliatic voaecla, 
as a rule, are tbe acoompaniments of tbe initial Iwion of ajphl- 
liH, and tutldriin undergo suppiinttion ; an a result of tbe soft 
cliancre-, however, tbc lymphatic vcffieU and glands are quita 
often aiTected (iu tn'enty out of one hundred cases), and gener- 
ally tliey undergo Huppuratiou. Although wc Iiave enumerated 
here certain peculiar features and dillurcncca of fonn, and laid 



SOFT CBANCIiE OR VUAXCROID. 



lar 



fitrcH upon Uie e«f>ciitiiil diatinctiTo sji'iupt4im3 for die piirposgj 
of specializing Uio cliornctcrUttcs of the soft chaucro and Uie 
primary lesion of Bj-pluIIg, still, to be candid, we must admit 
tbat bcre, as in oilier iiittUinciM of natural plieiiotnena, excep- 
tions and peculiiirities of condition njiiic-titiieH occur. The in- 
itial BclerObiti may be indi^tuict, or the indolent Dwelling of the 
g^diS may be alKieut altogctlior, and yet a cliancre may bo i 
followed by sypliilitic inanifvetatitHia. 

It it! much ua^iur to mistake a soft chancre for an epiih^ \ 
Hal cantxr, as tlio latter rery often oceure on the prepuce, glana 
poiuM, and Bcrotiini, and is frequently atti'udod by euppuration 
of tltv adjaoviit lympluitic gl&nde. Kpitbclial oimoer gcocrally 
oocun in the fonu of a papillary, wart-liico growth, which eooa 
bec'inea necrotic, and gmdually attacks the deeper atructiiPea 
whortjby the textures upon which it is fiitoatcd soon bcconio 
eroded (ulcus rodcus). Cancerous ulceration progrraeea more 
by death of the ii|>pcr cell-Htniti of the duUcfently umirished 
akin than by suppuration, llcncc, we usually find here flat 
wosions whom upper surface ia tolerably dry. Now, while 
the base of the nicer purities Ititclf, new papillaiy growths 
originate on iu bordere, by the dvath of which the deatraction 
of the tiMiiea apnoda farther and fartlier. From tlieiie papil- 



Ury growtbH, comedos or eebacenuA plngH, oonnsting of flat or M 
cylindrical epithelial cells, may be preeeed ont, fhrongh the " 
pniliferation of which Lbo sldo and fiubcutaneoua ti^auc are de- 
itrayod (Kloba). M 

FngUMii and Treatment of the Soft Cbaaor«, ^^H 

Tlio progTKwia of a soft venereal ulcer dcpcnda (1) upon its 
location, Hnd (3) upon the state of the ingnJDal h*mphadonitlA, 

In n^i;ard to it^ location^ some kind of chancrtiidi), i^fipecially 
phagedenic and gnngronoiM fornix, caiieo greater deetruotion 
and mntilation of the partti than otben*. ArtC'Hal ha-morrhagea 
nuy take place from enmun of tlie arteria dorvaili^ \wmn uud uf 
the arterial branches in the fnenum, and cause oonsiderablu 
troable. 

Iu regard to the occurrence of inflammation of the inguinal 
lymphatic glands, experience has shown that in twenty ont of 
one hundred casoa of soft chancrea suppurating adenitis of tho 



123 PATBOLOOY AXD TSEATMEITP OP STPOIIIS. 

(n»in tjtkes plncc. t}ia,t it occurs more frcqneutly in the malo 
tlian in the female— in tbc mtHny capeciAJl.v wlion the chancroid 
u Bittiatcd on tbc fniMiiim and on the internal Bnrfaoa of the 
prepuce ; and io iho female, in coneeqnencc of the cbai>croi<U 
oceorriug ia tiic Iucuiub od both mdm of the urethra. In ro- 
ganl to the affection of the ingoioa] l_\-mphnUc glands, bidbII, 
rapidly cicjitrizing chancroids do not adiuit of a progiiosiA that 
is more favurahlu than othur varieties. 

The treatTDent of the soft clmncre is either prophylactic or 
ahordve, curative or methodic^). 



PKOPinri.Acnc Treatmkst. 

Bo^de* the condom we have no remedy or aj^t titaf vill 
protect one against receiving the vinw of a chancroid, or will 
render tt hanulees to the syeieax after it is bronght in contact 
vith some port of the living cutis ormucoos membrane. Even 
tLo higtdy praifiCil lotioni; wliich Iiave been recommended to 
be nflcd immcdiatelj after exposure to a enepicious interoourw, 
prove entirely uecloM in very many ca«8. By thoronghly 
washing tho genital oi^ns immediately after cohabitition, we 
may succeed in removing any infecting Bubetance tltat may 
Iiavo been lodged there, and in this way wc niay probably, bat 
not positively, prevent the vims from taking ruut and exer 
cislng its cffucta. 

Abobtivk Treatment. 

Bicord SDoceeded in preventing the further development 
of the chincroid pustuleg which he had produced by inocnla^ 
tiun by timely cauterization, thuH bruiglitg about cicatrization 
and healing, and tlicreby obviating the cxtcnigon of tlie dieoaso 
to the adjacent lympliatic vessela and glanda. It waa found, in 
tbe oouree of experience, Uiat the pustules cd soft chancrea, 
and of croxionaoontaininatod with the pua of a floft ehanere, 
if thoroughly destroyed within seventy-two to ninety-«ix houra 
after infuciiuu )md tjdicn place, will ho arroeted in their farther 
devehijHiienL But if a lunger time titan that just mentioned 
has elapsed since exposure to the action of tlie vima, or If an 
adjacent gland is already attacked by inflammntion and awelU 
ing, cauterization of the infected spot will lie entirely useleas. 



I 



To be eScctnal, the canities mttgC also destroy sufficient adja- 
oent sound ut»uo. Fur tbu iturpueo a great variety of cttutics 
has boon recoiumended. Kitrnto of silver, caostic potassa, 
pure or oconbined with unslaked lime (Vienna paste), or HI- 
bo^s Gsostic (equal parts of caustic pototih oud unslaked lime 
cut in molds like » pt;i)cit)T chloride of zioc, tluid, or combined 
witli eoiue simple substance in powder (pnlv. secalis or pulv. 
iBcL lirj.), oa Cauquoin''s paste, or iu tbc fonu of pencils rocom- 
meuded by Kiibncr (jsineum mur^ gram. 1 Igra. xvjj, kali 
nitric, 0*20 to 0'4<l [gra. iij to vj], melted and quickly wrapped 
iu tiu-foil and preserved in glaaa tubes or bottles), butyr. antinto- 
nti, diioridc of mercury, 0-50 to 5*00 or lO'OO water [grs. vij 
to 3ir or 3ij, 3ij], sulphuric and nitric odd, and the actual or 
galvanic cautery. In the ab(?rtjve treatment we only euiploy 
nitwitc of silver in stick or a coticcntnited solution (a saturated 
solution is eleven parts of the nitrate to ten of water). This 
solution destroys the tissues that are impr^^ted with tlie 
cbancrous virus more effectually than the solid stick of nltntto 
'. of alver. No wet compresses should he applied to the cau< 
terized spot; it ahoitld lie kept dry, for tlie puqxise of keep- 
ing the eschar produced by the caustic from dissolving and 
flowing OTer adjacent parts. After tlie slough produced by 
the cauittic has been cast oil, some astringeut pre])anitiuu may 
l»o applied by means of cotton-wool oonipnwecs. 

Xbe part on which the vims of the chancroid has been 
Jodgcd may also be excised. But, iu tlic first place, the oper- 
ation can not be carried out in every case ; and, secondly, it ii 
not always effectual, because wo are not sore when tbc eluut- 
crous poison ceases to be active, nor to what extent tlie ineiiHon 
be made around the affected spot 

Cdbattvk OB MFmoMCAi. Tbbatkmst. 

If the abortive treatment hss fuled, if more than five days 

have elapsed dnce infectittn took place, if one or more of the 

^Adjsoeot I^'mpbatic glands is alreAcIy irritated or inJlamed, 

the methixUcal or cumtire trvatment should be )nstitutL>c]. It 

lIuu to futtill the fulliming ubjcctji: To prvvont tbc cxtcutuon 

Ecf tbe ulcer in breadth and depth ; to protect adjacent porta 

against auto-inoculotJon ; to promote tbe cicatrization of the 



124 PATS0L06Y AND TREATMENT OF BTPBIUS. 

iilcor; luid to <?hcclc the swelling and siippuratiDD of tlie Duifi^- 
boring lymphatic glands. TliL«e objects are atluioed portly by 
appropriate regimen and conduct (in tbe part of tbc patient, 
and partly by proper local treatmeot. 

The patient ehould avoid all actirc exercise, such as fenc- 
ing, riding, dancing, etc. If there are already fiigrm of actire 
inflamuiatiOD iu the affected partis, wpocially if any of the 
glands of the vicinity are tender or painful, tJie patient will do 
well to go to bed. ilis diet should be light, spirituous or other 
frtimulatiog drinks ilioald bo interdicted, or at tho m09t al- 
lowed in modorato quautitiee, and only to those accaatomed to 
their ose. 

The cliicf indication in local treatment consists in keeping 
the affected parts scrnpnloiuly clean, which is best aecompIinhed 
by the speedy removal of the diitcUarge from the eorc, by pro- 
tecting it frcjrn cuiitamination with pliy^olog^cal secretion and 
pntholngic-il excredcm. This is b^t acliieved by repeatedly 
wattling the diseased part (topical Uatlu), and by the applica- 
tion of iodoform. 

Iodoform in powder should be dusted upon the uker, and 
a hit of abeortieut cotton dipped ui a two-]ier<'ent solution of 
carbolio acid in water, aod sqnee?^ ont well, is then applied. 
To prevent the dressing from becoming too dry, it should be 
covered with a piece of gutta-percha, and the whole secured by 
a bandage. Thie dressing most be renewed two or tliroc time* 
a day, according to the qoantity of the dischargeL If the penis 
is markedly swollen, the patient shoald bo confined to bed, and 
the organ kept upon the abdomen. In the majority of eaaoa 
tbo uk-er becomes deal] In a short time under this treatment 
If graiinlaticMis have begun to form, tlie iwlofonu dressing may 
still be used, or only a carboUc-acid solution; or, still better, 
empl. hydrarg. may now he substituted for either, especially if 
the patient detdnsfl to leave the bed. lixnberant granulations 
should Ikj repressed by touching them from time to time with 
tbo solid uitrato of silver, which will also expedite the cicatri- 
zation of the sore. 

If under thii; treatment the ulcer remains etationary, and, 
stiU more, if it enlarges markedly and rapidly, which is a most 
uuusnal cironmstauoe, or assumes a diphtlieritic character; If 



SOFT OUANOES OH CBAyCROTD, 



lasj 



^tfte «U»cl)3rge i^ profiiite, and gruiolauijus urv sloir to appear, 
one of the foUowiag prcparatious should Iw rtiiCirtcd to : 

tt Co^iri snlpbnrici, O'M {gra. rnj]; 

Cof. dem)^ 60-00 | § iw., 3 v]. U. Fl nng. 

A bit of tiU salve, of the size of h lentil, ia smcarvd opon 
a small strip of muslin and applied to the uloer two or tlirej _ 
tiines a dajr, oftc^r bathing the origan in tvpid vann wster, lu f 
dlphthiiritic or phap'tJenic chancroids, tluit ik> not heal under 
the application of iodoform, an cmalsion of camplior, caustic 
potash, or nitrate of eilrer, with bidfiuin of Pent maj be em- 
ploycd — like the following : 

B Camphoni, 6-00O W]; 
Mticil. g. Arab.; 
Ai{ui]cMU.,UAO-00[SJ, 3Tj]. U. 

B Kali caustic 0-10 [gn.JMl; 
Aqii«dwtlL,IW-00[SJ, JT). IL 

B ArircnL Ditrici, 0-10 lgrs.JM.]: 

Bokam. PeravlaiUD, SO-00 ( J JJ. U. Fl an;. 

Id ulcus Inxurinns or elevatimi [fungous]^ a slrong astnn* 
gent, or mild caustic, should be rt-sorted to. 

Id dry gnuiular ulcura, with callous cdgtM and Gcan^ eecre- 
tioci, lint inoifitcnod with gl^'ceriac, or the etiipl. hydnu;g.,BlioaId 
be applied. 

In pliagcdcnic soft chattcrott gcnunt treatment will be noCCfr 
Bory in addition to the use of local remedicfl, Ixxjbum tho 
fxhagedieoa in all probability is duo to Bcrofula, tnberculosu, 
antemia, ecorbntn^ habitual dij;o&tiT« distarbaneee, etc It 
will, tlicrufore, be neceeeary to resort to tlie remedies ino»t 
effectnal in tlie treatment of these various di«t>aec«. Mercury 
ifi to be strictly avoided in the ircatiiieut of pbaj^udiBiia. TTa 
bare rarely RUGUMfded in arresting tlio progress of pbagedsona 
bj caustics, bat urc are able to recall numerous instances in 
which we obtaiacd tbt.- b&ppif^t rvcnllK fn)ni the am of acetate 
of lead or citrate of iron, combined with tincture of opiuin- 
In simple pliagedenic chancre we therefore recommend— 

B Exl. Mdinii, 2-00 fgra. xxxij); 
Aiiaadc«UL, 100-00 [^vjw.]; 
Tr. opii«oiiip^, 6-00 [^ Iv]. U. 



12« PATBOlOOr Ayi> TREATUEKT OF 8TPmU3. 
e Cilr. ferri, I'OO [nn. *vj); 

Tr. opii comp., 2-UU (gra. xzx^}. U. 

One of Uie most rclinblo mnedics, bcpides iodoform, we 
foasd to be a mixtim) of chloroform iuid gl^'curiiiu, one part to 
eix. Tlic tartrate of iron, one \mxi to ax, is reconmieiKled b; 
Ricord as a epedtio agaioet pluigodffiDL 

ExcidoQ of the phagedenic chancroid, at tfao most, c«n 
only be recommended when it '\» eituiittrd npon the fnenom, 
the free nmrgin of the prepuce, and at tbe edges of tbe kbia 
majora or minora. 

In tbe tnatuKint of gan^noue chancroid it will be neees- 
etry fint of nil to ascertain the caaseit tlmt brought about the 
gangrenous condition. Tbeee are apt to be: Grave utari*!, a 
prufiue dnvr of blood in ttie phlegmonouely iuHamed pert, and 
mechanical oT^atraction to tbe return of the bhxMl, when die 
BUppI/ LB exceesire ; this rnav occur t& the result of prefisure^ 
strangulation, pliimoas, and porapbimoKia. In anj erent, rest 
in bed should be recommended, Ice-cold applicatioos made, and 
in men tlic penis should be kept npon the alxlomen. for ibo 
purpose of diminishing the snppi t of blood to the port, and ao- 
colorating its return. In oongi-nilal or phlegmonous p/ittno«U, 
in which tlie retraction and extension of the prppnoe for the 
pnrpuee of clcatiaiiig the parts cause intense pain and irritate 
tbem^ betndes rendering tlic clianeroids altitoet ioaeecaeible and 
preventing the local application of romcdios, it will be moro 
advnntageoue to gplit tlie prepuce, or to perfonn circumciftion. 
Arterial htcmorrhape caused by gangrene mui* be arreelod by 
the application of tlie ligature, compreeeion, or transtision. If 
these metliods fail, eliloride [or persulpliato] of iron, or the 
actual cauterT.', should be used. In all cases of phlinoais, where 
there is no danger of gangrene, and the patients decline to be 
circnmeised, Injwtions of Roliition of nitrate of silver should 
be made into the preputial pouch foar or live times a day, and 
retained there for a few momenta. Or, after injecting water 
into the ponch, and then drrinp it w well as pondble, the glans 
should be cauterized by inserting a solid piere of nitrate of 
silver l)etwecn it and the prepuce, and rapidly rnhbing it all 
over. After the btjectJon or cautorixatiou three or four pieces 



SOFT CSAirCRE OS CffAlfCSOU). 



1ST 



of oompraseed sponge, eacli about two and a half centimetrcfl 
long and two inilUmotres tliick, according to the di^enaibility 
of the propuoe, ahoald he inBorted between tlie prepuoe and 
fE;liuis, find renewed nevenil rimett dailjr. In tMi maimer tlie 
preputial aao is eomedmes dilated to each a degree tliat after 
the cicatrizatton of the cluuicroug ulcers it cao be retracted 
with the utmost facilitj. We do Dot rocommond this method 
of treatnicnl very strotiglj, preferring early circomciyoii for 
the relief of tliiit complication. 

In cases complicated with paraphiioosia, cinnunci<uon will 
ahoost alwa)-e be required. H thi* luitiunt alMolutely refoBoa 
to have it dom\ the jicnis i^ to be luid upon the abdomen, cold* 
water dnedofs appUcd to it, and attempts made to apply ap- 
propriate reriR-dies, br means of camelVliiir bnishea, between 
tho folds of the oonatricting prepuce. If dangvroua staris, in 
eonaeqnenoe of the constriction, takes place in the prepuce or 
glanfl |)ents, the ojwratiun will luLve to be performed without 
farther delay. 

In chauoroids of the wtiam cxtemnm urottirm. it will b« 
the doty of tho phyrieian to prevent contraction of tho an>- 
thral orifice during cicatrization. Thia i* Iwst effected by in- 
serting Into the meatus phigH of eli.iri)ie, or some other mate- 
rial, dipped in mme resinous or other kind of ointment, or 
pieces of Iwugie, wlu'ch should Iw secured to the iienta by 
tapes anil adliL-xivo plaster, imd wliich tho poticnt rnay ninovo 
before micturition. Iodoform, made into sticks with some 
solidifying- ralistaucc, is also very ^voll adapted for this pnr- 
pose. 

Chancrous ulcers at the anas reqairo proI<»igcd washing 
■nd sitE-baths after eacfa stooL 

In perforating chancroid of tho ftvmum^ pledgets of lint, 
smeared with ointment of sulphiito of oop|)er, should be earo- 
fully iutroduciHl, several time« daily. Into the hole, or the per- 
foraiitm t^mehed with the solid nitrate of gjlvor. If the swell- 
tog is very great and tlie pain iutenso, diriding the bridge 
10 the nio^t appropriate pnK'ediire. Ricord has soggested an 
exccllcut incamire for (hii; purpose, by which the bleeding b 
avoided anil the farther pogress of the niceratiou rcstnunod. 
Two wased ligatorcs are passed through the opening, and ore 



138 PATIIOLOOY AS'D TREATMENT OF SYPHILIS. 

then separate!; tied iipcn tbe bridge of tlio frumuni, one thread 
after the otlicr. Tlio part between tho two tied ligatures 
breaks down id il few hours ur days, or it may he cut through 
at once, without ftiar of c>atitiitig hn'tnorrliagf!. 

In t\ivfffmah, {tcrnpiilous clcsnliiic^ must be CDJoiucd, and 
carried out with eren greater rigor than lu the nialfi, because 
the 6ebaji!eouB luid mucous foUirlcw of the genitn! orgnns. ov- 
iug to thu pn*enco of cLaucroids, are rtitauhited to hyper- 
secretion. The diiicharge from the chancroid sores, and the 
secpefion from the genitaJ orgaoB, flowing over tho iidjoining 
parti<, will cause eroeioud to funu at thu geuito-cniral fold, on 
tho jicriuL'um, and around the anus, which eoon derelop into 
chancroids. Mcn&trual blood, the lochia, and vaginal catarrh, 
delay for a long time the cure of a soft chancre, if it is eituatcd 
upon the vulvo- vaginal mucous membrane, and especially on tho 
posterior comtuiseuro. Care should therefore ho taken to omc 
tlie exiKtiug pat&rrh as soon ub jtotwible, Rir^lmthfl taken often, 
vaginal douches repeatedly reported to, and the sore ffcquontly 
and thorouglily cauterized with the solid crayon of silver. Tliis 
method is oil the more applicable in tlie female, lieotiue the 
chancroids, in Uio vast majority of cases, are eituatod upon the 
mucous membrane, and bear strong cauterizations better than 
tho£c in the male, eitnated upon tlic common integument. Aside 
from tliia, tin; treatiueut differs in no respect from tliat of clian- 
croids in tlio male. Chancroids situatvd upon tho upper port of 
the vaD^ina or nc^^k of tlio utcrtis must be cauterized tbton^ 
the s])i.'culuiii, with a long caustic bolder. The porta that are 
Ukoly to come in coutact with a chancroid should be protect- 
ed, hy ineiertin;; repeatedly between them pledgets of wad- 
ding, saturated with soue diflinfecting solution, to prevent auto- 
inocalation. 

DiMBm of the Lymphatic T*uels ani Glands (Xymphangloitll 
and Adenitis) in ooasequence of Soft Chancra 

Daily experience has shown that the lymphatic glands, 
situated in the vicinity of a ct»llection of pus or ichor, which 
are produced idiopathically or by infection, furthermore those 
in the vicinity of inflammatory depofflts of a malignant nature, 
very often beoome inllomed and swollen. In some cases thoy 



80rr OBANOBB OB OBANCBOID. 



van 



undergo resolution, but m otLere tcrmiaatd in suppuration. 
Tbceo fomu of swelling of tlic lympliatic gloDds arc duo to the 
agODcy of the lympliatic vcescU, the tluidti orif^inaiitig from tbc 
irritative Itisioae, indeed even viable cells and |)articl(<s of dead 
gtrncturvis being taken up by Ibem and cniiveyed to and do- 
fio^ted in tbc corresponding lymphatic glands. As a result of 
tlila condition only those gUudi become alTectcd in whicli the 
diseued lymphatic vefwelM termir.ati^ while t)iu lymphatic res- 
ttk^riiich run toward tlie primarily diseased epot undergo no 
perceptible morbid alteration. Occaaionally, however, the mor- 
bid matter that luia licoi abfiorbod alw irritatoti tlie tympfaatio 
veeaels. 

In many casee Uicre it) found a swelling of the thickncfla of 
a cortl under the eltin, njion the dorsum uf Iho peniH, mnning 
from the local sore to the nearest lymphatic glands. This 
cord-lilce ewelHog is notliing mora than a lymphatic dnet, 
thickened by coagnlation of lympli, as a nwult of abeorption 
of diseased fltUds from the original legion. Tim thickooing of 
the lympliatic vessel may bo unhered in witli marked inflam- 
matory phenomena, or vithouttho Ica^t ooDfititutional disturl>- 
■nce^ Purulent tiretliral and preputial eatiirrli, erethistic nl- 
ceri, Boft chancres upon the extemid genital organs, generally 
give riae to painful inflammatory swelling of the lymphatic 
vcMcht. Initial «yj>hilitic lesiocui Ukowieo produce disuaHO of 
the peripheral lymphatic veffseU ; iu the latter owe, however, 
no inflammatory manifestations occur. 

Tlie fii^t form of disease of the lymphatic Teitaels is called 
infUmmatory; the eecoiid is spoken of as irritative. In both 
CMes the affected lymphatic cord may be imiformly distended 
throughout its entire length, or knotty in one or more plooos. 
Tiieee lymphatic nodules are called l/JihonuH, while tho swell- 
fog of the l^Tiiphatic gland-H is called bvbon^ or bubo. If 
the patient w earefidly and pr.-iporly trciitwl, the affected 
lymphatic duct will regain itg normal ttiietucss. In the con- 
LnuT event, and eopedally if the cause of the disease of the 
lymphatic vowel !» a soft ehaiic're, tli« infl.ime<l norlnleR in the 
lymphatic dact will undergo i-iijiptinition. The integument 
eovering Lho eweUlng of the lymphatic veaeel mirtures, and a 
chancrons ulcer develops at this place. In swellings of the 



inSO PATBOLOGT AND TRKATMBXT OF STPmLFS. 



lymphatic ressels, as a resnlt of syphilitic initial lesiona or of 
Tirotbral catarrh, sappnrntion eeldom oocnre, 

Ttiv affections of tlie lympliatic vcaeela of cbo oxtenuU geor 
itais, tliat have been juBt described, oecar moet frot]ueiiUy in 
the male on tbc dorsum or iiidt'S of the pcni^i, imd along the. 
frffiuuiu. They are very seldom met with in tht- female, aud 
then only on tlie labia majora. Distia.<ie of tlie hinphatic Tei>| 
sela which start froin tite preputial oriHce may pnxluce tem- 
porary pliiinoas. Lymphatic dncts that hare rnider^Dc eup- 
punition utrlil rctjuiro a much longer ttine to get well than, 
would be rctpiiruJ for ruaolution of non-mppn rating' inflamraii- 
tion. Afiections of the lympliatic veeeels and BwcUings of the 
lytapbotic glauds do Dot lUwuya have the eomc cdutm! and ter- 
mination. The fiwclling of the lymphatic veseeb* may l)cconic 
absorbed, wliilo that of the glands goes on to Bopporation, or 
vice v*r$a. Swelling of the lymphatic gknds may origiuoto 
without coincident Bwelling of the afferent ]_>Tnphfttic vwBela, 
in the Eame manner as an epididymitis may occur without 
thiokeuiug and iiillammution of the s[)ennatic dact. 

The morbid matter that has been transported to the glanda , 
does not &lwn}'R occaiuon inflammation in them ; oometfrnes it | 
only causes an irritation. In the course of the complaint this 
irritation niay develop into a painful inflammatory lesion, acu/e 
mxUiny of th« i/lanttt, or it causes, without any incrawc of 
tbc temperature and witliout any pain, on hypertrt>phy of the 
glands through increase of the hypcrpkstic element, forming 
chronio or indoi-cnt glandular enlargement. The acute or 
chronic state of the glandular swelling, and its future destiny, 
depend firet upon the character of tlio morbid matter trana- 
portcd to the glands by tlio lyuipluitlc rc^^-ts, and, secondly, 
npon the constitational condition of tlio individual. If in- 
tercellular nibstanoe, pore, or gonorrhfEal pna, origtiuiting 
fn)m excoriated placed, is tninapf>rte<l to a gland in a pcreon 
in all other respecta porfoetly well, an acute glandular Bwell- 
ing will be produced, which will either tenninatfl in reso- 
lution or 6n])purition, accoiding to the Whsvior and constitu- 
tion of tho i>aiit;nt. JJiit if mattrr from a soft chuurrc in 
a state of acnte inHammatoiy suppuration is conveyed to the 
glaud, the hitter will to a certainty undergo inflammation a&d 



SOFT CBAXCSE OR CHANCROID. 



131 



mpporation. If tbe discharge or the detritus of an initial or 
eeeoDdatjsjrpliilitic ulcvr m conveyed to tbo glttiid, un indolent 
glandular awelling ^(*)11 result, whicli only nmlcrgoeA sappura- 
tion when ccrUiii preexisting conditions (KKtperate, or when * 
Duw irritation favoring gnppuratioD u transported by addi- 
tional matter. Of all tbe lytnphatio glands in the human 
Ixtdy, the glands in l)otb inguinal rs^iond nro the moat fre- 
qDCTitly atfochsd in tho manner dewrrilM-d. All glandular ta- 
inore arc now called bubon, bccaiigc forraerlj the Greeks called 
the inguinal glands buhonee, or buboes {^ov^Avei;). 

Ptiysiohigit^atly conHidurt-il, tho gliuidnlar afTectton dtJinc- 
ated above ma; be called rrfoluiion biiboca. But. if the »onroe 
of tbe ahaorbed flnid is taken into considcratiou, we might 
upcttk al common^ gonarrhtOdl, cAanoroid, and typkilitic buboos. 
Further, since ahtw>rptioii-babov8 are always precciied by Bome 
morbid alteration, they may be dceignated as deiiUreyxUAic or 
ttcondary buboca. 

Protopathic^ or idiopatMc bubow (bulon* d'emiUe of tbo 
French) are mid to occur when the glandular hj'perlrophiee 
WBTB not prpcodod by any Iceions of the adjacent skin or mil- 
<0ti8 mombnuie, and oonsequt'iitly did not originate by absorp. 
tii.in of noxiong matter. Cazcnave, Vida! de Ca«riH, and Didny 
are even of the opinion that chancroid and eyphilitic virus are 
capable of causing disease of the lymphatic glands wjtiioat 
prerionaly establishing any purulent f(Xfi on tlie nkin or mu- 
cons membrane. Virchow maintains that all glandular hyper* 
trophies arc preceded by a Iceiori of some kind, and where 
nime is foimd be asnertH that it luut dit>u]>j>Lun.*d, as in tbe so- 
called idiopathic adenitis, vbile tlie enlargt-ment remains. He 
foyfs moreover, that in tender, irritable lymphatic gtandi^, rach 
as are generally fonnd in scrofulous perbom, any le«ion which 
in a nbofit person would bo of no consequence whatercr ii 
liable to produce the most ecvcro and ob«tinat« glandular swcll- 
iogB. We can not, however, refrain from expreesing our opin- 
ion tJutt, in coneeqncnce of con^titotional conditions, such aa 
•crofola, lenlcffimia, or syphilis, lymphatic glandolnr enlarge- 
ment may originate witliunt having been preceded by any le- 
aiona of tho adjacent parts. These kinds of glandular bypcr- 
tropbiea are called contiUtUtonal buboeg, or adenitU. 



133 PATBOLQQY AUD TBEATMBNT OF S7PHIU3, 



Bnboes originating m a Besnlt of Soft Chancres. 

Swelling of tlio I_yuii»Iiatie glaiuLt, oenuiTiiig iit ci»i»sequence 
of a soft cliaucrB, geiieraJI^* noon uiidei^gocs sappitmtion. Ov- 
ing to tlieir rapid development, these baboes are called acute 
buboes, and, aasaaiing that the pcmicions TDHttcr thiit w-as con- 
voj-cd to tlic glandu vraa cliaucroua virus, viruicni or chancroid 
Imhofit. However, even soft chancn* ma^ ^vo rise to indolent 
diacase of the glands. It is still a mooted point whether, in 
such caecs, an; cliaDcri>id pne has been abeorbcd, or whether 
other factors play a part. This form of indolent glandular 
Bwelliug may, later on, after weeks or months have eUpMil, 
ngsonio au acute character, and in its eub&oqucnt oonr&c differ 
in no rcepoct from those affbctions of the gIaod« that are ush- 
erod in by acute symptoms. 

A virulent bulM asually originatea in the iirst week after 
the appearance of the iioft chancre ; eometimes, however, after 
the latter has completely cicatrized. This form of retarded 
adenitis indicates tiiat the pcmicioiis matter that has been ab- 
Borbcd ifl being slowly transported to the glands. IJut if Mich 
a gl:ind(ilar swelling does not imdeigu Mippniution, or if, in 
caee it suppurates, the pus by inocnUtion in jH-rsonii unaffected 
with Bvphilia occafcione no nicer, we may a-neume that the chan- 
ctxjus fiorc, »t the time the di^borge woe absorbed from it, no 
longer generated any vimlcnt mattct-. 

It in higldy probable that by the absorptioQ of the chan- 
croid riruB, at tiret, only one or a few gland* are ntfccted. The 
original sisu of the glandular Bwelling is barely as largo as a 
pcu. The swelling generally begins with severe pains, which 
are aggravated by the least presurc, and oocadonally accom* 
panied by febrile movenienL (imdually the territory beyond 
tlie affwted gknd bwccmus ftetisitivf, the skin covering tlie 
glandular tumor also betvniing tender. £vcn tltc moTcmenta 
of the limb on the same nde as the glandular swelling cause in- 
tense pain. The skin over the swelling gradnally increases in 
redncsB, and it is dilHcuIt lo ])incb it up in a fold — a proof that 
it and the subjacent connective tieeuo have altt>ady become 
mtited to the affected glands. In the coun>e of the dilM^a£o the 
capsnle of tlic nippurating gland bur»>ta, the surroonding eon- 
n«ctivo tisBUo imbibcfl the riralciLt matter, tenniuating in a 



SOFT ClIAyCRB OS OUASCSOID. 



13S 



punUcnt faidon of the entire miuis. A virulent or chancroid 
bubo b therefore geoenlly il complicutiou of Hupimratioii of 
the oooDcctivc tusuo and of the lymphatic glands. After the 
ptu lias fonnod, the febrile pheoomena usually sabeidc, oad the 
jmiii? oil movinfj (Jie wiireflpondi ng Uml) are lesa severe. Grad- 
nnlly thn swelling poiiiU, the nkin over it bceomoe livid red at 
Iho highest polut, the epidermis peula off, and, floaJly, l]ie ob- 
scest breakfl and puH («raipes. 

Up to the point of rnpUire, adenitis originatittg from ab- 
sorption of diancrous pus is aoalogoua in its development to 
thoiK; lyiiipliatie HwcIIiiigit of the glaiKJR tiiat arc caiuted by or- 
dinary or goiinrrtKcal piiH. In a patient who is suffering from 
gODorrhu-'a and chancroids at tbu aaiue time, it is tlicrcfore im- 
posnlilc to fay, ttcforo the iuguinal abecoiw has broken, whether 
it ririginatcd from the absorption of tbe gonorrhceal or chan- 
croua poa. After it has broken open it may be diagnosed as 
being probably a case of chancroid bubo. A poeitivc diagnofiis 
that the glandular abMea£ is a chancroid bubo, or, more oor- 
rvotly ^akiug. a glandular chancroid, can only be made from 
tho coarse of the abwcm, and the result of inocidations made 
with the pns from tlio abec^sa. 

If tite glandular swt-Uiug opens RporitaneooBly, or ia opened 
by tho rargeon, a tliick, croam-Iike pus cecapes, like that 
from oilier acute ab*cea=efl ; but, in clironic enppunittng l;tTn- 
phatic tswellingttj thin pus containing cheesy paiticleit, like 
that of cold absce«Bes, ia discluirged. If some of the matter 
fnnn the ahaceEe, taken indiscriminately, is inocnlated under 
the ddn, a pastule will form in some ciii«c9>, wliicL may become 
tnuuformeil into a chancroid ulcer; in others, again, it soon 
dries np and form.') a cruet. If. howcrer, an iuocolation u 
made with matter taken from the bottom of the abacees, Aom 
• fpot where two or three niche-like cxcavntJonB are found, tbe 
postnle produced 'n-ill almoet always be transformed into nn 
nleer. These excavations ore diatingaiehcd by the fact tliat 
their hascA appear to be more ja^^d and covered with a larger 
amount of molecular dt'trittis than iho rest of the bottom of 
the abseess. From all indications they are the depots of thoee 
lymphatic glands to which the chancroid vims was conveyed 
by the lymplmtic ducts. 



K^^^TETOLOOT Am) TREATVENT OF STPBIUS. 

Tlie oponlng of an abdcces, however, doce not tennioalo 
tije morbid process that biid become cAtablisiusd in the j^Uods 
and adjacent conneotivo tissue, as is the caeo in ordimuy ab- 
^maim of the glands, or of the collubir tiitsne ; fur instanea, in 
gonorrhoaal buboes, in winch the latter, aft«r beins; opened, 
quickly bocoiuc8tnalk>r and cicatrize. The chmicroid vinuthat 
Vfat. tnntipurted to the gUud« utd connective tisAue produoos 
its ch-wacteriiitic effect* here, as m a soft cliaiicro of the Rkin. 
The bottom of the absceas eecretes a titiii, ichoroiu tliiid, which 
ooiTodcH the adjacent tiaaaes, especially' the mar^ns of tfae ab- 
Bcesa, undennining llu-m »nd giving tlium a jogged appearance. 
An ulcer of the ^kin^ which ^wluallj enlarges and haa tbo 
clianictcra pc-culiur to a otitauouus ohuncroid, origiuatos frou 
^is abecc»4. tHtinetinies the inarj^ttK uf the ul<x>r are nndctr- 
mine<l and almost deprived of nutrient vessels, livid in color, 
and eljglitly overlap the bottom of the uloer. In other eaaea, 
tbo marffine proliferate, and tindery a condition of sclorafiie, 
becoming evcitcd and forming a wall of oicatrized adlositjr. 

A period of eight, ten, or more davH may elapM) from ths 
time a virulent bubo bc^infi until dietinct flactuation is felt. 
The softening which tiikcs place soouur or later depoadit inun- 
ly upon the behavior of the patient and the care vitK which 
tbo chancroid is treated, and also upon his constitutional con* 
dilloo. Glandular chancroids require a longer time to ran 
their course than chaiicroida of the itkiu or mucoiu nieiDbnuic, 
becao&e glandular tissue and connective tiesoe heal innvh iiioro 
sloivly than ordiuank- Hkin and mncoufi membrane. All foroM 
of dbturli&acce of nutrltioa, euch aa scrofula, tubcrculoaii» 
wwbatuA, etc., exercise greater itUlucnco over the ulccimCioa 
produced bj a bubo than over a ?oft chancre of the akin. 

In favorablo cases, tfae abwcss doees by the end of tha 
fourth week after it tvaa opened. During this period tbo open 
bubo may present all tho moriitd changis that are ohoerved in 
a chnncniid on Uic skin. It may bo attacked by [diagedffiDB, 
and the phag«di]>na may assume a serpiginous character. Tbo 
Borface of the ulcer may become ooveied vith a diphtheritic 
incmbraitc. Luetly, tbo bubo may also beoome gangrcnouci. 
The loose connective ti«sue in which the glands generally aro 
imbedded ia more readily destroyed by thu inflammatory pro* 



SOFT CaANCRS OB CBASOROID, 



136 



henoe bnbo-alcere, eepcciiOlv the {mfiffreDous rariuty, 
lly UBomB inordinate proportions, Fiatulic may foni), 
tuuicnuining and destroying ttio tiseace, and by eroding blood- 
veGfleU cauHe li^morrlia^ct tb&t may endanger life. 

Tho closing of .1 glaiiduliir cliancroid takes ploco in tbo 
sauiD manner nn in a cliancroid of tbc ekin, partJy by the 
fortoatioQ of cicatricial ti^ne from tlio pcripbory toward 
the center, anil partly by tlie retraction of tlie integimic-nt. 
Large glandular chancroids, however, do not cicatrize as qaickly 
at soft cbancrtts of Uio sb'a. At the bottom of tbe latter the 
tunes arc nf a bowologouB uatnrc, whilu fuM-iu, hypertropbicd 
and nlccrating glandii aiid lyiiipliatic tomkIh forming arches 
and prolongations are fonnd in a bnbo. The glandnlar ebon* 
croid offers aumerons couditions which are favorable to tho 
decompoeition of animal matter. Under the iullucnce of goo- 
enl morbid conditions, enoh as hoepitalism, or in. couscqueooe 
of Irritating dreseinga and ointments, tbo proUfcrating gr&na- 
Utiom niddoal^ become palo, wilted, and collupeod, nnd imder- 
go eheesy or gangreaoua degeneratlau. Not only is the eica> 
trization interferod with by tlieoe morbid conditions, bat tho 
growth of puB-oelU is greatly fo^erod. 

The nvtitution of tho epidnnniR, flA a mle, pmgremcs from 
the margtnit of th<« ulcer, or small islands of epithelial colls 
spring up at a distance from the margin. 

Chancroid bul>oes occur more frequently in men than in 
women, owing doiilitlew to tlie fart that in the latter mortaoft 
chancres are eJtuutod upon tbc mucoua membrane of tho gcu* 
ital organs, and also because fcinalcB, aa a role, lead a mora 
qnict life 

Bite, Shape, and 8i2e of Chancroid Buboet. 

Afl a rule, the giands wituated neartvt the chancroid become 
aSocted. Tlie chancroid virus seldom ortTleaps adjacent 
^ands and atcacks those at a distance Thus, in consequence 
of a soft ohancre on the genital orgaus, tlic inguinal and femo- 
ral glands ; on the lips or tongue, tlie submaxillary and sublin- 
gual; on the fingen, cubital or axillary, or also tlie jugular or 
snbclavical glands of the corresponding extremity, become af- 
fected. The ingniniil glands ore nut always affected on the 



136 PATHQloaX ASJ} TSXATMeAT Or 8YPM1LIS. 



side corrcepooding to tho eitoatioQ of tbc chuictoid on Uie 
gonilal urgaoe. Tlie soft cliauore may be situated ud tlie ri^lit 
side, while the ingniual glaiids on tlie left nn> di&eoaed, or the 
revcrnc w the CAi^. This fnct is exj)Iaiii(Hl by the atiutomOBlfi 
of iho abeorbeat lymphatic vesaeU. Chaueroida situated upon 
the mcdiau lint; oi tlie |H!iiiA, e»[MM:ially those on die fntDtua, 
are apt to produce titiiiefsctioti of tJio lymphatic glands on 
both sides. riMures in the folds of tlie mncooa membrane of 
tbu anus, ulcent or f uniiiclta on the tuber iscUia or on lUe bnV 
tockfi, likewlso ^ve rise to ewolUng of the inguinal lytnphatie 
glands. 

The g1and« found in the inguinal triangle arc divided into 
the 6u]X'rticial and deep hy the fsficia of th« region. The en- 
{jurtjcial gUuidij an.' uum«roue, covcrkI l>y the fascia Empcrfiei- 
alis, and Lie Jmbi-dded in the nic(*lies of iidipCBe tissuo ; there 
aro only thrco or four (Boniotintcs only one) dcop glands which 
lie directly U{H>n the slieath of the femoral vefi^ela. 

Tlie Riiperfidal inguinal glands are affectwl much more fre- 
quently than the deep, and when the latter are a^ected, in 
conseqaence of a Boft chancre, it U not caused directly, but by 
imbibition from a fniperficial mippmnting gland or tlie contigu- 
ous connective ti&»ne. SuppnrBtioa of the deep glands is much 
more dang«roua than that of the superScial ones. 

The form of Uic glandular tumor i» more distinct in lean 
persoDfi than in etoiit oneo, and thus it often happens that in 
women n-ith pendulous abdomene no swelling can be seen, al- 
though they may have laffirod from febrile phenomena and 
complained of pains in one of tlie inguinal regions for several 
days. Acute chancroid bnbocfi vart' in ttliapt.'. Inguinal swell- 
ings of the ]}inphatics are generally elliptical ; their principal 
axis ts in a lino with the inguinal fold. Axillary and jugular 
glandular tumors are nsually round. 

A glandular Hwelling formed by the inflammation of oo« 
gland only will present a smooth snrfaoc; hut if screral adjn- 
oont glands are involved, it will present, at least at the begin- 
ning, an oneven. hilly lump. This form of swelling of the in- 
gainal glands not iofreqaently acffuircs a ehn)xi like a wallet, 
owing to Poupart's ligament being stretched traneverecly 
■cross iu 



SOFT CBASCRB OR CBANC&OW. 



187 



Tlie eizo or circmufcrpnco of the glandular gweltin^ de- 
peods, abcive all, upitii tlii; cuustitutioDal cuiid itiuii uf ttio pntient. 
ThoBy large bnlioex fonu in ncrofnlous per«jtie vrlien affected 
with chancroids. It t-oems that the chancroid virtu in tbcw 
patlontit cauBca more irritation and increase uf hyperplastic 
exudation into lliu gliuidulur «uh3tanc-L> lliaii dwtrnctive action. 
Hence, iindur appmpriato trodtiiient, raH)lDtii>n of tlio bubo is 
Boon achieved ; hut should pnralent de^neVation occur, which 
aeuully liappuiis by thv third or fourth wevk after the Kwcllliig 
has appeared, it will only affect tUo oonnectlTo tiasne eurrouud- 
ing the glands, while the glandular piiruach^-nia escapee. In 
thoeo eaeca, fistula? often rtuiult. Thin kind of glandular in- 
flatnmation is known as strumous buboes. 

It ii* more ditiicnit to deinotu^trBtt! Kuppurslion of the glands 
than of the enlwutaneoiiH cfllular tissue, hecaiiso tlie former 
are situated at a greater distance from the ekin than the lat- 
ter. In biilxiert formed uf in:uiy glands, uot iiifnxjuently eheeijy 
degenenition or piinilent foci develop, and gradually either 
oooleace into a common cavity or rupture separately, forming 
muUipU buhoi'S. 

Diffeisntiol Dia^osis aod Prognosis of Baboea. 

Buhoefl of the groiu, before they art t/pen^ may be mif^ken 
for an inflamed teidticlo that has been retained in the inguinal 
oonal; for a strangulated or rcducihlo honiiu; and, Listly, for a 
rnrix of the Toim sapheoa at the point where it Uipd into tho 
vctia crurali». 

The diagnostic featurett of a non-dwomd^ ir^lantad UttMt 
arc : The absence of one testicle from tho Bcrotuin ; tho pecul- 
iar pain on touching the swelling; and, la}<tlj, itft ctuiraetertfttic 
bardoess. Glandular swellings, before ptis lia» fonned in tliem, 
are hanlcr to the touch than a testicle. An epididymitis, in 
addition, is distingnisbed from a Buppuratlng bubo by tlie ab- 
■mcc of Boftcuing. The i>yniptuiui; o£ a rfducihlc hernia arc : 
The tamor is soft, compref<t<ibIe, and becomce Bmaller when the 
patunt aBSumes a horizontal poeiti on— larger when he eitands^ 
000^^ or snoczcg. On pricing an enUirocvIe, Ixirbork-gini aro 
heani, aud, attendod by a gurgling noise, tbo prolapwd gut 
slipe back into tho abdomen. In eiivnfft^aUd Ai^mia thero 



138 PATHOWar AND TREATMBUT OF StPBllia. 

arc, in addition to tlic gcacral sjr'iuptoitut, ooUe-paius flatoleoce, 
etc Tliv pcrcufision-eound is gciicraJly tympoutic. Later, 
the gyuiptoius of infloiutnation and the evideneee of gangrene 
ensne, followed hv vomiting of Rtereoraoeooa matter. 

The chara<!t«ne:ic BvinptotiiB of varKe are : Tlio rise and 
fall of the tamor, ^cbronoiis with inspiratioD and expir»- 
tiou, itit iuorea^ed teusioa whea the sapltena vein ia com* 
pruaiwd abovu it, and its collapse when the Teiii ijs uompreeaed 
below it. 

Ojfen inguinal buboes arc apt to deceive the pli\'Bician by 
the fiiinilarity thvy eoiuutimcs prceent to cjnihciiiil carcitioJita 
situated ill tlic inguiual region. lu regard to the diSecentUl 
diagnoeis, we refer tbe reader to -what baja been said ounccni- 
ing the differential diaguoeis between a £oft chancre and epi- 
thelioma. 

The c]iarat!t«r and idtimate result of n bubo can not be 
definitely decidtKl at it« uoiiiinencbuK'nt. It is only ]H>!i»iblc 
to infer from the exiating or preceding chancroidfi that the be- 
ginning bubo 18 the result of absorption of the cliauoroua virusy 
and that it will ineritabty 8U])piirute. But if the chancroid 
vaa dcatrized long before the bubo began, wo ore justified in 
aasuming that tlie pns from tbe eoft chancre wan bronght to 
the glande at a time wlicn tlic former vnm no longer virulent, 
and in this event suppuration need not necessarily ensue. The- 
conatitutionul condition of tbe jwticnt, hie behaviurt and tbo 
character of the chancroid, play an important port, and ehould 
be taken into consideration in forming a prognoeij. lu feeble, 
anieouc, ecrofuloos, tubercnlone, and cachectic persons, the anp- 
poratioQ. and cicntrization of a babe never progrew BBtiafao- 
torily. Not infrequently tliey are intermpted by the nipor- 
vention of a gangn'noufi, inflatnmatorj condition of iht! aub- 
cntaneoire c^Mlnlar tissue, especially when the patient is confined 
in an unliealthy atniosphere — for instance, in a hoapitaL Vio* 
lent ei»rciie ap^ravatea tlie inflammation and the tendency to 
sappiirate. The greater the number of the glands affected, 
the larger the abscc^ vill be. and the longer the cavity will 
take to cicatrize. If the nnft chancre becomes phagedenic, 
the suppuniting bnbo will alt^o a»iumi! a phagedouic cliaracter. 
Gangrenoufl buboee are exceedingly daiigeroaa. The hyper* 



SOJ-T Cn.l.VCRE OR OBANO&OIO. 139 

pUnlic enlapjfwl glands, baviiig been doprived uf their cajwnlefl, 
project into Uie cuvity of thu alisee^ und prvvoiit iU cicatri- 
sUiotL 

Tnatmeat of Diaeaiei of the Lympliatio TeneU produced by 

Chjuoroidi, 

In iuflunmAtioT) of tho lyiiiphiUtc vo«>e1d of tlie donum 
of the pcnU, Itowever it may be produced, tUe or^D u to bo 
pot on tbo abdomon and wrappud iu cumpn:&H.<tt dippo<l in 
toe-water. SuppuratiDg babonuU sboald be incited, and tlio 
open lymplintit! abeceatt, if it hao originated in consequenoo of 
« soft cbuncrc, trooted precisely like a cliancroid on tbo skia. 
If erideucee of inAammation of tbo lympbatic Tossela ap- 
pear, tin irritating caustios or lotions ^ould bo applied to 
tbe tshaneroid. 

Treatment of Baboea before they are opened. 

Tie abortive tnsittin-nt may bo nssortixl to iu the bop« 
of anesting the beginning inflammation of the glandular and 
connective tissue, and of avoiding or limittug siippnrution. In 
buboes canflod by soft chancrm it in tictdoiTi gaccct«fiful ; it may 
prov« moro eacceaaful Id contagious catorrbg of the orbtlira or 
tho glands, in swoIliDg of tho glands duo to a syphilitic initial 
chaocru, or in cases in which a simple lesion in coexisting 
ficrofula was the caiue of the glandnlar swelling. 

first of all, evcFytbiag should be avoided that may increase 
the irritation of the gUuda. Tho patient niuttt etay in bed ; 
but, ID torpid, fitnimoQfi buboes of cachectic penwns, tnodcnto 
exorcifie in the open air ia beneficial. Cold coDnpreMOB ahoold 
bo applied to the glandular gwcUing, if it presents a» iuflamed 
nttter tlian a liyperptaKtic ind^jknt characlur; but if the leaot 
pnlmonary catarrh be preoent., tlieee applications fihould be 
made with the utmwt cautioa '^V« have found the i-oniprew 
or T-hand.ige to be wry useful in hyperpIaRtic gwelling of 
tjie lymphatic glands, for tlie purpoee of encouraging absorp- 
tion. BliMcrs, with or without the loco] application eubae- 
quently of a concvot.rut<Kl dilution of comjiiivc eiiMimate, in 
oar liandft. failed aluioet entirety. In riev of the phannaco- 
dynamid action of iodine, the tinctnro of iodine may be em- 



140 PATHOLOOY AND TREATMENT OF SYPaiUS. 

ployed for tliat piirposo, jKiiiiting tlie i*kiu over Uio swelling 
with it br Dicuns of a. camel's-hair bnuh. Tlie irritating eficcte 
of this remedy mny bo {Iiniiniali«d by the addition of no 
anodyne. Wo therefore order the following eompotind : 

B Tr. io.Ilne, 3000ISJ1; 
Tr. bclladoDM, IfrOO [3 vViS\. 
U. 8. fur extomal use. 

B Tr. i<xIiDe,W)'00[Sj]; 
Tr.gaHar.. 16-00 II «.]. 
U. S, For cxt«rDiU lue. 

If the ftkiu ueverthtilexti bccomm irritatocl, wc order iodine 
plaster in±itead of the tincture, in tlio following nuumcr: 

B lod. plumbi, 5-00 [9 iv]; 

Empl&a. dioob.vl. eorap., SOtll) | ^J««., ^ It], 
Cog, elcmi q. ^ at Sat vui^ uollo, 

The plaster \& spread upon mnelin or eoft leather, a&d 
&ppU(Ml to the glandular swoUinfc. Iodine, after all^ is beet 
adapted to accompliiih resolution in indolent stmmous buhoea. 
PiM the odor of iodine is disagreeable, vie employ inst«ad tlie 
'haxio acetate of lead, and hare obtained at l(»ut as good results 
with it aii with iodine. ComprviwoH dip[)iMl iti a solntluii of 
aootate of lead ore applied to tlic Ewelling and ehanged Kvertl 
dniea a day, aeonring tbeiu to the parts with a spica bandage. 
Uuder this treatment tlie hypenemia and rednew of the aldn 
disappear, and the swelling diniinii^bee in dxe. 

If, however, despite the application of the lead-water oom- 
pre86c«, suppuration takes place, and flnctuation ia detected, 
the piiH niiiHt 1>c cracnated under (ttrirtly antiM^ptic pre(!autiona. 
FirBt, the hairs fthould he eliared off, the parts washed care- 
fully, and while the operation is being performed a stream of 
a two-pcr-cent wlntion of carbolic acid should irrigate the 
parts. Tlie abscess may be ponctured with a sharp-pointed 
bietoury, or laid open by careful diseection witli a scalpel In 
a line running along tlie inguinal fold. Tlie latter eouree ia 
eepocifllly recommended to tiie inexperienced. We have known 
inntanceit in wliieli very good phyneiani; injureil tha arteria 
crnralia while punctwring a biilxi. At first a small opening 
sboold be made : if no poa escapee at once, a binnt probe, pre- 



SOFT CBJJfGSS OS CIUKOBOW. 



141 



Tlooftl/ dipptxl iu tbc diHitifLtrling fluid, .tliould Iw inserted 
into the wound, and the little tinger (also waslied in tlic same 
fluid) being placed in the wound to laoertiun b;y tlie Bciue of 
toneh whether any important orgiuus aru in tlio way, tho cap- 
eolo of the gland, and the glandular euhelsnce il^lf, should 
then be broken tip. If pus be present, which is oure to bo 
the case when prtjseiipo with the probe at any one spot of tho 
unopened glandular tnmor eau£es very severe pain, it will soon 
flow from the wound. A director is then parsed into tlie 
wound, and the cavjtj- freely laid open. It is best to roniovo 
the nndennined skin at once, iu order to liavc a unifono wound 
without any jKwketB. Any divided bUK>d'V«»el mn«t l>e tied. 
Particles of the disorganized gland should be mr^uUy scraped 
away with tlie MMop. 

After the opt^ration ih linlKlied tlie wound should again be 
washed with a two-per-cent solution of carbolic add, tlien dried 
with Bnin's wadding, and powdered with iodoform; next, 
eeroral Uyeni of anttM-ptiv gauzo lundo into a compreaa and laid 
upon it are -covered with a piece of gutta-percha cloth, and tho 
wholt: secured by a epica bwdagc This drcaaiDg must he re- 
newed every day, and the subecquent treatment of the wound 
ia conducted in acoordoncc with Uic general rules of aujgoiy. 

Tho «*c of caustic pastes for the purpose of opening buboes 
has been discarded, ae they are unsurgieal. 

In aiiteniic patients, in whom very little pus is ^iroecntr wo 
may first attempt to puncture the abscess with Graefe's cata- 
ract-knife, allowing the pus to escape, and then applying lead- 
water conipreneB. Zj\ i\\\» manner, in aonw cues, a eiire was 
achieved, the skin that had already been raised by tlie pus 

beneath it 



i^ain uniting 



parts 



The TreatmeiU of Open Baboeai 

A bubo that broke open sl}OIlta^e^lu^^y, or wujii opened with 
a knife, originating in conwjiinence of gonorrhrpa or an ero- 
sion, should be treated like on ordimLrr absceae of the lymphatic 
glands or connective tissue. Bnt, if it l>e the result of a soft 
cltancrc etill in fall progress, it is to be regarded as a cliancroid 
of tbc glands and cellular tiseue, and treated like a soft chancre 
of the dcin, taking into oouaidcration, liowever, the location 



143 PATBOIOGY AlfD TRBATUEST OF STPBIUS. 

luid atnictare of the diseased fuci. A glacdniar chancroid 
forms na ulcuratiug carit; hi which piu mixed with tiisao- 
dctrituB may eaeilj aecnmnlate. Tfae«6 cavities fibould, thcro- 
fore. bo washed out wjveral tim«e a day, either with a eyringe 
or by irrigntion, or by means of aitz-baths, in which the patie&t 
i» kept fur a loofi; time. After this the cavitiee Bbould be 
pncil<«4l with |iledgetii uf eottnii dipped in a solution of cirbolie 
ncid or chloride of zinc, cb]or«t« of potoeh, caustic potaiJi, ur, 
better etitl, powdered with iodoform. A Bpicn oomprese baud* 
age should theu Iw applied. lIypertro[^ied glands, whose cap- 
soles have been doiitroyed, and wliich project into the cavity of 
the absccES, should not always be cut away. It u prefcTable to 
paint tliem several times a day with a weak Bolation of caoedc 
potash or soda, or once a day witli a concentrated ttoltition ajU 
nitrate of silver. We have also eecn good reeiilts from filling 
the cavity with a compound consisting of balauu of P&ra, 30*00 
[ 5 ««., 3 jv] and uiy. nitric, 0-05 [gr. j]. Ocowioually, wc 
have derived much benefit by injecting onco a day a little 
buic aflctate td lead, with a Pravaz itrringe, into the expoficd 
hyperplastic enlarged glands. Hypcrtropliicd lympbatio cords 
ahotdd bo divided with the sdasors, and callous maf^gin^ of the 
skin removed. In commencing gnngrenc, we apply an emal- 
eion of camphor, or fill the cavity of tlic abeoess altcmately 
with pled^ts of eritton dip|>Gd in chloride of lime and with 
plaster of Paris and tar or iodoform, and cover the wliole with 
ice-cold appliralintiit. If the gangrene can not be checked, the 
actual coutcT}' Bhoald be employed, tir the patient put into a 
bath. Lastly, the room occupied by the patient ttlioutd be 
thoroughly and frequently ventilated, because in damp, darit, 
and badly ventitatcd rooms buboca readily aeatuue a putrid 
character. 



Fiitolffi in «oiueqacnoe of SQpporating Buboes. 

Fietulie result either from the borrowing of pti^ or thoy 
are the eoneeiinences of a progrcHdive inflammation of the sub- 
entaneoos or intcrmufiniliir cellular ti^oe and of the cellular 
tieBOO of the sheaths of vessels and fascia. Tlicy run either 
superficially nuder the skin and fascia siiperficialis, or form 
ainnoaitiee deep between the tissnca. Fiatul» may last for 



SOFT CBA^CRB OS CBAliOROTB. 



14S 



years, and thereby render tlie patient CAcbectic The danger 
from tbom ineireues with their extent ; those peut^ratiiig 
deeply arc more dangeroiui than the ROperfic-ial on««. At* 
tended by intlamiOAtory piienomena, an infiltrated fiwelling 
forms at the external end of the lifltnla, which soon becomes 
•oft uid breaks, iu maxty cues at a distance from the uriginal 
tbeeesa. Ab a rotnilt of this burrowing, the HstnlsB aoqnire a 
^exy tortoons conr»e, having branobee that lead in different 
dfreotion«, but ani co&noctcd by one poroat canal. They may 
become tilled up with granulations whereby the Itunen of their 
anal* is plugged up. In euri^quenoe of tliceo gnnnUtiom^ 
tfaay may beoome cicatrized tike eanls, temporarily or pcnna>- 
neotJy, or the walU are only lined with dcalrioial tissue while 
the HUpptiratioa eontiuuoa. 

ThiB Tariety of fistulre may oocnr above and below Pen* 
part'fl ligament Those alttiated below Poiipart's ligBment be- 
come seriouK when tlicy burrow beneath the Hhuath of the funi- 
onJ TCfiseU and between the abdnotoni of the thigh, or when 
Ch<y extend into tlie leeeer pelric cavity along Gimbeniat's 
ligament. Tlie greatest danger in iifitula appears when gan- 
grene givee rifle to ercidon of Eome of the arteries — for inetauce, 
the eitcnmflex. 

To prevent tirtulffi from forming, the physician will find it 
neCQfleary to bring about a miioD of the undurmincd akin with 
the labjacent parts, or, by making a cotrntcr-oiK-niiig, or, by 
fntAj Inyiog open the nbeceee, to evacnate the puB. Xo fttttu- 
lona tract should bo laid open till all hopc« of resolution are 
gone, and the inllaminatory phenomena plainly indicate that 
pas has f»rmi!4l. With thai object iu view, cold-wnter appli- 
cation!) shoald be made, and changed m often as they become 
warm, and the tract Bhotild he conipreseed with appropriate 
dnasings and bandage. 

The fistula may cither lie slit open with a eciaeora or bis- 
toury upon a grooved director, or a ligature may bo passed 
through and allowed to ulcerate its way out. The former 
DKthod is better adapted in eaporticial, fltraight fietulffi — the 
latter in deep, tortuous ones. By the uee of the hgature, 
haemorrhage i» aToided, which, in a patient already exhausted, 
may prove very eerious. Thia meaBuro, moreover, brings about 



144 PATHOLOGY ASD TREATilENT OF STPBIUS. 



a more speedy cloeare of the tract tliau l>v slitting it open. 
Tlie ligAtare maj be eitlier of silk wuli waxud, or an clastic 
dniaago^bo. 

By means of a probe arme^ with the Ugatoro or dmlnago- 
tabo, an effort h made to Uud the tenmnal opening of the 
Gstiila. If it tcnmnatce at a point on tho ekin in the vkiuity, 
the instrniiioat ie pusbod tlirougb, and one end of the ligatnre 
is brought out at the lower opomug; but if the tract ttrmi- 
uates blind, iiiul tbe jioiut of tlm probe ia felt beneath tlie 
skin, the probe shonid be withdrawn, a grooved director in- 
serted, and aa incision made with a bifttouiy on its point; after 
which the probe, anued with the ligature, ma/ bo pawed 
tlirougli the HetnU. If tbo tract penotratet! per[>cndieular]y 
into tho titHuest an effort should be made, hy iufierting into 
it comprce&ed ^pongee, laminana, or the like, to convert it into 
ft fuDDcl-ehnped cavitj, Trhoso larger nportiirc is directed oat- 
wardlj, and by the applioatiou of etimalating drc<««:n£ make 
it cIcK« up. If thia faiU, a drainage-tube of tlie pro])^ length 
and thieknoas ahould bo inserted. Finally, by cleanging the 
fietnla froquenlly, and by applying cauRtio or antiscjitic rcmo- 
die6, tiucli as weuk Kilutions of cnogtic potasli or eirlxilie acid, 
Lister's paste or iodofonn, a union of its walls may be brought 
abuuL If a lardaceouK iiii>mhrHtiH (fatty and luolecular do- 
generated connective tiague) fo^m;^ along the lintnloas poange 
that has been laid open, pledgets of liut dipped in a weak so 
Intion of cautttic potattli, acetate of iron, iodo-glyeerine, or 
chloride of zIik^ ^liuiilU be applied once or twice daily. 



SECTION in. 

SVPJ/JLIS. 

0«ft«nl Conoeption. 

Bt the tenn mjphiiis U meant a blood-poUoning, prodacod 
bjr ■ peculiar aniiual virua, ah the nstuU of wbicb v&rioos mor- 
bid louons, oocarrin^ id a more or les^ constant wrieK, aro oo- 
canoneil in the difforont tissuca of the buman bodr, and id 
which the specific inltatiunatory preMltictH, und the blood from 
tlie affected person, when transmitted to other hcalttiy pcraons, 
prodoce in the latter giiDilar morbid eflecta. 

Vaton and VeUcle of tlie Syphilitic Tim. 

Th« 8\'plii]itie couU^ou adiicrcs to all textiiral dements 
and t«xtural d^tntiiit pr<Mlu(H.il l>v mipjiurBtioii or hiuDcerocia 
In coiueqiience of Bjpliilis. it is most abnndant in dioorganized 
Bjphilitic papules and the 6loughin|; initiAl eclerosia or bard 
chancre. Tiic blood and huiuuu of virile ejphilittc persona do 
not Boem to be totallj, and at all dmes, tainted with the eyphi- 
Utio element. In this wny tuny hu explained the variahle re* 
mite obtained from inoculatiooe with the blood from syphilitic 
poreoog, and the fact that a Rjphilitic father will at one time 
bej^t a healthy child, and at another a ej'philitic one. Tho 
milk, sativa, tears, and urine, do not Eeem xo form a vehicle 
lor the transportation of the erphilitic vinu. Ilvnce tliose 
patholo|i;i«al secretions that have no oonnccttOD with syphiHs — 
for jntftjitinft, gonorrhwat duwhargeis the matter from ecxema, 
the spnta of pneumonia in a syphilitic person— can only be- 
come infectiom ayphilitieally when they are mixed with syphi- 
Utio blood or ^rpliilitic detritus 
JO 



146 PATSOLO&r ASD TRSATUSiTT OF BTPBJUS. 



The contagiou of lijiiliilis, from all accuunts, is a fixed 
principle. TJiere \& no fitich thing m eyphilicic miaani. Kcithcr 
tbe microE«ope nor chomUtry has eo fu* been able to fumiali 
U8 with nii^ more dcbnite iofomiatioD regarding its nataro. 
Some uuthors claiiu to have diBcovoi^d a peculiar micro-organ- 
iun vrhicli ia prewnt iu tlie bloiitl and tlio morbid lennos, ani] 
which engender! the Byphililic dise-Rse; nafortimati>ly, how- 
ever, the discoverer etill lackg contimiadoo. 



The 



In 



Transminlbility of STphiUa, or tlie Tarions Way* 
wUch SfpUlitio Infection ma; take place. 

STpbilia may be tmnsmitted cither direcUjr bj contact 
with sypliilitic tiABUo-etouiuntx or by procreation on tlie part 
of fij'philitic parents. The manifeetations of the firet form 
are called "acquired" Bjpbilis {*yphilU ac^Mtta), tboeo of 
the latter hereditary eyphilia {typMlU hereditaria). The con- 
tagion of e)rphiU3 being, as stated, a tix«>d priociplo, it Wgins 
to manifest iti%If at some given ]>oint, and tlience infects liio 
entire system. The LnfeetioD of tbe system most be preceded 
by a solution of continnity, and it is entirely immaterial wbotber 
it is pnjiliioed at tho same lime or some time before the syphi- 
litic viras took effect. The uninjnred epiderraiii, as a rate, 
fonus H proUtctioD ajjainst infection by syphilis. In mo»t caMB 
the lesion and tlu; iiifoction take placv through coitus, during 
wliicli, by friction or maceration, the epidermis or tlic epithelial 
layer at some point on the genital or;g;ans is abraded, and the 
denuded spot on the skin ur mucous membrane is readily acted 
on by tho syphilitic vims, Tho vims may, however, also gain 
an entrance into the system through many Other pLaooB — for 
instance, tho mouth, tongue, cheeki, eyelidft, forehead, nlpplea, 
fingers, etc. Tbe tronsmisnoD is eitlior direct from a dis- 
eased to a well person, or it is indirect. Tlie direct transmia- 
sion of the Byphilitio virus usually lakes place during coition, 
kisdng, wet-nursing, operations by surgeons, tuidwi^'os, nurses, 
etc The indirect infection may occur by nlen^ils, cigar-hold- 
er*, pijjcs, surgical inatruincnta, bandages, etc Even persons 
who are welt may serve as agents in transporting the virns 
without becoming themselvea aJfecte<I, mmply alTi^nling a tem- 
porary ahelter for it at some place on their bodies — for instanoo^ 



arPBTua. 



14T 



In tlto vagina, or andcr the Dajls. The evphilltic contagion, 
nnder favomble circiimKtunues, may give ru« to ttyphilU in aU 
peraons who hitherto had not lit-en HlTecled with it. No age, 
no temperament, and, as it seems, no nation, have, a^ r^arda 
srpbilis, any special iiumunU^', nor again any epcctul miiiccptt- 
tiiiity. Syphilitic tiKifnc-utemcnta retain thuir jwwcre of infoo* 
tion for « long but nncortaio poriod ; syphilitic papnlee, for 
instance, arc capable of commtuicating ih6 diseose after man/ 
montJw. 

ZruuDLiHioa of STphilii by V&coioation. The Aelation of Vw* 
cine Lympli to Syplulitio Vina 

During tlie early part of Ihia eontnry many phynicians ro- 
port«d nitmarnnH iiiBtancei^ in which, iu coiisoijucnce of vncd* 
udon, hard, protracted, indnrated iitcers funned iit the site of 
Taocinatlon, followed eubeequently by syphilitic eruptions of 
the slttn. The qaaotion now zrm^ How is the trau^mittaiun of 
ayphili», in t-onswiuvncc of vaccination, brought about t Oar 
opinion is. that syphilis can only be tnuiemittcd by vaccioatioD 
when «yphititic gt'rm-idoiiicnts arc transplanted at the same 
time with the vaooino lymph. Tlitttio elements are the blood of 
a ^pliilitic penon, and the molecular detritus, or tho pus origi* 
Dating from nyphilitic cruptioodb AVe only agree in the opin- 
ion of Viennoie in so for au to admit that in wimo cowk nyphi- 
Ib may be tran£mJtt«d by me«ns of tlio vaccine lymph taken 
from a syphilitic pcreon, when tlio vaccine Tirni? bocomee 
mixed with some Ulood from tUat patient Tliin qumnur of 
tnuiBportation also serves partially to explain the fact that, in 
tlio class of vaodnationB in which blood has eimultoneouflly 
been transported, only a few of the vaodnated 1»ecame Ryphi- 
Utic The experimental inoculations of healtliy personti with the 
blood of syphilitics have shown th.it the remits vary very macli. 
Those inoculations in which some ^ivphititic lilood was ttans- 
mitled with the lymph tulcim from a normal vaccine vesicle 
eorrespond to tboee coses of vaccinal syphilis, in which acir- 
cmnscribed, hard initio] node formed at the place of voccina- 
tiopn aft4:r the votwino reeiclo had gone thrfnigb the puocx^et^ivu 
stages of normal development, dried into a cmst, and snb- 
•eqxiently fell off. Syphilifl may, howewr, also be transmit- 



U8 PATSOLOOT AND TRBATMBNT OF SYPBtLTS. 



tod in viiocm»tiug wHb Ijmph, taken from a sypLilitic per- 
son, and uiixud witU tissue detrituii re^iUtinf^ from evpliilitio 
difiorganiaition. The reeults of the inoculntiona which Pick 
and KmuKe obtained b; luing the mutter of bullooe or poEtn- 
lar erupti<»i8 on B^'philitic {m^fsodh justify db in aamminf; that 
in patienU affected with tatuut or durid Kypliiliti, if %-»cc>inntod 
-with cow-pock rims, a vesicle or pustule majr be prodnoed 
that gradually develops iuto a little nicer. Now. eueh a vehi- 
cle situated upon a syphilitic putieut may he luUtakcn for a 
Taccine veaiclc, uud ita cutitcntH, if need, may eerre as a meAits 
cf transmitting gyphilie : the disease b gture to be franaaiitted 
a some of the pus it contaiuB is ueed. 

Tliis vicvr also ecrvos to explain tlie fact that In some 
ca««« the vaccinations failed, and yet at abont the end of 
the third wvek after the person was racciniitcd s circum- 
scribed KyphUitic ficlcrosifi of tbo tiwuee developed at tbe 
point of vaceiuation. 

The tlieur^- that vaccine lymph iu its paisage tlirough a 
syphilitic system likewiBe becomes syphilitic, i. e., acquires the 
property of Bypliilis in addition t*> Iwing cow-pojc, is refoted by 
nmneron^ vaccinations performed upon healthy pereons by 
some of tlic nioet reliable investigators who nsed vaccine Ij-mph 
taken from Rvphilitic pAticiit«, and invariably ])mdnccd normal 
cow-poi — never syphilis. Were tbe cow-pox lympb of syphi- 
Htic iiKlividtiidfi clmrgcd with the contagion of vaccine aitd of 
sypbiliSf every person that is succcesfully Taccinatcd witli it 
wonld also become a£ected with syphilis. Cut this doc« not 
happen. 

From the preceding; remarks it is evident tbit tlie fotlov- 
in^ rules ebonld be otworvod in performing vaceination : 

(1) The child from whom the vactuno viruH ia taken, and 
hie pirents, ehould be subjocted to a most careful examinatioo. 

(2) In view of tbe fact that congenital syphilia rarely 
breaks out before tlie eud of the third week afu<r birth, no 
vaccine lym])h shonld be taken fn>m a ohilil under eight woelu 
of a^. (See Hereditary f>yplnli».) 

(3) No vaceliiu lymph uiixed witli blood or pus sbonld be 
QBcd under any circnmstauoeB, 

[The Barest way of avoiding transmisdoo' of sypbilia by 



SYPmus. 

Tncctnation i« to diwurcl hnmanizcd raceme ontircly, and use 
aoimal vaccine Ijnijili oul/.] 

TranimiaubUity of Syphilii to Warm-blooded ATiimalf, 

'NSIiutlicr inii'pliilis can be transmitted to animiilB, and pro- 
duce in tbeiu loanifeetatiDQs ejuiilor to tliosc i>rodueL-U in mao, 
U itiU iLU o(>eu quoetioo. Wliilu eomo invcetigatore — for ex- 
amplOf Rlebs and Martiiieau — report enccesfftil inoculstiona in 
ap«0 and Logs neithor >'cuutiuui uor myeelf succeeded in pro- 
ducing cither a primary local effect or any otiier manifcEtatioa 
of luos by inoculating this class of aniuiaU witli eyphilitie ptis 
or blood. In one ape whom we inocnlntcd in tliree plauu) on 
tho bock witfa the pus of a snft chimcK, we succeeded in pro- 
dacmg piutulee wluclt e^un lH.>caino convortcd into ulcers tliat 
healed vittiiu tliree weekH. ^luiiy tiiuiilar experiuieutd fnr- 
nided aae<inslly striking proof of tbediQercnce between aeoft 
chancre and nypbUis. 

Tint Hanifentationi of tbe Action of the Sjrphilltic Tinu. 

The lirst tiianifistatiuii of the a<.-dou of sypliilltic poison is 
prcicntcd at tlie spot where the rinu woa deiKwited and ab- 
sorbed. Tlie first L-xtcruiil nianifutttaliou tliat appears at tbe pLice 
of infec&in varies, however, according as the Byphilitio COD- 
UgiuQ 10 aesociatod with on irritativo factor, i. o., pue or icbor, 
or with some hannlct>a fluid, ^cli ae blood, ecrum, or lymph. 
In the former event, there appcare at the place a circnmscribcd 
hypennnia and awelliug, the latter pnHsing in a few or several 
day» into a condition of pnnilent goftening or nlccretion of tbo 
tiaene& The ewelUug and ^suppuration appear there all tbo 
more qniekly and more inteiiKuly, the deeper tbe Rolution of 
continaity tlirongh which the syphilitic virus took effect. The 
turaas, in penons who bad not been previou^y affected with 
n'pliilis;, do not aj^tmne for a lon>; while at Ibe place of infeo- 
ti<«u tbow pathognomonic alteratiouB which we would recog- 
nize as evidences of luetic infection. Jlnt if the infecting con- 
tagion was not combined with puBHjells, hut only with ^ucb 
flnida as are nsiially eetircted on tliu superficial surface of tho 
sclerotic ulcer {iniarceOvJar erud^ition), at with the hli>od of ft 
syphilitic iadividool ; and, above all, if at the place of infection 



PATW0L0Q7 AWD TREATMENT OP SYPHILIS. 



tbcro WHS no deep eolution of coatinuitj, but only % am- 
ple excori&tion — do enpporation will toko place, and tbc ex- 
ooriatiuu will beul quickly. Aitcr a longer or ^lorter period 
{firti jwriod of infmhatum)^ a nodule, varying in eize, will 
form. At the janctioD of integument with tlie mucons mem- 
bnuie tliU roeomblea a luoltit ]»ipulc that is just bi^iuUEig 
to grow. 

Repeated observations, however, liave tangbt ns that per- 
sons affected with latent, feeble syphilis, tbough having no 
Bjrpbilitie eifecU on any part of their liodits, tnav commDiucatc 
the diecaee to their wrives, altlmngh it iw not possible to dis- 
cover any initial syphilitic lesion in the latter, and have not 
buconie pregnout. lu tlicso women BvpbiUs uianifeeta itEolf 
bj extremely rapid etniiciatioD. In the farther coaree of the 
disease tbey loae their hair ; sometiinoa periosteal p*im and 
Bwellings come on on some of the bones, aiid subsequently tbo 
menseB booome profuse and recur frequently. On becoming 
pregnant they will often abort. In what manner the syphi- 
litic cuntngion, in stich cmosy has gained nn entrance into the 
system, is not yet clearly known. "VTe know jnst as little in 
what niaunera iromnii who sntTer!: from latent syphilis iacapor 
btc of commanicating the discflse to her hnftband. Posdbly^ 
in sack cases, the blood has served to transmit the infection, 
some bleeding eixwitons or exconatious having occurred on tlio 
genital organs. 

In tliose cases in wliich the action of the luetic vims mam* 
feste iteelf in tlic form of an ulcer, the tieaiee ut tlie base of 
the ulcer begin, at the end of the third or fourth week, to eon- 
dense more or loaa markedly, or, if it is already citatrized, the 
cicatiix becomes bard. If the action of tbe virus began in 
the form of a nodule, molecular diBorganiEation wilt ensue a 
few days after it appeared. The dieorganicstion is coniiDod 
either to the upper layers, the epidermal or epilhelial eovoriug 
only being destroyed, and the infecting focus simulates an 
erosion, or the disorganization extends deeply into the nodule, 
and sometimes occasions a marked lo« of giilietance. The 
solidification of tlie tissnea at the base of tliu ulcer and the 
growtli of the nodule are identical proceeees, and both of tbom 
give nee to that gr&daal hanineas and increasing induration of 



8YPBILI8. 



161 



tliQ tUsaefi vhioh si« designated by the term initial tdtntSt 
of sjphiliii. 

The sclerosis does Dot originate at once, bnt gradually, ond 
develops with well-uiarked reraisttione. For a time it in at a 
atand-sUll in iU dovelopment, aod thea it suddenly tokea a for- 
ward ete]). It may attain the size of a lentil, |)ea, or bean ; it 
maj* aleo extend over a largo area of tissue. The li|ia, the labia 
majora nr minora, or Uio tkin over half of the glans or body of 
the ponie, may become iiidiirat4Ml. Abeorptiou Iwgina in the 
center of tho induration, as S& ehown by the diminished hard> 
COuof the tifiSUMat tllia epot. After the hartlneta Iiaa entirely 
disappeared, a bloish-red dificolontion, eorre^poudiug in nza to 
tbo indnmtion, rcmaine behind. The diwolorod epot gradually 
grow6 pale, finally becoming whiter even than the normal ekin 
{j/ignttmt atroj^»J^. If tho iiidunitimi dii<ap}>oarB by absorp- 
tioti, a Central depression only will form ; bnt if tho indnratlon 
undergoes diaorganization a depressed cicatrix will remain. 



Anatomy of tlu Syphilitic loitial Soleroua 

The macioflcopio picture of a eyphilitio initial sclcTotuB t»- 
rice according u it boa developed upon. an nlcoratod or eroded 
spot on the skin, or is undergoing development or rc«ointion. 
If a cntanoouB ulcer acquirer a tiderotio condition through tho 
reception of syphilitic virus, the solidification of the Mssokb 
will, at first, bo limitod to the margins and base of the ulcer; 
grujually, however, the parU Iwyuii<l nj(« hocomo affected. If 
no noteworthy loss of sabi^tnnce, either through injury or ulcor- 
atiun, took pbco at the point of infection before infection oo- 
ciured. an inSttruted node wiU fonn, whicligrBiluntly inrmntni 
both in circumference and in dtrpth, grows harder and denser, 
and finally forms a tirm tubercle with weU-defioed ontUneS) 
whic^i sometimes feel) like a solid cncaj»uiatcd piece of certi- 
lage. Tho npper surface of tho infiltrated epot may in a few 
days undergo nhxratioQ* in consequence of granular d^^uer*- 
Ctou. An ulcer, varying in form and extent, may thu« be pro- 
duced ; it preecntsa flesh-colored, finely granular, readily hlocd- 
log, velvety appearance, secreting a thin, winetimee gummy 
diiobarge, to which are found a very few pusKseDs. Here, too. 



168 PATHOLOar A-XJ) TREATMENT OF EFPSTUS. 

tbe Bpitw beyoad tlie lino of demorkation surrounding the 
Bloer Tory »Iowly undergoes sclerosis. 

Id coDBcqiienco of tlio prosBiiro which tLo eclerotio node 
exercUcs upuu tliu capillar}' vcaeeUi uf tbe affected tiesuix tbe 
titppl; ot Ulood tu tlie parts is diminished to snch a degree 
tlia^ when the node is incised, a sound is beard like thai 
produced by cntling cartilag*, and very little blood flovs. 
Tbiti presKtm: upon the oipitkry vessel tiiay also be the ruwon 
why theficlerotic tiefloe is not remoTcd by eoftening and suppn- 
ration, but ie destroyed by the slower process of futty degeuw»- 
tjon uud iibeiurptioii, or by iiocrotus, leycr by layur frum witboul 
inwonJ. External and local iofluenceei, fiucU as friction, canteii- 
zat^oD, etc, may bring abont a more rapid degree of necrotio 
dUorganization of tho sclerotic tiaeues. Softening and pura- 
lont infiltration tlien becotue fmpetadded, and extciuivo do- 
Btroctioa viH ensue. In addition, a large or sm&ll part of tbe 
necrotic tiseae may be destroyed by gangrene, and the node 
may then become so excavated as to leave only a bard gheH 
beUiud. After the slough baji been cast off and a pcrmauent 
cicatrix fonued, this will give it the oharaoteristic liardneM. 
This process differs from tlie Bluiigluug that takes place in a 
soft chancre by tbe fact that the Utter dciitroys uoriual tissues, 
wliilc in syphilitic iaidal ulcers morbid products tJiat have 
been deposited arc dtaftroyed. 

Sclerotic places that have undeigano nccroeis ctcatme r&j 
slowly, and even when they bare fairly cicatrized they do 
not always remun eo, ainoe sypliilitic sclerotic cicatricos oftea 
break open again. This may happen so long as the sclerotic 
tiasaes arc not entirely absorbed and repkoed by perfectly 
normal material. After ttie sderoeia has disappeared, an exca- 
ration results, in conKequeuce of atrophy that ba£ begun in the 
center, and this has a ecmiotic dgnificaiice. 

Under tho nucroeoope, the initial Bclerosie of syphilis pre- 
aenta rery deuBe cellular infiltration which is not particularly 
chaiacteriHtic The cellular iafiltration affecLs tlie pajulla of 
the skin and the sabcutaoeous cunnectlTc tibiae, aud is cspo- 
cioUy abundant in the adjacent tissue of the blood-reseels, the 
adventitia uf the bttter being frequently inrolred iu tlie infil- 
tntioD. In motit inetaiicoe Uie luaicn of the vessels i^ only 



SYPnius, 



153 



dimiimbed in size ; etill, ttiey may also be entirely oocliidod. 
Wo agree witli i^icgler tliat tho mdaration of tho primaiy 
lesioD uf syphilis U pr<idu('ed by tite lonj; perRixteDce of tl^ 
fibersof tlie coniitHrtive tL-uttio, notwitlistamliiig the profoaoiun 
fd the intiltniHot). TIk) mujority of iIip cells nre small ; some- 
tunes they are lar^, epirlielioid ; »onie of then] Imvu uumeroua 
granuleH. If tliB jiriiuary luetic leaiou uuder^om reflation 
withont disorganization, a markedly diBOoIorod spot reniaing in 
ilfl place, wtdcli subsequently beoonies perfectly nonual. If 
tbc ntMlu undcrgoo:! suppunttion, a ecur will reiuaiu. 

Site and Form of the Huntenai) Induration. 

Tlicre iii no pliico on the common integument on a person 
onaffected witli ftypliilis at whicb » Iluntcrian clmncre can 
not originate. No place poasceaes any immunity, neither does 
uiy poMcee a special qnalilieation for producing it. It occurs 
moe( fj«qaently on tbo genital organs of both soxoe. In the 
male, on the internal mirfaee of the prepnee, on the giant) in 
tho ftisiut eoronnrin, on tho fmmum, and on the penis gener- 
ally ; in the female, mostly on the edges of the labiii, &t the 
anterior and posterior commissure, and oil the pnepntiura cH- 
turidis. On the mncoos membranes, tlio eelerosis \a lesfl dis- 
tinctly iitnrked tn freuunil, and sometimes is totjilly overlooked. 
Hence it fmppenii that, on the parts of tlie female penital or- 
gan^ irhere infection naturally occufb moet freqaently — ^for in- 
■taocse, in the ToatJbule and introitus tb^iud— a sclerotic node Is 
very eoldom detectod on tliu mncoun membrane. ih\ tlie other 
hand, it devdope more distinctly on the oe nteri. where, boir- 
ever, it can only bo definitely diagnosed by the aid of a aterine 
spccolum, into whieh the indurated m uteri doce not glide like 
a Donnal os, but shoots in in coni^uencc of tbo elasticity it 
hu acquired tbmugh the Hunterian induration. If the speett- 
1am lie pr\««ie<l against the iiidumte^] ck, or if prcf^SDie is made 
a|)on tlio latter with a wooden rod through the iDBtmioent, 
the 6bro-pla«tic material deposited in the part will appear like 
■ initM of transparent motht>r-rjf.])«arl. 

Hunterian indorated chancres may be produced on the con- 
janctiva of tho eye, on tho mucous membrane of the narM^ on 
tho cheeks ami chin, by Iranapurtation vitb tlie lingers and 



IM PATBOLOGT AND TREATiTEXT OF STPETUa. 



under Uio jm\ and hy kiesuig. ScloKitic cluinerve on tlie 
lips ind t-ongno of both ecxcs ocear bj kissiDg, eexuil depntr- 
ity {cunnUinijm), by traustiiitisioii by tli© aftency of utensUe, 
pipce, etc. Indiinkti>d cliancrefl od tlie lipf generally extend 
(inly as for as tliu vcrniilion border, and M>Idom reach beyood 
it to the mucous moinhrano. The Himterian initial ederoMS 
i» fre4]U6ntly seen upon the uippleii of the breaft, when; it 
ori^nates in wet-nunuug oyphilitir children. It often ooonrs 
OD the fingers. Only one syplulilic initJtd ^IcroaU, u a rule, 
is met with on a pereon; but, if eevcral places Ixscomc infcct«d 
at tliu Hume time, all th*: purttt uru npt to Ix'cnmo inJuratwl. 

The form of the iiidiiration depends upon the diameter of 
the infected portion of ttie akin, and idso upon the depth to wlildi 
the 6y])hiUtic viruB has penctralcd. The dd-jjcr the Wrus pcoo- 
tratos into the tiefiiee, the more pronounced will the Indnmtion 
be; the moro epongy the tieeues of the infected place, the 
inure diffaB(<d u'ill it be. If the pypbilltic pnitinn \\a» peuo> 
trated below the integuincnt, round or Bcmicircnlar nodules, 
aa hard as fibroids, will ori|pnat«. If, during infection, the 1^ 
sion nfiTect^^d only tlic epidermic layer, and the solntinn of con- 
tinuity \» an extensive erodon or excoriation, the induration of 
the tiagues will be like a tliiu plat«, having the hardnwe of 
cliondniid tiasuo, and the tingern experience a M-ueation on 
pinching up a fold of (he skin as if a bit of parchment is 
imbedded in the sore (chancre par^heminSe of Kicord). This 
last form oecure almost exclusively on the mncons mcmbnuft 
of Uie prepuce, where in retrtctiuj; it the chancre becomes 
ereitod in the same manner as one everts the tarsal cartilage of 
the eyelid. In addition, it poeseeMs tlie peculiarity of cica- 
trizing with surprising quickness. Frequently th*? phimotie 
prepuce becomes converted into a bard, dense, cartilap^non» 
funnel. In congenital con»triotion of the prepuce, the lips of 
the foreskin are often lacerated during inle«'<mr»e In several 
plaecR, into which the sypliilitic virus is apt to be depowted, 
and all the lacerations aftcnrard become Indurated. The orifice 
of the prt-puce then becomes converted into a dene*; ring, pro- 
ducing atmuct total phimosis, that is not relieved until rt-reulu- 
Uon of the indurated deposit has taken place. If the poieon 
of eyphilis adheres to one of the Mhacouoe follicles — a condi- 



SYPmiis. 



155 



tioD that g«aerallj Iiappenfi nrbmi a. fglticle is doprircd of its 
epitiioUam by seborrha-al disease — tlie iudnration that then 
takee ptaco in tlio iolliole wiU UBiime the form of a cylinder 
standiiif? on ood. Bnt if a duuiIkt of contiguous sebacoons 
grlandii beocnne infected, as in ofton tbc easo in those aitnated 
in the foflsa ooronaria uf ihu glujis jieuig, a liard waU originates 
from the coaleacenoe of theae indnrated glands and encircles 
the glana tilce a wreath. If both lipH of tlie nieatna in the 
male are thv ate of tliu sji'phititic infection, iLe oritlct; beeomea 
tnouformed into »dfiit«.-,ptuiuini,fuDni;l-tiLa|iedo|Kruing, which 
foub like cartilage. 

Combined Effect of the Syphilitic Vims and of the Chancroid 

Viroik 

In the Bouio way that an iudiridaal may he infected at the 
came time or in Bucccsiion on two dilferent parte of the body 
— on the genitals with a soft chancre, on tlie lips with a con- 
stitntional nicer or syphilitic chancre— »o both poisons, that of 
tbc eoft chancre and of constitutioual syphiliB, may b« d9po»- 
itei) on tho Raino port of hio p«rs(>n eirniiltaiieooiily, or oitc after 
another. In such b case, botli contagions may develop thdr 
local effects together. Tho chancroid derolope and the inda- 
ralion follows ; indeed, if bi>th jxiiKoiiH are depcwiited iit tho 
ume time and place, the i^oft chancre will have been far ad- 
TBDcod before the indnration manifc*t« itself. Generally, thia 
doat net occnr till tliu eighteenth or twentieth day froni the 
time the chancroid appeared. If the syphilitic viras has been 
absorbctl eeverul days before tJie t>oi^n of the »oft cbanore wu 
dcpotdtcd on tlie same spot, tho indnration will appear a fun- 
daya after the chancroid. If a eoft chancre u ini>ciilatcd npon 
asjrphllitio indtirated ba%, it will display all the modi li cations 
it natully shows on tbc normal skin and mncom membnince. A 
Boperficial and deep phagoiieiiio, or other variety of chuncroid, 
may originate u|K)n a («_v|ilii]iitc>, iudunited chancre. In the 
latter cane, the phngedaeiui will destroy the indnration, and the 
cbancr«>ii.'! ulcer will be enrronnded like a haM Ehell by the ex- 
cavated iudorated tisane. But if the indnration was !u proces 
of derolopment when the infection witli the chancroid took 
place, the tissace adjacent to the phagedenic chancre will be 



156 PSTS0L0Q7 AUD TREATMENT OF SFPSIUS. 

destroyed 1>j tbe pliagc<tici)», uiid the iatluration will Bpread 
puripliumllj- in tbc ouutiguouB tkeuce tliat arc unalfvct«d bj 
tlic fioft cbanore. In both casee the cicatmatioD of the olian- 
croid progre«8ee Tet7 slowly. Tins, we think, is due to tbe 
Itict that DO retractioa of tbc akin c«n take pl&ee bcrc, bocaoM 
Uie cbaDcroid is tmrrooudod hy induntod tcgnmoDtary Ufisao. 
Cicatrizntiou ie effected by & jiroctss of new j^mwtb, eouneet* 
ire t'lsunti fihrilUe efTecting, in tliui way, Um closing up of tJie 
nicer, wliite the rest of tbe original induration now sunotuidfl 
the ctcatrix like a waU in tbe form of a hard ring that fns 
queutlj.' dcM^uuiuatcK (ctrcukr induration). Uodur geueral auti- 
ejpbilitictruitiiiotU tlie tibro-plaistic exudation \nll be absorbed, 
renderii^ it possible for tbe retraction of tlie skin to lake plac^ 
and expediting cicattizatiou. 

laooolability of the Sdcrotio Uleer. 

As haa boL-u n;)H.>atcdly ttlatt-d, iuocalatlunc witU the dia- 
chargcfl from syphilitic infecting foci, especially euppoimcing 
initial indurations and Hyphilitic papnles, will produee pn*- 
toJce and ulcere in tboee aficcted vitb those leeions, and in 
other ayphilitic ]>er«<>ns. Hence, the auto-iuocuLibility of an 
ulcer upon a pcreon afTectod witli it is oC no greAt value as a 
diagnostic aid for tlic purpose of docidinjr whether an ulcer is 
a syphilidc iiiil Ul Kure or a simple venereal eore (chaDcroid). 
TliiH in all tlic more tme, iiinoe even pus of non-i'enereal origin 
will produce on pyphifitic persons a seriee of inoctiliililo utcera. 

Therapeutically, however, the uuto-inocuUtion of s^-pliilitic 
infecting foci munt be token into consitlcratiou for tbc purposo 
of c&refolly isolating suppurating eclerotic imlurationo and 
syphilitic papules, lest they pruduuc ulceration by impreadon 
npon adjacent normal tiesuee. 

Bigniflcanca, Doration, Coortc, and Differential CiagnotU of the 
SyphUitio Initial Bclerocis [Hard Chanor*]. 

A fully developed s>*pIulitiG initial scleroeis is of the ut- 
most irn{>ortance from a diagnostic and prognostic point of 
view, becanso from tbc moment it originates tlie effects of tbe 
oommeneiag syphilis may be reoogtUMd. The patient is un- 
der the iuflueuee of the sypliilitio dlaUiceis so long as the in- 



87PBTLIS. 



dttntion la8t«, nnd it only bccomcft Icsg gij^iticant when it has 
entirely disappeared along with tlie coiidtitiiti^)iial phenomena. 

I^ft to ilAelf, a primar)- induration that is sttua.t«d ujion 
the common integument will nndorgo dosquamation attended 
by repeated congestions of the part. Tlie epidermal (."overing 
of the inilumtion, which is fre<]itent1y nmcwed, ha£ a peculiar 
|;;lo8^ appearance and dark-brown color merging into rednesL 
The upper Burface of the nodule often dt-gt^ncratei! after re- 
peated d(M(jiiumation — a coitdition which, if preceded by aexnal 
interoonrse, will lead tlie pntient to believe that he lia^ been 
infocted anew. The coneccutiTe ulceration may b(^;in in tho 
center as well as at tbc upper eurfoco of the nodale, or eccen- 
trieally, and may remain eaporficial or attack the deeper layers. 
It may originate at several points gimultAafou^ly and progrces 
rapidly, and thus resombte phagcdxDa — a phagedena that con- 
flaroes the entire nodule without attacking tho parta around it. 
Tliii) kind of phagedipnii vniiitiheA all the more quickly when 
the nicer is not interfered with by caostica or irritating reine- 
diee. 

Sometimee, tliongli rarely, the primary Rclcrocnii Dnde!^oe« 
a peculiar softening. I'he center of the nodule hquetie«, form- 
ing a yellowish, purulent, or icborooa fluid, which, u iu an at)- 
■oeaa^ gradually cit(Ta[)cs outwardly thi-oiigli several ittiiall open- 
ings. The remaining walls of tbe abMCitees tliat form in the 
primary induration disappear by absorption. A second ecle- 
roltc nodtilo ooca«ionally originatce in tttc immediate vicinity 
of tlie first one» although recorrence of the infection baa not 
Uken pUoe. 

Tbe Bize nod extent of the tndnrntion poeseea no prognostic 
dgnificancc iwpccting tho bcnij^ or malignant charaeter of 
the syphilit). Kmall and recent iuduratiuus uoually are more 
amenable to treatment than those which are lai^ and old. 

On the appoarimcc of the eruptive fever and of tho cata- 
neons Byphiliile the indunitiou generally becomes small, and 
■oon dimppears entirely, leaWug behind a copper«olon?d apot', 
which, aa a prognostic ^ign, is of no less importance tlian tbe 
induntlon Itself. So lunjt iw this discolurud (tpot is not en- 
tirely ahftorbci], the ftvphilitic diatheein is not cured, eroo 
Uioogh all tbe other eyniptome of tbe sidn and muoouB mem- 



158 PATHOLOGY AND T&EATMSNT OF STPSTUS. 



brane jji-oduce<J by tbe syplUUs luive vatiiahed, or pcrliape LaVe 
nut yvt apjyearud :tt all, bL-causc thu induretiuii has bccu treated 
vitl) loerciuy from ita rerj iDception. 

According to our esi^erienco, it sometiiues happens that an 
induration that has wcll-nigb di»ippcurcd, gtovt %gnia after 
a longer or shorter period, and attains its former proportions 
{ekanrre redux), a condition that has been described as ropul- 
lulatiou of the; sclerotiu node. This iit, in bo far, of prognostic 
importance, as it proves the obstinacy of tlie dieeose, and may 
be conudcrcd a prodrome of the speedy entption of a syphilide. 

"We have seen indurationa tnst three months, even when 
the patient was treated witii mercury from their very incep- 
tion. Very often they last eight or nine montlis, and oren 
longer. 

With n-gard to the differential diagnosis, Bvphilitic initial 
sclerosia may easily bo mistaken for epiOtdioma. Tbe micro- 
scopic examination, to bo enre, ^till furnish satisfactory evi- 
dence of the nature of the morbid nlterution; but the expo- 
lieoced clinical pbyaiciau will also be able to exclude syphilitic 
induration fiuni the continuone di^integmtionof the carcinom- 
atous infiltration, and from the ultseuee of the solitary, degen- 
erating, peculiar, rosy-red, velvety sclerotic nloer. The dif- 
ferential dat^ between soft chancre and a Tlunterian indurated 
chancre have already been described. 

We have repeatedly (teen in children, who had been ctr- 
cumcised acwrding to the orthodox Hebrew rito, a dif^tinct 
indurated node undergoing diuDtc^tiMi, eitnated in tliat part 
of the forcakta which remained, and in tbe glans }ienie, with 
coexisting hypcqilaflttc enlargvil l^-mphatic inguinal glands, that 
kometimcfi suppurated. Yet the children never Boffcrod from 
secondaiy eyphilia, having been kept under obeervation long 
enoDgh to ecttlo that point, ilcnec it seeniB tJiat thU kind of 
induration mnst be ascribed to the nnskillful manner in which 
the operation, especially the laceration of the mneoos mem- 
brane of the prepuce, was performed. 

ITmcity of the Syphilitic Infection. 

Since otlier specific diseases, such as gcarlaUna,mca8lee, etc., 
seldom occuiTcd more than once in the eame pcreon, it was 



srrmLis. 



159 



rapposed that tlun miglit also be true of syphnis. And, in 
faot, instancea of pereons hai'iug syphilis tn'ice are very rare 
oxcoptiona. Experimcata undertaken for the ptirpo«c of cod- 
fimiing tliJs bflitf iiave provwi tlmt iniwulations of pcreona 
with syphilitic virufi who aru ettll under the influence of tha 
BrpbiUtic diathesis prcxluce no indurated cbaucres. From 
tbo refwltfi of thcee cxi»criuicute Bicord vraa ablo to formuLitc 
the dogma of the anioitj of ejphiliti {}tncit4 da la typAUit) — 
i. 0., IDV one who bad or ba» srpbibe, or, what ajuounts to tbo 
same thing, bas bad a Huntcrian indonitod chancre, never can. 
get it again ; nioro correctly speaking, novor can be infected 
again by Byp!iilt>. Iticonl explained this law, wbiob he an- 
noonccd, by the aflBcrtion that the syphilitic poisoning, when 
onee produced, ksts forever, and our tn>atiueiit h only able 
to GUtse the mauifeiitjitiuut) of tbe disuse, but n<jt the diseasa 
itself, to disip])var. 

Tbifl dogina of the nntcity of pvpbitis is not, bovover, M> 
inTorinirly true as Hic^ird cluitu^. 11. ZuImI and other phyti- 
csaoB have bad repeated opportunities of obeerring reinfection 
in one and the same person. The reinfection witb 8}'pbilis of 
a poreon who has had the di«cafto provm that be was totally 
cured of bis flist attack. According to Diday, tbroe important 
eoroUariee may he deduced from this law, namely : 

(a.) Syphilis can bo cured radically. 

(h.) Tlie length of time neceaury for a radical euro of 
Rrpbilis i» at least twenty-two montbg. 

(f.) The best proof that Hyphilln can be cured radically is 
tbe poBsibility of reinfection. 

Tlie treatment of syphilitic reinfection is tbo same bb that 
of primarjr infection. 

Aflectioni of the Lympbatio Bystem occMloned by Beginning 

Sypbilijb 

On examining the parts of tbe body in tbe vicinity of a 
Iluntertan indurated clumcre, there will generally be found 
one or more lymphatic glands which arc swollen and dcnee, 
and have tbe same bardnees as tbe chancre. This glandular 
spelling is, it is true, rather painful during tbe early days of 
its exlBtenoe, but, after a while, it nsnolly becomee leaa Benntive 



160 PATHOLOOT A^D TRBATXEIfT OF STPniLIS. 



when touclibd. On ofcoiiut of thk painlces conditloa, it ts de- 
wribcd at» an indolent swelling ot the Ijmphatic glands, or 
bobo. Tbe eDkrgenient of the affect«d glands takes place 
■withotit any rnarked reaction, or the leaet febrile movement. 
At firet tho injpUcatod glands are but slightly ewoUon, and 
qoite movable ; but the more tbey swell, tlie more tliey become 
adherent to the mibjacent tinsue*. As a rule, the clciii over 
them reinaina unaltered, and for a long while nftern'urd may 
be pinched up in folds. Sereral adjacent glaad^ are tunallj 
Bwolleu ; rtill, they remain isolated from wich other, and only 
exceptionally do tliey coaleeoe into one common tumor. 

These indolent buboes OBvallv do not form until tlto initial 
ledou of EyphiliK is already in a state of dieintegnitioQ. Fi- 
Didly, if wo take into cousidcralion the ^t that indolent bnboee 
arc almi^t ulwa\-s fouii<l on tlic parte of the l>ody ncortet tbe 
eito of the infection, we are jaaiitied in miintaining that, from 
a genetic point of view, they are buboes of absorption, and not 
of constitutional origin. Anspitz a^ecrts that tlio propagattoD 
of the oontagium of eyphilia to the blood, from ita point of en- 
treiice into tlie svRteni, A<x& not take pbux through the lym- 
phatie veasclfl, and thns caaf« all tho lymphatic glands of tho 
body gradually to swell up as the poison progreeaea, but that 
the indolent inguinal hutxxw r>iily iiiditate tlie local &bsori)tioD 
by the glands Ipng adjacent to the primaiy lesion, while the 
direct alworptiou of the pol«oa from \\a place of entrance moet 
probably is brr>iiglit aliont through the blood-TcsHcls. The 
general swelling of the glands which occnis in syphilis is 
eirnply an evidence of the blood-potaoniug that is already 
present. 

The patholo^cal alterations of tlie glands under considera- 
tion are the rednlt of hyperplastic enlargemeat of all thoee 
elements which constittito tbe affected glands, not exoepdj^ 
even the glandular capsule, which is more or IcM thickened. 
In tbe further course of tho disease tbe glands ondaigo fatty 
or amyloid degimemtion. 

The hidoleut ghmdular gwcllinga sometimes are roand and 
then again oval, and, as a rule, become as large as a hazel-nut or 
walnut In Hcrofnlouit, tuberculous, and weakly penoos, tfaejr 
i|uickly attain, as a genenl thing, an enormous are, attended 



arPBiirs. 



i«i 



hj mora or hm mnrkcd itifliuuuiitory plienomcna, and ooc&> 
sionaUj coiistitttlc, when iiicy arc c\cm to eacU othor, tumon 
•a big u a man's fiet. Tboee eDonnoDB gUndoUr awelUngs 
have long be^i desifi^ated as alrurnou4 buboes, because the woni 
" ftlmmous " eigoitics tbc some m MrofuU. Stramoiu bubooe 
Dgaallf pr«6«Dt an uueven, lobulatod appvarauco, aud aro con- 
fttrictod in TariooH places. 

As has boon mcntioncMl above, the glands adjacent to the 
plaoe of itifectiun are alwayn affected first, in cooBcquouoo u{ 
the absorption of the Kr])hilitic virus; still, the cnhital gland, 
in exceptional iostancea, in chancres on the fingera, is orer- 
leaped, and the axtlbu-)- or jtigular glands on the oorresptinding 
aide bepoine involved. An most of tlie ofphilittc infections 
take place on the genital organs, wo consequently tind that the 
glandular disease that invariably follon-H ixrcurs iu the inguinal 
•nd foinoral region. As a rnlo, only the superficial inguinal 
and femoral glanda ewell up, the deeper ones becoming iti- 
Tolrod wh(*n com'titutiniial oomplicationn are prcM^nt, such as 
scrofula, tubereulosiB, or rachitw, or throngh local purulent 
itnhibitiOQ. Several inguinal or femoral lymphatic glands ara 
generally affected. 

Indolent glandular indnrations, In consequence of Bjphi- 
litie infoution on the genital organ)<i, ino«!tly owtiron the side 
of the body that the Ilunterian ehancro ie situated on ; excep- 
tjonallj, however, the glandular induntion is met with on the 
opposite side, and in primnry legions situsted on the median 
line of the genital organs, such as the fnuDuni or posterior 
eommiwnre of the volra, the glands iu both groins will become 
indurated. 

Indolent bnboes often remain Ftationary for three or four 
months, notwithstanding the anti-syphilitic treatment employed; 
after many yean they diminish, and disappear by absorption. 
Hometimee tbey undei^ calcaroouB degeneration. It«soiution 
takes place by the )>raccss of fatty degeneration. 

Syphilitic buboee seldom undergo euppnntion ; and, when 
they do, it is in conficqnence of constitutional or load compli- 
ontiona. Scrofnk and tubercDloeis are the chief causes that 
bring about softctiing or caseous degeneration of the indolent, 
faypertropbied lymphatic glands. Stnnnona bnboea, bowevor, 
li 



^ 



162 PATBOLOQY AND TREATMENT OF STPBTUS. 



dificr Toetly ta tliub- cout-si: fn>iii tlic eitinll onlitiarr indolent 
Imboee. Tho morablo ^kiD, covering Etrumoiu lymphatio 
glundfi, Boon beoomea adherent to tbe swelling benetth h, 
gmiluallv tiinitt red, :ind uveti slight jireaaiire causes pain. Bat 
notwithstanding the {jal|mble iiittaninnUory pboDomcao, it re- 
quires an extremely long while for deep Mtftening tu enmiu. 
Tlie same is true of na^utuliun, wlii(;Ii the )wKt directed n)ea»- 
□res are elow to bring about. FinalK, a few solitary spotis in 
the swelling, aa big tii a hazel-nut or walnut, beconio ipong^ 
and ttuctaate, Nercnheleiw, when an incision ii made, 011I7 a 
&U19II quantity of glutinous fluid and eou«ideml>le bloody aerum 
Ctfcapt*. A prematui'o iuL-ieion into one of tlieoo bubooa wilt 
prudaco a rapid, but only partial, disoi^!;anizatton of the swell- 
inge. However, only tlie subcutaneous and the glandular in- 
termediary cellular ti^uo i» destroyed, while the liyjH;ri)luatic 
enlarged glanda thomeelTcg remain intact. Uencc, one or 
more tortuous tistulra form in the entire region of the glandu- 
lar swelling, beneath the skin or hetwccn the lobea of the 
g1and& Ii the undcmunod skin i^ diiided with a knife, a 
layer of now connoetive tiE«ne often forms on the lips of the 
wound, hetween which the new tiseue frequently extentk, at a 
later period, like bridges and arcfaee. The adventJtioaa tienio 
DBoallyisdestToyed, and invoIveH in moletrular disintegration the 
subjacent oelliilar tisrae that exiHts l>etween the swollen frlanda, 
thereby vastly enlarging the nicer. It acquire* a yellowish, 
lardiLCcouB coating, and at tite bottom the glaiidm, hyix^rtnjphied 
and increased to the size of walnuts, and partially deprivvii of 
their capsule^ arc seen aa if dissected ont with a knife. As a 
result of tliehiirrowiiig. and also of the imbibition of tlie pna, the 
diseased lymphatic glandfl and other portions of connectiTc tassno 
become involved in the morbid prooees in different diroetioiu ; 
new straight or tortaocs inllanimatory foci istart up on the pro- 
longations of the adventitious connective tiieac, which likewise 
soon deliquesce tbtough molecular disorganization, oannng 
now fiKtnloiis pasfuigee. Along the coiuve of the fistula the 
connectivo dst^ue Ix'contes indnrsted, and the tract becomca 
lined with a pyogeuio membnme, which, however, does not 
accrete pus, tho discharge being at the most a duid that con- 
tains molecular disorganized matter. Tho pus and the ichor 



SYPBtLlS, 



163 



VMy barrow in tbeee fistulooe paesagee ; and, in caee & timctjr 
exit is not provitled, new inflammatory foci will Btart. 

IJudcr tlie local oomplicntions ^phicb eoEtenio^ of indolent 
boboes tnaj oeotsioD, evoo in persons with good oouBtitatiom, 
we nndcreUnil KUppuratiiig foul ttituatad on placut which, by 
means of \ha l^inphntic vcwvU, arc intimately connected wilii 
the indolent ghutdubir Hwelliuga. To this cntegoiy belong 
moiflt, nloernting jtapTtlvis ti/philitic and uon-«yp)iililic pn»- 
tabr eruptions, specitic and m.n-siKicitic nicers, sypliiiitic 
and non-syphilitio panaritiee [paronychiie], but, abore all, 
ebancnms ulcora, and someliines blciiiiorrlia^a of tlic gunitul 
OTgana Now, if the pw originating fnmi one uf llic»c enppu- 
nUing procefl&c6 liD'is its way, through the action of the lym- 
l^iatie r(!«ec-lt>, into the itiduloni BwoUen gland, ail the inflam- 
matoyr plienouicna tliat oci:nr in an acotc btibo of abttorptjon 
manifest cheniinelvee in the swelling that hitherto had remained 
dormant. 

Inoculations made with die pnrntent conteni« of indolent 
bnboea on persona affected with them, as ubio on iiyphilittc pa> 
tientit gencmlly, arc of importimco only in so for as they show 
that, even in ihoM- vasex in wIul-Ii M^ftoning was not camted by 
complicating cliancruid nloera, any kind uf poa, aa we havo 
alicady eliown. when inoculated, will prodnce positive reenlts. 

The proynosix of indurated bnboea which aopompany Finn- 
toriaii chancrm must be considered from a donhic Mandpoint : 
firat, as regaitla their signJIicaDcc for the general system ; and, 
aecoodly. zs regards the local morbid alterations (hat art; liable 
to occuj in thv aftcfltoil glands and their immediate surroundings. 

The Unnterian primary le»ton does not acquire its fnll par 
Ihognomonie and prognostic valne till tlic indumtcd glonds ap- 
pear; i. e., we are not justiticd in considering a eirrainHCTiljed 
indnntion of the tiwncs as a rcsolt of syphilitic infection and 
In prognoati eating the speedy appearance in the affceted poreon 
of other syphilitic leaiom in other tiggues of the body, till the 
■welling of tlie glands haa ensned. 

Now, as regards the local signifieanw. m«wt nf the indn- 
rated baboes in iiereons with good ronstitntions, under an ap- 
propriate treatment, are made to disappear in the coniaa of 
four or five months, cither by abwrption or calcification. It 



164 PATB0L06Y AND TREATMENT OF STPBIUS. 



ig totu]ljr (liferent in tlie c-iw of indolent etrutnoas buboML 
Tlie^' aiQ the imfortaDate products of a complication tliat is of 
the utmost importance for the fatnre of tlie patient — name- 
ly, of BypliiiiH with sonifulu or tuberculosis — two diatbcees that 
are liable to bo kindled, and which, if devi^loped bj evphHis, 
exercise a moat pernicious influence over the development and 
resolution of the eyphilitic morbid lesions. The tedious cliar- 
accer of ecrofula and of tuUcrcnIoeie is soon maoifcet frotn the 
tedious course of the strumuue bubo, i^tromous buboes osu- 
alty outlast all the other early phenonienn of syptiilis. Under 
favorable contingencies they reqaire five or six mombe for reeo- 
lution, which, however, ouly partially taki'ji plai>e ; a la^ge 
portion of (Jie affected glands nndci^ocs calcification. Still, 
even fluctuatmg strumous buboea may undergo resolatioo, 
provided 6ii]tpiiratiou watt not oocadoned by tlie ahsorpdon of 
chancroid virus. Theoe kinds of buboes often burst; a small 
quantity of pus mixed with bloody serum escapes, and the 
reumiuder of the tuicior won lieconios smaller. The fnturo 
diwtiny of titrnmous buboefl, when they are prematurely opened, 
assumes a far more uufavorablu course. In this case, deep, 
pviietratitig destniction of tlie tissues may follow. In inguinal 
and femoral glandular buboes fi&tulie may orifcinato, which may 
extend from Poupart's li^ucnt dowun'ard to the apes of the 
trigonum inguinale and upward as far as the navcL The pus 
may escape into tlie inguinal canal, and thence into tlie abdo- 
men, or, following the spermatic cord downward. acenmoUte 
in tho scrotum ; or, after penetrating the femoral fascia and 
the sheath of the femoral vceeota, rcaeh the knetvjoint. Maras- 
mus, tabes, fatal peritonitia, and pyaemia ore freqnent rcsnltsof 
thu condition. It jb even poasible for gangrene to supervene, 
and deep arteries, that are difficult to Ugate, like the epigastric 
or iliac, liooome eroded, caiudDg haemorrhage that terminates In 
dnath. Tlie cicatrization of Ktnnnonii, ingninnl buboes, too. 
may afHict the patient with the most serious jK-rmanent annoy- 
anco^by the formation of a cord-like cicatrix that extends from 
the groin down along the anterior surface of the tliighi or 
upward upon the abdomen. These cicatrices, in time, ntay 
contract to such a degree as to prevent tho jtaticot from stand- 
ing nprighL 



BYPUIllS. 



16$ 



lodontiOB and Hypertrophy of the Peripheral LymphiLtic Tet- 
hIb in eonKqaence cf Syphilitic InfMtion. 

In Bome casee it i« possible to demonfttrute ttic manner in 
Mplii«b the primary affection of tLe lymphalic glaiidis lijr tho 
B,vpliilitic viru« was brouglit alwut^ l)v a patliulo^ical alttiration 
<A tlioBc lyniphatie Tcescls which ran from the liQDteri&o 
chancre to the indolent glands. Without any piilegmonoii* phe- 
oomcna, and in the most posiiive manner, an inflammntory pro- 
oras dovetops in the affected lympliatic refiscle, in coDS>tM]ueQCQ 
of which they beoDnio like ooixhi, hard and iiiovahli* nnder 
the likin, painlexs, and of tlie thickness of a nvcn^a (joiU or 
gooee-quiU. The hypertrophy of the eord-ltko lymphatic ve»- 
■e) i* not always unifonii throughout ilH entire ext«nt; many 
nodalar ewellingit of the urs of a roillet-iieod up to tliut of a 
bazel-Dut form at varioiiB places in tlie cotUBe of the lympb- 
cnrrcnt Tlic skin covering ihe lymphadc cord is naoalty un- 
altered; hut aft^r tlic noduhtr 6WL'IUng» have laatcil for many 
veeka a slight fnrfuraceona d(«qnamAtioii and redness of tlie 
akin over ihcni arc obecrved. On the appcamnoc of thc«c pbc- 
nomcna, a a\-philitic eruption pcncrolly suporvonoa. 

The indolent induration of the lymphatic vessels ori^'natea 
at tbc same time with the induration of the lymphatic gtanda 
that nttimalely becoiuo indolent, and it has the ranio ]>fltliugno- 
monic significance. The (iaiiiu morbid allerDtimi which laJies 
place in the cclk uf the gland occurs in the lumen of the af- 
fected l^'Qiphatic vease). In moet case^, however, the swelling 
of the glands, in coexisting induration of the lymphatic Te»- 
ael, U not Ter}* primounced. The infarction of the lymphatic 
venel always disappears by resolution. If ijiany notlnlee exist, 
those fiitautetl at a diKtanire fn>tn the place of infection, and of 
tiie most recent formation, disappear tinst. Wo haro rarely 
Been suppuration and breaking down of thia bind of lymphatic 
roMcla. 

Tho affoetdon of tlio lymphatic Tc^scla, jut ticecribcd, oo- 
core with the grcatwt freqnency on the dorsum of the penis ; 
aometimee, howercr, on th© lateral snrfaeea of this organ, as 
aUo on the prepuce and near the fncnum ; but at the latter 
place the cords are much sJiortcr. We have never oUcrved 



IW P-i TBOLOQT A}iJ> TliSATJTEyT OF SYPUIUS. 

tLis morbid lesion on otiier ports of tiie bodj ; ia foniaJcA, it 
vccara io exceptiooal iu&tancee odIj. 

The Syphilitic DiMhHii, 

AlthougU ono ia justified in a^imiiDjjr that aflor tbe Hon- 
teriai) iiidurdtloii has takeu ]>liit!e, and tlto iuduleiit l>aboM 
have appeared, Die genernJ toxtemia is estnUisilied, Rince no in* 
diirafion pan be produced anew on llie persons afflicted with 
tlie Iwal Icjiioiifl uiciilioiied bj- iuot'ulaliiig tbem irith s^LilitJc 
vinu ; ncTcrtliclesn, puttciib salTcring from the eaj! j phnioni- 
enn of p^vpliilis arc apparently in gw^d liealth for n time, and 
we are total I j unable to discover the h'ast sign of the coneeca- 
tive plienoincnu of the diMawo that are dei;tincd to doTd(^ 
in the varioua tifisoes of the body. Thie period of qnieacence 
in the development of the constitutional phcDomena is do 
•eribcd M the second pniod &f \nc\ihai\cn. In order to explain 
thie interval that tikes place between the occurrcneo of tbe in- 
dnration and of the indolent ewelling of the glaiula, on the one 
hand, and the ontbrcnfa of the remainder of the conetittitionsl 
plieiiomena, on t!ie otlier hand, it \& aesumed that tbe syphilitic 
viroB is dormant for a while in the ejstcm, and then becomes 
active again. Tlils hypothecs Is Bnpportcd in a meamtre l^ 
tlie fact that frecjiiently, even in thu latter periods of constitD- 
tional Bjphilie, a temporary period of apparent extinction of 
the disease occurs i^atencif t^ eyphilu). 

It iB our opinion that in syphilis the disease of the l\in- 
phatic B^'Ftcm, at any ntc, ia of prime importanoc. and that 
the syphilitic viras is conveyed to tlic blood by the lymphatic 
reeaeb ; and that by tbe constant muttiaJ interchan^ that 
takes pbro hetwocn the blood and the lyniph the pyphilitie 
vimB permanently changes specifically tbe entire ([nantity of 
the blood. Our senses, however, are not cajiablo of perceiving 
the morbid aUeratioii of the blood produced by Uie sjbphititie 
virus. With the same degree of josliec tJiat we iwsnmt llio 
diseased condition of tlie lymph from the morbid alterntimu 
of the lynipliatic vwwels and plnnds without Wing able to prove 
the morbid alterations of the lymph, eo do we feel jostifled in 
assuming tbe diseased condition of the blood from the morbid 
state of the rc»t of tlio tiasoce of the body. And just as tb« 



srpmii.f. 



16T 



lymph tatist b« diseased before the affection of ttie Ivmpbatic 
TflwelB and glands appears, ro mast th« blood bo morbidly 
ohaoged boforo aoj gigti pcreeptiblo to our eeosM will indicato 
itH iliseased oouditioii in the vajduus tJRsues of the bodj. 

These pathological difiturbanoeR of die oompoBition of the 
blood that are undemoti^tmhlo, bciog only inferiblo from t}ic 
reavItB, havfi been desigoated by the lume of syphiUtio diath- 
ens— a condition tluit Is iiiteitde<l to fill up the gap between 
the iofectioD that liad taken place and the prunounced syphi- 
litic dysctaida. 

Pathological AlteratiooB of the Blood of 6n>hiUtio Fenotu. 

After the Uuntcrian iuduntted l<»ion hati hinted for eight 
or ten weckis thiwo phenomena gnditally appear which invon- 
teetablj prove that oertain morbid alterations of tbo blood baro 
taken place. The skin of the patient Iwes its freoli, healthy, 
rcmy color, and gmdiially notjuircs a 'wn:(y, sallow, chlorotic hue. 
At tho same time a funeral ouiaciation ensuce in many caaea. 
So far, neither eheinietrj nor tho mivroRewpu lias Buuceeded in 
finding any pathogaomonie prodnctg in the blood of sypbilitio 
potionta. 

We believe that altlioagh the syphilitic blood- di»ea»e begins 
with the absorption of the syphilitic rirus, etill it is just aa tit- 
tle poasible iu the early days of the disease to prove thu allcra- 
tion of the blood an in most other infcctifmt* diiu.-uMti. I'be 
maonwoopical alterations on the ayphilitic patient compel iis 
tooMumo that the nntritivc clement, at least the albumen of 
tbs blood, has auficrcd some kind of change. Tho altered 
blood, on the one band, then cxercttoe an extraordinary amonnt 
of irritation open the lyntphatic glands, whereby they t)ceorae 
hyportrophied ; on tho othi>r hand, by tlie diaease o( the lyin- 
phatio glands, a rotrooctiro effect upon tho blood miiet aim take 
plane, eitlier because tho abnormal inpreaw of cell-life of the 
glands fSBOsx larger ntrnilwrv uf wliite bhiod-eurpnBclui to 
cuter the blood, or because after iKch^mia of the lymphatic 
glanda has ensued, the Eonnation of blood-corpnscles is entirely 
urested. Unt neither leurA-niia nor oliga;mia andcliloni>mi:i 
are the catiaea of the original bloud-diseaso — they are simply 
ila eSocba. 



\ 



188 PATSOLOar AXD TSEATUS^TT OF STPBlUa. 

[Quite recetillj T.iiHtgarbm and Doutralepoiit liave fuon^ 
in tbe morbid protliict of the tijrphilitic liuwatres an<l in 
(liBcliargcSf bacilli which in form reeemble tubercle bacilli, but 
are dttstiuj^iehcd Xhmi Utuai by the et&iniog. The bacilli are 
moHtly inclnsin] in cidls, fnmi two to eight in one cell ; very 
few of the latter are found in the ceuter of a eyphilitic enda^ 
tioQ, but in lur^T iiumlH.-r8 at its borduK, oud iu the odjaoont 
apparently etill normal tissues. 

The bacilli arc always found in. tho initial syphilitic lesion. 
In the papules, in the gtinunn node^ and iu the discharge from 
n syphilitic clLincrc and from the jrapales. This fact, inkoi^H 
in eoDoection with the ui^tivo ri'^ultti obtained by similar ra^| 
soaroheK, made iuto the munt varyiug murbld products, renders 
it \\\^i\y pn^K^f'- UhU i/uve beunlli actvaUy eontiituU the typhi- 
litio jmson. TLib probability becotiies still greater since ve 
have teamed that bacilli are likewise the contagium of iufeo- 
tiouii diticaMCH that aru aiialDgt>u.4 to HyphiliH — lepra, tulKrirulo- 
Bia, etc. — though tliis will not he irrefutably established till we 
arc able to geuemte the bacilli out^de of the human body, an^H 
to protlnce oyphilis by iooculations with a bacilli product ob* 
tained. by culti ration. ] 

BnptiTe FeT«r of Syphilid 

The first eruption of general Fyphilia is usually preceded 
by febrile movement, which in not unlike that occurring in 
catarrhal or I'heumatio affcctiong. The patient* are hot, rest- 
luMt, and KluepluAi, aud fuel uueomforlublt*, tirod, and mffer 
from loss of appetite. In itome cases, a raTenoiis appetite comee 
on. The exjnwsiou of the face becomes dull, the ekin pale, 
the eyet) sunken aud tired. At the same time the indivtdualirj 
arc torturod by ritguc rheumatic, intcrmittiug jioiiu!, wblc 
now affiict tho Iiead, next the Klioulderv, and tlien again 
of the joints and Umbs of the body, or localized neuralgias, for^ 
instance, of the infra-orbital nerve, arc present In many p«- 
tienta a blowing' heart-murmur is audible. The pulse oftoa 
rcflchee one hundred and ten per minute, and some increafie of 
tcniporaturo is also nodoeable. Tlic jtaiieut^ siitl«r frum nigfat- 
aweatit, and their urine deports a heavy sediment of nrio«eid 
salts and uierytbriu. 



87PBIUS. 

The eroptivo fcTcr enbeidce on the outbreak of tbe morbid 
phcuuniemi in the vuriuim oi;gaiu and on ilitferent porta of tho 
liody, bat flomctiiiice it rctiimg agiUD in die course of the ti- 
foetioD, when soquelo) or ralapeee ensue. The eruiitjx'e fever 
osuaUy attaiiu its atMue iu tweiitjr-four or farty-eigtit bonre; 
tlioD it generallji* reniitii, aa in acute exnntheninta. In regard to 
the influeocc of the remedies that have been resorted to ui a 
given com;, ujhju the iiicr^xuM: of tlie teiii[K;rature, it may be 
euid tlie inimction of blue oiDtment muall^' caoses a slight 
increase of the tempcraturt:*, but later on in the disease it b 
often folIowL-d by abnormiil diiiiiuutioii of tlie tctii|KTaIiire. 
Tlie treatment witli tlio prepariitions of iodine at tiret does 
not acein to bavo any marked effect ujiou the temperature; 
later on, it camMM au iticrc-u^o, but lioon after uf\ng tlicui tbu 
tompcratarc retturiid to tiie Qonuul. 

Time of Emption of General Syphiliik 

Acconiing to onr experience, the emption of eecoodary 
phenomena never takea place before the eighth week after 
infection. Remedial measures may iKjetpone the outbreak of 
aypbilis, hut tbey can not prevent it ; we poa&ees no remedy 
with which we can eradicate tlic discan!, aud, etill lc«e, annihi- 
late it, in the first few weeks of ita existODce. On the otiier 
band, injurioue iuflucnoes, inicb aa violent mental excitemeot, 
exceacs in Baeeho el Yetu^re^ forced, inarcbefi, traveling at 
night, etc., ntay hastea the ontbreak of the wcondary pbo- 
DOQiena. 

LocaUsatioa of the Byphilitio Fod. 

All the tiesuoB of the bumun body may bcoomo diwMed 1^ 
qrphllis ; (till, the morbid process eeems to bare a ]»oforeDce 
to boeome localized U|K>n the common iutegumenL Next in 
fre'gncncy, certain parts of the mncoibt membrane — for lufltanoe, 
the uanw, faacea, mouth, laryus, n^fiJciphagOB, rectum, va^na, 
ntcnu, uretlira, etc. ; next tbe perioHteum, the endoeteum, and 
tlie lione» lliemsclve* (fi»poc'Ially aome ilat and n few long tubu- 
lar bones), the perirJiuiidriuni, and tbo carliLige of certain or^ 
gana, tbe septnni nares, and larynx, for instance, and ocatain 
ecions mcmljranes, tbe periniyeiuai and the iris — arc attacked. 



ITO PATBOIOOY AND TREATUENT OF STPBIUS. 

Of tlio fibn.iii8nii<mbraDcg,ttica1bugiD(n tostisaiul tboeclerotic 
ouat of tlio c>yo atu the only ones tli&t are aJTected. The sab- 
niucoQB au(l KubcutaiieoDH tisKiiiis are often attacked ; the liver, 
spleen, l^eart, kidneys, langH, brains, and certain Dcires, tha 
blood-veseeU and bowels, ue loea fraqoentlv diiteafied. 

The Cachexia produced b7 Sjphilii. 

If syphilis bus once engendered certaiD morbid nllenttlons 
in mms of the or^^ane that pluy an iiuiK>rtant part in tlie eoon- 
Aniy, tLv L'ljiibtituLidQ of the [uilituit is Kiire to sitlTer from % 
cadiexia that will completely exhaust him, and the disease wiH 
tonainato in death. This ia especially the- case when, lu eoii- 
aequcuce of amyloid degeneration of tlic kidnej-s, Hlbuminuria 
or htcmaturia is produced. Certain conditions of the individ* 
nal— bad Ii\'iQ};, complications with otlicr disea^toct, tsurh ra tn- 
bercaloBUs gont, scunry, improper treatment, etc. — are likclyto 
hasten snch an unfortunate termination. 

Combiuatioiu of SyphlU^ 

Acnte ili£easea exerci«e a remarkable degree of infloence 
OTer eyphiil^ especially orcr the early phases of the dkeaaa 

The muco-papular Hyphilidc of the Kkiu, and of the mucous 
munibrane^ quickly disappears on the occurrence of »n acute 
aDFectdon, but returns as soou as the latter subsides. On the 
other hand, the dry and tUcoratiro fonna of skin Iceions, mu- 
cous patches, plaqHf4 mw/Mv^f*, eTphiUtic discaccs of the 
bones, are but little affected by acute tnaladies. 

Chrome ditfeAses may not only coexist with syphilis, but 
will accolorato its course. Thia is especially the case with the 
consumptive affoetlons, saeh as tuberculosis, ^iirvy, etc A 
combination of gout and syphilis renders both morbid pro- 
oewes obotinatfi to treatment. Syphilis exereiiteH a iiiodt iiiju- 
rioQS effect over pregnancy, frequently resulting in abortions 
and mEscarriagcA. On the other Imndf prefrnancy retards the 
tetrogrado df>vt'lopment of nvphilis, the anti-syphilitic rcmodiea 
being'lundered in their action by the prooees of gestation. 

Id regard to the influence of fi}iAuli4 upon the oounv of 
a wotuid, clean cuts heal in syphilitic persona as rapidly as 



SYPRILIS. 



m 



tn tbc nan-gyphilitio. Dnt if a freeb Kyphilitic scar ia cut 
into^ it vrill occuHioiiaUy be h-aiisfunued into im ukcr. Tho 
union of fniotures k BOmetimirK n-tanlwi by tho syphilitic di> 
athcMB in eyphilitJc pereoas. Mechanical or chemical irritatioiiB 
are liable to prodnce, on the irritiited jtlaees, inBatniimtory prod- 
ucts analogons to tho phoiK! of luetic leeiona from which tlie 
patients happen to be sofferiog at the time. Cauterizations 
performed on pcmoiu afflict^^il with a recent or Intent form 
of the disease do not fnmiflh sneh results ns would justify ono 
in inferring from their appearance the ebaraetor of the eyphi- 
lU present (eauierisatio provocatt/ria of Tumowaky). 

gDcoeuion and FhasM of SypliiUtlo Affeotiona. 

Not only the manner of gucceasion In which sypWIia attacin 
the different tiitsnca, but tlit- local morbid ]>ht'n()meuu and tlidr 
metamorphoeeH dt&play a certain degree of ivgiilaritj. I'^imt 
of oil, tho lyinphutic glandular ttyetcu, the comniou Iut(^- 
ment, with its apiHindagi-s, and the mucons membrane, become 
dicea)^. The ntfection of the periosteum, of the bonefv of the 
mbculaDouHd and stihinucoue oonncctire tifieiie, follows later. 
The ofiectioDB of the viscera l>eIonj; to this category. In con- 
ridetatioD of this well-nigh cooatant eucce^ion of attach, Ri- 
ooivl divided them into three groups, and dceij^atod them as 
primary, iwoondmy, and tfrtiary nyphiUji. In the primary 
■tagc he pUceii tlie Ilunlerian MslerwU and glandular indolent 
Bwelling ; in the accondnry, tho disease of the upper layer of 
tho p'ncral skin and tho miieoua meniliniiie«; in the tertiary, 
the affection of the Mihctitaneniis and suhmacons connective 
titcnea, the boiie», the seroaK and fibrone membranes, and the 
parenchymatous orj^ans. 

Bat no Huch distiiid division as wan made by Kicord really 
•xiita ThtUf there are often eeen eyphilitio affections of the 
hones in the early period of the disease, and, conversely, ozn-na 
Byphiliti(si frc(]ncntly oocurn in connection with those erup- 
tions of tho eliin which Ricord pUcee amon^ tlic Becondaiy 
phenomena. It seems to tts that the el awiti cation adopted by 
II. Zoissl, namely, the sta^ of moiti paptUis^ or (/nuJijhmat^, 
and the etage of ffummat-ous adventitiw9 gromtA^, is much 
more correct, beeanee tlie appearance of the firet gnmmutous 



173 PATB0L06Y AlfD TREATMENT OF STPSlUSi 

ikkIb upon till! Klvin, nr in anj of tlie risreral oT^gtiu, aliiHut 
excludes the presence of moist pspiiles. The morbid procesBM 
of the cond^'IoQiatoua Rfage may be regarded aa leaioiu of Irri- 
tatioii, tliuM: of the guinrtmt<nifi Btage ns new growtlis. The 
first gnjHp oinbraoee the ikffections of ilvo lytnphntic 6.vate(u, of 
the ekiD and '\i& appcndagee, of some parta of the mucous lucin- 
linui<:8, aud of the im. TLe socond group includes tlio dis- 
eases of the subcutaoooiu and fiabttiucou£ cellular tuques, of 
tbe tibroas membrauee, of tlie bones iuid cartilaj:e, of the mtt»- 
cle8 and viscerx 

Development, Conrae, and Dtuatioii of Conatitntional Sypbilii^ 
and its Mortality. 

Tfao dovclopmc-nt and digeomiuutlon of eyplJU^ donotgo 
on steadilj' ujkI uninlfrrujittnllv ; apparent rerovenuK (ittagea 
of latency) occur periodically, and are followed by new enip> 
tions, which may be more severe oveu than the preceding 
oneft. The iutL>n-als of apparent recovei^ may laat many montha, 
even many years. On carefally examining snoli a patient* 
traces of latent syphtlia, such as ftwelling of tlic lymphatic 
glanda, opacity and hypertrophy of the epithelial colle of soniB 
pnita of t^ macoDfl nieiubnoic, discolored cicatrioee, hypeitm* 
phi«« or uodcd on the bcHUM, etc., vriJl always be found, llie 
Blow or rapid eucceesion, as aleo the Bpoody or tardy dcrclop- 
ment and rcsolatioii of some of tlie morbid leeione, varies ex- 
ceedingly, and depends cbletly upon tlie congenital or ac4|aired 
Individual peculiarities of the constitution, and npou the ajje 
of tlie patient ; Mmietinies, however, alfio upon variotu acci- 
dental cau»eH tind indaencee. In tii,-])hiHe, tite Inn* of jfortium 
minoris rtmsU'»ti*p h bcob cvorjTrliore osemplitied. Tlie phe- 
nomena of the first 8ta^, as a rule, di:«play % certain degree of 
activity, while the eympttimit of iuveteratc Kvplillia (guimna- 
toQ9 plia«ie) rnn a tedious course. In eouic chhs the different 
phases of the discaso follow eacb other rapidly and violently 
\fyphilU galc/Ktnfh fvhtle in othunt, montha, and even yean 
paS3 before a new eruption follows, or more bcr)ou£ effects of 
an almost for^ttea disease appear. In tlie tirst phaece of 
By])liilia the dry cmptioDs of the akin osually disappear by 
resolution ; in tlic later periods, however, alccre form. 



arPBius. 



ITS 



The duratioD, lilte the cotirse uf ejphilift, varies exoced- 
in^\y, according to the individual peculiarities, tlic age, and 
itie conduct of the [uitiuut, uiid the rarioua compliuitioae tliat 
may occor. If tlie natural ooune of the diflea&e ie not inters 
furod with b> therapeutical measures, a complete Bpontaoeous 
care may tiiko place at the end of a certain Icn^h of tinic ; 
bnt, conversely, in patient* who undergo no trcntmcnt., the 
most eenouA forms of aypbiliit may develop. Tn'utmeut exer^ 
cisca a moet important inlluence over the courxo and duration 
of the dueasD. Syphilitic pHticnts who are mercurlolizod very 
early, esjiecially boforo genend pheuoiuena have ap|)eared, are 
ofttfner attacked by grave ImtiuiiA uf uyphilis (cerebral and vis- 
ceral), and they are oftener snhject to relapses than thoee who, 
for a long time, were not treated at all, or tiret with iodine, 
and later on with niercory. A cure uf the dLtcoMi luar indeed 
be brought abont in any of its atagee ; tho moet rapid and 
pcnoanent ifl achieved in thoee mot<t recently attacked. In 
Uio most fATorable coeoa, to bo euro the rarest, a cure may bo 
accompli»hed in from three to four months ; in most instances, 
bonrerer, it takes two, three, or more yean. Under imiflTor 
able conditioM and onsuitable treatment, the discuo, now im- 
proving, and ilion ofFun becoming aggravated, will drag along 
many years till finally some serioua leeious of tlie tiamies^ or 
disturbance in tliu fnnetiOQB of important organ-*), ensoe, re- 
sulting in pamlysis and chronic invalidisn tliat terminate in 
death. 

SyplulLi itself rarely caueeR death; and, when this hajv 
pens, it tji generally in con«eqoence of gangrene, profuse biem- 
orrhage from arterial branches that are difficult to ligate, or 
nccruua of tliv honcH uf tlie t^kull. In sitme erne*, tiufTaeutiou, 
in oonoeqnence of hirmorrhtige into Morgagni's cavity of tbo 
larynx, or oedema of the vocal corda (lAO^gofitenosis sypht- 
IBJca) puta a sndden end to the paticnfs existence; while 
in etnully rare caece tho patients saccumb to albatninnria 
(Bright*A di8eflBe),B}'philitic affoctionti of tiic liver, of the nerv' 
009 mmterft, of the cardiac mttscle, to mnmsmus, or, finally, to 
tnbercnloiiiB generated by syphilis, or an unprupcrly managed 
mercarlal troatmeDt. 



174 PATHOLOGY AKD TRBATMEyT OF 8YPEILI8. 



SeTelopment of Lsrmphatio Olaudnlar SweUio^ (viguuting in 
the oourie of Syphilis (Haltiplo Adeaitii). 

In about fivo or i\\ weeks after the mdolc'iu bulioes tiavo 
formed io the immodiato vicinity of the prininry ejphiliiic in- 
dnration, othor cbainB of lymphatic ghuid« enlarge in various 
regions (if the hoAy at a tlixtaiict* fnitn tlie iiulolent 1>ii1k)M. 
We think we are jiistiJied in offering tlie follmring j)liyHi> 
logical explanation of the B^'phiUtic swelling of the lymphatic 
gluntk, viz. : The syphilitic viras u ah8url)cd by the lyiuphatio 
veescltii, uiid the fintt putliolugifjil mgn that al)eorptiun has taken 
plaoe is tfao appearance of an indolent baho. The s\'philitie oon- 
tagioQ m not retained in tltis primary swollen lymphatic gland, 
but is conrcjcd ^vith the fyniph to other tiwacB and glands. 

The chains of lymphatic glands that swell up Tooet mark- 
t»\\y are tlioee situated in the neck at the posterior border of 
the miuitoifJ procoee and gtomo-cieido-mastoid maBcle, tiie jttgo- 
lar and eubctavicular, the axillary, and the remainder of the 
inguinal ghuuU which were not prinuirily afTevtvd, tlie cubital 
and tlie Habnioxillary glands. In the syphilitic cadaver, tlie 
lymphatic gknda situated upon the inner surface of the ster- 
ntun, the bronchial, tlie abdominal, and tho pelvic g'hmds, are 
also fonnd greatly enlarged. 

Til© enlarged syphilitic glands at first are only as huge as a 
pea, bean, or hazel-nut^ and, an a rule, swell up without any 
inBaiiunation, and are not fienifitivc; but^ lik« tho primary io- 
dolent buhoed, they may Bubseqnently become greatly enlarged 
in comeqacDCO of scrofula or tuberculosis, and tuidergo sup- 
poration, in put at least, if they ab«orb pnmlcnt matcriiil 
from any ulcerating »ore in the vicinity. 

Multiple adeiiitia is an almost constant attendant npoo all 
the other syphilitic lesions, and generally ku^ps pace with 
them in thoir aggravation and improvement. In doabtfol 
casea it is a most valnable aign regarding the na.ture and char- 
acter of the morbid lesions situated in other tit«uec of the 
body ; and even in thoM caaee in which a partial cure has 
oauaod tho other effects td the disease to di^ppuar, it is often 
tlie only evidence tliat the syphilitic diutliuos is not entirely 
extint;;uiMhed (_l<itent i^jyhiiig). 



BTPBfLIS, 



175 



Tbe BVpliilitir glandular Iiypcrtivpliles, in persona wlio are 
in othtr respects well, never attain snch large proportiong as 
the scrufulous liypertropbiw, Tbe furiuor iiru tuuoritL on 
their upper eurfacc — the bttor nodular and ane%'pn. Svphi- 
litio swclliuga of the glauda, under favorable couditious, ^ntda- 
ally grow nnaller and duappeor, or Ibcy undergo fatty, cal- 
cnreouEk, or amyloid dogenemtion. ^rofulons gbmdolar hy- 
perplajiise fro<|nen1]y become inBamed from wry slight exter- 
nal wuM, and pu? forms in is^rpml plneos. Tho pus bocontee 
ioBpisBatod, fatty, calcareous, or dogencratos into s cbtway enb- 
stanoe; but iu tbe end tlio tumor nipttireii stKcveral points, 
and torpid nieers of the akin, irilh livid undermined edges, 
originate, which now secrete a tliin, sticky, adhesive matter, 
and then again an insplseatcd cheeay dlscbar;gi>, and heal bj the 
formation of (MmLnictiug, radiulliig' cicmtnceiL 

Korbid Lesioiu of the Bkin caoMd by Syphilii (Syphilitic 
Diaeaaes of tho Skin— Syphilidcs). 

Syphilid produces on the skin tbe tiret and the uioet fm- 
qoent morbid alterataonB. Alibert baa included thdtn all undt^r 
the oommffli namo of " Byphilidoe." Tbo nature of the morbid 
proceaB upon tbo skin, like all eypbititio forma of disobHS is doe 
to chr<>iiip,oiraDmscrlbed intlaminatiom nod c-irPiiniK^^rilwd for- 
mation of new oonnective tissno. Active grtuinlar and cellular 
pruUfcratioRfl take place at tbe affected phu!e«. The grauulM 
and celht are either rvabaorhed, or ihey degenerate into pniv 
oorpuflclea, or become traiixfonned into connectiTe-tissue cells 
and fibera. Tlieae processes prodnce either dry or pomlent 
eruptions. The dry eruptions are ruprescntod by tJic macuhc, 
papulu, nodtdee, and tubundua; the puridvnt by vesicles, 
postales, and nipia. These emplJons, however^ are also pro- 
duced by the moet vanr'ing morbid conditions not allied to 
lyphilia. Hence, there are no eruptions tliat belong cxclu- 
avoly to s,>'philis ; the latter imitatos all cniptlonf of the ordi- 
nary affeotiouft of tbe ekin. 

Tbe re«emhlaiioe of the Byphilides to tbe non-*ipecifio dia- 
oases of Uie integument, the form and the kalcidoecoptc appear* 
anoe of the eruptions, as also tbe variable degroe of the ioet» 
nwrphoaea tticy undergo, always make the diagnosiH of nyphi* 



176 FATSOLOQY Aim TRSATMENT OF SYPmUS. 

litic afFectioDB of the dkin exceedingly difficnlt. The following 
signs will aid us id foruiiug a diagnosis in ei>Gcific diseases of \ 
the skin : 

(1) Tho Jjutrlvdfy rirc'unftrrihftJ (orm of «otne of the crnp- 
tioas. Even the so-called areoL-i, when present, does not mer^je 
gnulaaiij' iuto the normiil skiu surroundiug it^ but t>iida sbruptlr. 

('i) Tho j>ec»liar cahr of some of the fiyphilitic ernptions. 
The red color; namely, of syphilitic raacalfe, papules, areolie, 
nodes, mid partly also of cicutricee, is Dot Hko the fresh, rosy, 
red color i»f iltu eorroflpoiuiinp non-ayphilitic eruptious uid 
scara, hnt is a dull, bronnidh-red, resembling someurliat the 
color of Incon when cut into, or of turni^cd copper. This 
peculiarity is not cqnalty mai-kcd iu all stsj^cs aoid phases of 
the dieeuse. The morv rcceut a eypliilide, the shorter the 
time that ha^ eln]>sed mnce the {>erio(l of infection, the soooer it 
appoora, and the more eupcriicial the eruptions — tho brighter 
the red colur will be ; the older the By{)U!lidc, the more slowly 
It dcvelopj*, tho later it appeare after the infection, and the 
deeper tlie layers of the sldn are involved la the eruptive 
process — the more marked will be its brownish or cop])erj 
color. After their involution, the enipUons leave a brownish 
stain of tJie skin, that gradually merges into bine or grayish* 
blue color. Cicatrices that iurui after the licoling of syphi- 
litic ulcerationB also present, at lir^t, a tiimiliir hr<>wnish-red 
color; but the older and firmer they become, the whiter they 
grow. So lung ta a cicatrix has this color, it in liable to break 
open anow, and the syphilitic diathesis is not cured. The 
cause of this coppery color, according to our inTestigations, is 
to be foand in the pathological composition of tho ompCioDS, 
and is due to a tclcangicct^is {m in acne rosacea) and to a pns> 
sire atmia and transudation of tJie coloring-matter of the blood. 
The simple hypenemia of the entaiieons capillaries gives rise 
to the rosy color, the dilatation (more or less) of the developed 
vessels to the dark-brown or bro^niish-red color, while the dull 
brownish discolunitioo tm the reituit of tlic traiiMtdation of the 
coloring-matter of the blood. In badly nourished, feeble per- 
sons, especially women, this tmnsudatioQ is so great as to ooq' 
stitutc actual ha'murrhiigc ; blnii>li-n>d, small and large spotl. 
and swellings tliou originate in the dopendiitg parts of the 



STPmus. 



bo()j. PaMTC etAsi« and tlio tranisadation of the coloriog-mat- 
ler of tho blood ore also promoted by a doponding podtioii, ae 
)E tbc caa« Ln the legs, eEu. 

(3) Tbc laoaticn of the Byphilitic ernptiooaL As u veil 
known, sy[>liiliric emptions have a prodileotion for ocrtAin re- 
gions of tlia skin — fi>r iiujlanoe, tho fort-head and nape of tbo 
neck, where the liatni ceaw to grow, the entire acalp, iu tlie 
groove between the n\m nasi and chevk, oommiwures of the 
lipe, the navel, uikd an&l folds; on tlie common integnment of 
tbe genital oi^puis and their vicinity, especially tho inguiaal and 
genitocniral fold of both eexw; laatly, l)ctwycn the toes, in 
tbe hollow of the bauds, and aolee of tbe feet Again, certain 
forms of Bypbilide have a predilection for ccrtuin localitios. 
Syphilitic aitaneota nodiilcs are met with more froqnently at 
tbo root of the nose, on tbe temple^ scalp, scapukr and da- 
vicolar regions, over the etcmnm and tibiie, while no ciythom- 
atons eroptions occur on the face, back of tho hands, and foot 
Lastly, certain specilic ernptionu, like plants, undergo marked 
modifications in their development according to their locationa. 
On the parta of the skin that are provided with an abundant 
layer of fat and large sobsceooa gland^ whoso eecrotions, in 
addition, are aiif^mentod by permanent friotiona — for instance, 
the anal fold — nioiHt papiile-s gntw exii1)erant1y ; while on those 
places where the eehaceoms follicles are totally absent (the hol- 
lows of the band and soles of the feut) the papules riae scarcely 
above the level of the Hkin. Indeed, the sebnceons and hair 
follicles eccm to promoto the development of certain erop- 
tions: thue> the impetiginous syphilitic emptions socm to pre- 
fer tbe hairv part of tlio fane and ficalp. Tbo ecthyma-tiko 
syphilitic pastulu dorolop oftener on the aca1p and legs tlian 
DO any other part. 

(4) The quantity and suooes^ivifcnm of tho specific erop- 
tions. The first eruption that appears after infection consists 
of immoroQg but Hcaltervd inflammatory spots. The longer 
the time that has elapeod since infoetion, the more pionoonccd 
the inflammatory foci will be, and the more deeply will they 
penetrate the skin, but the less numemiiK will tbey be and ag- 
gr^te in certain places, iicemingly preferring to form circles 
and curves. 



178 PATBOLOQT AND THEATMENT OF STPBIUS. 

(5) Tlio poli/nwrphove form of the eirphilitic eruption. 
The GimuttaueoDs occurrence of maculse, papules, aiid piutnlcs 
of various kitida, vltich, owing to tlto pmtructed cluractcr of 
syphilis, may alrcadj ttc nndct^iu^ resolution in some places, 
vhii« now ODes are derelopin^ in otben, oeoasiona the most 
dissimilar mudificatione in tli9 eniptiotia on the dificrcnt parts 
of the body, tliongh ideiiticnl in tlieir fiindnmcntal form, Tliia 
givod the Bjphilitic diseases of tho skin sndi an UDnftoal poly- 
morphoos picture that this symptom ooii8tituteti one of iho 
most important aids in the ditTurunti.iI diiignone from the 
analogous noii-«pecific diseanes of tlie akin. 

(6) The construction of the scales and onistt of the ayphi- 
litic ernptions. Specific eniptJODS never generate sucli thick 
scales as nou-eputniic uniptiotiii, and their color is never as 
bright and eilvcry ae ia the caee, for instance, in pwriafiis vnl- 
garu, being more of a dirty-yellowiah or gimyiah-irlute color 
(peoriaKis syphilitica), (nigncana id Cazenare). llie scales of 
gyphilitic papules oonaist of the cast-off epidermal ooveriug-^iD 
other vords, of old, dead scarf-skin — wtiile tlie sealee of psoria- 
sis vidgnris coneiet of recent though dtseoBed epidermal odls. 
The dark color is due to the pigment, which, as we have al* 
ready stated, tlie syphilitic iaflamniatory process deposits in 
large qiiiintities. 

On the other hand, epooifie pustules produce thicker cmsts 
than the non-specltic pustules of corresponding dimensions. 
This is readily explained by the extremely tedious coarse of 
the syphilitic eruptions. By the prolonged suppuration, not 
only a greater quantity of material for the formation of enuts 
is generated, but tho crnsta tliat have alitady formed con- 
stantly absorb pus from the aupjiiiration that goes on beneath 
them, and they grow more succulent and larger. Non-eyphi- 
litic puBtuIar eruptions develop more rapidly, and dry up com- 
pletely into a scab, llcnco, in the latter the scabs shrink up 
more and adhere more firmly to their bases, while the ontsta of 
syphilitic eruptions swim as it were upon tlio pas beneath 
them. By adhering a long time to the skin, the soft sy^pluhtic 
emsta become dirty from [tartictes of dust, etc, that aocuma> 
late upon them. 

(7) The peculiar form if lAg sgphUUic ulcer. As a pocol- 



BTPfflZm 



179 



iarity of the nicer prodnced by constitoh'onal sypliilis, the Itid- 
no/or horseeboe fomi is npokeu of — 1. e., it prcacnto a couc&re 
Borhcc at ODO pUce vrbicb ia already licnling, and a eonrex 
earface at Mother tbat stili ulocratos. This form of ulcera- 
tion is not met with in all wrea produced by BGROiMlary Bvphi- 
li«; and, nioroover, it ocwurs oven in aieere uf non-sjphilitio 
oligin — for imtanoe, lupus Bcroplialosorum. It ig met witb 
most freqaently id t.be am^patin^ nodular eypliilidiw ('falsL-ly 
called InpuK nypbilitiea), iii MMHrndmr iiWra pnMtodtt) by nipU 
and ecthyma pastilles, and in instanoes of new ulcerations re- 
mUing from tbe reopening of cicatrized sores. 

(8) Tbc iidting of the akin caused by syphilis. It is as- 
serted by some writcni tlint the Ryphilides cause neither itching 
nor pain. This ne^tire clumicteristic. however, doee not prop- 
erly belong to all the eypbilidcfi. The moist papulce on tho 
fondameDt and near the genital organs give rise to sovcro itch- 
ing that cauAOft violent Bcratcbing, and when they become nlcer- 
■ted, for instance, around lite aims or betn-een the toes, arc in- 
tensely painful. Papular ntid nodalar syphilides in the stage 
of deeqnamation, ee^wcially those on the sculp nnd in the beard, 
that form cmstB, occasion a marked dcgroc of itching. 

iff) The poeuliar odor of the exhalation and tranaptratum. 
aacribed tu Kvphilitic jutieut^ by some writers is not proJucetl 
hj ayphilifi, prr *?, hot by the decomposition and pntrefaction 
of the ditchargen from the moist pnpnlea, the scbiun^ the pei^ 
spinition, and the poa from nnmerous pustolca, or the ichor 
from dcin and oaseotu alcct«, or by a stomatitis mercurialis. 

All of the abovo-mentionod morpliDto^^cal poniliaritics be- 
ing only of relative diagnostic value, the physician, in order 
to nuke a poeitive diagnoeia, will have to take into consident- 
tka all the morbid lesions that occur in other tismes and or 
ganj simnltaneonsly with tlie skin-diMaasB. These ooezieting 
pbeoomcn A or /i/TU'omifantia of iiypliilitic diflease of tlie akin are 
hyporplastie entargemeut of the lymphatic glanda, the falling 
out of tho hair (alopecia), affections of the nails, of tlie mucous 
raembnine, of the bone*, of the iriii, etc. We must here eiii- 
pbaaize the proposition that the physician should not be con- 
tent with making a diagnosis of ^rphilis from one ^rmptom 
only, bot from the sum total of all the tnjinjttom* present 



190 PATHOLOOY AND TRSATMSST OF STPBIUS. 



Deflultian &acl Clauifleatioii of BTphiUtio 6kiQ-DiieuM 

AsmiiniDg, lUte Biott and BaM>cr«3ia, according to WUUo'a 
priaciplee, the elemeDtarr form, of entptioDS aa a buis for 
claseitication, wo divide the ayplulidofi into tliefoUovriogfonDfi: 

(1) The crytbcmatotu form: 

(a) Erythema macnloeuin. 

(5) Er_?thenm elevatuni ur papulatnm. 

(2) The papalar form : 

(a) Syphilis papulosa lenticalaris. 
(d) Syphilid papulosa miliaria, 
(c) Psoria^ paliiianH et plaiilaria. 
ifl) The iiioiflt or humid papulen. 

(3) The pustular form : 

(a) Acne nustolar evplitlide. 
(i) Impetigo pustular syphiliile. 

(c) Varieolla pustular e^philide. 

((/) Ecthyma pustular BjpbilidB. 

(o) Itnpia. 

(4) The tubercular form : 

(a) Supcrllcinl syphilitic cataneoas Dodefl. 
(() Deep syphilitic cntaneous nodes. 

1. Tde EBmiKMA Syri[iLji>% Ebytiiema SvrniunoiJM UUo- 
iTLOSTm BT PAprLA-rrv, RoeBOLA SrpntLmcAt STrnt- 

uno Spot9. 

By er}-t}iem3 ftyphilidctim in understood that affection of 
the tiktn originating from ByphiUe wldch manifests itself by 
tb« formation of roundiBli, sharply defined^ saperficiftl inHam* 
matory foci or spot^ of the size of a lentil, pea, or even larger. 
If acute, tlie eruption itt of a hright*red color, and then lastn 
only from eighteen to twenty-foar hoan; ; hut the longer it 
laets, the duller or more brownish-red it becomes, changing 
jinally to lead or graphite gray. On pressure, the color does 
not di«ap|}car entirely. 

Syphilitic crrthematons ernptione consist either of smootli 
spots «'hich are not mii>«d above the level of thu BJdn (erytbe- 
ma syj^Iiticmn macnloeum or roc«ola eyphititica), or of thoeo 
-which. UG provided witli atutU papular EwoUingB, or dots 



STPS/llS, 



18t 



(etytlunua BTpbiliticam pnpulatQn]^ The lost fonn is onlj a 
grade higlitT Uian the ftmocr ; fur in acute caeoa it appears 
Bimnltancoudy vrith tUo firet (erythema BjrphiliCienm macnlo- 
pepiilatum). lioth emptiotu are based upoo a circumacribod 
iatianunoloTy proceot in tho papilltD of thu cnti« ; erill, the eo- 
btOMoa and boir follicles al^io nndergo marlced patbologic&l 
alterationa. Bioeiadecki regards ntacula eypliilitica aa a eir- 
enniscriljetl hvpcncmia of the 1i!wMl-ca[)iII:tri(>i^ n>Rilting cither 
in haeonorrha^ or cransadntion oi the blocid, with eooseqiient 
diBooloration. The walla of the blood-veeeola of the papillie 
and of till) o^riiun tutt |)enueutcd aud aurrounded hy newljr 
fomted celld and granuleti. 

KiTthematoDS syphilitic emptiona are found id grcnteat 
nuuilicrs on tbe trank, es|)ociallj on tho eidca of the che«t, 
groiiiK, and alKlomon. Tho neck, the tttcnial region, and tho 
face genenilty, are &ee'from epote; but on ttie forehead, where 
Ibe hain cease to grow. ntuncrooB emptione ori^nate. On 
{be extremities tlicy nro tuoolly only fonnd at tlie bends of the 
elbow and inner giirfaco of tJie thigh. Thoy very seldom ex- 
tend upon tlie forearm and letdown ti> the wriiit and ankle; 
btit when Ihie hnppona to bo the cara a few crylhematooa 
patehed uf the elze of a iLiilil or uiillet-«;eed are found Bcat- 
tered npoii the palm of the tuind and ttole of the foot (paoriaril 
[lalinaris and plantarift). Ho macular emptiona are found on 
the skin of th« genital orfi;aiu^ except the penis. If a bnlono* 
blennorrh<ea be prexent at tho tame time, the apota or papules 
will be transfonned into elevated, sharply defined, bright-red» 
moiat or eauly bleediug en^ioui*, aud they may be miatakea 
for miperficial chancroua alcora. 

The dcrolopment of erythema (--i-phililicnm im generally 
preeeded by tlie prerionsly mentioned spccitic eruptive fcrer. 
Tho more intense tJic latter, tho more numerous and pro* 
DooDCod will be the cHIrtrescenoes. II no eruptive fever oo- 
eorred, or if the pntii-nt was tieated with mercurial or drastic 
pui^atire remi.>tlte.t, mum after the ap^iesnuioe of tJie Ituntertan 
obanere. the ^ts of emplion will he few in nnmber and 
appear slowly. After indulgence in excesses, exliaustiug. 
marches, or In oonset)uonc8 of violent depreming mental dta- 
turboiocos, the erythema attacks the entire akin wlUiin twcn^- 



189 PATBOLOOT AXD TREATUEKT OF SYPBTUa, 



four lioure. Its slow dovclopment is Uie rule ; but, compared 
to tlje other dvptiUides, it develops mora quickly and isDmes ud 
earllur after tlii: Infection. Ki-itUcr thu ticiuon uf tl>e jear, nor 
Bg«, nor sex exercisee an/ inlluenc« tipon ita development ; the 
teuiperatore affects it to a certain extent, inasmuch oa liigb 
tciupcralunr rondore tlie ^ot£ Icea dialiuct, imd low tctnpurb- 
tiiro hrioga them out brigtitor Q^alnat tlto palo BarrouDdlng 
akin. 

In exceedingly rare ca»», tLo erytbcmfitoos sjpluUdo i* of 
very abort duiution (roaeola Eyphilitica ovanida of the old writ- 
en). Ab a rule, it will r&main unobanged for many weeks, 
erOD yean, if nut interfered with l>y tr\»ttaent Although a 
laorcurio] trcatmont maj diasipfltc the cmption in aboat four- 
tcon days^ still it oft«a happens that, daring and notwithfltaod- 
iii^ the treatment, tlie eleinuntar/ form of tlie Kjjiliilitio eraj^ 
tion developtt markedly, and desqaamatjng papalee and pnstnles 
result from it The reason why erythematous efUoresceDcei 
In 8ome pereuna occasionally imiif;u itu (piickly into other enip- 
ti<His that it is entirely overlooked, while in otlicra sypbilia 
pereiets in the form of an erythematous syphilide. is dne neither 
to the coiiceatmtiuu of the abtiurbcd rirue, uor to the character 
of the infecting fed, nor age, nor eeasoa of the year, bat to 
the ooiutitiitlonal condition of the infected individual The 
gjrphilitie erythema always disnppcara by resolution, leaving 
behind a brownish-gray mark (leutlginea or ephelidcs syphi- 
litica of tlie old writeK). It oecnni as often in couganital sy;^ 
ills as in the acquired form. The erythematous spots, when 
the eruption relapses, are larger (three to foor millimetres) than 
the primary ones, and are sometimes aggregated tn clrcleB. 
Tliey occur mostly on the abdomen and the lower part of the 
choet — less on the back. The relapsM which manifest them- 
selves aa eiythema syphilitica generally come on a little while 
after the first emption disappears. Still, wo liad one opportu- 
nity of seeing a relapse of tliio kind occur one year after the 
first erytlieou vauiidiod. A rclajiso may take place so long as 
the Himtcriau primary lesion orthedi»rolored spots of the first 
eruption are not entirely gone. Febrile phenomena gcneralty 
do not preoede a relapse of an erythematous outbreak, and tlio 
spots usually then nm a very slow eouraa An erythema that 



BYPfflLIS. 



188 



rebpeu is oftener nooompanied bj peoriasis palmttm ct plan- 
taris tlian » primary eruption. 

It seldom liappcus that a person affodcd witli erjtbema 
s^iiliticam has not at the same time otbiar forma of efSoroe- 
venec on some port of his body. Especially is tliia the case on 
tiioee partfl of the body where no erytheiiiiitoiis oraptions ever 
oocar ; for itutance, on the scalp, in the fat^e, and around the 
hrge oriiicea. Thou, in patients who have not been subjected 
to mercariaJ treatment, there are often found on the scalp in 
the third or fourth week of an existing sj-philitic enrthcma, 
numerous, irregularly (Kattun^d, small, black, finnly adhering, 
or brittle crii8t«, ae big &<« s miUet-eeed or lar^r, ef a brownish 
color, or numcroua yellofriaii or vhitisb amall bran-like ecsly 
aCabK form thcro which arc easily detached, and whicli aro the 
recolt of aofrmented eecretion of the Eebaceona follicles of the 
Malp (wborrlioea sicca congestiTa). Similar small cniate of the 
■cbaocous ghinds, sitnatod npon a reddened ba»o, arc found In 
the oroviooB of both aim na»i. In addition, eiuiilar impetlgi- 
DODS cmrts, flitnated npon pnjmlar elerationii, occur with cfjnal 
ire()iie[tcy in the beard and mustache. 

On the nape uf tliu neck, ch)SG to the Rcalp, also tiere and 
tliero on tlie tmnlc, there are fonnd, after tlie syphilitic ery- 
thema haa lasted eercral weeks, a nnmber of lenticular papules 
in rarioua atagoa of development. Beginning psoriafiia pal- 
maris ut plantaria is not so frotpicntly obwrvcd in oonouctitm 
irttb syphilitic erjrthoma. 

On obese pereonp, an intcrtrigo-Hke affection develops on 
the external genital organs, especially in the genito-cmral fold 
■nd anni fissore. Tliia condition generally encouragoe the for- 
mation of conflnont, moist papulos. According to onr expo- 
rienoe, half of the patitmti! who are affected with erythema- 
toDi syphilides sntTer also from moist papules on the genital 
organs. 

At the angles of the mouth diphtheritic exudations are often 
lonndT which merge into the mncona membrane of tlie mouth, 
■nd here present only an opacity of the epitbeUal cells {jdaques 
muqueuMa of the Fiviich wri(<_T»). likewise, tlio imuooub 
membrane of the tonsils, tsoft palate, and nvnb, haa a hluish- 
nd eolor; here and tliere it is milky, opaque. The hain also 



184 ^ATBOLOar AJfD TSEATMSNT OF STPmUa. 

Boffor ft lesion of natrittoo ; tliey loac their gloa?, and fdl out 
at Vftrious places. 

Xov aiul tiiuii some feebljr marked perioKtoras, on the an- 
terior surface of the tibia, craiiliiin, etc., are met with in oou- 
U(M!tioD with syphilitic erythema. In eome caaes^ rarlodla-nke 
vesiclea occaMoiiolly form ou the truiOc, whUe tho pnwenco of 
acne-like or ectli;rina-likc pimtnlee on the legt) is not infreqneDt. 

Filially, it i& evideut that, in patients mi^ering from roseola 
syphilitica, the lymphatic gUud^ accceaihic to tlio wow of 
touch muet 1x3 more or \vm eularge<l. 

Of all the diae3£«e of the akiu, erythema B^'pbiUticnm may 
lie rc^ianlcd us the meet favorable form, iuasmuch as it may 
disappear in a short time withoot leaving any pathological ol* 
terations of the skin behind. The morbid Icuona in. other 
tiasnet) oocurriug in conneution with it are also leca ohetinate 
to treatment, and lu^iinic a more favoiabte coiirM;. "N^lten tho 
syphilis, after a long interval of apparent recovery, recurs again 
in tlie ft>rm of an erythema, the latter ie to be regarded im a f »■ 
Torable prognostic eign, in so far a;s it indicates that the graver 
specific forms of tho disease are incapable of affecting the 
system. 

In regard to the differential diagnosis, sj'philitic erythema 
presents nuuy eimilaritiee to eome of titc uon-eypbilitic enii>- 
tions of tlie ekiii, mch afi moritUiit rubeola^ eOarUUina^ and 
rotMia tt/pAoaa. Tbese typical exanthemata differ ^nt aj^hi- 
litio erythema by the severe febrile phenomena, whioh con- 
tinue even after the above-named eruptions have appeared, by 
the higher tompcratnro and uniform hyperemia of the aids, 
by the location of the eiflloree^encee, by tiie accompanying oa- 
turrluil symptoms (in nmrbilli and ru^tMilie), by the intense 
angina (in scarlatina), by the splenic tumor (in typhoid fever), 
and, finally, by the duration and the whole course of the aSeo- 

tiODS. 

The resemblance of specific erythema to urticaria and roto- 
oiahaUamica was the aiuic that misled physicians, Cazenave 
among others, to regard the virus of gonoirhcua as identical 
with thfit of s^iiliilis. Now, roseola balssmica oocnis only in 
0omo of the patients suffering from gonorrhoea who an trcatod 
by the internal admioistratiou of balsam of copaiba, cabebe, 



37PHIUa. 



185 



turpentine, etc., and di^ppcara ei^ht or ten days after tlie use 
of tlii»u rcmultutt U discuiitiuucd, without luiriug any dis- 
colored H|wU. It is uttc-iidcd by iutnIt;rahlo itclitiig and bttm- 
itig. The violet-red edHoreecencea are of the size of a pea, 
Iuivi> B teudency to aggregate ui grou|Ni, ei>pet!taUy iu plaoctt 
where proeeare is conistantly kept up, generally coalfscc, and 
then tbe skin, bwoHvd and of a violct-r«d color, is ficeD cot- 
ercd with brownisli-rcd wheals. The temperatnre of the skin 
is conjtdenhljr Increased. I.A«tly, roeoola hnlsaoiica is always 
attended by gastric disturbances. In addition, the chomi(»l 
rooctioD of tlie urine, upon tlie addition of a Ktroug uiiueral 
acid, which has already been mentioned in a furmer Mction, 
•flbrda OS snlSeieatly reliable erideoce in differentiating tbo 
two exantliemata. 

In some very rare cases tlie internal use of mercury pro* 
duces an er^'Utematona affection of the akin, which may be 
mlstakou for the Hyphllitio form, Erjfthema mercurials yn^ 
dnoee not ecatteredj but coofluent elHoroscencoSt and largo porta 
of the skin aasame a bright-red color. It is localized, as in a 
case TO had an oppfirttiriity of secinj^, on the flexor stufaco of 
the forGAnUi and on the leg and trunk. It Uketrise causes a 
prickling sensation, and disappears quite quickly when the oso 
trf the mercurials is discontinued. 

KeUpfliiig erythenuttous sypbilJdes that appear in circular 
gn)up«i reseinblu very much erythema circinatum, or nnnulnris. 
The .icnto cooiw of the non-flypliilitic eryllieniata, the ahnost 
exclu&ivo appearance of the eruption on the 1>ack of Uie hand 
and foot, and its rapid resolution, afford sufficient guide for a 
diagnoau. 

The discolored remuantt* of extinct erj-tliernatous and papu- 
lar syphilides — in fact, all discolored upots prodnccd by specific 
inflammatory proces^ea — may be mistaken iorpitynasU verti- 
color. This affuctioQ of the skin, however, is distinguished by 
the following fcatiiivet; Tbo brownish Fpota of pit>Tia£iit ore 
caused by the aoouniulatjon at certain placee of discolored epi- 
denoal cells, the dark color of the eyphilido is dne to coUec- 
tioQS of coloring-raaiter in the retc Malpighii ; the former may, 
therefons bo scraped off uith the nail, or removed by baths 
and lathering ; the latter can not be so rsmoved. The solitajy 



^m TATBOLOQT AlfD TSEATMEifT OF STPmifS. 

spots of pityriaws vereicolor coalesce afttr a wliile, and form 
irregiJar Htatrui as large as the palm of the tiand. This never 
ooonrs in syphilidcd. If, in addition^ the fungi-sporet^ mi- 
cnwpomn furfur, aii<l tUulluB fibcn of phvriusis rcrfiicolor arc 
eeen with the miproecope, in the ecrapcd-uff scales, all soordCe 
of diagnoetic error will be avoided. 

3. l*Ai>n.AK SYrntLiora. 

The papalar ejphih'dd ia chftraot«riiced by plano-coDvex, 
Bometiines acuminate, painlt^sfi nodular utevalions, of the aze 
of a popp7-«MMl, or eren of n lontil, which, aocordiog to their 
location, will be more or loga advanced tn tbo proectt of evolu- 
tion or involution. These elevations confititute mJnnte gran- 
nies or kernels, covered unth a markcdijr dn,'. glossy skin, with 
or without a crust. SomeliiiiL-s tuual) granules with broad bwee 
are seen, and, frran their up{H:r Kurfaoe, in conMxjucnce of the 
eoftencd condition of their cpidennni corcring, oxndee a nu« 
note qoantity of moiatui?, Tlie color of the syphilitio papidu 
at Gni it) bright rod, but Bul>80([uentl7 1>ecoiuc8 brownish- 
n-d. After dewpianiation has taken place, the papule ac- 
qaires a glodsy, livid color, and, the more the resolutitm 
goes on, the more it grows dirtT-velloviab or bluuh-graj. 
Under the pressure of tbo finger, tbe developed papnle tome 
yellowish. 

The speeifio papule develops from small or largo brownish- 
red epots which ^^wlnally rise above the level of tlio skin. 
According to the Kize, we diHtiuguisli a viillary and lenticular 
papule. The sjphilitio paptde never attains a lar^ aize on 
the palm of the band or sole of the foot (p«oriaius polmaris oiid 
plantarw), while in the vicinitv of the genital organs it some- 
ttme« attains enormous diiucn«ious (moist pupulc). 

This pathological procefis is caused by perifoilieidar and 
papillary coll-intiltration. Tbe former oocurB especially on 
thoee placM where tlio aobaceoiis and bair folhcles are beat de- 
vclopod : for itwtanoe, around the anu and the genital orgwu, 
in the azillarj region, and, where tbe acalp merges into the 
bairien ekin, on tbe iorebcod and nnpo of tbe neck. 

The papnUr ej-phiUde originatea meet frequently from ao- 
qnired eypliilis; congenital eyphilia very seldom produoas it 



SYPBIUS. 



187 



If die infected per«oa wafi not treated vitli mercury at 
drastic pur^tiTes, it develops nou after tlie appearance of 
tlic HoQteriui prioury lesion, a few days lutur than tUc cry- 
thcniatoos syphilidc, from which, in fact, it Sa apt to origi- 
nate. It appc-aiv, thorcfori?, at about the eleventh or twelfth 
wuek after iuicftion. But if the patient nvaa put ujioii an 
intisjphititic treatment aoon after he t)ecame iufecttn], this 
manifefitaticm of syphilis may be postponed for on indelinito 
tiuu, aa we have stat«d before. Only a few pajJulcB will tlien 
dorelop, and thcitc are amuiged in circles, aeguKUitM of cirdeSf 
or ellipeoida. 

Large as well tm small papnlce way be abaorbed before tlicy 
andcrgo uny pathological tnui»fonaation, especially witL. the 
aid (if mcdiciiiu. They leave l>ehind olmoet black or Mui^li- 
rcd. di^olon-d doprcesioos, which giadaoUy become smooth and 
disappear. 

But if no treatment is instituted — somotiiiUH, indeed, ia 
spite of it — the papulefi under^ abborplion, by paeeing tbron^i 
the most remarkable morbid cliaagee. The epidermal eovor- 
ing of the [uipnle is raised and fomifi a dry, jfrayish scale. The 
latter falk oS and is renewed of^in and aj^aiu till the dc«- 
quainuting place luut liecome level with the skin. The papules 
tiiat have already cast nil their scales present, on their flat- 
tened surface, a bluish tint and a ^nmmy glos9, and ore mr- 
runnded by a whitish, undermined epidermal border. Ilie n>- 
moval of the 0[)idenual ouvcring of the papule, however, does 
not alwa^'d take place by the dry proceee ; often it is tlie moist 
proocea which brin^ about that ooodltioD. Twelve or fourteen 
da}-fl after the papalo appears, a Bcrous cfioeion forms under 
tlio epidermal cover, thus causing, according to the siso of the 
papule, the furuiatiun of a lai^ or small veaiele. The con- 
tcnts of this vasiete, however, are soon abeorbod or iospiesated 
by evaporation, and conjointly with the elevated cpidennal 
cover form a tbin cnut, wli!(-h ii^aiu imdergot« dewjuamatiou. 
This pniceas rarely happens in the lentictilar papule, and ia 
the moist papule it escapea observation eo easily, that bnt few 
writers mention it. Jlilitiury papulva, eiipucially when they 
appear under an acnto form, arc gcaeially transformed into 
Booil pnetulea 



188 PATffOLOOT ANJ> TREATHEHT OF BTPHtUS. 

(a) Leniicidar, Papular Sypf>3id^. 

TUu Icnticabr, papular syplulido ia gonerallj preceded hy 
a inoro or leaa severo eruptive fever. Nevcrtbcleea, the ef- 
floresceoc«e are cot veij oamerotis, but appear in a certarn do- 
groo of patliologicat order, bo that Rt leut eight or tea daj> 
elapse before the cniptioQ has attacked the whole tmnk. The 
first iadicatiuue of the eruption are alif^htlj elevatMl darii-red 
epotit, of the »ixe of a lentil, ^niendly origioadiig oo the unpo 
of fka Declk and on the forehead aloug the hue where the 
hairs cease to grow (oOTOoa Tenerea). While the papolea at 
these pluocd uclrancro ui their development aiid motamorpbosi^ 
or have alreodjr undergone some retrogressive changes, new 
paptdar effloreseeuccs appear oil over the trunk, especially on the 
hack, eidui of the chest, a.iid itunietiiric« on the ahdouien. Gcncr- 
allj' tliey are pretty cvcnljr bcattered ; still, over the ecapalar 
and mcrj\ region, and in the geulto-crural fold, the/ are more 
uggrcgiited. On tJio anterior ntrfaco of the upper extmuitj, 
the lenticukr papules are Icea numcrouE and not eo woU de- 
veloped. They &rv wore nunicroue, and tend to eoaleeeo at 
the' bend of the elbow and wrist. On the lower extreniitiea 
they are located in tho greatest numborB on tbo internal, in 
leas iium1)ers on the external and poeterior Korface of the thigh ; 
on the leg tliey occur almost excluidvely in tlie bend of the 
knee, where two or three of them are usually found gTx>npod 
together. On tlie dorenm of the hand and foot syphilitic 
papules are very rarely found. In tho face the lenticular pap- 
ule 16 equally rare ; and when seen hero it is not as pupala 
disseminata, but omuiged in cinrles, eepecially wlicu it occora 
in the dimple of tlie clitn. 

Notwithstanding ita acute oommcnoomcnt, the oonreo of 
a lenticular papular eyphUide Is always protracted. If not 
modified by treatment, U»o papules remain etatioaary for ft 
long while, or they desquamate 8C7crnl times in enccesgioii. 
After desquamnting, frequently or rarely, the pnpuloe con- 
stAntly grow more browui^h-yellow, flat, and finally disappear 
by teeolution. The ptiice« where they were wtiiated are marked 
for monthH by coppery-brown or blimh^ray spots of the ^e 
of a lentiL 

The duration of a lenticular papnlarsyphilide naturally de- 



67PmLI3. 



pends, like tliat of any other evpluHilc, upon tlio life the patleat 
lcad» aiid tlie trvauiitiDt be gvUL If he is not treated at all, 
the abore-tleecribed dmjiianiation will ensue in about fourteen 
da/» oa some places, while new papnlca will appear on others. 
Tliia dinappcanuico and reappcarauce of new papulea majr go 
on for a long wUllo; liowcvcr, later they aru uot ihj numt^ruuA, 
and are located in bodio places in circles, ef^onts of circlesj 
and eUii)^u>ids. ■Undor an appropriate treatment a papnlar 
sjpbilide ufiually dlaappears in from two to three montlia. 
The treatment vitli iodine, as a rule, requires a slightly longer 
time to effect a cure. 

Mixed in between the lenticular papules of variiiu^ phows, 
tliere oocur developed or retrograding miliary papules and 
crythomatoas effiore£«eDcea. Aene and eethynm puHtutee are 
ftlao met with hem and there, especially on the lL>gH. On the 
palma of the handa and solea of the feet there are found the 
tnusea of [vioriaHiK paluiaHn stkI [)Iuiitariit, and moiet j^apuh's on 
their favorite places. The falling out of tiiy hair and tlie dis- 
ease of the nails are of more frequent occurrence, and laet 
kHiger in papular than in erythematous gyphiUde, and cmsta 
ore found eorreepomlingly oftencr in tlie beard and scalp. 

In rej!:ard to the lesions in other tiaenee, the swellings of 
the gl&nda liave, by thk tame, become more marked, and aiTco* 
tiona of the nincous membrane and ^dargemcut <jf tlio ton- 
sUa, eapecially in relapsing papular eyiiliilidv, are more often 
observed. Iritis sypliiUtica is usually found acconi]>anied by 
pnpular eyphilie. Ttio morbid alterations of the bone« are 
aimiLir to tliose occurring in oiythematoas «yphilidc 

An ap]xux'ntly cured sypbitiH may relapw and manifest it- 
aelfj eren after many yeara, by a papular ej-pliilide. The ro- 
hipaing papular gyjiluhde ta diatinguiubwl from the primary 
entption by the fact that the efllorcticencea form on a few 
(one or two) placta only large or email circular, ellipaoid, or 
cnn-ed lines or gronps; and, further, tliat no other fcniag of 
eruption occur between the rvkpEing pnpnles. 

(J) StmUI Papular S^philid^ {S^phUi^ Pajmiom Mtliaru). 

The small papular or mih'ary papular aypIiiUde is eo called 
on, aoooont of its minute size, being hardly larger than a millet- 



190 PATBOLOOF JJTD TSEATMSyr OF SFPnnJS. 

seed. It appears, u a nile, in a very acute form, .to Uiat in 
tirentr-f our or forty-eight hciiir% lai^ Lract^ af akin are covered 
iritb namerotu groupa of efflorescencea Another effect of tlio 
acntc nppea.rajice of tb« granulee is, that tbcy Uotc hardly de- 
veloped when thcT become acuminated, and tho apices arc oon- 
verted into miniilD vesicles or pustuln. MiliaiT papules are 
m^nly kicatcd iu the iace, on tlie hojsk, and, like lenticular 
papnli!«, in the palm of the hand and boIo of tho foot, in the 
genito-cmml fold, in the anal crovicc, and a1x>ut die genital 
m-gans (modificatioua of pAoriatiut syphilitica pahnaris et plan- 
tarts and moist puj>iile:i utready mentioned). 

]Towever acutely a miliary papular ayphilide toay be 
oBhered m, it assumes the protractt- d character in a few days, 
ospocially after the ycsicntar inetntnorphosia has ensued. "Dte 
Bcalea that form after the conlentfl of the vceidee have beooniA 
iufipiasatcd, gradaally full off and loavo hluieh-red cteatricaol 
dcpiYsuons about the &r^ of a pin^E liead. Tbeee depraasions 
correspond to the cxcretoiy dncts of the diseased sebaceous 
and hair follicles, and disappear in a few weeks without leav- 
ing any tracee. Sometimea a leoticuliu' papule dovclope npon 
the dlsGolored epot remuning after tlie miliarj effloreecenoe 
has disappeared. 

Tlie vceicnlar Btoge of a miliary papular svpliilide lasts 
only a few days. Tho conioU papule upon whioh tlie vesicle 
is situated pcmsts for ecvcibI weekn and mrmths, accordiug to 
the condition of the jwlient and his mode of living. 

Miliary papular syphilidc, like the lenticular variety, ter- 
minates in reeolution, with or without dcHjuamatiou, and leaves 
no cic-itrioe*. 

This eruption is afsodated with cr^-theraatous epota ai»d 
moist Icnticulur papuUs. The phenomena tliat occur in other 
tiflsues are analogoos to those which accompany tho lenticular 
papular syphllide ; hot in the miliary form the falling out of 
the hair ia more marked. 

This crnptioQ i* Um yre^ent ihm the lonticnlar varioQr ; 
in the female it occurs eoraewliat more often than in the mala. 

Relai>ee8 of Byphilin under tho form of miliary papular 
liJ^lhilide are mre; an a mle, the recurring ^philitic emptJon, 
following 8 tniUary papular one, will be of the pustular varietgr* 



BTPBIL^ 



Relapses of miliary papules occur either in gronps, or they coo- 
•titate Uaee arnuigeil in circle* or ha)f-cirdi:ii of <]e«i]iimiiatiiig 
pranaltSL Tlic_v are especially located on tiic forclioail, on tho 
napo of the nockt on Uiu scapular region, or the interaal eat- 
faccfl of the upper ami lowor cxtnrmitiua. 

The proguoeia with regard to tho blood-poisoning at the 
bottom of tho dificoso ia lees favorable than that of tho 017. 
thetoktoud form, bccauec tho morbid altorations in the rarious 
Ot^ana and ti^aes, which coexist with the craption under 
oODsidoratioD, aro more pronounced aud mors ob£tiDat& "Ra- 
gnrdod lo«d)y, tho prognoets is favorable in so far as the erup- 
tion leaves no discoloration of the skin. 

Ttio deetjuumatiiig papular gyphilide which many authors 
eoOfider as a genuine Hvphtlilic diimaae of the ekin nndor the 
Dune of " psoriasis fivphilitioi," may easily ho inistakcn for 
pmriaai* rv/t/aris guttata or punctatiu The follaning are tho 
diflerential fcatnnM of the two forms of tho dii«caae: In peo> 
riuis Byphilitica, tluj ficolc, an a nito, coruustA of a thin, yollow- 
Uh, caeiroU epidermal lamella; while in psoriads vulgaris tho 
acalcA may W scraped off iu broiiny flakes. In psoriaas vnl- 
guis the brilliant white tlake i>enotrat«6 deeply into tfao rote 
mneoeimL; iu ptpnlir syphilido the scale ia formed, from tlie 
epidermis nii«e<l up by the pnpnle. The base of the Byphilitio 
papiUo is light brown ; in peoriaais vulgaris tbero h no discolor- 
ation at all, or it is bluidh-red, eepocblly on tho Ic^ SvphUitla 
papules that ate oovered with f>rales ncvor become continent 
&ke the flaked in pmriasis vulgaris (psoriaHis vulgmria diifusa). 
At the most they form, when a relapse enraes, a few drcles or 
segments of circled, iu wtiicli the contours of each papule ro- 
coain diatiuut. Psoriai^is vulgarin occurs on the HCalp and i-ais, 
where deminamating papular eyphilide never occurs. Fur- 
ther, it api)cai8 more on the extensor than on the flexor eur- 
faces of the extremities, and especially un the tip of tho elbow 
and over the patella ; while tho Eo-callcd 6<{uamous ejpluUdo is 
found mora on the inner enrfaces of tlie cxtrcmititfl, and very 
aeldom oti the elbow and knee, or Uie donnmi of tlie hainU mid 
feet. PwriaRis vnlgariii inveterata prodnoea a cirenmscribcd 
thickening of the akin that is covered with scales ; desquamat- 
ing papular syphilide scarcely ever causes any thiokening of 



193 PATSOLOQT AJfD TRSATXESTT OF STPBILIS. 

the corium. ^bilo papnlftr inrpUilide ie almost alwayi aooom- 
piiiitMl '\}y tnurked {alliiig out uf tlits linir, tltiu ut not DOtJcetble 
Id psoriasis rulgans, oven whoa it attncks the ncnlp. 

Tha effloroBoouceB of milury ptpalar ^philides resemble 
somewhat teatiet, on account of which Plonk deRcribed thorn 
as ficabiea venerea. The riolvot itching produced by scahiee, 
and the excoriationa caneed bj the violent ecratchinjr, and, 
above all, the finding of tht: acarua Bcubiui, nill decide all 
doubts oonceroing the nature of the tnaladjr. 

The reaemblance of lichen Bcrophvlowrum to the email 
papalar ^rphilido f ormerlj caused the latter to be called lichen 
gypliilitica, and, according to the arrangement of tbo groapa of 
tbo eruption, di££«min&tiu or eorjnnboeue. The graanlea of 
liohcu ijvropbuloeonmi, being do bigger than hempseed, pr&- 
wnt no etriking contrast by their color to the gtiTroonding 
Bkin, And imder aiiti-ecrofuloiis treatment dieappcar in a short 
time, leaving neither discolonid marku nur scars, while the 
sniaJl piipiilar pypliilides leave behind for a lung time livid col- 
ored depreseiong as big as a pin's bead. 

A relapsing amall papular syphilide may be tnietaken for 
herpes drcinattit, and, owing to the resemblance between these 
two emptions, lUoord called it herpes e^hilitica circinatna, 
The very acnte coiinc of the herpes veeicles, which barely last 
mom tliaiL a day, and quickly diy up into Kioall acabe, and 
tlios form a large or small circlet or wreath of ecalee eitnated 
upon a slightly inSiuued base, the microscopical demoustratioii 
of fungi-spoTCS and thallue fibers, the favorable local effect of 
prcporatioiis of potaeh aro sufficient difforontial data to prevent 
an error in diagnoeia. 

(o) 7^ Papidar SypAltid^ or Sgvamam SijphUide tjf tAe 
Palmt vftUt JlantU and qftAe Soles qfOie Feei {PaoriatU 
Palmaru et PianiarU^ and SypkUUie D^vted Affao^ 
tian of tAe Epidermal Strata of the Jland* and Foet 
{St^philia Cornea). 

The equajuoua syphilido of the pahrn of tlie bands aod of 
the soles of tlie feet in reality is a papular syphiUde, wboee 
solitary cffloreecences are but poorly developed, while the epi- 
dermal afiection becomes markedly noticeable, owing to the 



STPBTLIS. 



198 



thlckoning and contitinoii? exfoliution of tlic iilcin. Od Ibo 
other hand, tliore is also an affection of the opidential Btratum 
of t]ie pftlin oi tti« liaiiib <K!caKtoiii>d by ey|ihiliH, which is due 
to morbid comeons degeneration of the epidonuifi, without the 
fonnatioii of papubr etfloregopnces. 

There originate on the palniH of the haiuU und i*otes of the 
ff^et circalar, dall red spots, Taijing in eize from that of a len- 
til to tliat of A pea, which gradually riec sliglitly ultovo the 
level of tlie nkin. After n while Uiu tmption cliaiigm its color, 
and becomes reddish-bron-n. When involation of the element' 
VtJ effloreeceooee begins, the epidcnuaJ cohering either W 
eomeA thickonod in the ceutcr of the papule ouly or through- 
out, resoltiiig eometimea in acuminated, then again in lamel* 
lated swellings or calloeitiee. These hypertrophies are, how- 
ever, gradually cast off Bpontancougly, the exfoliation b*^Jn- 
ning at the center and prc^;reeetng to the periphery, or tliey 
arc detarhed by the patient. They are nuthiiig more than 
lamcihe of dead cpidenuiB. Tho diseased place, after the re- 
moral of tho ealludity, forms a bright-red, brilliant, attenuated 
circular spot covered by a delicate epidonnal disk, corrwiiond- 
ing in size to the efflonKConoe, aud is Biirroimded by a border 
of undermined skin. In oomc cai«i! the corneous transforma- 
tion takes place only in the center of the papules to the extent 
of a poppy-seed, and after Uio comcoun portiou has dropped 
out they form dLikn, in tlic center of which the epidermis ban 
disappeared over a eurfare as large aa a pin's head. 

The eruption that hoe juat been dcucrihed, however, is not 
olvaya eirculur in form. On the palmi; of tho hands and so1c« 
of the feet there are no sebaoeous or hair follicles, upon whow 
ibape the round form of the syphilitic papule depeudf=i. The 
aggr^tion of the inilummaton.' cells within it, aud likcwiHj 
between tho rcto Malpighii and the epidermal stratum, may 
go on onbindered and irregularly. On the other hand, tho 
firmneas with which tho cutis adheres to the guhjaooac faeeia, 
and the thickness and dimintshed di.'sten.tihiUty of the epider- 
mid, maybe the caiwe of the t!atne«s of the efflorBHcencee on 
the places under consideration. 

In most casQB a few (four or live) ttpot^ form at first ; these 
we gradaally followed by more, all being scattered and at a con- 
18 



194 J'ATHOLOOT ASJ> TRSATMBifT OJT BTfmU3. 

Mflcralile dUtanoe from each othor. THtcn apftpotar sjrpbilide 
appeals in a subacute forui, the eoies of the feet and palms of 
the luLudtt, aluDjc with tlie vohu surfaces of tlie fingens <ue cov- 
ered with nniiiei-ooft er>i.heTniitoQg spots or papoles. When the 
disease haa existed for % imm, the scattered effiareacenoeH eoft- 
lesce and then fonn, c«|K!(:ialIy m iha Saniros of the pxhiM of 
the haadrt uii«] on tlie volar Biirfaces of the hngera, longitodioal 
epidet'oud hTpertrophicB or exfoUadoua. 

In in06t cHAca tbu voIb mautiH aud plaiita \kA\s arc nmat 
tnneoaalj attacked. There are, however^ many cases iu which 
the disease occurs only in. the palm of the baud, and r^re caees 
ia which only <m^ paltn and 07t« sole ore diacucd. 

In Bome ciues paoiiaae palmaris or plaotaris may get veil 
without iiiodical aid. In most cases, however, new emptioiu 
originate near those already desquamating, recurring even on 
the places that have eicfoliated. Tlie effloreBcencos ibereby 
heooine conSuent and Iom; their cirt'ular fonu. Od t3ie other 
haud, the diKea.'ie<l epidermal cells accumulate in large quand' 
ties, thick patches of ekin exfoliate, resulting, especially in 
the grooves of the paints of the hands and Boles of tha f«et, in 
crack* or Siaurefi — '' rhagadt* s^vphi litica " — w hich cause severe 
pain at every itiovemeut^ and Homedmcii slight bloeding. So 
long as there are only lenticular lipotfs resolution may be ef- 
fected in about fourteen day* by treatment with mercury ; but, 
if callons thickening of tlie opidenuid coveriiig of the offlo- 
rcficcnoca and desriu&niadon have already taken place, tho dis- 
ease will la«t for niuutlw, eveu years — papular syphilide of tbe 
palma of the hands and solos of the foct being now regarded es 
one of tlie most obstinate diseases. Fsomas pulnums and 
plantaris syphilitica very frequeody relapees, and eomctious 
returns after many years. Indeed, cave the falling oat of tbe 
hair and tlie ewelling of the glands, it is naially tho only symp 
torn of relapsing syphilis. 

Still another syphilitic affection occurs in t«re cases on the 
palniB of tlio hands and ^les of the feet. In run trad iittinctiun 
to the mactdo-papular fonu of p^ria^ patiuaria and phintari5, 
it is kn(»wu as pmrianU iit^kilUioa palmaria, or ptaatarie 
d^tuoj or cortu-a. It consists of a unifonn diitujted, rupi*! 
ooraeoQS degeneration of die most supcrddol layers of the 



srpmirs. 



195 



ebj the affooted placcu look as if Uio epklermis were 
led into a tine, whjtiiib dlrer-brocatle. 

In Uic vust majority of ca^es peoriuis palmarie nnd ploti- 
tuu g^philitica occiira in connection vitti orythema sypkiiiti- 
tfum niaculo-papDlt^enm and papnlor syphilidoB, especially the 
relajMing form. Tn rare cases nypliilitio acne and varicella ef- 
floresoencen an* fonnd along with it ; ti!>iia.Uy, howevtjr, marked 
falling out of the hair and onychia syphilitica occur at the same 
time, in very marked peoria^ paliuari^ we have seen not in- 
frequently n lymphangioiti^ comtnendng at the wrisUjoUit and 
extending toward the internal surface of the forearm. 

Allhongh peorioaifl palmum and plantarid often obfttinntcly 
reaislBall kind^ of treatment, iicrurtheloss it itf a gnod omen for 
the patient, and we are relieved of the apprehcnnion that dan- 
genma parulent iniUtration of some delicate organs, or that ex* 
ndation under the perioeteam, etc., wis impending. 

It U modt frequently nii«takcD for proriafiia vulgaris pal- 
maris and plantaris; likewiiie for ordinar}- eczeina of Uiese 
K^'ons. 

Feoriasis mlgaria palmarie and plantaris difEora from )»ori- 
•na syphilitica in prodac-ing innch larger and more gcatterod 
plaques than the latter. The attacked places, helng deprived 
of icales, dijiplay in vul^r {isonaHiH a more Hrid ciitor, while 
Ed the ayphilittc form the well-known copjjery color is quite 
dktlnct. The epidermal scales of psoriasia mlgaris ore much 
larger and more difficult to remove than tliu acalos of proriaflitt 
syphilitica ; the Bcalcn ni the latter represent the hypertrophied 
^dermal lamells, wliile the ecalee of the former are an ag- 
glomention of dhwased epiiienuul OOII0. The itcaloe of psoria«ia 
vulgaris form an elevation with a central prominonco;, while 
(tie scale of jworiasia syphilitica is defective in the center. 
Paoi'iaaiB vulgaris of the parts in qnet^on it always aflaociated 
with goncral psorinms, while pmriads palmari« and ptantaria 
caused hy eyphiUs either oeeura alone, or is attended liy epecEHc 
•ffeetioni; in other orgaiw and tii«nefi of the body. 

Eczema polmaiig develops in the form of scattered or 
gronpcd hyaline veelelea, wboae contents may he absorbed or 
evaporated, whereni»on parchment-like hypertrophic*! patchea 
of epidermie a& big as a pin's head remain. If the latter Imp- 



196 PATBOIOQY AND TBSATUEST OF STPHIUS. 



I>eiw to bo nrriuigvd in gn>u|« the exudMtivo aiilwtunco may be 
pulled off in die fonn of yellow, thickened cpideniuU plates 
of the dimensioDa of the diseased spot. When the exudatioa 
recurs very often, the epidermis becomes so intenstlv h>-per- 
trophicd that, by virtue of it« dctLScncsa and ihe xonthopro- 
teiD color it avqiilrcs, it is best coniiNtrod to a mummitiLHl, parcb- 
ment-like hi<t«. If a re<'ent evzetna vesicle is pricked or 
BoraLtihed open, a giiniiny fluid will ran ouL If iUi epidermal 
lamella is torn off, there \s seen on the sorfaoc facing the catifi 
tlie negative inipresgion of the former veeicle, but npon the 
cutia itaelf a very dcHeute new epidcnnal plate having a roay 
or brig^it-red color, whidi after a few days becomes the ailo of 
a new voeiele. 

Kow, if the development and course of ccrcms palmare are 
compared with the already delineated e^-inptonu of paoriaaia 
ayphiUtica palinaris, the difierential signs are infitaotly recog- 
nized. In regard to location, psoriai^is Bvphilitica pohnaria de- 
velops more in the middle of the hand, while eczoina oflencr 
Rttaoks the nlnar and radial margins. Farther, in ecoema pal- 
morLS ec£0matous vesicles are osnaUy fonnd on the iniordigitol 
flurfaces, or on the back of the affected tingem, which is never 
tin case in psoriiu>ig pnlmaria ayphilitica. Finally, no form of 
eczoiiia eausea &uch violent itching as eczema palmare and 
pkiitanj, while syjihililic dcp-ncratiou of the epidermis of the 
palms of tlie hands and soles of the feet occaaiuos no Itching. 
In »>Die ca:§ca, the occnpatiou of the patient may also aniat 
ua in the formution of a diilcreutial diagnoata, as is the case 
in eczema of washer-women (peoriaius of waahcr-wotucDX or in 
ecseina of bakers (ecabiea pi&toruin). 

(rf) The Humid or Moist Papules, or Flat Coivhjhmatc ,* 
jPaptdea ffamuhn; Pwiiula Fa^ida Ani; J'utCul**, 
Plate», rfo., <yfvarhm Authort. 

Tho moist or humid papnles are dry papules metamoi<- 
phoeod by local conditiouEi. On examining a pati^it affected 
with- recent pnpulnr eyplulidw, a few feebly developed pap- 
nlee covered with dry sealos are DBnally found on the upper 
and inner surfaces of tlie thighs. But the nearer the papular 
eruptioiL approachcM the genital organa, tlie mora developed 



STpmiis. 



197 



will the efnoresccnoee be; and the mora warty thoj are, the 
IfToater the qnantity of viscid, (1ocoiii)xjs«1 fcfid matter will 
thoj discharge. This !s e«|>e<:iuHy true of corpulent women 
who are carel(»5 of their personal cleanltDess. The^ moist 
papules often anrronnd the anal opening like a row of buttons. 

The tnoirtt jiiipulo bc^^ius na a djirk-red B|Mjt, uf the ttizu of a 
lentil, whicih graduallj rises above the level of tho skin, and is 
exactlj like the dr^ papule. But, while a drr Bcale originates 
upon a drr papale, the epidermal cover of the humid pap- 
ule \a similarly tranaformcd by inoisturo into a moist, gray- 
isb-white, macerated, easily detached uembrane, after wboae 
reino<>*al the earfnce of thu ]>apule is seen like a fleeb colored 
]iUqnc. Now, if tlicM papules, bereft of epidermis, continue 
to be exposed to frielion and miiceration by the physiological 
svcretioti? uiid ])atho1ogtcal exen*tio»H from the adjacent skin 
and mucouB membrane, a diphtheritic membrane (molecular 
dStrituii) forms upon their gurfacee, whereby tbej acquire an 
Dueven, vemicose, and luxlular apjiearancc If thiJi membrane 
In forcibly rubbed off, the papule will bleed considerably. 
It gradually andvi^^» more and more molecular disintegra- 
tion, wheni-by the former papniar elevation ia eo rodltced that 
it 19 finally indicate onlj by a gray iali -white peGudo-mombni- 
nous layer, varying in nixe from a lentil to a pea. If the 
uolecalar destrucdon coDtioued, ehallow or deep nleera, dis- 
chatfjuing a dirty-grayisb matter, are formed. By tlio ooalcs- 
cenoo of several such p^pnlce undergoing didntegration, or by 
the progress of the ulcerative process ujiod the adjnoont in- 
tc^tunent, the papntes lose their original rooud ehape, atid 
form polygonal or longitudinal uleers (fiwnres). However, all 
these ulcerative processes, as a rule, only bring fthoiit a idtallow 
loM of mbfltance. 

The moist papnie may, however, nndergo 6till another 
change under favorable conditions. The newly formed oelU 
of the pa[)nlar inflammatory foci may develop into connoctivu- 
tiaeue fibriihe, in the same manner as they Ttndei;go dcjgenerap 
tion. In thifl case the papule eweUs ap to the size of a pea or 
bean, and becomes KOmewhat constricted at its bofc, while its 
semicircular eurface ac<inires an nncven, caruncukr appear- 
ance. In the further coarse of the process these caniiicnhir 



198 PATnoLoar axd rREATMsyT of stphius. 

prormnoncoe, by losuriant growth, develop into conical ooo- 
aective-tissuti fibrillee, which branch off UicliotomoQBljr, &> hi 
orJhtarj oondylomnta. 

Somelimes the molecular dogeueratlon on the uloetathig 
papnlcB rvtiuuiM ([uiuM-ciit, the diphtlicrittc membrane '^aX' 
tiallj' dtGap|}ear», aud in its place conical cicatrizLOg connect] ve- 
tiasoe btnda — i. e., condylomata acuminata— originate from the 
intlainmatory foci. 

According to tliis description, we dtstingnifih the following 
phases in the development of a moiet papule : 

(1.) The intact pipulc. 

(2.) The pha»e of elevation and casting off of the epider- 
mal cover of the papulo (pniitulc crimt). 

(8.) The diphtheritic phaa*. 

(1.) The phase of the connective-tiasao proliferatioa (syphi- 
lis vegetans, condyloma latum). 

Not ever/ papale, however, goes through all Lhe«o piloses ; 
it mny disappear at any phase, and a cure ensne. 

In our opinion, the dry syphilitic papule i« due to cellular 
infiltration of the papilla of the slcin ; the moi«t papules, eepe* 
dally those on the edges of the labia and aroond the onus, to 
diseaBe of the t»chac6oiu glands. lu eouie cases, moist papules 
have originated npon cicatrices of chancres, even upon the 
iilcemting surface of a eoft cliaucro. 

In guncral, moifit }>apulctt originate on thoeo ports of the 
skin where laige sebaceous and hair folUcIee are found, where 
the iotcgument forms deep folds, where two Burfnces of the 
cutis are constantly in contact with each other, causing, by the 
friction of the parts, nn increaao of the tempornture. Such 
places are the inguinal and f^uito-cruntl folds, the folds pro- 
duced by pendulous breoFtR, the [leriiui-uiu, tlie pubis, the anal 
indentation, the labia majora, the axillte, the interdigital folds, 
and between the toes and at tlio navel. The thicker the layer 
of adi}x»e tiiwie u]>on the plncx:^ mentioned, the more they are 
irritated by sebaceone, perepiratory. and otlier sccretiond, the 
more exuberantly aud abundantly will papules develop. In ad- 
dition to tito phccH numtioned, the moist pujiulu is met with on 
the nipplus of wot-nur^ee, the angles of the mouth and lips of 
amokera of pipes and corDe^playerB ; sonietinied on the groove 



STPBIU3. 



IM 



at the alio nasi, tho meatus anditoroB extorntis, and very rarel^j' 
in the groorbs of the oaiU. Tliey are fouQ<i Ui greittest abnii- 
dance and more cloaolj^aggr^atcd uq tliu Diar^iiu uf the Urge 
aperturea of tlie Ixxl^r, where the mucons membrane Joins die 
iiitcgumcut. 

I'lio moist pApuIcK ttitiiAtwl upon tho genital oi;gnnB and 
aronnd IIlq snos nsoalljr produce eercre itciiing, and when thej 
become nliH^ratcd occasion intense pain and fuuctiuna] diiiturli- 
Anooe. iri<xinitiiig papiilca around tliQ aaii» renilur ttie oracu- 
Ation of tbe 1)owel8 panful ; those on the surfaces between the 
tooe hinder the paticmt in walking ; thoflo sitnatcd on tho nip- 
ples of tlie mother or wet-onree'B breast, Intorfcro greatly 
with the function of wet-nnreing, while thncuj situnted on tlie 
lips of tho nnmhng hinder it in socUng tho browtt The do- 
eonnpoeing discharge from nioirt papules not only produow an 
injurioiiH effect npoii other papules that ounie in contact with 
Hiarn, hut a1i;o oeraiuon nn eijtboiaatoiiK inflnmmation nnd ex- 
conation of the adjnceut parts. Ifoiet {Ki]>nle8 on tbo labia, if 
numerous and undergoing supiiunition, will canse tho latter to 
swell enorrnoiisly, winle tlie abtiorptiwi of tho ichorous matter 
from tlu«e {lapules situated neir tlio genital organs wiU giro 
rifle to acute enlargement of tlic indolent ingniiud buboes, and 
re^t in softening and eappuration. 

Moist pu.pul««, if situated on parti of the skin that are iu 
contact^ will, if not kept asunder by tho interposition uf bits 
of lint, ete., and kept perfectly clean, prodnce siiniliir papules 
«n the opposite surface. Tbia condition, howcrer, is not to bo 
ngardod as an instance of epontancoua inoculation, but as an 
effect of irritation on a part that is leee capable of resistance — 
a morbid letHon rcpnxliicing itncif by pimple imprciwioD. 

The etiological factor tliat is capable of gouontting a moist 
papule on one plaoe acta aUo upon the other, and. fostered by 
the fitul aecrelion of the morbidly changed snrfaoe, excrcisee 
its effects npoa aii apparently healthy eouliguons part 

NotwiUistanding the acute and inftammatory manner in 
which moist papules are nshcrcd in. they, like other syphiUde«, 
ran a chronic cour^«. The elevation nnd removal of the epi- 
dermal cover of the inoist papule are nsitally completed iu a 
few days. Tho diphtheritic stage, however, will Ja^t sovevkt 



aOO rSTBOLOQY AXD TBEATMSHT OF STPBlUa. 

Teebs; indeed, not Infrequently serenl inoiitlia, if left with- 
uat treatmeuL Under au appnipriito Joctt and gcacjral troat- 
ineot, tbe paptilee undergo reaoLntion quilo rapidly, «ml will 
tie entirely ubsurbocl, wtiilc tho vegetaiions situaUHl n|>iiii 
ttiem, if Dol rumovfd hy vKohuroLics or uwlrnnientA, will (ihriiilc 
and dn>p ofl. \a noon m utisorption b^iu, tbe diaclivf^ 
ceases, and the papule becomes dry. If uuuiy luoiA papolvs 
am gruupcd tugetlier, tbi»e tuluated in the tvnier qf fJU yrv»p 
generally dUutppear Jirtt, and tliooe on tbo periphery tben 
form a circle, Tbe aon-utceratiug papnie, after liaviog liii'n 
cotapletcly aliaorbcd, leavi« a copper-oolurfd ^tain of conv- 
sponding dimuuiuou& An ulcerating papule beaU by tJie 
formation of a very eupertieial ecar, wbicL tikewiw reoutUB 
brownish-red. Tbii} dific'olored epot disappears only after pro- 
longed treatment. Occaeionnlty tbo scar U characterized by 
tbe almnee of coloring-matter in it. 

The nioiBt puptilo is one uf tlie nn.«t frequent forms of Uie 
fypliilidce, bat it occurs oflener in females than in mates. It 
ie usually the prvdroum of comnieQcing or recurring ^yphUitio 
eniptiuns. It is, liowever, not only tbo product uf ucijuired, 
but also occurs as a eymptom of berediLiry Bvphilis. 

Ko eypltilido relapttee bjs often es the moist papolc. Be- 
lapsing niniiit papules may reapiicar upon litcir former site 
They ore tht-n ueuully leas numerous the longer tlie time that 
has elapsed nuco infection took place; they diecbarge ]qm 
matter and itch lose, are loss painful and develop mora elowly. 

The uoist papule is not infrequently tbe only morhid 
lesion on tlic skin hr which eypluli« nunifeate itdelf— i. &, a 
rel^»e of tbe tii-st phafce of eypbilis is often notiocablc by tbe 
sole tppearanoe of moifit papules. As a rule, however, they 
ore attended by the macular and pajndar and alw by jHifituIar 
Byphilides, The loeions which occur in thi- other titicues are 
identical with those of the dry papular ej-philide. 

Confluent moist papulce, when a coutiguuus part of the 
skin u rendered nore by their discharge, may l»e mistaken f'lr 
an eeserna ruhntm. Tlie distinctive signs are : The ecreiua- 
tons skin tliat is denuded of epidermis generally does not pre- 
sent that dirty -grayish, shaggy appennmco which is pfcaliar to 
papules covered with molecular dijtritiis. Tbe eccrcdon in 



STpmtis. 

eczema is more profnxo ami Uio itching much nioro severe 
tUoii that produced hy mout papulee. Kczc m a heals from the 
l)criplici-.v toward the ocuter; conflurat moUt p«pule8 from tJie 
center toward the periphery. In oe7*nia thcrw ig foiuid, on 
the cxtn^me periphery of Uie affeeti:'*! pkeee, new vesicles or 
their foniier preneiioe is indteat*d hy scales of corresponding 
dimetttions. At the external harder of the phure on wliich 
mout papules Alt' situated isolated ulcerating or non-ulcerating 
papnlu are iK-oatiioiiaUv aeon. 

IsoUted inoirtt japulca may he mbtakcn for a diphtlusriiic 
cfuitu-roid. The alow result produooil by inoculation* with 
the eocretion of a moi»t papulo on the person bearing it, Bud 
still better the coarse it pureuiv, will furnish the he6t proof of 
the nature of the teeion in question. In conclusion, wc will 
add tluit a granulating external orifice of a rectiU fistula may 
readily be uiistakcu for a moi&t papul«. 

3. PtrsTCLAR SrraiLtDB. 

By tlio term putUUar »>jphiWU wc understand a form of 
tkiivdisGBW produced by syphilitic pui^ning of the blood, 
wbo«a pfBoruBocucos consist of pugtulw (according lo Willan) 
wludi originate fniiu a luoro or Igsb marked elementary' pa|)u- 
lar eniption. According to the variation of tlie pundent trana- 
formation of thi^ papnlar eruption, we diiitinguish different 
kindd of pustular ctilon>«%nces. Thus, if the apex of tlie pap- 
nlc alone undergooa softcuiug, a pniitular ityphilide originates 
tlut U unalogooB to actia and rartcoUa vulgaris. If the entire 
papnlar intlatmoatory foous undeigoes purulent uetauiorpho- 
na, without, however, affecting tlie corium deeply, the vcsiru- 
tar or impcti'/mou^ form will unfittc. Put if the pumtcnt 
eoftening attacks the coriutn very deeply, then we have ecfhi/ma 
typhUitienmot ruput »yphtlUi<:a. The most frequent form i« 
ooUkjma ayphiliticum ; Itiaa fre^pient u impetigo ^yphiliticoro ; 
fdtl more rare is acne syphitilica ; and the rarest of all forms 
are varicelhi and rupia ttypbilitica. 

The piLotular nyptiilides, compared with tlie dr^", occur in 

the jiroporlionii of Huveiity to one hundred, and generally come 

on at a later period after infection. The pustular form of 

■ ayphiiis always Gastd a mournful shadow npoa tlie condition of 






: ■;-r-!i;(r 
■. ^LiiiiU i: 
- ■ :.i!l.K-. 



:: \v!iicli a |. :■.';■ 

• ' .:;';in.-r en';:.-!- ■'- 

•.•\M. T'.:.- .,'-...- 

.:,!ris, i- :',■ - ■.,|. 

;::il !-;icr.i! rri;i..!j-. 
.:.■! oil tin- 1 \;:-, Mii- 

. of lIlCMI riil;- ti.i 



t~i. 



■ii.' f.'l'tll. Ill l!:r' 

V iV'lir il;iv~ l.v I'.li- 

■'•J. ( Ml rh>' jilai'i- 

^itrviiiLT tViiiii i!,,' 

", j'l'nii. 'I"lii-v ;irc 

..:iiiiiati''l r!ji- iirT.^ 

— i-iiiiiKirai. Ill til,.- 

■,>liially ill hau-lh--. 

-'■;[>* (acTir svpiii- 

- In' rc;rNnirii a> a 

- titnii. tlic iM.'T'r 

■.;iii]i al I'li.' :i]ii'X 



STPmus. 



I^nnles will tako placo. The redness of the grannie 
i bccx>uies dull, mure hrownieli in color, and on it^ tpcx 
lated Uttte puntule of tite diztj uf ii pinV Xvaa/X forms. 
36 contetite of this little pustule is absorbed, uDOther 
utd resiUts in a thin scab. Afi«r the do'siccutiou 
nstnttuD of the pustular ajicx tho ]}a£)ulur Imum.* acqatree 
appearance, and di»ciiiamatvs seroral timce in eucoeft- 
Ou MJmo deorustated ax:iic ctUorc^ceuoee ftnotbcr puiitute 
wliii-I), however, is flatter tb&n tbc preceding one, tJie 
iHre pApulo becoming involved, and the pas 6ub«eqacQtIj 
[(trit4 up and forms a cmiit. The Bcale«, after falling oS, leave 
ntimitc depreeeioD, barely tlie size of a pin's bead, which in 
lime becomes imperceptible. It often requirea tliree to four 
' Woekis or even a longer period, for a pustule to become dry 
l^xud form a crust. 

IXoH-over acnto the eniption of acne gyphilitica may be, 
[It «^)on asniiDes tlie protracted charact«r of all aypliilideit. New 
BfHon*cence« crop out from time to time amid those already 
csiflting, and il the patient reuiaiiia untreated the acne-pu^tulea 
ay develop into ecth^'ma-puRtiilvfi. Acne syphilitica is likely 
I ccdlat the most appropriate (rcntment for bix or eight wceka. 
It ia Qsnolly accompanied by ervthcuia syjibititioim macu- 
jm and papillosum, or papular nyphilido, while acne syphi- 
conferta s. gyrata, occurring as a manifestation of a re* 
of the diacaae, is aeeociut^'d with ecthyma and nodoa. 
Opacities of the mucoui membranes {plagues mttg^^wei) in 
tfae month, on the toiuilts and on the uvula u.lwDys, aud perioe- 
titis sometimes, eocsist with acne s^-philitica. 

The prognoeia of eyphiliB in cases of ncno-liko sypbilidoa is 
leas favorublH than in those of erytlieimitouo and papular svpUI- 
lides ; its local bearing, however, is in eo far t^till favorable, as 
no permanent cicatrices remain on the skin. Acne syphilitica 
diaseminata, as a nilu, disapjiears quicker tlian acne syphilitica 
oonferta or gyrata. 

Acne syphilitica disseminata may readily be mistaken for 

I oo«« vfdfjaria diaacminata. Those two cutaneous diseases differ 

from t-ach otlior in the following respects: In aaic K^qtliilitica 

the pUBtale is sitnatcd only on tlie t»p of a pspnlnr Ikuo ; in 

acne ralgaris, on the contrary, suppuration penetrates dova I 



SOI PJ-TBOLoar AyD treatment of sypbius. 

tlio ftiitiB. The vulgar aene wffloresocnwJ \» a minuitnre folUca- 
lar fnninclo, from wliicli, by slight preeenre, a piiruleut core 
uiay he ^qticezcd out This is uot tnio of i«|>eci6c scne eBloroe- 
cences. On acne viilgnris the crustK form sooner, are lat;ger, 
denser, eeem tu be wedged into the skin, and adliere firmly to 
it ; the cruets of srjihilitic acne are eoft and eaxily renioi>'EK]. 
The c(llon»ccQCcs of acno I'ulgum aro eurroundcd by an in- 
tensely red arenlji, while iJiw pajiiilar biine of awic prpbilitica is 
diarply outlined, and ha^ a. coppery color. Acne vnlgaris Icavve 
petmanentf ovul scars—ocue Bypliilitica eomll funnct-Ukc de- 
pressions, which disappear without leaving any tracM. A 
fijpbilitic acne efHorescence may become transformed into a 
deaqnamating papule — in tlie vulgar ncno crnptioo Ibis doe« not 
oecor. Acne vnlgariii, as a nile, aitat-ks only the nppcr parts 
of (be l«)fly ; acue eypliililica may alfto be met with on the 
lower extreuiities. 

(ft) Varicdln^il-e SifphilitU or VarlexUa Sffj^Uhlca. 

YarlccIIa syphilitica in cliaractcrized by a round pnstnle 
witli a depressed apex, varying in size from that of a lentil to 
tiiatof a pea; it \a mirniunded at firet by a coppery areola, 
coQtainiDg tliiu piinilcnt matter, vrhich gradually becomes 
iDSpiuated, so that the eruption reiximblcs variola modillcata. 
The majority of B^tqibilido varioella postolea are sitnated in fol- 
licles, but eome of tbciu aleo develop (m places where no eeb*- 
ccouB glands occur — for instance, tlio band^ and feet. They 
oeeur i» acquired as also in congenital eypbili^. Wc tberefore 
diatingtiish varicella syphilitica aduliorum and nmnatorttm. 

Varicella eyphiUtica adultoram oocnrs under two fomw— 
namely, varicella gyplulittea tU*»emuttUa and varicella Bjpbi>' 
liticn con^uttit. 

VarictUa gtfphUitiea dinseminaia devctopR occwionally 
even before the Iluuterian chanero has cicatrized ; often, how- 
ever, uut till the induration of the chancre has entirely disap- 
poarcil, having been preceded or aooomponicd by erythonia 
Fvphilitica. Kouud dark-red spota form, uid vary in miic from 
that of a lentil to thai of u \K-a. They become converted in 
twenty-four hours into spherical pn^tnlce that are surrounded 
by a rod halo. In abon6 two days the pustule loses its round 



8YPBIJJS. 



205 



form in cnMegnepoe of tho purtial BWrjitioD of its pnrulunt 
coDtente, and beoomes flattened and umbilicated. The cover 
of tJta pttAtulo Biukf) lower oud lower, oud finally is traiuformed 
into a tliin cnist, which after it falls off leaves a dark or Itluiah- 
rod deprcaeiion. Mt&r tho dcprceeioD on tlie ftpex luu) formed, 
tho poetnlca sotuctiincs grow larger in clrcumfereuce, vxttind 
over th« former nreoln, and a ticw one forms nroiind it Ttio 
eruption generally lasta gix or eight wooks, and even longer. 
Ab a mle, ttwre ure only a ft>w ptii>tuk<R; iiiobI of them are 
met with in the face, on the forehead, and here and there on 
the flexor surface* of the eitremities; occaaionallj on tho 
trunk too. It takes from two b> eight uhuiIIlh to gt;t well, 
beeanae new crops of the emption form from time to time. 

Varif^Sa eypfiilitlca coufiueng adultontin, or poinphigiis 
Bypbiliticiu odtiltoruiu of Uiu fiyphilidologicil^ w chuructcrizud 
hy flat, grecnisb-jelJow, epidermal Ucba of tho nau of a i>oa, 
filled with pn6, and Bunonnded 1)^ an areola ; the blelM grado' 
idlr coale^e and form a large vueide. Thlg cntptloo la 6o 
rare that 11. Zeiael liaa eccd it only onod ia thirty thousand 
Byphilitio patients. In thia cue Che Teeiclea were found on the 
vdar nirfaoce of both hands, oa tho dorsal sorfaccc of eome of 
tbe fingers, and on both elbow?. 

ViwiiyVa fjpltilitu'a ivhtUnrHjrk iliiaeminaia ia raoet fre- 
quently assoeiated with erythema gyphilitieum luaculofium or 
pspulofium. Impedgtnoua pustules are apt to occur on the 
liaiiy part of tlie face and lieml in connection with it. Tlie 
prognosis of tbi£ form of varicella \s as uofaTorable a* that of 
all the purulent syphilidea; still, it is more favorable than that 
of impetigo, ecthyma, and rnpia syjtiiilitiea, becauiic it heals 
withoat leaving gears. Neither have we aeeu an instance in 
vhieh this cni]>tiou relap;M>, which certainly cau not be eaid 
of the contlticut form of nyphilitic varicella. 

A Taricella-like sypbilide is most likely to be mistaken for 
varicella vulgaris. The distingni^bing 6igna are : The eruptive 
fever of varicella sjrphilitica never bec«m«« as violent as in 
ordinary varicella, and fnheided as soon as tbe eruption has ap- 
peared, while in tbe litter it continnee. The skin in varicella 
syphilitica la not only not increased in tomperatuio and is not 
led, Imt sometimes it ia even pole and chlorotic. The oMo 



306 PATUOLOOT AUD TRBATMEST OF STPUIUS. 

reeoeooee, as a role, are \^m unmerous in svphUitic TariceUii 
than in variola modificatu, luid in the latter tlie ^upe \A ef- 
fl<»«fleeaoeB do not sssnine a olrcular form. Tho pustules of 
the Bypliilidu iire not aa ten.ie, iior do thej dry ii]) aa ijnickly, 
as tbo!« of rariola modiBcnta, nnd etiil le»« than tbo«; of vari- 
cella, vulgons. lastly, tie eruption of sypliUitio Tarioella lasts 
miicli lungLT tlimi that of varicelU valgaru or of rarioU modt- 
ficata. Tlie puMules of Tiricolk Nvphilitica are dtstiiijpiubsd 
from the ptutnles of glanders by bdng decidedly smaller, 
etuTouuded by etuallcr ureobe, and filled with u clear liquid, 
while the latter are eiirTOundud by larger and mure iidlauiMl 
cones, and generally tilled vrith bloody pus. P'urtber, tlio ful- 
lowin^ chancteriattc features of glanders pustules v,-iU serve aa 
nddititHud help in fonning a diignoeis : The riolcut fever, de- 
lirium, and sopor of the patient, tlie bed-eorM that eoon fonn, 
the ichorouH dieohar^ from tbu mund muooUB membnno, oad 
the speedy fatal end. 

(r) Impetigo Syphilitica, 

By tho term impetigo syphilitica is meaat a pen-foBicu- 
tar exudative process in the dkin uueurring as a result of sypkl- 
Us, which quickly brings abont a paralent oonditioa of the 
exudation, whereby the cpiclcnnis becomes elevated, and fonos 
irregular, tlat, ycIluw-iMli-grveu psydnaical pustules. 

In the development of impetigo nypliihtica i^pajmlar stage^ 
or Mttidium cntdita^ which hwts only three or four da>->s and 
a atMiium auppwraiionitt may he dietingoiihed. 

The papular stage is characterijsvd by tbo formalton of infil- 
trated places on tha ekin, vu-yiiig in size from that of a lentil 
to that of a pea. Tho infiltrated places are irrcgidar in aliape, 
nuflod slightly above tho level of tho skin, and violet-rvd or 
brownish in color. The softening of tlie exudation raises np 
tlie cpidomiis on tlio affected places, and then there originate 
Sat, soft, roundish pn«tnlgr cfflorosconces which are surrouoded 
by a violet-red, sharply defined areola. The epidermal cover, 
however, »oou bursts, and a sticky, dirty-yellow umttor cscapea, 
whicli dries up and forms flat or rtalacti to-like cnwts. On vio- 
lently tearing off the crust, a reddish-blaok, bleeding s|K>t is laid 
here, which soon hccouies covered with a new hut thinner 



sYpmiis. 



907 



scab. BoiiBftth the latter u new epidermis generally foriias. 
Aud after the aeab hoe fallen oS a coppery-rec]« sliglitl^ do- 
pneaed epot reiuains, wltich gradually, tkougli after a long 
vhile, bocomce lanotith and piJc. Konictimca, however, iherv 
originate upon tlio ulcer beneath the cniat canincular, wart- 
like cxcnsscencc*, resembling mulberry or raspberry growth?, 
which are notliing more than exuberant granulntiotis, the new 
oells not having undergone either purulent trantiformatiun or 
dinntrgnition, but beiug cunrerted inui Bpimlle-ahiiped vellfl 
aod ocHULcctive-tisBDO fibrillte. The Frencli phvidcianjs call 
this fonn impetiffo d &a» ilevi*. We, however, prefer to re- 
tain tlio name of "/ruinhotiil^^ or m^rmekta ityphilitica, an 
being more appropriate. The warty elevatioDS are gradoally 
abtforbed. and afterward the aitectcd place«reiuaiablimh.*red 
or coppery for a long time 

Impetigo syphilitica seema to have a prediluctioD fur tho 
tender parta of the skin, such as the ecalp and benrd, the com- 
mtssuree of the lip«, the nasal orifices, tlio gruovca of the aln 
nasi, the axillae, and the scrotnim j it occurs leas frequently oo 
the trunk and extremities. At the angles of the muiith im- 
petigo cnuta merge into playu^^ mugtuwe^ on the mucous 
membrane. The impetig&«pots Hitoated in the beard and on 
the walp gcnemlly leave behind them alopecia areata. As in all 
syphiUdea there arc eases of impetigo which appear soon after 
infection took jilaoe in a dtMetnttiaied /"urm, white in others 
the eruption comes on long after the development of con^^u^ni 
groups uu circii inscribed places. In the coulluent Tortety con- 
nector, blackish-brown, thin, and soft orusts form, which ad- 
here very loosely to the surface of the cxudiuf^ and sUghtly 
thickened skiu. Grudually, however, tlie purulent collection 
onder tho cru»ts drius, the latter become more solid, adhere 
more firmly, the center is depreseed, while on the jteriphery 
new pustules and crusts form in a serpiginous manner. If 
eutili coherent cnii^bs e?[iet for a long time, the softc-ning will 
penetrate deeper and deeper into the cutis etmotare, and then 
there originate in the periphorr of the already formed scabs 
kidncy-Hhnpe<l snpcrticial serpiginous ulcers. After ctcatritt- 
tiou has taken place, a bhiish-rcd or coppen^'-colured superficial 
Bcar remains, which datcjuamates for u long time, and gtvdually 



308 PATnolOOT AJtD TREATMENT OF STPBtUS. 



i)ecome* pale. Wo havu atlduin wen tliis form, and wheti it 
occuTB it IB only found in the vidnitj of the genital orgau», tm 
the exCcHEwr snrfacefl of tlic forearm, and of tho log ; some- 
timefl, however, on tlic niHloriicn and bnck. 

Impetigo syphilitica disgeinioata geoenilly rcqairee several 
months for a complete cure; tlic condnent form a wholorear 
iuid even lonp.'r. With the first form the enrlv Byjihilidoa, 
(iuch u er^'thema macnlacum and papuktuiu, the de6c|iiamat- 
iDg papular, or the varicella Bypbilitioa ; -with the Utter tlie 
tardy syphilidce, namely, ecthyma or nipia. are associated. 

Impetigo syphilitica disseminata is still a tolerahly favor- 
ahle form of syphilide, aoee, with the exception of a limited 
luuouut of alopecia of the head and hi--anl, it Icavi^t no diefig- 
ui-omcnt ; while the conSiient form?, but eepeoinlly lbo«e to 
wliich scrpigiuooB olccnttion has become superadded, admits 
only of an extremely unfavorable prognwi*. in view not only 
of tho local disfigaring cicatrices, but also as an indication of 
the oht^tiuacy of the diaeiLte and the dee]> inroads it liai> made 
into the system. This is evidenced by ntbuminuria and the 
cachectic appearance of the patient, and offers a vary grava 
prognosis 

Impetjgo sypluiitica may be mistaken for impetigo vul- 
garii. It ik di^ti^guis!ied from the latter by the fact that the 
cniiit«i re^piire a longer time to form than in iiii{i:;tigo vulgaris; 
the syphilitic crust remains soft for a long while, and may be 
easily raised from the still mppurating bwe, while the cmst of 
im|ivtigo vulgarie is denser, (inner, and more hrittlt.-, and ad- 
heres firmly to its base. In impetigo vulgaris the arenlte dis- 
appear when the pustule dries, while, in syphilitic impetigo^ 
the areola Tcmains even after tlic cmst is fully developed. 
ynrthermore, the cruste in impetigo vulgaris arc nirronnded 
by a margin of wIiitiKh scalefl, which never hap])enB in spedfie 
impetigo. Connective tissue, adventitious growths under the 
cmstA are of the rarest occurrenee in vulgar impetigo, and 
when they do oeciir they are ripidty al«orbed, while in im- 
petigo syphilitica elevata adventitiona growths are often prvo- 
ent, and remain for a long time after the crusts have fallen 
off, or they may undergo molecular disintegration. 

Impetigo syphilitica may be mistaken for J'Miatilitig har- 



srPBjus. 

hce, menfiy laMi tuperiosU, or »ycc«i« harla pxutvloM. Syeo- 
sta, liowever^ \a a prooesB that penetrates much deeper into the 
cutis than impetigo sjphiliticA. Coiu»e«|aeiitl3r, in Bycoeis Ibo 
infiltrated ekin of the affected places !« very tltiek ; thiB ie not 
trao of impetigo, the prooesa in tlie latter beinj; lot-ated more 
niperticiiUlj. In ini]ietigc> i«^-phititica the liiiini of the hvard 
fall not very qnickly, and none ever grow after recovery (alo- 
pecia areata). In Bjcoeis the hairs of the beard do not fall out 
at all or very Utc, and if a euro has been eSectcd early tJiey 
inll grow again. Sycosia attacks only the l)cant, the eye- 

.Juhes and eyebrows; syphilitic impetigo tuually oecors at the 

itmoib time ou tbo scalp too. 

The Utter is apt to eprc&d somewhat beyond the growth of 
ibe luUre on the forehead, on the cheeks, or on the ears, and 
there form conHncnt pusliilett, greatly reH'tohling the morbid 
picture produced by eaema rubmm or impetiginosum. Bttt 
iin|M!tigo sypliilitica eonfluoiie is difitiogubhed from eozetna by 
tlie peripliery of the ktter lioing pato and indi^itinct, while tlio 
syphilitic impetiginous pnetules are very sharply defined. Fur^ 
thennnre, the discharge in eezt^ma is mucli thinner than in the 
impedginoiM syphilide. Erxema forms an adht'rent wale, r& 
aembllng flakea nutde of a solution of rock-candy, while specific 
impetigo pri>duoci(grL-etiifili-yelIow,8oft8cabe that may be easily 
deUched from the pustules. 

((/) Ecthyma Syphiliticum. 

Kcthynia fiyphiliticum ig characterized by poatnlea varying 
in pize from that of a lentil to that of a bean, ntiuted upon 
mftamt-d, infiltrated baecs, snrromided by rod zone*, and gen- 
«mUy contain sanioos or bloody pnfi. 

Ecthyma pustules either occur in scattered uniform efflores- 
[jDenoes or a group of ftniallcr epots is found around n large one 
on eomo part They may fonu on any port of the body, but 
are moet frequently met with on the eealp and legs. 

The ecthyma pUHtule may di;ve1op in a twofold manner. 
An injected place, of a violet color, and varying in size from 
that of a lentil to that of a beau, fonu.% and then u[ion this, in 
twcnty-fonr to fortynrigfat houni, a pUKliile dcvelopts at the 
periphery of wbicti the skin aoon becomes infiltrated (iwMy- 
14 



BtO PATBOIOQY JJKD TBEJiTMBUT OF STPBlltS, 

tita guper^cial'ix). Or tlie primary congestion inoreuQB, ozodu- 
tioQ tttkcs plaoo, uid fraoi it a pnatole reffliltfi ifxthyma pr&- 
fnndum). 

At first tho pustules contain s tliin, Bcrous floid, which, 
however, soou becomes t}iickur and purulent. In most etstt 
tho poB is mixed with some blood. The lunger tho pnBtulo 
grows Oie redder it becomes, and the more the area is indl- 
tmted. The cover of the pustule is seen to be soft and Aabbr, 
like tliat of otlier Hjpliilitic puKtuUr eruptions. After a few 
dajrs the central part of the pustule collapsca, bcoomtM dry, and 
a maty'Cotored or blackiah-brown crtist forms, which, owing 
to the continuation of the suppuration beneath it, keepB on 
growing tliicker, and, at Icatit at first, ia easily detached. Uo- 
demcatli the cruet an ulcer \& founJ, varying in extent accord- 
ing to the intcnaity of the intiltratioo. The ulcer ie surrouoded 
by a steep border, and tho cavity id tilled with a grayish tCDi- 
cioos mass of molecular detritus, which erodes adjacent tisraes, 
and not ouly fosters the deep deetniction of the cutia, tmt also 
its peripheral disintegration. 

In ecthyma profundnm tho crujit is always thicker, and the 
nicer of the ciiUti )!• likewise kcou]nhI out more. Sometiniea it 
extends beyond the margins of the nicer, and then agaia it 
may leave the cavity partially uncovered ; and thus it aeema 
to lie liurruuiKk'd by atuift, purulent furrow. The ccnt«r of 
the croBt, being the oldest point of the pustule, is depreoaed if 
the ulceration estends in circumfcrenoa 

Ae moa aa tlie iiiHuimnatory pracoBS mheidca at tho pe- 
riphery of tho ulcer, graaulatioos befpn to £onn at tho bottom, 
the cru^t becomes denser and adlieree more timily, bat aDOQ«r 
or later falU o&. Tlaa leaves a depressed, durk-rod ecor, whidi 
is apt to dcsqnamato a. long time, bat gradually bocomoa pale, 
even pater tlian tho surrounding normal skin. Jn superficial 
eotliyma, after the crust baa fallen off, the cutis is found in- 
filtrated in the form of a papular elevation, whose sorfnce, how* 
ever, readily becomes eroded and oloerated. 

The coune of the eruption, uotwitlutanding its acute be- 
ginning, ia very tardy. Thia ia shown on tlie different spots 
by the fact that tlie red arcole Barrounding them gradually 
become dark-brown or coppery. 



STPnUTS. 



A perio4 of BIX months or more generally elapses frotn the 
time tlie infection occurred till an eruption of ecttivma nppcan). 
An outbreak of tliis oyjibilidu is Uimiilly udienxl io willi sercro 
febrile movement ; and if ectbyma profnndum iafita for & long 
wliilc, remittent fulirile tt^inptoms of a liuoUo cliaractor raper- 
vcne (fimbria hecticA sypbititica). 

Ecthyma sypbililicum occurs in connection with erytliema 
macubiMini and juipuIoiMini, witlidrAijuiiniiitlug papules, as well 
u uritb odicr pustular eypbilidc^, especially acne and impetigo 
Kypbilitica. Onyclun, falling out of the bair, mncons patdies, 
ulcers on (be tomtils aiui in tlio fiiuocv, and iritiK, not iiifro- 
qncotly are a^^ociatcd with this exanthema. In men we bare 
often scon syphilitic orchitis accompany specific eotliyma. 

The pn*t«Iefl ma_v remain for weeks withoTit undergoing 
doBiocation. We have seen some pnstules of fyphilitic ecthyma 
I ^wrsi^t for more tbnn a year, and rclapee, notwitbitanding the 
zaost JTttUcioua treatment. 

The ])rv)}^osi.4, tiotb gtmeral and local, of this eruption, is 
more ^mvn than that of any of the sypbilidce already de- 
•eribed. Ecthyma leaves disii^inng ointlriccjR. IMapscs oc- 
cur frwinently. There Is a remarkable tendency to anppnro- 
tion of the complicating inHamiuations in all the organs and 
tisBuea of the body. 

Thin eruption is most likely to be miiitaVen for frthyma 
vulffore eachefticum hirulum ; bnt ecthyma vnlgare is more 
like fnrunculoeia, or like the bolk occurring In ecthyma 
nodoaum or oontntdformc It is more painfnl, the arcoln 
•itrroonding the eonvi xbule off gradually, and hare more of 
a bluifih than coppery color, with a greenish tint on the \ie- 
ripbcry. Furthcrui<>rL\ in ecthyma vulgarc there is 1cm tend- 
ency to purulent degeneration, and the ntppnntion ia more 
anperfictah The fnmncnlar cruptiona 1>ecome eoft, rapture, 
and a (jiianfify of sanioiiii flwid «»papcs. Ecthyma vulgare Inri- 
dnm nsnally oeeiira onJi/ on the legs, C6{>ecially in the most 
wretchedly intemperate or acxirbutic pereons. 

{iff Rupia Syphilitica. 

By the term rnywa Kt/j^Ht'ttea, syphilitic filtb-tetter (/inro^— 
•OTdea), is meant an uneven, dirty, nutty- brown -colored cruets 



913 PATaOLOOY AXD TREATMENT OF STPHILIS. 

flituuttid upon nn ulcer that penetrateit more or Itsu iulo duj 
oiitU, bemiued in \iy a pustular wall, and gnrronnded bj a livid, 
inflaiuniatorjr zone. 

Tlie eruptiou ap])e&r« at about the same time as ecthyioo, 
ftod ia alwa^-s atiendwl h^ febrile phenomena. The elementaij 
6ldn*di»ea%of nipia ^jrpliilitica coxi&sXnol livid papular inflam- 
matoiy foci, Torjing in eize from a pea to tbat of a hean, which 
are tnui^formcd within twenty-fuur or forty-ciglit hours into 
flabbj blcb«, filled with a dirty-colored or bloody matter. The 
center of these blebe eiaks in, and in two or tliree days they 
drj* up entirely. The blebe grow in circnmfopenoe by new pus- 
tules forming on tlieir outikirW in cireles. suiroandcd bj aro- 
ohe, which in turn dry up. In this manner a rupia ernst may 
attain a diarnKtwr of two to fonr eoritimetres. The cntst i« 
uneven, thicko«t in the center, bcconiee flatter at the edges, 
thereby acquiring the form of an oyattif^slivU. 

If the crust if forcibly pulled off, there is immA. unrler- 
neath a ii]thy*looldng, dufiky, flabby ulcer, hairing etecp, onder- 
mined, livid margins, which Becrete a aaiiious ichor. 

A rupia ulcer hcale in the Kmic manner as an ecthyma Km. 
Not infrequently, however, it happens that only a eegmeni of 
the rupia ulcer heals by dcatriKntion, while the ulceration goes 
on in the opix»ito direction, and a creecentric or kidney-dmped 
ulcer is the remit. 

Rupia pustules occur tuther in lai^ numbers of the size 
of a bean, or very sparsely, and then they are oe lar^ ajs a 
dollar. Ttie enialler form may cover (he trunk and oxtremi- 
ties in thick groups, while the lai^r will be repreoented by 
three or four crusts only, which am usually situated on the 
extensor mrfaceci of the UmlN. 

The average duration of a rupia postnle is two to thrso 
montlis. 

The attending phenomena of specific rapb are like those 
accompanying ecthyma syphilitica; but, in addition, we have 
in the former a wore frequent ocoorrenoe of cariee, and still 
more of ulcere of the faucca. Furthermore, the terribly viti- 
ated conditiifii of ihv fiyittt'm is alway^^ oMt^ociiitcd with albumi- 
nuria, hiematuria, an<] scorbutic lentone, In confioqacnce of 
tbeeo compticHtioos, the pcognosia ia even more nnfovorablo 



SYPBfLIS. 



a«r 



tli&n in syplulitic ect}i}*ma. Of the patients who sQcconih to 
sjphili.4, the great majority suffer from ni[>i«. 

Aocording to oar experience, spocific nipia originatoe oiilj 
in nmfieqaence of accjuired syphilis. We have never wwd an 
instiinoe of Oiis eniptiou iu children suileri»g frotn congenital 
eypiiilis. 

4. NoDTLAK BtPHIUDK OF THE SeIM \ TrBEBA SxfmUTKL ; 

TuBEBcci^ SrpnjLmcA ; STmiLrno Nodm of the Cctk 
AXD or THE Sl-iioi!tanbou8 Cbllclab Tissui: (Guuuata); 

BTPHfLOMA, AlXX)«I»lNa TO WaoHEK. 

Syphilitic nodes aro due to a morbid proliferation in the 
eutiii or mbcutaueooa ct'llular tiBSue, in con^equcnvu uf which 
globulur tumora foiiu on the surface of tlic skin. Hcnc«, we 
may dietuigukh do«p and eupcHictal eyphilidc calaneoaa 
nodea. I'he auperfidui ones are Binall — elwnt as 1>ig 03 a pea ; 
tho deep nodisi nre iik big 9» lHiin», or ovon hnzel-nutfi ; conso- 
qaeutty, the supcrticiid nodular ^yphilide may ako bo called 
tiie amaU, and the deep tlie laryt, nodular liypbiUdu. 

Snp<^rficiii] syphilitic node* originate eitiier from a mesh of 
die coriuni, or from one or eeveral adjacent cntAncoua folliclea, 
and develop iu the same uuuuer aa a f unmcle, but with levtt paiu, 
and also niiich inure nluwly. When tlie intlaniniatory foci have 
attained the size of a lentil, the snrface of tlio affected places 
of tlie akiu becomes engorged, and tliu patients e.\|ierienoe |Hiin, 
which i« aggravated on preiwurc'. If the cntaneoos kernel coo- 
tiuues to develop, a du^ky-colored ttpot, as big ae a pea, ap- 
pean, gradually grows, and forms a dark-red globular node. 

Tiic deep B^-pliilicic nodes «tart in the eubcutancoiu ccttiUar 
tiasoe, where email niorablo kernels, aa big as bird-shot, form. 
On external pre^ure lliey aro somewliat ]Kiinful. Ah the 
nodnle continues to grow, the overlying ekiu acquires a rod 
color and bccomea adherent to il, and in oonnoetion with it 
forau a tumor. Aft4;r utany montbe or years tluH attains tho 
size of a bean or of a luua'l-nul. 

The Huall nodular syphilide attains its nsnal eixe in a 
abort time. In m)uiu cuses only small nodee — i. e^ cuianmxts 
««£(•*— originate thrt>ngljoHt ; in otiiere only large ones— i. e., 
titicatatteou* noUet ; in tnoi^t ouca, however, cutaneous nodee 



2M PATEOLOQT AXD TSBATilENT OF STPniUS. 



will bo found ou one part of Uic l>ody« and enbcntancoiu onee 
cm another port. 

Tiie dtiwloiKMl sypliilitic iiudo ie generally globnUr, pome- 
times oonicnl or tcaraiimtod, Dot infreqnently it is flnttoned. 
Id color and eonaUtency tbc node vnrics according to ite age 
and pliaso of devclopmoBt. The reoeut Itul fully developed 
node tiAH a bruwaiitli-nid or cx>ppery color, is 6at, gloKy, and 
liard. The older tlie nodeti are, aiid Uie nenrer tliey appro»di 
tlie regressive stage of metamorphosis, the paler tliey bccomt*. 
Wlicu absurptiou ects in they torn brunn, and, after they are 
entirely nbtHtrbud, gru^'ith diMXtlitrt-d apots will remain for a 
while. If A node m about to Quder;go ulceration it tiim» livid, 
soft, oud doughy, and eomctiiutiM lluctuatioD may bo detected 
in it. 

In its hifitological development the eataneoas node rosen- 
blce very mncli the syphilitic connective-tisme nodes or ^um- 
ma, Aceording to Wagner's Pcsearchc«, the eyphihtie node, 
which he regards as a t\ew groaHh, presonts itself, when roocnt, 
as u grn^-ish, soft, bomogeneons, diy moHs, yielding a alight 
amounl of elimy, clear, or murky juice. The Deoplasm forms 
either a nodular masK, varyinji; in tdxe, round or irregular, soiue- 
timcA sharply defined, or it is a diffused infiltration of varying 
dinicDsions ; or, lastly, nodular masses appear tn a diflnse in- 
flltnitiun. Tlie most imiiortant elements of tills ncoplastio 
growth arc oolhi and granulea, tiucb ns we find in a Hnnterian 
indnrated primary Iceion and in other syphilitic infiaiimiatory 
proccefcee. Tliey lie^ partly eingly, partly in numbers, in cavi- 
tiott foniied by eouuectivft tisiDc, but which ai-e by no mcttis 
characteristic of this Icdon. The older the nodo is, tbc Ices 
niimorons are the cellular elements, and the moro oxtennTo is 
the connective ti«ue. After existing Utr a variable period the 
node either bocomes very dty or it undergoes ulceration, or 
both morbid changes go on tocher. Simple and fatly auo- 
phy of the oella and gnumW is the mos-t fn-tpient mvta* 
morphosiaL The central and oldest port of the nooplaun od- 
dergoes metamorphosis tirst and thcnoe it ^n-eads to the 
circuniforeuce. 

Acoonliug to Virchow, a syphilitic node most closely Te> 
MUiblea roocnt grauuUtion-tissue, and the process that takes 



BTPHIUa, 



315 



p3gce in it diffcn from the nsoal nlccration and suppuration 
aAj in 60 br tliat no licaltJiy or good pne forme, but only a 
tModouB ^;anunocui), ^limv, disorganized Eubetance. Owing 
to tiuB glutjnons, eynotial-Uke substance, the aypliilitic nodnles 
received tho name of ^mmata. Wagner niggcets tbc term 
" fivphiloma." 

Ttie extvninl fonn of a specific node changea aooordlng to 
tbe manner in witich the retrogressive metaniorpliotus ia in- 
angnreted. 

If t!ie nodee arc about to be atisorbed by fatty degeneration 
thej fifRt become pule imd flat, and tliti cntiK mvcrittg tbvm biv 
gin* to fthrink. After ba\nng desquamated repeatedly, tbcy en- 
tiroly disappear, learing a slightly depressed spot — \. e., a dr- 
cnmseribcd ntmpliy of tliu itkiii. The depresat-'d spot romaiua 
blnish-red for a long while; tinally, the pigment disappears 
and tbe sear beconiee pecnliarly whitiah. Nodee ate absorbed 
only itndcr tbe mo«t favorable circumetoncca in robtut,hcaltliy 
pereons. Vnder less favorable oonditions, in comtitations tbat 
hare become debilitated, oentml softening usoally eiuucs. This 
vill inanif««t itself in a different manner, according as tbe 
Dodea are of tbe outaneoiu or eul>cutancoua variety. 

If the node that undergoes disintegration is of the entano- 
oas apoeiee, a »na]l qnnntity of aerou^; flnld will be poored out 
under the glossy epidermis covering it, wbicb gradually solidi- 
fiea, and, ^ntJl the cutia tbat baa t>een dL>tacbod from tlie aiibja- 
oent tlMue-. forms a cmst. By this proceea tlie former globular 
fonn of tbe node becomes flattened. ]f tbe crust is now re- 
moved, tlio sorfaco of the exposed node ia seen to be even 
more gtoeay than before, and more ecrons flnid of the kind ab 
icody mentioned exudes from it Tbis again dries and forma 
anotliur thin cruet, beiu^atb which mipptiration of the node 
goes on, finally rwnlting in an ulcer that penetratee into the 
cntia, corresponding in size to the former node. So long as 
the diMrganization of tbc node continuce, the erast will be 
soft and e«sy to detacb. GTadnally, however, the base of tbe 
ulcer licgins to gmnnlate, tbe crnat becomes firmer, more nd- 
berent, but finally falls off, leaving a doprcaecd, dark-brown 
sear. 

If tlie node tliat nudergoee central molecular dimtgam'za- 



316 PATUOLO&Y AND TREATXBiTT OF STPmUB. 

lion m uf tlie tuiliciitanutiiu viirivly, Utc ftkio covoriu^ it — outl 
whiclif in conjunction with it, fomiB a htmor — becomes red. 
An iufiauied ^wclliug, luoro or hat cxtciisivo ucoording u it is 
coiujHWud of ORU or Mrt'cnJ cuuglomcTutcd uodw, ori^natec 
The tamor, wliich at tirst is eoUd, gradually Irecomee doughy, 
Olid begins to llactuatc on palpation. TLe oiTected part of the 
8kiu linally becomoa li^'id, attenuated^ and bursts in odo or 
more placoe, pccordiuf; as tbe tumor cuusiiits of one node or uf 
an agglomerHtiun of severul, and a Uiin, purulent 0ai(] then 
usuapes. ]f the tumor was compoeod of one node only, (be 
opening will rapidly Iwcoine larger, and an uloer tliat jieuft- 
trattM to tlie very botttim of tlie former node will form. Its 
edges are steep, undermined, and its bottom is covered with 
dirty-looking matter. No zone or inflanunitory areola is osa- 
uUy to be SL*u:n around tlic ulcer. If there are H.'vi;ra] ujiuniii^ 
tbe bridges of the Bkin between tbem gradually slough away, 
and a laige aloor forms, which Is Burrijuiided by a livid-red, 
undiiriiuncd, cntancous margin. The pUA fnun tbe ulcer dries 
irp, and forms a large or small, tiiin or thick, greeniah-ycUow or 
reddish-brown soft crust, which lies quite loooely npon the bot- 
tom of the cavity. While the cniat of u superficial node that 
lias undergone degeneration is somewhat larger than tbo node 
itself, in, tbe deep variety, it h often emaUtir tlian the uloer, 
lies beneath tbo ekiu, and is surrounded by a circular groove 
that SL*{iBrHtes it from the sharply outlined mai^ns of tbe lat- 
ter. If granulations begin to sprout on the bottom of the 
nicer, the crust bwomes duuser, and adlieres more tinnly, Tho 
nicer seldom clones up by concentric contraction of the skin 
alone; ctcatncial tiiisno is almost always formed, and Blls up 
the cavity. 

Ulcers wliicb have fonnod in consequence of tbo disorgini- 
aitioa of tho cutaneons and siiticiitaucous nodce may retAin 
their round form till cicatrization has ensued. It very fre- 
qtientlj happens, however, that a roand spot on the margin of 
tbe nicer cicktrizcs in one direction, while slongliing goes oa 
ouncentrtcally in another, and cicatrization gradually creeps on 
over the newly nlcerated space. Thus kidnoy-sbapod, serpigi- 
nous ulcers may originate fmm circular Kloughs. This serpigi- 
nous tilcer nsualljr lasts ■ long time, and sometimee spreada 



srpmus. 



over a l&rge surface. But kidDej-«baped nicers mav b« pro- 
doccd b; tlio disorganization of catancoiu and snbcutanooua 
Dbdes witUout having » ^c^pig)nons cbaracter. Xliis is the 
caee wlicn the Dodw are aggregated in a eemidrcle, and tlicn 
mxlorgo pnmlerit dtfgeneralion. 

After tlio ekiii formerly oocnpied by the node lias cotn- 
pletol}- cicatrized, it becomes attcnuattHl, depressed, lias a bluish- 
red or coppeij color, feets Lard to the toacli, and deetjiiamntee. 
Tlie cicatrix oulj becomes pak and soft when the proper treats 
nietit has bucu continaed for a long time. It theu ecasu to 
desquamate, and it^ rcuiarliably white cuh>r [>rc:i(?nt4 a etriking 
eoDtrast to the Hiirrninidiiig iiormaJ integument (iitropliy of the 
diaootored e|>ot). The upi>enuogt stratum of the cicatrix, which 
takee the place of thu cptdennal layer of the uunmd ekin, has 
the appearance of Btraw-paper, and becomes wrinkled, as If it 
werD too large for the cicatrix. In sonio casea, the gtunma- 
QJCAtricee are not deprosecd, but, on the contrary, prajoct otod 
above the level of the ekin. The^ scars have a keloid appear- 
ance, and, acconting to our expeiieoce. soon degenerate. In 
fact, only tlioso scats rcsnltin^ from nicenttion of e^'philitlc 
uodee are likely to \>« permanent that have oeaeed to detiqiia- 
mat«', are perfectly white, and not abuoruully hard. 

Syphilitic nodes may appear ou any part of the akin, but 
are usoally met with in the face, especially on the forehead, 
the tip of tlie Dose, and the Hpe. On the trunk, thoy acem to 
have a predilection for the region of the alioaldcrs. They are 
very frequently found in the immediate vicinity of a joint, as 
tieo on the extensor surfaces of the oxtrcmitiea ; further, at 
the steriKhclavicular and ctaviculo-acromial joints. (>n the leg, 
thoy doToIop generally on the anterior and internal surfaces. 
OccuiOQally wc huve even ^ccn them on the paim of the hand 
and on the eer. Ttiis syphilide is generally confined to one or 
Several of the phices mentione<l, and uo«uni in grniijMi of two 
or three simullancou&ly. It is seldom t^oon scnttured uiiLfomdy 
over the body, and even then the nodes do not appear on all 
the places at once. Wlien occurring in groups, the ntxleH form 
ovaJ, curved, or circular segments, which develop in the fol- 
lovring manner : A single node, remarkalde for its size, or sev- 
enl nodes near eneh other, originate at a certain place o» tho 



S18 PATHOLOGY AlTD TREAT3tBXT OF SFPffTLTS. 

ekin, and, as tlieeo bcffin to disappear, partly by abeorption. 
partly by desquamation, new ones slioot iij> on tlieir out>tkirts. 
TJie UtttT again mnj' disappeiir in the Mine miinn«p as tlie ppo- 
csdiog crop, and bo EDccoodod by another, resulting in ciralee, 
of lar^ or umall dimouaioos. Tho nodules that fitrm a cirale 
are grouped more or leu closely, or tbey ocnletce i>o that the 
globular conformation of the indlTidnal tamonj U no lon|;er 
distingnishablc. In Bonic cases the nodit]c«, L-a[«cial]y choae 
oocturing in the fnce, ore apt to be huddled together fo closely 
that, collectively, they form a conglomeration like a closter of 
gnipea {lyphiliv ratemiforinis of tho old writcre). The origin 
of tumoTB reeolting &oni the coalition of ferenil nodalee, on 
whose eurfaces, howevor, the eontoais of the indiridunl gum- 
mata are nodistiiigiiiahod, bae been designated by ^me authora 
as lupvs hypertrophieut ayphUUicua. Like the dr>' nodo^ the 
gup]>uratiiig nodules aUo occur in groopa, and are artutiged 
in eircledu Pitunt^rating griintnatn, whieh are so closely clna- 
tcred together tliat they almost form one node, have been called 
by gome bipua gypMliticua esndcffrativtts. That form in which 
the nodes, arranged in a Remicirclc, snppnrate in a given diree* 
tion only, wliile cicatrixation goes on toward the center, and 
new Boftening gummata constantly spiring up at the periphery, 
has bwn termed /'//>«■* fterpiffinosiu. The term lupua ought 
to be reserved for lupns Tolgiirtft, and the suppuration of syphi- 
litic nodes alone should be spoken of in dc^uibing the diaeaao 
under consideration. 

Of all the Byphilidcc, nodular syphilide mns the elovest 
comse, and ia the most obstinate to treat, 2vot only do new 
gummata epring np on Torions parts of tbc body, deApit« treat* 
mcnt with mercnry and iodine, bnt they also form on those 
placee where some of them had already isdstcd and disappeared. 
The earliest period in whi^ we saw syphilttio nodee appear 
was four months after infection had taken place ; the latest pe> 
nod twenty jears. Other syphilograpliore mention even thirty 
and forty yean. Of all tlio ayphilitic diiwflM« of the akin 
which came under oor obeerration, specific gummata were tho 
least frequent. 

Being tlie renalt of a later phase of tho sypliilitie dieeflse. 
nodular eyplulido never appears in conjunction witli tlioec phe* 



noraCQa that nm peculiar to tbe earlier imuiifeetatioafi. At the 
nuMt, & few ectlijma-pnstuke or rapia-uK-ere lua^ be found 
UBOciated with it The presence of moist papules may b« 
«xolmIc<l apriori with tlie ntmort safety, Tbc moet fro'|ucnt 
complications of tho tubercular i^ypUilidc aru orchitii; ^yplii- 
litieo, esteUHivo diHeusc uf the fibrutis xtnu-tiirett, iilferntiong 
and mtlformatioiu of tbe nas*\ and pharyngeal walls, syjiliilitic 
dlMase of the liver aod of tbe brain. 

SypliUido Dodes or gummata always indicate a far-advanoed 
iyphilitic affection, and at the same time tbey are tlw final re> 
autu uf the morbid pn»efgBes. They not only occur on the skin 
and mucoiu mciiibmuc, but in utiicr tistfiioe and organs of the 
ImxIv. a specific cutaneous node is, tliuxiforc, on indirx for 
the dingiiosie of syphilitic di^caive of the Tisoera, brain, and 
ncrvcfi. lltTic.0 it ill also clvar iiow a nodular eyphiUdc tnay 
esseulially alter the prc^oeu. It may alM be added that tbo 
may rolapM after many ycara of qaicMBDco and appar- 
^Int euro. When syphilitic cutaneous nodca undergo degen- 
eration, tbe snppurution of cocxistiuf; iiitlammatory products 
^for insianoc, in tbc perioetcum, and, in conseqaenee thereof, 
caries and necroeig of the affected portiooa of tlte bonea — may 
lie np]>rohcn<led. Fiirtliennore, ukt-nitiiig nodes may canso 
terrible mutilation and disfigaicment with frigiitfnl rapid- 
ity. Thus, one ala naris, a part of on eyelid, or a li|i. may 
be destroyed. In like manner, the scant which nviiilt from 
the ulceration of the syphilitic node constitute tmnuBtak* 
able eTidencc of the obaracter of the diaeaae that preceded 
tLvm. 

Of the epecitic diseases of the skin, iaUicular papitlar 
typhUidc alone con be mi&taken for the ufxlular ayplulidc — an 
enor tliat u of no importance a« regards the treatment, bat 
altogether diitercut as regards prognoau. Tlie smaller size of 
the papule, the site, the total al>wnee of pain, tbc much earlier 
appeonuice of thie eruption and its proAueiWK, tlio Bimulta- 
neons prtsenoo of moist jnpulcs on tbe skin and on the mucoiis 
membrane, as alRo ite entire course, will lie more than suffi- 
cient to guide tbc physician in ditferentiutini;; the two cntanc- 
cuB diseaece tliat were engendered by the same morbid condi- 
ttoD of tbe bltKxI. 



S20 PA.TBOLOQY AiiD TBEATUBiiT OF SYPHILIS. 

Of tbe DOD-sypliilitiG dieeasee of the ckin, niollu^um ao- 
bacenm and fibrosum, aone rosac«* tuberosa, rhma^clvroma, 
lupns Tulguis, Mid o«pecuUy carcinoma of tho cutis, aro the 
onlj ones that can be mistaken for nodnlar irrphilide. 

The moUuicum differ? ivom ppecitic gumiDBttt hy tho con- 
Btriotion at its base, as it is more or loss pedicaktoJ in most 
cases ; but oven tbo non-pediciilated nioUusciim sefi^ilo afloniK, 
by tlie plate-lilcti depression at its bigliust point, hy its eoft- 
uess, aiid by tlie iiiiipi.s(iat«d itoboceons secrDtioD, wbicli nmy be 
BquoeEcdout od piincturc, sufBcient data to prerent an error ra 
diagnoeifl. MoIJn^cnm tibrosum is recognized by its tinuDees 
and painleasnees, and also by ite pcrei^teuce. 

Tbu kcmela uf ocner rosacea hAeroaa dilfer from rrphilitic 
nodes of tbe faco and noee by tbe fact tliat tlicy are not a« 
smooth and gloaej as tbe latt«r, being almost always uneven, 
f urtbcrmore, there is a total abecuce of the diUtations of tho 
capill&i7 vceguU io tbe vicinity of the gypbilitie node, and its 
brownish color is distinctly outlined, while the diirk-rfd color 
of acne roMcea niergG8 gradually into tbe nonnnl carnation of 
the skin. The skin adjacent to Clie specific node is not so by- 
pertropliiediwin acne rosaceai of severe grade. Ijistly,Bypbilitie 
gammata ireqaently undergo degeneration^ and in this manner 
ofleD destroy part uf the nose. This never happens iu acne 
rosacea. 

Tbe g^reatest difficulty in reference to the differentia! diag- 
nosis will be occasioned by tlie nw»jilii«tJc growth which Uebm 
has called Mno-scf/^iimta, bccanse, like Uio nodular sypUilido, 
it has the tendency to destroy tbe soft parts of tbo noeo and 
of tho nvulii; and, mon-ovur, also runs a protracted courK. 
The absence of the phenomena preceding and accompanying 
syphilis ; tho stony hardness ; tho dimtnisbcd permeability of 
tho nasal passages; the alow destruction of tho eoft parts of 
the now, while tbe bony structure remains intact ; the inef- 
llciency of aiitUypbibtio remedies; finally, tbe history of tlie 
dia-ase, preceded by a trauma of the nose— will enable us to 
exclude syphilis, and sospect that tho ueoplasju is a rhino«cle- 
roma. 

Tlie following jathugenetic and morphological fligns may 
be pointed ont fur tbe ])ur|>06e of dietiogitishing iujnu vtU- 



BTpmiia. 



221 



jmn*from confluetit and nloiighiug nodular sTphitide: Lupus 
vulgaris (Ifvcloiw gt^nerallj before tlie occurrence of puUert^, 
trhiie epecific gummata are usually met with in persona of 
more advanced years. Tlic doetructiou of syphilitic uodc-e goes 
on more rapidly than that of lupus tiiberclcii. I^ipuA«i>i)t» are 
alwaye eurrounded hy ao active zone, wkicli ^dually fadea into 
tbc normal akiu, and not infn^ucutly forma a phlegmonous 
Bwclling. Specific oonflucot nodes and ulcers n^sulttng from 
their dinnt«^ration have very little or no intlammntor}' areola 
around tliem. TIic tulwrclefi and ulce-nt of lupuit vulgaris arc 
painless when tonehod, wliilc ninrkcd prosfiurc on syphilitic 
giuumata causes eeroro pain. Lupus vulgaris, as a rule, dues 
not attack the hony part of the noee, while giimmuta of tlie 
nose genemllr begin with uzrena Bvphilitica. Lupus vulgaria 
nsoally heaU hy leaving radiating scars; syphilitic nodee It^avu 
dqnvascd scars. It ui often difficult to decide whether, in a 
given case, we have to deal with hipus vulgaris or hereditary 
lacs; hut the course and the effects of the remedies, and still 
more the fact that in tho latter affection the ftoft palate, as a 
rule, is ulcerated or adherent to tlie posterior pharjugeal wall, 
will often fnmi&h a key to the diagnoets. 

MuUipl« carcinoma of the aim and Mjr»»na mfiaMdtt 
present great eimilarity to nodular fiji*phitide, which, tike them, 
is scattered over the ititegument. However, carcinoma and 
Bucoma tnmors never have the Fphcricat form of gnmmata ; 
they aro flat and smooth. They usually occur in large niun- 
bera on the trunk ; a few eolitary tumors ordy may be mot 
with In the face and on the extremities. In color they are 
bluish or brownish-red, whereby tlie Bkin acquires a marbled 
appearance. Of eoune, no carciiiomatouA or Kirconiatous tu- 
mors disappear by absorption ; and equally rare is it for a car- 
cinomatous tumor to ubMrato speedily; for long before this 
takes place omccrona growths will have formed iu some of the 
risceni of thebody,undermined the syiik-m and produced dealii. 
At the autopsy multiple carcinomatous tumors are f oticd in 
the form of small medullary cancers, white, or entirely black 
in color (cancer mcIanodc«), or only eprinklcd with black ipots ; 
sarcoma melanodes appears ns an incomplete tibroniatoos neo- 
plasm, profusely tiuted with dark dotsL 



222 PATHOLOOT AND TREATVEST OF STPmUS. 

Tbb So-called Pioiiekt Svpuiug. 

Syphilitic efllorew:t'nc«S(»!peciaIIygaminat«,pTisttilarBjplu- 
lide, and the primary lesioo, unually leave intensely diacolored 
iipola, wlueh last for a loug time. These disooloratiom diup- 
pair wLvii the tivpLiliji is entirely cured, and are tKitnetimes kuo- 
cocded by a pcnnaiient blaDcbing of tbat part of tlie eldn pre- 
viously occupied by the specific ulcer. We know of no sypbi- 
lidu tliut mauLfi»it« itself ooJy by tbc appcaraitco of primary 
didcoloi-ations of tbu bkiu. 



Bypbilitic Affectlooi of the Hair. 

Sy^diilis, like eoioe of the actite febrile afFectionA, often 
oansea dlaeaees of tbu bair, and tbu pereomi attacked by it bo- 
come bald — «ometini«« temporarily, in other cases, permanent- 
ly. Tbe Iiairs that are about to fall out lo^ their liuter, and 
tbe patient, on combing or bmidiing Imnself, or by nmning 
bin fingers thruiigb the hair, caueee many of tbcm to fall out. 
Tbufi, tlio capillary covering of the head becomes diminished, 
and the ecalp is more or leee cxpo&ed. Marked balduees of the 
Iiead becomes evident when flie deBuviom capiiluratu has coo- 
tinned for a long while. Variooe forms of baldnees are dis- 
tingutebod according to* tlie location, extent, and severity of 
the 1(MB of hair. Thn&, when tbe haire begin to fall from tbo 
crown of the bead, it is called phaEacrosis ; from the back of tfao 
bead, opi^topbalHcroeis ; unilateml baldness, hcmiphHlacmciis; 
and if tbo falling out of tbo bain oocnr in »^rpeutino linos, 
opbiasia. Asareeiilt of £ypbilIs,not only thohairRof thehead. 
fall out, Init al«> ibe eyelashes, eyebrows, tbo beard, tbo Ittlp 
of the pubis, and axilla. The morbid proc«>68 that caujics the 
falling out of tbe hair is due, according to our researches, to tbe 
Khriuktng of the celts and granules tliat cnitNtilnte tbe luur- 
pulp. 'J'bc hair in tlic follicle, Iberefore, dies, and wonUl fall 
out, were it not retained in its sheath at tbe root. Finally, 
hovcver, Uio r»»t-»bcath, ttKi, is cost oS in tlie fonu of minute 
K&loA, tlic hiiir Iwee its \w\<\ and drops out, or it fallfi out iritll 
its root-eheath. 

Tbe falling oat of the hair, u n mie, begin? a few days after 
the eruptiTe fever has been oshonxl in, and it is not only Vf- 



srpniLts. 



3S3 



rested by caring the underlying disease, l>ut tlie liairs speedily 
gruw agnin. If Uie treatment baa been inappropriate, tbo 
dcflnriurii cnpillonim nmy rocnr aevenl timee ; the plciitifitl 
growth of tlio bair after c-ach falling out niay, in fact, be 
loured upon w, a favorablo prognostic omen. Ses, age, and 
MASon of the year cxcrciec do modifying influence over tbe 
Migin of alopecia eypbtiitic-a ; hot tbo growtb of tbo btirs is 
eo far atfectod by age, tliat in yonng persons it takes plaoe 
more quickly, and is more compU'te, tlian in tliose of adviuioed 
years. Tbe falling out of the boirs ueually precedes and oe- 
companicfl early syplulidea. 

Sj-pbilis, however, sometimes causes a circumscribed bald- 
neea itiJfqxcia are^i) by mppontion and destruction of tlie 
hau'-follicles. This hapjiena, especiaUy, in con«e4iucuc« of con- 
^ncnt, impetiginons 6y]»liilidcs or de*'p ulrrrs of tbo scali>, in 
the beard, or on otlier plaoee. 3fo hairs can grow upon cica- 
trtccs that fonn bunx 

In onlcr to dtAtingiiiAb alopecia syphilitica from aiojMcia 
vu/garis jmiematura and eentlts, it a Qeoeesary, ia additicm 
u> Uic aiit«cedent« and concomitants, to take into eoDridoratioa 
tbe facts that in tbe latter affection tbe bairs only fall out on 
the crown and anterior part of tbo bead, while tboee on tbe 
rest of tbe Walp remain ; that in cslvitiee senilis or pnrmatnra 
the skin is ronmritablc for its luster and Bmootfanoss, because 
in those diseases tbe bair and sebaoeoua fulliotea disappear en- 
tirely ; in alopecia syphilitica, on tbo coBtraiy, tbey are not 
only not destroyed, but even generste an increased amount of 
ecbum. Tlie deposit of sebum upon tbe smooth and bold ekin 
IrcM it a scaly appearance. 

Alopecia prodnced by Aerpe* tonden» (j>/i}/fth4xI^^dola, ac- 
cording to Omby) may readily be mistaken for tbe circiun- 
errilfod alopecia riwulliiig from tlie suppuration of syphilitic 
ftlUirwcenoBS. Tlic forrner diseaee of the haJr» howeyor, is 
distinguished by tbo fragility of tbe liaira. and, aboTo all, by the 
pnssDCO of a cryptogamous parasite. 

BypliiUtio Disease of the Balls. 

Hic naik, like tbo hair, to vfaicb tbey are histologically 
akin, Buffer from syphilitio morbid alteratians, wbidi manifest 



m PATJIOLOGY AXJ> TREATMENT OF STPSJUS. 

thcmeclrce in an iuflamoutoij affection imd nloerattoa of tlie 
skin iti trnniediate contact with Uie nailg. The kttcr ue Beo- 
ondaiiljr destroyed, and cast ofl— paronychia stfphUUiea — or 
the texture of tlio nail undergone certain alturatiuiis without 
the parti around it beewming in oiij way affcpttxl — onychia 
ayphilitiat. 

(o) Farooychia svpliilitica appcare either aa an inflammation 
of the nail-groovf — jtat-onychia irt/j>/iiiUica luntdaria — or ae an 
influinmation of the tiifsares of the ntXi—parmiyc^ia sypJiilitiea 
latefalit. 

Paronychia Innularis he^ae with a modeiatc degree of swell- 
isg and redncea of the cutaneous structure Irordering on the 
root and lunula of the nail. The swelling gradoally incrcafica, 
has a dull, roddlali color, is eemilunor in ehapc and painful to 
the touch, and coven tlie lunnla more or Xcm. In some cneee 
this swelling bocomoK polo and 6uhsv<}auutty underi^oes rceolu- 
tioa. In most easee, however, the epidermal covering of the 
Hwelling under consideration ia raised up by a scro-purohjnt or 
sanious Suid, reuulttng in a filoughtug ttiill which sarrouiulB 
the root of tlie nail After the ijlough has lieen cast off, an 
nicer will be found H'hicli may debtroy die matrix of the nail, 
and then gradnally extend to the lateral diwiires, being, in 
fact, A contimiation of tlie morbid process of tlio root of the 
nail. When tlie **lough forma, the uail loses its transparency, 
bcoomea grccniKii, and Gnally rough and brittle. The more 
the nicer encroaches upon the bed of tlie nail, tbe more tho 
Doil will ho niscd up from Wa bud ; and, fmaliy, it is caet oS, 
or is gradnally macerated by tho secretion of the ulocr and di»- 
aolred. In most caees a new nail grows after the old one has 
btlcn off; but it is quite sure to be crooked and ungainly. 
Tho iuflanimatory process that brings aboat tlie deetmctioti of 
the matrix and the lte*l of tlic nail, constitutes, aofonling to 
OUT TMCarchea, a locally modified ecthyma pustiJe. TVo have 
aaen, in fact, in most cane of ecvere pustular tiyphiltdos, ulcer- 
ating paronychia, while in the dry s^'philides panmychiu u<q- 
ally dieapptiant by absorption. 

Paronychia lateralis accnmpanios papular syphilides. In 
one of tlie lateral lif>suree of the nail, a moist pajuile forma, 
slowly extends ondcr it. and, by increasing in size, gradually 



si'pmijs. 



SftS 



nlsea, and, at the samo timo, enucleates it. Having been 
digtarbed frum it« position, Lhe tiail miuii diBpluys tho toxtaral 
lerioDB atreadjr described. If tlie papole nnder (be Bail nuder- 
goes molecukr destruction, the latter will graduall_v become 
«oft, and then Itc cast ofT. 

Paronychia syphilitica may develop upon the fingers; bat 
it oocnra by preference on. the toea. At any rate, the prwenro 
of the aluK eccmft to foster its production. Ak u rule, it ia 
met with only on one finger or one too. 

(b) Ouyohia syphilitica di^laya Tarious grades In the low- 
est ft»de tlio dificoEcd nail has a rosy color, its glees ia gone, 
and email white spots, as big as a i>in"6 head (jftww or mtndacia 
un^ii'um or lifg of the Engliah writers) ori(fiiiate upon it. They 
aro due to the imperfect lianlening of the celU tliat form the 
substance of the nail (Valontine), and irritation of the matrix 
aecma t4) be at tlie 1>ottf)m of iL If the genenil s^-pbiUtic dis- 
ease U treated early and oTicoeiiitfnny, the nails will subsoquoot- 
Ijr liaire no white epots. The succeeding healthy iwilions are 
then acpantcd from the diseiutcd portion by a white line; but 
if the apedfic duease condnncs, the nail becomes mora and 
more opaque, rough, and brittle, and dii^torted ou it» free mar- 
gin, wlicre email fragmenta may be broken off. At the same 
time ibt root ia gradually detached from the matri.T, and is sue- 
coodcd by ii nail tluit m iikewifte discaecd. 

The affection of tlie tissne under confiideration, which, in 
eontradiBtinction to paronychia sapparatiTa, wo would call any- 
chia sicca^ develops moetly in cases of pronotmccd and ]>er- 
eistent psoriasis palrnaris ot plantarid diffusa eypbilitica. It gen- 
erally attacks all the nails of the tJngers lu well ait of tlio toes. 

Wo will only «peak here of the viiriona non-eyphilitic af- 
foetione of the nail which might be mi^t;ll:en for the specific 
variety, and, not being able to point out any dialiugaiahing 
pathognomic Atgna, we are compelled to refer the rendvr to tlie 
fact that the etiological factor of any diaeaae of the naJl can 
only be ascertained by the previous and present history. 

The non-inphilitic diseases of the nail are either of local 
natare, or originate in consequence of a geiiOTnl diaeafto. 
Thus, paronydiia ushered in by suppuration of tlie oail-fidrarea, 
vpocially on tho big toce, often originates from pressure o<f a 

IS 



226 PATaOLOQY AKD TBEATMEXT OF STPUILTS, 

luidlj Bttlug eltoo tlmt causes crowding of tlio lateral mu]^ 
uf tlio nail into tiie flceb. In cott8ct|acuce of c^aema of the 
BftiU of the fingers and of the toce, a p&roajcliia cndinji; in loa» 
of tho nail likewise is sometimes prodtieed. Scrofula, alM, not 
infreqacntlj causes an iiiflammatory biilboos liyportrophy of 
tlie Dttils; etill, in tUis case sapptinition of the bjpcrtroplued 
purt Beldom ensues. Furttior, it ia eald that in {wreona wlio 
Goffur from valvular (litttoite of tha heart an onychia iiioca ooeun 
(Wunderlich), which » known to anthora nndiT the name of 
di^oedatio, or BCabrili<« unffulum^ and is distiuguiahed hy the 
fact that the nail not only becomes rough, opaijue, and hrittle, 
but unilurgocn hvjjcrtrophy, ospocially uu the free margin, and 
acquires a color dmilar to the mold on cheew (cheee/ nail). 

STptulitio Affection! of the Hucoas KembruiM. 

Next to the common inteffoment, syphilia avails itself of 
the mucous membranes upon which to locate its morbid leaiona. 
It manifeets itself apon these Btmctoreii under three Tarietiei^ 
namely: 

(1) Diffused erythraua. 

(2) Papular inflammatory foci. 

(3) GiunmoiiB, nlcerating nodes. 

Puetnlar vfflorceccnoea in consequonee of erphilte ncrer oo> 
car upon mucous mfimbrane. 

(I) STPinUTio EnTTHEMA OF TBB Mrcocs Mehdrajib; Srrnt- 
UTic CjkTARunAL I^'FLA^ULA.'^ON ; ERrmciu. Sypmun. 
CPU Heubkax^ Mcoo&b> 

Syphilitic cr|-tIiemaU>ut! affection of the mucooa membrane 
iji aeon in the form of a diffused, sharply defined, peculiarly 
livid color orer extenaire porttons of the mncooa morobnne. 
It uuy disappear Trithont caoang the least textnnl liuiou, and 
mbeequcntty return ; ttut it may also prodace such ledoua as 
will leave the epitheUum upon tbo affected places opaqnei, «r 
they arc cast off hero and there, resulting in Kuiall eroeionfl. 

"Wliilo in eomo places 6y]>lJlitic erytlienia \<rill prodnce a 
BODsation of drynosa of tbe uincons membrane (erythema of 
the palato and of the posterior wall of the faaces), on other 
places it supcrTeucs witli anomalies of secretion of the affected 



sTpmus. 



227 



part. Tlie disease alw&j^ begins witli a diniJnished degree of 
■ecretloD of tbu mucous tucinbraiKi uud Uiu K.-iiKatJon oi dry- 
ness, but in tlie coarsu of t.liu iiiHtadjr w mticii mucns is se- 
cicted that it aiQoimU tu a mal blmiuurrhapa ; or oven actual 
folliotdar fuppumtion, evpliilitic catarrh^ or EDofflce, eyplulitic 
vaginal and preputial goDorrliaea, and follicular nloeration of 
ttw^tonsile, may cnsae, Tlie Bw«lling of the syphilitie, 017- 
tbematous miwoiia membraBo generally is eliglit, being very 
marked on otirtaiii places only (avula, tonsils, labia minora). 
In coni<e<jnenoe of tlie Rwelliug, certain tabular traols of mu- 
OOUB membranO'— for instance, thu Lurlimaid duct, nasal and 
nr paasagcs, and tlio lan-ox — may become narrowed, producing 
serioiu functional dititurbuucua in Uie conduction of sound and 
of tbe tears, as al»o in speakitig. 

Tiic Bp«:i6c catarrhal affection of the mucous membrane 
gencTally is a H/inptoin of one of tlio tirat pbofles of syphilia, 
and ift tbcn-foro ulwn^'s accompanied by early morbid phenom- 
ena in other tissues and organs. It occurs either as a solitary 
manifestation of syphili*, or it ia only the forerunner of pap- 
ules of the raucous membrane which aro in conrse of forma- 
tion or nodular exudations, or it appears in company irith the 
latter only, and remains as their £0(|ncla). Certain external and 
internal conditions promote eyphiUtic catarrhal affection of 
■ome r^ions. Tlnis persons who smoke or cliew tol>acoo to 
ezcosB, those who are exposed to nnfaroi-ablo conditions of 
the weather, or wlto often suffer from angina catarrhalis vul- 
garis, and tnhcrculouii paticntR. are more frequently attacked 
by angina cotarrlio^ 8ypliilitii-a than others. Caturrh of the 
Tolra seems to be fostered hy frequent intercourse ; congenital 
I^iUnosIs favors tlie prt>dii(-tion of balnniti», etc. 

Syphilitic crytlnrtnatons affection may relapse like other 
specific affections ; rrphilitic catarrbal affection of the isthmoa 
ftoctum, in fact, relapses most fretpicntly. As a rule, when a 
ooterrhal affection relapsH, papular inflammatory foci will again 
form on the same places. 

(9) Svpuiunc Papulks on tub iUcooTd Meubuane. 

The muconB ntcmbrano papule iloee tu>t always, nor on all 
pkces, poaeces tbe nodular ^pe of its dstereffloreseences on 



228 PJiTBOLOQY AND TREATUENT OF STPBIUS. 



the common mtegomeot. Ae a role, it barely riem above tJie 
level of tlio muc-oiu meuibrane. But thoae papales that am 
dtaatod upon places of tlic mucons manbranc wbcra the papil- 
la are markedly developed — for inBtanoc, on the cup-shaped 
folliclCB of the neiise of taste at the root uf the tongue — have a 
good op{M>rtiiuity to develo]> iuto the papular tyjie of the dia- 
ea£o. Like the syphilitic papnle of tlie common integument, 
the i<.p<3citic papule of ibe mucous membrane is caused by cel- 
lular iuflkraliuu ui ihe [lapillu^, or iuto aiid aioaiid the fc^olea 
of tlio mucous membranes. 

A mucous - membrane papule devdopa in the foUovring 
manuer : A circular Hpot on the mucous membmne aa bi^ ae a 
lentil or pea becomee red and risee somewltat above the lord 
of the membrane, from which, in ca^e the mii<.-oiiis membrane 
is not catarrhally reddened, it will bo didtingulsbod br iu livid 
color. Early and appropriate treatment may cause complete 
absorption of papules that are developing. But, if left nn- 
(rcatod, and if the pemiduuo eSeola that tend to promote Ihetr 
dovolupment oontinne to exercise their influonces upon the 
chwued mucouB membrane, the epithelial layer will become 
opaqao, acquire a uiUky wliiteness, or the color of motherof- 
pearl (jiiaqfies opaIini» of the Frencli writers). These opaque 
Bpota on the mucona membrane look as if the bitter had Itecn 
penciled with a solution of nitrate of silver. The pearly-white 
epithelial layer on the mncoofr-mcmhrane papule may ho cast 
off, in which case the efflorescence, deprived of its epilholial 
cells, wilt Tceembte an intensely rod eroeion that bleeds readily. 
If several papules denuded of tltcir rpitbL-liuui-celU are sitn- 
atod closely together on some place of the mnoous membnnc, 
the latter will become dotted with red spots, u ia often the 
oaee on the npper sor^ce of the tmigne. Even in this stage, 
the papular offlorcscenco may disappear entirely, or nndei^go 
etiD further alteratioiu. These pipttks, like those of the com- 
mon integument, may. in rare cues, by the sprouting of the 
papiUfB, grow into conical, comlylomatoua products, having an 
irregiibir cnninciilnr apjiearanco — a condition that \» frMjuentty 
met with on the uvula and imJer surface of tho tongue. Most 
frequently it undergoes molecular degeneration, resaldog in 
whiti»h gray patclies, with rough, shaggy holders (»yjilulttla 



8TPB1LTS. 



S2d 



aphthie of the old writcra). Tf tho miicotie-mombnme pap- 
vlee that liave nndergoiie uiolucular (It^iteiutiuu are KtuaUxl 
doecl/ togetlier, or if tlipy coalesce, ibe affected spot will ao- 
qoire a diphtheritic appearance. If a part of a papule covered 
with niolt-cuiar d^tritiw is Bitnated n]>on the mncous lucm- 
branc, and tliu other purt uu tho C4>ii]aiou akin (tuoiet papulo), 
the dStritns upon tho latter will dry up aiid form a dirty, 
brownifih-colored cntBt, wtiile tluit upon the maoous mem- 
brano will remain in a pult«ceoiis condition. Such bifuniUMi 
inpnlca are frequently found at the angles of the month, on 
the mtrgina of tJic Ubia majors, nt tho aniif , etc. The longer 
tho deetroctivc process in tlte papule la$t«, and the longer the 
injarioas oxtomal causes continno to oxoreise their evil efteets, 
the deeper the eluugUitij; will extend ; and round, straight, or 
S>8haped tLuitireet uf the mueoiis iiieiubmue {rKagadefi) will 
originate. They are situated tipon a hard base, and 80Diotimes 
nLTrounded by a rod wall. Tliese clefts of the mucous mem- 
bnuie are frefjucntly found on tlic borden of Uie tongue, eKpo- 
ciall^ when they are constantly irritated by rough fragments 
of toeth, and in patients addicted to the ii% of tobacco ; at 
the anns in consctjiieiice of difficult defecation. They arc, 
however, abo met with on tho upper surface of the tongao in 
inrctonte rclapung; eypbilis. 

The papules are obeorvcd most freqncntly on the mncooa 
mcmbraDe oi the month, uvula, fauec^ and the tracts leading 
fpom these parts. They originate here mostly on tlia muooua 
membrane of the tonsils and of the Upe, especially at tlie anglea 
of tho mouth, on the nvnla, and in the sinus between the an- 
terior and posterior [)ill!us of the palate; next iii order of 
freijuency, on the lip, edges, and root* of tlie tongue ; then, 
on the mucous membrane of the cheeks, particularly near the 
angles of the mouth. Bometiraes they develop on the vocal 
oord^ and ui tho sinnH l^lorgagni of the larynx ; nu-cly on the 
posterior pharyngeal wall and in the Eiifitachian tnbe. They 
ooeor leae freqacntly on the mucous membrane of the vagina, 
on the cervix and os atcri, at the meatus and rectal mucous 
membrane of both se3C«, on tlie internal eurfoco of the pro- 
pnoe in the male, and, lastly, on the mucosa of the nasal pas- 
eagea, especially of tltc uares and of the cartilaginoua portion 



MO PATHOLOGY AKD TREATMENT OP S7PB1US. 

of tlie septmn. Mucous -racmbraoc papules occor eitlier iso 
latcd or m gronpe. 

Althoagh they aru uiilicred in witli acuta inflanmutoiy 
pbenomena, eucb as paia aad er^thematoos rednesfl of the fikin 
in Uiti vicloitr, etill tliey flooD usauuic a protracted courao, oV 
fitin&tcly rcsistitig the most judictoos local and genenl traot- 
tneot for raonths ; or they occasionally disappotr, bat eoon retara 
again. As soon ad re^lutioa evta in, the opadty and tliieken* 
ing of tlie epithelial coveritig lK>f^ii to disappear, whilo on 
tho disorf^nized papiile the molecular di^tritne grows Ices, and 
new bluish epitbeUum-oolls sprout up. In ooiifluettt paputtM 
the heaUng Ik^hh in the center, aud gnulually prc^^recwe t<> 
ward the periphery. The vegetations that BometiDies form 
u])oii the ])apulcd disappear by alirinkiiig. Even tdceiatiiig 
mnoou&-tneiiiljniuu papulcu Iuavo no noticeable scuflL 

Ulcetatiog papidoe of ttie tongue and lips interfere gitetlj 
with masdcation and speaking. Papules on the mucous mem* 
bnuie of tbo tonsils binder tlio proccM of ewallowin^ verjr 
much. Those in tho Eastachiaa tube caut« ringing; in the e«ra, 
and tenporaiy hardiufls of hearing. I'lticntg Eufiering from 
ilongbing popnlcs <m tbe tomilLuy macons mcml»«iio htvo a 
foul broQth. Papules on tbo mucous membrane of the moalb 
o&Bse an increase of the flow of salirn- lTlc[>RiHiig pii[inU>A at 
the commaasnres of the lips often prevent the mouth from 
being opened properly. Nurdinf^ arc hindered in siieking 
the breast when tlie papul««t are ditiiated on tliL' iniicuUM nicra- 
brane of the lips. Papules iu llic rectum intexfere writh defe- 
cation, and, like those on the vnlra, caafe pain in mlldng. 
In caiws of ulcerating papules on the mucuua tneuibrane of the 
lips, tho submaxillary glaiuls may bcooinc itittaiuixl ; and in 
oonsequonco of siuiilar eruptions in tlic vagina the labia uiajofm 
become ocdemabous, and cause indolent hypertrophy of tlic 
ingninal gUnds. Papules on the mucous mombnuio of tiiu 
vagina, utoms, and Uie meatus, often cause slight blonnor- 
rbagic discharges from these parts. Slouglung |)«piilce on tho 
mucous membrane of the septum nasi umy dtstroy the peri* 
chondrium of tho H!ptum, and catwo tho tip of tlie nose to sink 
in (sheep-noee, or nex de mKntton^ of the French trriten). 

I^ipnlar i^iilidee and tlic morbid lesions occorring with 



87PBIUS. 

them in otJier organs oKoallj accompany muootis-meuibraiie 
[npulea. Bat orythomatonj aod pngtular itj|i)iili(]es may also 
coexist witli the affectiou uuder <M>nh-i(leratmn, mid conflnent 
impetigiiiotis sjpliilide is ettpecialljr apt to bo oesociatcd with 
Bnppiiratin^ mucoa^-meiubrane papules. Somctiuit^ this fnrm 
(if papule ia the aa\y evideuoe of «vpliiUri, eitiiecially of the 
relapsing form. 

MnoonaHnenibrane papules originate as a result of acqninxl 
■s well 08 of cougeiutal sv'pliiliA; however, ccitiiii coiulitions 
may favor tlieir formation. Tlius, ancleaiilinefis of the female 
genital orphans and of the KOtnm will promote their develop- 
ment. Iiivetente amokera, glaas-blowcrs, bnglcn, and others 
got papulM on the tongac and hps, places that arc moetly irri- 
tated by the mouthpiece of the pipe and of the wind infitro- 
meot. 

TLo papules relspso even more froqaontly than thoeo on 
the oommou intej^inent, niiiinly, howe\'er, in the form of 
scattered or ooutlueut pearly-white epithelial opacities of tlie 
tip of the tongue and mncouH membrane of the lip^ either 
abortly after an apparent rex-overy had been achieved, or even 
after the lapee of a yunr. Relapsing ratiooufr-membrane pap- 
tilei run a mneh more obstinate course than the primary ones. 

(3) The SvpiiiLmo Nope ok GrMsA or tiik Mccous Mku- 

BRA.VE. 

A gmnma develops in the mucous membrane, and in the 
Eabmncoua tissues in the game manner m in the cutis and Euboa- 
taneoni tissue. Bnt no<let)of the mnc^niH membrane are flatter, 
leas prominent, and less gharply defined, hence more like dif- 
fneed infiltrations. They may become as big as a pi'a or !)can. 
Histologically aud morphologically, gnmmata of the mucous 
membrane and of the eltin are perfectly Iduntioal, and the for- 
mer, like the latter, may disaiipcar tiy absorption or dcgcn- 
orato. In the latter event, deep ulcers with hyportrophied 
bordcn: arc fonnod, boeansc the nodes break down frr>m within 
outirardly. Tbe course of the mucons-mcnibrane nodes is as 
protracted as that of gTimmata of thf general skin. The nleers 
that originate from their deBtnictiun do indeed heal 0om» 
times In robuBt pcreons, but, as a rule, tlwy grow larger botli in 



239 PATHOL007 AlfD TBEATXBST OF SYPBILtS. 

size aiiii in deptbt iind ffive riae to liomlilc ilisfiguruniL'nts and 
leaTo puniianciit dufonuitict^ b}' dc&tro^'ing ]>urlion3 of an 
organ, for ioettDCc, the uvula or a part of an ejelid ; cmuMi 
4ariefl and neoroste of adjoining bones, sacL as the vomer; or, 
finally, perforation of tbe tii<b'ucii, for example, the pAlat«. Tbo 
ukcr usually heals \>y contractiug cicatrices, caueiag a<Utcciioae 
to form. Tubular orpiue. swell as the pbaryux, larynx, tra- 
«liea, kclirymal hol', iiitv^tiiivii, rectum, aud urethra may bo- 
oome constricted. 

Syphilitic nodes, like other speclSc aitectious of the nineous 
inembrane, moat frequently ori^tuit<: upon the miioona mem- 
brane of tbe mouth, cspixiully on the tonails, on the lips, oo 
tlie Tuliim palati, on tho posterior wall of the fauces, borders 
of the tfffigue, on the lips, and ou Uio hard jNikto. However, 
a gumma may nUo develop in thv pliar>-nx, iu tlic miius Hor^ 
gogni of the larynx, and iu tbe upper and posterior regi{»u of 
tbe nasal passagce. It occurs le6£ froqucutly on tbe mucoua 
membrane of Uio rectum and the ccrvis of tlie ntcrti&, aud still 
more rarely on tbe mnooua membrane of tlte male orethra. 

In mo£t ca£os fipeeilic nodes of tbe mucous membrane and 
of thu Hnhniucoits tissue are the on/y perceptible external numi- 
festatioua of an inveterate syphilitic dieeaae. In other caaea, 
liowCN'er, there are aI»o present thuM eypliilitic morUd lesions 
in other tissues and orgniift tliat cuexurt with gimuuata of the 
skin and of tlie sabcutaneous tissues. 

Like guiniiiata of tbe coiumoo iDtegunent, nodes of the 
mucous membrane, aud especially tboM emanating from tbo 
submucous tisEue, are not ouly the result of actjuircd syphilis, 
but freiinuntly act^mipuuy (hat kind of congenibal sypbitis that 
first ap}>ears in youtli. 

These nodes relapse just as often as gummnta of the integu- 
ment, appearing months and sometimes years after tlio diwaw 
was apparently cured ooroplotely. A re1a])t>ing speciSc node 
may even recur upMi tbe scar of a previous node. 

In the vart majority of cswes the manifestationB of sypUtlia 
of the mucous membrane are confined to those rc^ona that are 
Tisible ; for instance, the mncoiu membrane of the nose, mouth, 
and fauces aud their ramifications, the IstTnx and phoi^-nx, tbe 
teotiQU and genital oi^os of both sexes. 



87PBILIS. 



S8S 



STptullfl of th« Mouth and Fauet. 

In regard to syphilis of Wx niucoii« menibnine of the lips 
and of the checks, tiiu reader 15 refemxl to whit was said in the 
general part on sypliilis of the mucooa meuibranc. The ma- 
OOUB memlinuie cuveriug the etructiuc8 that coiiBtitntc the isth- 
mna fancinm bccoiuoa affected ctrlic«t and oftone^ We dis- 
tia^^aiBh three kinds, namely, angina syphilitica er)'themato8a, 
papalosa, and gumniosa. 

An^na 4tfphilUica ^rythimatwa is dietingnished. from the 
ordioaT}' iuflutniuations of the fancea and from other spevltic 
affections of tlieso parts by the facts that the entire part of the 
macons membrane affected (soft palate, uvula^ paJatiDo arch, 
and tonsik) h livid in color ; on both eidcs this tcmiiiiates at 
the line Be}>aTa.ting the soft from the hard p:iIato. Kxcept that 
the nrola is »inietiiut« elongated, no texttiriil alteration can be 
detected in the diseased mucosa, and consequently thL' patients 
MMom complain of anything more tliaii diyuctiu o£ the faucea 
and slight diSlculty in evratlowlng, 

Syphihtic erythema of the fauces will disajiiicar sporitane* 
oii^ly if the patient takes pmper care of hiiuKulf. Ijnt if the 
peroicioofi catues continue, snch ae UBing tobacco to cxceae, it 
will extend to the Enstaeliian tube on the one hand and into 
the laryiix on the other, and will catuie nobcs and ringing in 
ihe eant(tinnitns nurinni), and honreencee (rancedo eyphilitica). 
It very Boldom becomes aggravated to a condition of actual f(A- 
licnlar suppuration. 

Angina Aypliilitica erythematosa Tory often aeoompaniee 
the emptivo fever ; in fact, it eervea to make the symptom*- 
tology of syphilis complete, and conHe([neutty almost always 
diftappeans when the febrile aymjitoins hare disappeared. In 
other catiea It accompanies evety By]>hilide of the early phases 
of the disease and lasts till the ot-uption has undergone rcsolu- 
tion, or disappears and returns while the Utter lasts, fist it 
may rctnm even after all the other aymptoms have been ap- 
parently cured, in case the latter reappear. Angina syphilitica 
erythomatoaa^vr w admits of a favorable prognosis ; but if it 
lasts a long while or repeatedly returns, it will excite appro- 
hoDsion that the isthmus fuucium is so enfeebled Uiat, in case 



a»4 PATBOlOOr Am> rHEATVEIfT OP STPmUA 

of ft relapse, especially in clel>i)ilatei] perKoiu, it will tieootoe 
the site of some grave lemon. 

Anfftna ayphU'ttica papulota may or may not be attended 
hy cotarrtiul ewL-lliiignf the 6tructun» vomtitutiiifi tlit: iitttinnil 
fauciiiin. In the luttur ca6e no niiicon^membranc papnlce in 
tlie iflthmofi become perceptible till they caaee, in conseqnenoe 
of their disorganization, difficultice ui sirallowing. Tliow pap- 
ules that arc atuat«d on the anterior surface of the Tclum and 
aoterior arch of the palate gcnonUIy are the beet developed, 
while those on ttie toiutils urc only rudimentary in form. 
Thoee eitaatod on the anterior arch of the palate, on the ton- 
dla, and anterior surface of tlie p<i6terior an>h of the palate, 
oftiiaUy undergo degeneration Terr qnickly, cansbg cinmlar 
turgid spots on the inneous mombrauo, or, where the d^net** 
tion penctnited decjier, a diphtlicrltio jieeudo-membraiie will be 
poured out upon the affected part of the mucoott lucnihrane. 
This i>sendo-nicmbrBn«^ which conmstn of molcrular dd+ritus, 
may grudnally disappear and uoriual epithelium-ccllfl then 
form, or it is cu^t oil and the places then present the appear- 
ances of eroded iiloers. ^en* papules may form on the periph- 
ery of these ulcers, ivhich likewise vubttoquently degenerate, 
and the nlccn on the racb of tho paUto may spread in tnch a 
eerpi^noQs manner as to e:ctend upon the nrula in one direc- 
tion and hard palate in tho other. 

Sometimes conical condylomata form upon the papulos 
that ore situated upon the uvnia. If opa(|ne or ulcerating 
papules occur on the tonsile, tho latter will swell up to sneh a 
degree as to becomo flattened bj mntnal oompnseion. The 
bolns of food, in pasMog over the ulcerating pa]>ule, mbs off 
the di)?htherittc molccnbu* crating, and the abraded^ swoUaa 
ma^s, bereft of epithcliom, and bleeding at the least toDch, 
may ho inistalcen by inexperienced phyaiciana for a deep ab- 
Hccm of tlic tonsil. Angina syphilitica pnpulom eometimea 
causes severe temporary- impairment of hearing, a eondttioD 
which is re«dily explained hy the fact that in tho afiected eMM 
pApulee occur in the Kostachian tnbe. 

Hncoos-mcmbrane papnlee constitute the most frcqueDt 
syi^iilitle affection of the i^thmos faucinm, and occur in con* 
jnnetion with all those plionomenn whicli are associated with 



arPBiLis. 



sas 



nioUt inpnles of tlio common integument. They, too, heal b_T 
roeolniioD, witliout producing anj' pereeptihle cicatrieos, and, 
for that reason, tlie prognOAts of angina ^yphiliticjt papulosa i& 
not less favorable tLsn tliat of angina e^'pliilitica «r^t1wniat0Ra. 
Tlie papules of the iethmua faucJum arc not infreijucntly the 
harbinger of a series uf plicnomuna of a renewed outbreak of 
Bjphilia. 

Angina eyphiUiica gummosa very often attoclu the tcrifiik, 
euft palAti^ and uvuto. Gcncrallr, eovcrol nodos fonn eimol- 
laneoosly in the tousils, whereby the latter may sn-ell np to 
meb a dcgr&e m to come iu contact with caob other, and tbo 
nmla placed between them, whieh, like the palate, is not only 
aflected with catarrhal infloramatiou and elougutod, bnt In ad- 
dition becomes constricted and JktleiietL It \» remarkable 
that the toDsHa cause oompanitively little pnin, even during 
the act of dofflutitioD, but tlioy alt«r the voice so that it souada 
hollow and dull, as if tliere were a foreign bwly in tlie month. 
On the other hitnd, the enlarged tonsils produce dejifnees, or at 
teast hardneHB of hearing, by compreasing tJic jjoeterior arch of 
tlic palate i^piiust the fauces, and thus occluding the Eosta- 
chian tube. 

At the banning of the diseaeo the tonsils prcflcnt a smooth 
but hyperaimic aiiiwarance ; gnidnilly, however, the physiog- 
nomy of these elands changes according as softening and sup* 
pnration or absorption and Bliriakingj of the nodes take place. 
In the first etue, one or more excavations, depending upon the 
number of nodc^ originate. The^ will display lanlaceoua 
hOMB, varying in sixe from a pea to a bean, and may coalesce. 
The abeorption of the nodes formed in the tonsils is attended 
by repeated oongeation of the entire gland. Every time an 
attack of congestion ensues, the minute ir^e glandular acini 
secrete a viscid mucus, ami remain ewoUen ami catarrhally 
aflocted, while tlie intervening places that harbor the nodes 
shrink. As a result of this process, the tonsils display a carun- 
cular, iimivcn mirfacv, and are intersected by wliitish atripea, 
consisting partly of cicatricial tissue, and partly of proliferat- 
ing oounective tissue. If these hypertro]>hied tonfiU arc extir- 
pated, the wounds will sappvrate for a long while. 

The development of a sypliilitic node on the ioft paiota is 



280 PATSOLOaY AND T&SATMSST OF SYPmUS. 

likelj to escape ilutcctiiiii l»_v tbt uinudttl t-jro for a long time, 
because it U generally met witii on it6 posterior surface alone. 
Tlie patient onlj complams of an aopleaeaut eonaitiou in the 
Tcluni uud difBctiHy ia fiwalloning. Tlio tcIuiu U livict and 
painful Avticn toucUc-d ; tUo tonsils, tUc arcLee, aud the utqU 
are (edematou& Saddeoly, to the gnat terror of the patient, 
and oft«n of the physician likewise, perforation of tlie palate 
takes pbcc. To avoid being talcen by gnrprise, by the occnr- 
reoee of eucli an incident, tlie pliydcian ehoiild never neglect, 
in these oaaea, to use the r1iioi«eo[ie early iuid often, aitd to 
palpate tlie poslenor surface of the palate with his Snger. 
The opening may be of variable dUueiuions, and »tuated ou 
any part of the velum. If it a sttuati-d near the free bonier 
of the jwilate, neither the voice nor deglutition will Ijc affected. 
But if tlie perfomtion has taken place near the hard palate, a 
nasal or ana0in<j voice will result, and the food, especially 
flnidt), will run out at the nose. The mom Intensely marked 
the intlaiiimatory redDcss, and the more the vicinity of the 
perforated place ia inBltrated, the greater tlie probability that 
the nicer is progrcssinf;. But If the redncsB and ew^Ung of 
tlie borders of the ulcer disappear under general ami tool 
treatment tlie aperture will gradiully contract and cicatrize, 
leaving a minute, generally oval opening, which causes the pa- 
tient no incoiivenleiioe whatever. 

The gtimina occurs more frequently on one of the lateral 
■D^eB, which the palate forms with the uvula, than on the 
poetorior eurfaco of the velum. If Hueh a paucnt is requested 
to pronounce tlie vowal a, it will bo seen tliat the uvula doca 
not contract, by beooming twisted upon itficif in a vormiform 
manner, but is l)ent like a hook toward the affected half, he- 
oattao one of tlio parallel azygoa miucke hoe Iwt ita power of 
ocmtraction. If the ntnle nndci^^e dlsoi^pmix&tion, a deep 
abaceea origiaatee, which may nltiinately slongh away the cu- 
tiro Dvula, or leave it han^ng by a thin pedicle. If the Bloogb> 
ing of the nvula ia arrested by early and succcesfnl trcatmcoit, 
a contracted cicatrix will originate, rosiUting in a permanent 
curvature of tlm uvula. A total loss of the latter neither 
affects tlie voice nor degliitidon ', indeeil, in conaeqncnoD of 
gjphilitic affections of the faucea, certain morbid alterationB 



STPBILI8. 



237 



may enBue which cause the entire destruction of the nrula, 
and jot give rise to no inconvcuiimco whatever. Thua, it nuty 
happen that when tbo posterior enrface of the vctum pnlati 
and the (loeterior pharyngeal wall arc nmultoneongly siippn- 
tating, Uie mncoufi memhrjiDGs of the opposing snrfaces are 
hrongbt eo cloeely in ooiitact wiUi one aiiuthvr, by tlie swelling 
of tlie ti^ues, that adhesions form hetweon them, and tlic en< 
tire free bonier of the velum and uvula becomes (innly united 
to the posterior wall of the pharynx by radiating white «»• 
trietal tiasne. Thin may occur to stich on extent that commn* 
nication between the phar}tiga-oral and phairngo-nasal cavity 
18 totally blocked u{>, and the patient '\6 compelled to breathe 
thiongh the mouth alono. But if the patient lo^es tlie uvula 
before the velnm become* adherent, the latter will beeimie fixed 
backward, and form a triangular tii»nn>, whoso apex is directed 
toward the hard palate, and base towanl the [JOBterior wall of 
the fauces — a dcfonnily which docs not interfere with the 
process of respiration in the leant. 

The sifphUUlc affection qftA^ jw^terior parts ofthefaneet^ 
like that of the plurvnx, a.^ a nile, doe^ not become apparent 
until the spccitic: diatlie^iH has existed for some time. Srythe- 
ma and papular eruj^tiona attack theae parts kws fretiuently, 
and do not present any j>eeuliar features. Wo hare never 
boon able to detect any nincoufi-niombnine papules on the 
pharynx. Suppurating gimimata are more frcqucuttyalMcrTod 
hero. Gumma of the poeterior wall of tlic fmiceK \& usually 
dtnatcd along the lines corresponding to the transverse pro- 
ceeece of the vertebrte. By the dieorganiaatiou of the nodes, 
dirty, repnldve, deep ulcere originate ; they may extend to the 
perioet«um of the vertebra?, and cause caries and necrosis of 
the latter, whoreby even the cervical spinal marjwv may be 
laid open. In some case^ — ^though fortunately this is very rare 
— the ulcers will spread, especially in cachectic perBons, upward 
into the posterior nareg, downward into the pharj'ux, and even 
into the larynx. 

If cariis and nccnwiB of the cervitral vertebrse have devel- 
oped, healing of the ulcer is hardly to he expected ; but if the 
tilccre only affect the mucoim membrane, they will heal, and ra* 
diating cicatrices will rosolt. I'ho cicatrix of the mucous mom- 



233 PATHOLOQY AKD T£SATJ£SyT OF 8JPBILI3. 

brmie has a gloeey, dry appeiwince (xorww), iind tlio pstif 
coDStJintly coruplain of a feeling of drvuetg hx Ibo throat, 

Uloere of tho pharynx {pharynQitit typ^ilitioa) originalo' 
eitlier hy the extentiion of Iho utcoration from tbo posterior vbU 
of the fauocR, or hy tlie dtiwrganizatioa uf a giimma tltst hm 
developed at the entrance of the i)har7nx. So loog m tbo 
pliarvtigeal node u small and uaopeoed tbe patients expcri- 
UDCu liitli: mure tUaii drviicaa In tbu throat, but if it bna broken 
open thejr will complain of buruiug and pricking pains, which 
become aggravated on 3wallo\ving. If tlic ulcer is confined to 
tlic phorjmx, no alteraiioQ of the voice will rceult, but il is apt 
to extend dowuwftrd into ttio larynx, an<l ii]>wiint along tbo 
posterior wail of the faucefi to the velum. I''or the ptirpoee of 
discovering the ate of the ulcer, it is necessary to depius tbo 
root of the tongue as much as po^hle ; sometimes ve may 
succeed in feeling with the index-finger its upper indurated 
margins. If tlie pharyngeal ulcer h i^tiall and euperficial, it 
will cicntrizc without leaving any mark : deep iilceni, on tba 
other hand, al\rays leave radiating eellulo-filiroiu cicatrioea, 
vhich may produce strioturea of the pharynx. 

ByphUitlo SiMHM of the Ton^ae. 

The tongue may bocimio uffi^twl during tlie early period 
of syphilis, aa well as during its latter phases. During tbe 
condylomatoQB stage, tnaculie and papules, but no difftued oa- 
t-trrhal inflammation, originate npon the muoou XDembnM 
of thia orguu. During the gummatooB stage, aU the tiamei 
entering into the stracture of the tongue may be affeeted by 
the syphihtic proccN (gloasitie syphilitica indiirntim and gum- 
moea). 

The maeuJarform manifcata itaelf by n mt^o or leas jm- 
nonnced, sharply defined, crythematotis, circular, snperfieial 
emption, mostly situated on the upper surface of the tongae. 
The Bpotfl generally develop without causing any pain ; oomfr' 
tfanes^ especially when they have began to undergo their da»> 
quamating metamorphoBis, they oocauon tmpleasant eeneatioiu 
during chewing and speaking. 

Thd paj^laf/orm dovolojie on the upper sorfaco ae weU 
as on the margiiu) and tip of the tongue. As a rale, fiw or 




I 



d.T papules, of tliQ size of a lentil, originate, at the root of 
tliQ tongue, but do nut attnict attention till tLcir epithelial 
ooveriug has become opaque, or the Utter him elreadj boon 
cut oQ, Th«T codceoe on the mar^:iB8 of tho touguo and 
lit tho tip ; they only appear in the form of opacitii,« of the 
epithelial Uyer (pd'^ria^iB Uiiguie). 

In consequence of Uie lueuhanioil nction of M>lii] nnd liquid 
food to which tho tongue i^ constantly oxpoeod, and tho presB- 
tira sad irritation often cnitited bj sharp aud angular teeth, the 
primary type of the papules soon dii-appeiirs, and they he- 
come converted into longitudinal or S«hai)ed, readily bleeding 
fiMnna, vith a coating of grayiidi-white d^tritiig, and mark- 
edly indurated bonlens aa a result of the inilanunatory reao- 
tioiL After these liasurea heal, oblong cicatrices often remain. 

Sometimes thcro arc found, ou tliu borders of the tongue 
and on the mnooua membrane of tlio lips of 8yx>hilitic patients 
who have recently been subjected to an insufficient mercurial 
trntment, a Dumber of abrogated vliitieh papular opacitior, 
Tarying in size from a millet- to a henip-doed, whicli the French 
writers coll mu(iiut, but, according to E. Zeissl's experience, 
arc nothing cUc than papale$ that were aborted by the meicn- 
rial treatment 

MnceajB-mcmbrane papnlc« of tho mouth and tongno are 
most frequently mistaken for aphthous affection and iipnie ; 
further, fur the morbid alteratious which may originate from 
stomatitis mercnriolis. 

Tho following symptoms may serve to dit^ingiiish aphthous 
affections from mucous-membrane papules of the month and 
tongao : Aphtha; cause pain fnmi their very beginning, even 
before the epitheliiil cells have become opaque. They present 
the appearance of email granules, are not bi°^er tlian a millet- 
seed, eurrounded by a narrow zone, and on their apices a blackish 
dot is Bomctimee seen, duo to a minute drop of blood; and 
before they become opaque, these granulca often are converted 
into vosicleft of the size of a pin's head. Mueoos-mcmbrane 
paptUea from the commencement display the features of 6at 
pimples, are abont the ivizc of a lentil, huvu a dark-red color, 
are totally painlces at this stage, and soon become covered with 
a pearly-white epithelial layer. Howerer nnmerons aphthsQ 



340 PA7H0L0QY AND TREATStSyT OF STPJULIS. 

mzy tw, tlivy do not becoiiio coiittiiimt, like fi\'j>liilitiR niiicoa» 
membrane papules. Aplitliie eomctimoe gire rise to small 
oloers, like erofiiona, which heal from the cireamference tovonl 
the center. SypliUitic croeioiis, capociaUj those thut haro been 
preceded b^r coitBucnt pitpalcs, heal from the ccotor toward 
the circnmfcrcnco. AphthcQ aro seldom situated upon the 
ioiuilfi and palate; eyphi'itie miiciiiis-nicinhnne papnlcfl uo 
very often found in ttiifi locaHt}'. Aphthm of the moath, ag a 
rule, is a disease of childhood rather than of adult life, and 
the a[^tl]OUB apote in Um; fonner are aituated aliiinst alwaja 
at the line of junction between the hard and eoft palate, whHe 
ajphiliric mncouB-membrane papules never occur at tUia spoL 

It will be quite cu£>' to distinguish Kyphilitic paimles from 
thni»h, for tliu epores and fungi fibers (oidimu albicans) may 
be readitj aeen with the microeoope. 

The morbid alterations which rceuU oa the cSecta of mor- 
curial prcparatiuos arc diatiiigiiiiihed from specific papulee by 
the follo^-ing peculiarities: jVEercorial sloughing aoree occtir 
(dmo^c exclnidvcly on the bordera of tlie tongue, on the mneou 
membrane of the lower Up and guma of the inferior maxUIa. 
Syphilitic pa|iuli» oecur by prefereno] on the up|>er mirfaoe of 
the tongue ; lews frequently and less nnmerouBly on its borders. 
The parts of maoons meiabnine altered through mercurial 
salivation never display the jieaTly-wbile, glossy color of the 
opaline pWinust, nor the grayish-white appearance of the dia* 
organized papules; their color is dirty'^reeniBb, and thcj are 
ooTcrcd with a soft, poltaoeoua alou^ The morbid altera- 
tioris produced by mercurial ptyoli^m aro duo, in the farther 
course of the prooet», to disorganization of tliu noniial mocoufl 
membrane ; syphilitic mucous-membrane papules, on the coo- 
trary, roprcHcut disorganized inflammatory foci, in which A 
ceitalD amount of plasticity is often noticeable by the fact that 
some of the papilla found at thc«e places prolifc-ratc, and thia 
proliferating structnre prodnees a hypertrophiud epithelial eo- 
vclopc. In many eases the peculiar dijigurting odor of mercn- 
rial stomatitis will promptly aid the phy«;)eian in fonuing a 
correct diagnanis. 

"Wc have had aeveml opportuuitloa of treating an affection 
of the mncoua membrane of the tongue which might readily 



BTPsam 



341 



be mistalcen for R^pliilitic plaques. Tim al^tloii coni>iitts of a 
dlftiued thickemug of tlie epithelial celU of the upper sorfAca 
and borders of the tongae. The b^pertrophied cells are OBit 
nS »t ramc plncce, and tbco succeeded by new wMiiiih cc-lls 
tbut become tbickemxl iu their turn; nr abru^ions, di^priredof 
epitJielial eelK^d wtiicb are oxceodtnglj painful, K«ult there- 
irom. lite genetuo of this le«ion of the epitheliai cells of tho 
tongue, wliich ia correctly designated us epiihdi-ai catarrh 
of Uio organ^ is totally inexplicable, ^mctimcs it heals spon- 
taseonel; and very quickly; eometimea, again, it speedily re- 
enzB u intensely as, if not more bo than, before^ and gonorally 
Jirti Berora] monthg. It is readily dietinguifihed by the hizo 
of tho bypertropbied epithelial cclk, by Uic intcnnty of tho 
pnin, by the absence of all pbonomena [HJiutiug to syphilia, and 
by tlie inoflicacy of anti-sypliilitie treatment 

. Owing Co tho teodency to iujUniniatlons wlucb syphilis pro- 
Token, proliferatinn.i f>f tlie cuiineetive tiiwiiu in various organa 
ensue. These prolifenitionB are either diffused and noted for 
the teodency to become Indurated, or they are limited to a few 
ciicoimcribed parts, aud tlien fcinn nodes which very ofUm and 
very quickly def;enerate, and tltus iu a abort time, often in a few 
idaya, caiuB & oonaiderable amount of destruction. If tbeaffec- 
tkm of the tongue has beou preceded by a marked increafe of 
the inter&titia] connectire tissue, we call it gloAsUis stfphilitica 
indurativa, while if nodea hare formed it is known as fflostfitia 
ifummatoaa. Gloeeitis syphilitica induratira may be cither dif- 
fused or circmnacribed, it may bo Umite<:l to tho nncoio, tbo 
muflcular tisauo or the interstitial conncctiTe tiBsae, or all of 
the tiaauee of tiie tongnc may be eimottaneoualy involved. In 
ooneoqneDca of tUia condidoa the tongue often swells up so 
Intenaely llat it is too big for the mouth. It is extremely red, 
occaaioitally markedly scn«iitire and painful. The Rwelling, 
hardneaa, aud redness of course affect only the dieeA&cd part, 
which then projcctH above tlie level of tlie sound porliou, 
and, owing to the disappearanco of the papillat, in conao- 
qtience of the iuflatumatinn, lo<»k9 as if it were srraped off. 
The sound port of t]io tongue may remain perfectly nomial. 
The epithelial cells of the discard pkcca gradually t»como 
opaque, finally acquire a pearly whitODcae, aud, owing to the 



342 PATUOLOBY AND TRBATilEST OF STPBTU8. 

BaliTa flouting upoD tbeiu, become g1u6»y ae if vamiiilied. Tho 
alternate red, aormol, and diseased white sjkiIs giru the tongae 
a tigcr-Ulce i«potted appcorunou (Founiicr). If tho inflimmii- 
taoa U limited to a small eoperticial epot of the liitjpial niucuaa 
membrane, we call it gloa&itit eyphilitica circui/ma-ij/ta super- 
peTJkiaiM. If the lio^iol moBcular tissae U attacked hy the 
cireumecribod luiilaunnatLOD, it 'will feel to the touch like a 
hard, little lump, and tlie ppocesg will remind one of the dis- 
ease in other muaclea affected by eypliilia. Wo call this form 
giomiit muwvlarU typhUiiiea intiunitiva circtifn«cripta f if 
the entire or a greater [urt of tho superficial mrtaee of tba 
toDgaaiaa&ecled/Uhlinovrn OR fflojutiiuinfj>AUiticaindvratitia 
dxfuea tujjerficialh ; while If the inflammation haa hiTulvcd 
the greater part or the entire lingual parencliymn, it is tenued 
qIowUU induratira tfifuta profunda. Tlii* inflammation of 
the tongoe may have a twofold tvnnination. It may roault 
either in a permanent hypoi-tro]>hy of the toDgw, or, in oodw- 
(juence of Uie slmnkiiig of the ucopbatic growth, the oigu 
may acquire a lobiilatul ap])earancc. After the ce«eatioD of 
a circamflcribed inllammation, a Urge or Hnall node projectiDg 
aboTo the sorface of tho tongue may remain, which is difficolc 
to difierentiate from an induration following an ordinoiy in- 
fl&mmatioD. Syphilitic intlammation that affects the entire 
parenchyma of the tongue may bo succeeded b^ a condition 
that has Iwen called truwrofflowia 91/phititiea. The bordeis of 
the tongue bear the iniprceeion of tho tcuth ; if one of tlio latter 
is gone, a portion of tlie tongue may proliferate into the racant 
apace and fill it up entirely. "Wlien the neoplaAtic connecdre 
tissue ehriukii, shallow or deep grxwrea of the tongue will n> 
suit, depending upon circumscribed proUfention of the ooa> 
nective ti^uo. If the inflammatioo ww diffused, tlie fiaBora 
will be so numcrons aa to give the tongue a ragged appeanuiCi&. 
The furrows lying near the median lino ran parallel with it, 
while those on the borders are directed Imrizontally toward it. 
The entire diseased territory is nodular and uneven. In re- 
gard to the location of tlie affection, the upper enrfaco of the 
tongue especially is affected, the lower being lees frequently 
tbe At» of the disease. 

The second form under which sypliilitic proUferatioaa of 



STPUILIS. 



243 



connective tiesno may occur is, as we have already remarked 
abOTO, gumma typhUiticum. 

Thid kind of tatnor, if it originates in tJie ton^e, may be 
iittutcd either in the mncoua membrane or the mniciilar etruet- 
TtrCt or it may bo eo largo as to involve the entire thickness 
of tlie organ. In regard to the gummota of tiio muiicular 
tifleoe we believe that the tomor ori^nally develops from tlie 
iDterstitial connective tiftsue, biit after a wliile it encrmchcs 
npoo the mosciilar tissue. In n'ganl to the termination of 
the tumor, it may be made to disappear entirely, provided a 
jadioions anti-Kvphilitie treatnicnt is imttitiited t.'arly unougli. 
Tbe gumma disippcars by rcsolutiun, often 8o completely that 
the texture of the tongue at tbe affected places atrophies to 
the thinness of a card. The majority of these ucopliunns, 
however, if left nntrcatcd, will nndcrgo diaiutegration. A 
caseouB disorganizadou seta in at the center and spreads to- 
ward the circumference. Finally, on excavated ulocr witli 
hypertrophicd and sharply ontlined borders originates and 
constantly extendi into tbe adjacent healthy tiBSuee. 

If these nk-er« are snbjeetcd to an appropriate local and 
general treatment, tbo hypertrophiod borders will, first of all, 
grow Uiinner, and then the solution of euntiuuity will hn jilled 
up by whitish, radiating, cleatricial tissue. 

Qnmmata, originating in the mneotiB raembmne of the 
tongue, wiil be most froquontly met witb at the apex of thai 
organ, on its bordera or in the 8|)ncc between tlie papiUie vol- 
latia. Naturally the height of a gumma of tlio mueous mem- 
brane can not be very great, for the reason tliat the lingual 
mucoua lauuibnme on the ajiterior part, being intimately uuited 
with the mnflcle of tlic tongnv, id quite thin. Bat toward the 
root of tbe tonpie we occasionally tlnd larger nodes, bccanee 
here tlio mocoua membrane is less tirtnly united to the eubja- 
eent moBColar Btmcturo, and a eompantttvely large amonnt of 
wbmneons tiMue la preeent. 

A syphilitic node of the tongne develops without causing 
«ny pain ; it is quite rare, and generally oc^cnnt singly. Some- 
tfanet It itt the only striking symptom which point* to the pres- 
enee of the syphilitic diathesis that is undcimining the entire 
qretem. 



344 PATBOLOOT A2fl> TSEATME^T OF STPHTUS. 

A. lingual gumiua rcudcnt 6i>cakiag difficult aiid prevents 
mflfitioatioQ. 

In patients snfFenn^ from inveterate sj^pkilis wo foand re- 
peatedly the plica Hiabriata on botli sides of the fncnnm of tho 
toDgae infiltrated and liypcrtropliiod to sdcL a dt^reo that it 
looked like a supernumerary lon^ue. 

There are prolxihly no dis«u>e« tliat arc so often mistalcen 
for one another aa carcinoma and goinma of tlie tongue. Thqr 
dt£Fer, however, in the following particnlarB : (:tnmuia nerer 
causes »ucli intense poina as 'carcinoma The diwfganixatioii 
of a lingoal sypltUitii; node takes place from within ontwardljr ; 
the disoi^aDizatioD of a carcinoiuBtouB tumor goes on from the 
oiroomferoDce toward the center. Further, as a rule, the enb- 
maxiUatj and sublingual glun<l» swell up in carcinoma of the 
t<Higuo to a size never met vrith in syphilitic ademtis. Tlia 
most important differential symptom whereby tho phjacin 
vill be able to distingiiifth epithelioma of t1ie tongne from 
specific morbid nlteralions, is the scbum-Uke plugi which in 
epithelioma may be S(]ueezed out from the diseased port uf the 
macons membrane, a phenomenon that never occnrs in tho 
•Tphilitic affection. A micro«copical examination of tlie dia- 
ori^auiied structure of carcluoiua will reveal the well-known 
canccr-cclld. If the phrsician does not find the diflcrential 
symptoms ennmemted here well marked, he may fall bock 
upon the raodt reliable test, potaesium iodide, which will cause 
the gnmma to di^pix^r in a few weeks, while in the carcinom- 
atous disease it will be totally inert. 

Finally, Hutchinson, in the " Loudon Hospital lieports " for 
the year 11^46, deecribes cases in which syphilitic nodm of the 
tongno became converted into carcinomatous tnmon. 

Syphilitie Diaeaae of th« OEuphagna. 

Diseases of the aeeophagn& in consequence of acfptired 
syphilis are extremely rare. We have never Imd tbe oppor- 
tanity of seeing such a case, but a few nnduubtcd inetanoes 
of this dUcase may ho fonnd as oorioflitiea in medical litenr 
turd. The aifection of tiie ceeopbagna generally is eansod hy 
gnmmata, which, if tliey undergo disorganisation and con- 
tracting cicatriuM origiuatc daring tho proooas of healing, n>- 



STPSIUS. 



suit In the formation of Atricturcs of tho tnbe. The simn)- 
taneoQs presence of eotne cltaractcrutic Bjmptoma uf Kjphilis 
in other parts of tha body will materially- &miplif^ the tUog- 



noBis. 

Sypbilitio DiHUO 9f tlio Stomach and Intestme& 

Lancereaax, Wag»cr, and KIuIns Imre furnished oa nith 
d^rtatioos upou e^-pliilitic diseaees of the BtomaciL Althoujch 
itffocQ'oos of the nx.-tuiii in cooeeqnenpe of aoquirod syphilis 
are apt to occur frequently, so far wc Imre had no opportanity 
of Boeing a case of epecitic diseo^ of tlio duodenimi, jojuunm, 
iloom, or of the targe iutu^tjiiud. Mt-Kchudi:, Omt^ and Klebe 
hare reported snch. caeca. Affections of the small intestioee 
in eoQscqneace of bereditiuy Inea occur more freqaenUy, and 
we will revert to the diseoae a^in whon we eome to epcak of 
hereditary Bypliilis. As a rceolt of act^mred sypMUa, the epe- 
cifio primary lonion, as well ae luetic imputes and guminata, 
occur in the rectum. Th« sypliilitic primary lenlon is liable to 
prodoco strictures of the rectum. However, we can only fonn 
a comet diognosiH if thene strictures Iiave been made to di^ap* 
pear uoder anti-syphilitic treatnietit without the co-operation ol 
tliktiiig InstrumentB, and the so-called Kcondary phenomena 
snhseijuently ap^iciir upon the skin or on tho mucous mem- 
brane withoot any oilier priinsry specific lesion having been 
ohBcrvcd on the paticot- ilowcTer £rec|nently we saw papules 
en and around tlio anus, yet rurcly did we eee them on the 
mncooa membrane of the rectum. Pspoles aroond Uie anal 
tipening and in the anus freq-aeutly become exceediagiy large 
in coneequenco of the irritation to which thoy are eonslanUy 
exposed. They often degenerate, and as a result of tho scere- 
don which tliey dL^ctiarge condylomata (ejLuberating conical 
condylomata) originnto upon them. Disorgnnixed papnlea of 
the rectal mucous uicmbrano generally generate only saper- 
fluiiil uk-erutions, and hence in our opinion they seldom give 
rile to strictures of tlie rectum, chough Muron and Malanecz 
maintained that they are the most frequent factora in producing 
them. 

The morbid alterations caused by gumma of the rectum 
ore more severe than tho&c pnxluccd by papules of that part. 



(0 PATHOLOGY ASI> TBEATMEKT OF STPBIUS. 



Tbe afiection ocean lUMtly va a grammatoas infiJtrfttioii (A tbc 
m1>inaoou8 tissue, hy which eomo of the inliltratcd loagitndinal 
folds BwcU up and pTojoct above tbo others. By (leg«aer9tioD 
of tbe infiltrated material, tliere orig^uste either on the edges 
of tbe foldfi or in the groovefl between them narrow, dirty-look- 
ing, oblotig nlcers, which penotrato the entire ihickneee of the 
mucoea, so that their bases are formed eitlwr by tlie sulimii- 
COUB connective tiatuo or l>y thi; max-nlar layer of the sphino- 
tcr. Cicatrization takes pkce either by a onion of two or 
more adjacent folds, or, after a fold lias been entirely destroyed 
by the ulceratire proceed that t/egnn un it« margin, by grann- 
laLiuus. In both coaca tlto rectum often becomes so narrow 
that ercD an ordiuaJT catheter can not paae through the oon- 
&trict<d part, llowover, circnmscribed gnmiuata may »1«o 
originate in tlie enbmucoas ti^encs of the rectum, wlucli may 
undergo degeneration, roeolting in deep utcore that penetrate 
the mneouit nieuibraue, and whuae cJcatrizatiou is fuUowed hy 
grave strictures. 

The painloss, rapid development of tlieee tnmors, their 
Rpeedy i1iKorgn»iz:ition, and tlie fact that the di»eaM mottly at- 
tacks younger pereons ; hietly, tliat they are preceded by other 
phenomena of syphilia — will aid tlie phyaiciau in forming a ooow 
rcct diagnoaia. 

In tn-pbilifi of the rectum, Ktrictiirca do nf>t form till tbe 
anppnmting procefs tuw been cured, while in carcinoma the 
eymptoma of atricturc appear long before the canceroiu degen- 
oration sets in; and in addition the patients prcacnt the char- 
acteristic caclwjctic apponrance. 

The pn^oaiii ia unfavorable. It will be nceeeBary to prac- 
tice dilatation for a long time in order to rclicre tJie patient of 
bis malady. Tho dilatation of the got must be carried ont witli 
tbe utmost care. We liare aeen severe peritonitis produced in 
cases where tbia procednrc was performed in a miipli manner. 

If only tho Dpper layer of the sphincter is nilected by tbe 
degeoemtion and cdougbiug of a gamma, and the deeper ones 
continue to perform their function, a apwoiodic cl(><'nrr of tlio 
sphincter during defecittion. attcndcxl by eerere pain, will re- 
sult Unt, if the nimcalar layers arc destroyed at one ot sev- 
eial places, a patnlons atote of the sphincter, involuntary ovao- 



STPmiis. 



a4T 



nation of ffeccs, and prolajMe of one of the walls of the rectmn, 
vill tnke place. The ttlcontioiu finally iiiiiy 1)C eu fxtonsiTe 
that the deecendiiig colon is perfonted, gravo hA.-morrlu^QB 
eneoe, and tho patient dice from peritonitiB. 

Byplulitio Affections of the Liver. 

Virchow divides Ryphilitic di^tHtaes of the Uver into peri- 
hepatitis, intorstitiiU and ^immatons tippatitiH. All these 
three aflectionfl may exiat sJQiiiltfliioou«Iy, and, according to Vlr- 
ebow, periliepatitis and interetitial hepatitis are always found 
together. Perihepatitis is eometinien seen in the form of 
finely gninnlar, miliaiy dots, extending over large tracts but 
moftt marked where the procees has attained it« grcttttst degree 
of intensity within the organ. Not only do hani, thick, liyper. 
trophies, of the capsule fonu here, but almost always adlieeions 
to adjacent orgaiiH, especially tho diaphragm. Theee adbo- 
«ona are remarkahly thick and strong, bo tliat long ligament- 
ous strings and htrnda extend from tlie liver to the diaphra^rm. 
Thou itringa of cellular tiEsnc, however, abo send prolonga- 
tions into the parenchyma of the liver, which, like cicatri- 
cial aulwtanee, gradnnlly contract, and cause shrinking of the 
mperfioial Hiirfaeo of tliis organ. The oi^n is tranrforraed 
iotu a number of globular protutiennces and globe^egments, 
i. e., it becomea multilobular. The lohnlation of the liver, ac- 
cording to RokitaDsky, is produced by the shrinking of the 
fibrous structure which has fonned from a previons pylephle- 
bitis in tho coiirec of tho imrtal vein. According to Wagner, 
ttie projections of tlie hver originato from the contractions of 
dcatricial tiesue that remainB after tho giuama has undergone 
nsolntion. Schiippol agrees with Wagner, bnt adds that the 
, sjrpluUtic neoplastic growth, if it occurs in the form of large 
l.'Bodas^ preferably follows the course of the portal vein, and 
embraces it on all ttide^ 

The now growtli, tlio giunma, which is peculiar to syphilis, 
is mostly found wedged in iMitweeu aiul near tlie liypertropliitHl 
. cicatricial tissue just mentioned ; tho former, however, alM 
occurs in apparently nonual hepatic parenchyma. Hepatic 
gnnimata frequently attain tlie size of a pea, or even tliat of 
a bazel-aut. On incising a liver that has undergone tlie do- 



S48 PATBOLOOr AHO TRSATMBHT OF BTPBIUS. 

geaention aW\'e descriWrl, the gnminata vDI be Men in Uw 
white dcacricia] connective tisetie, vai^-iog in form aooordlng 
to the stage uf their doToJopraent. Some Are of soft, elastio 
texture, and for tliot reason ttpring up aboro tlie iDcisioas, r^ 
Bembliag xery much, as L. Mejrer, of llambur^, correctly eajK, 
die glandular Btructure of the pancreas. They are yellovriah, 
reeomblc tnborclce, from wlucb, acoordiug to Tircbow, thej 
are dUtiuguiaUed, in addition to their siw, by their eito within 
or near atroj^ed wars, next by thdr diynese and uniforniity, 
wace hepatic tubercles, if Roiiiewbnt large, aJwaye becotne toft. 
The nninber of gummnta tlint may be present in tho liver vft- 
riee \fiTy much ; aomctimcs there arc only two or three, some- 
times again eight or teu, and in Btill other cases an even lM;ger 
number have been found. The majority of them are sitnated 
upon the surface of the Urer, and in such places where trac- 
tion or some other mochunical irritutiou tdces place; fortu< 
stance, at both eidcit of the lignmcntnin soBpeDSorium. It is 
tnie tliat they are found in tlie deeper parts of the organ also» 
bat then they are ahuoet alfrays connected with the enpcrficisl 
aarfaoo by narrow fibrous brands wliicli hold them low down 
by the retraction the latter undergo (Klebs). 

The ramificatioiis of the portal rein and of the hqiatio and 
biliary ducts, however, nraally do not rcouun nnnlTected. In 
consequenoe of the impeded circulation in tho domain of lUo 
portal vein, ascites may originate, in the same msDDer as in 
interstitial inflammation, or in cirrhons of tlie liver. It is not 
yet quite olear why icterus occurs in some cases and not in 
otlieiK The Kubolance of the liver remaining between tho 
cicatrices and the nodes may l»e normal, or it may be in a eon- 
ditioD of &tty dcgeneratioo (Frenche) ; in other cases there is 
hypertrophy characterized hy cnlBigetnent of the acini and 
liver-celts (Yirchow) ; or, lastly, the nodes are imbedded in an 
amyloid liver. In addition, pyphilte may produce that morbid 
alteration of the texture that has been denominated waxy Uver 
(WetElar). 

In tho simpte perihcpatitic form tho livor is somewhal en- 
larged, but it slmukii when tho indammation attacks the inter* 
stitial tissue (syphilitic cirrhosis) ; if gnmuiala are present, it is 
osoally larger ; still, even in this case, it often becomes smallo", 



STPBIIIS. 



in ooDseqncnc* of atpopliy of the noraul parenchyms. The 
gyphilitic livor is [>enuanoatl_v and extraordinarily hypertro- 
ptiiod only vheii it uko uuilerg<K» lardaoeoiii) degieneratiun. 

Syphilitic disease of the liver is very often nsRociated with 
hjrportropliy of the epleeo. Otherwise it gives riMj to tha same 
Bymptoma as a nou-«ypliilitic cirrboiius, micJi a clyK|M>ptic plie- 
nomena, conBtipatioQ, biunmtcmusis, hteuiurrlioids, epistaxia, 
ansBoiia, etc. 

The most important sign pointing to tlie presence of i7i>hi- 
litic disease of the Hver ia undoubtedly tlie alteration of the 
01^^ iti*elf ; l>ut despite a carcfui pby^oul exaimuaUon, and 
the indubiUtbtc anatomical eigua furuieled by the ntost pro- 
Donnoed morbid proccas, we are not alvrays able to avoid malc- 
ing mlBtokca in diagnosis. Perihepatitis and cirrhosis syplii- 
litica differ in no Rspocte from otticr hepatic ufEectinia that 
result in either hypertrophy or atrophy of the organ. The 
presenco of syphilitie cicatricee or iiodw in tiie liver is tbo 
only reliablo diagnostic «gn ; still, even in this caso, it is noces- 
laiy &rst to exclude all affections that occasion similar morbid 
altemtions, such a» the gramilar liver, carcinoma of the liror, 
die fihriuldng of the liver following obliteration of aome of the 
branches of the portal vessels, and obeolete eohinococci cysts. 

In all cases tlio phytucian will 6iul a detailed clinical history 
and thorough examination abeoliitcly indispensable. Yet the 
•tstement of the patient should not be deemed sufnclent If 
there be the least siiApicion that tho case is ono of syphihs 
of tbe liver, the organs in which the specific dieeaae ia apt to 
occur in ranous forms should be snbjcctcd to tbo most careful 
ctamination ; for there will almost always be found cicatrices in 
the pharynx, swelling of t!io lymptiatio glands, exoBtoscs, etc. — 
in sliort, symptoms tlmt have been designated witli t)ie names 
of secondary or tertiary gypbitia. In regard to tbe diagnoeis of 
waxy lirer, Welzlar nuiintaiim timt, in Uiose cases in which tlie 
history points to Ryp1iil{.s iind the physical examination ebows 
the presence of the morbid alterations pecnliar to that disease, 
although no otiicr striking svmptoius ure present, mcli as 
miglit be expected from tho extent of tlie iHsease, one is justi- 
fied in sBsnming the lesion to be waxy liver, all tho more so 
when it is associated with an enlarged spleen. It ia not so 



850 PATBOLOQY AXD TREATMSNT OF SYPBILTS. 

oa&y to decide to which stage of the erpliilitic infection the 
bejffltic affection belongs. Oppolzer, liUo DJttiich aad Ga1> 
ler, ba« seen ca^ee of hepatic eypliilia which were awociated 
with the so-called secondary form ; nevertheleee, most itutanoet 
belong to tlic lator jiIiuko of tlie (liseaw;. 

Tho aiTectioii of the liver that has just been described is 
also a tolenbljr f reqoent pbenomenon in koroditarj sjpfailli^ 

Tho prognoeia is nut al)6o1ut4:ly unfavorable; indocil, io- 
EtanOM of hepatic Byphtlie aro occasionully fonnd at the aatopey 
of pei80ii£ who died &ota eome totally different disease, and 
the affection of the liver wa8 not even eiupcctcd, no eyinptomi 
of it having been present daring life. In j^enenUr the prog- 
nosis is more favorable n-hile the liver i« in tho stage of bjper- 
trophy tlian wlw^n !t has already commenced to atrophy. Tlw 
concomitant atlc-ctiona of thit syphiiilie cnelicxia, dropsy, pro- 
tracted diarrlioia, difease of the kidneys (amyloid degeneration)^ 
secondary intlammation of the plenni and tnngR, arc significant 
of an evil terumiation. According to Wetzlar, the ycw^ lirer 
is speedily cored by specific treatment 

ByphUitio Affootlon of tha BpleeiL 

'\S''eil, of Ileidellwrg, deecribcd an enlargement of tlie eptom 
that occnrs in the earlier stagcfl of tho dif)ea«c, which lie churned 
could be made to disappear by antigpocific treatmeDt. Hanj 
writen have described morbid alterations of tlie spleen foand 
in syphilitic radarers, such as hypertrophy, tbickcniug of the 
capsule, cicatrices, etc. In oar opinion, however, these can 
not be ascribed to s}'philis with absolute certainty. Nothing 
bnt gnmmuta are uifHlliblc pruductiona of cyphililic origin. 
Nodes in the fipleon have boon described by R^>kilaiwky, Vir- 
ehow, Bienncr, Wagner, Gold, and other reliable writers. 



Byphilitie Affeetion of the Fanereai and of the Salivary Qla&de. 

No other inetancce of ByjthiliUc affcctiona of thLfM.* glandu- 
lar structures are known, with the exception of thooc rcportod 
by Lancereaux and Yemeail. The former found, in dim com, 
two gnnuuata in the paneroaa, in addition to some in tho mus- 
cles. Id another case bo fonnd the mbnaxillnry gland on tbi 



STPBIUS. 



9S1 



]eft 6ido markedly tiasured and lol>uUted, veiy dense, yellow- 
iflh, duo lo fntty dcgcnenition ; in addition, cicatrice* of ulcere 
on the posterior wall of tlio faucea, wnjoinlly with pul- 
monary and Uopatio eyphille, and a gummatous (uraor in the 
pericudiiun. 



Syphilitlo Aff«ti«3i of the Larynx and Trachea. 

U'o arc nnaHc to give exact fignres in reference to tho 
frequency of laryngeal syphilis in caacj of gcnoral fyphilis. 
We can only avail onrBolves of the figures showing how many 
pttie&tB among tbotw who souglit roliof from throat tronblet 
puffered from laryngoal Ryphilis. If w« avail ourselves for 
that purpo$o of ttio number of csa^ ttiat canio ondcr our ob- 
florvfltion during elt-veii years (ISTl to 18B1 inclusive), it will 
be found that, among 21,(144 cases of diwases of the throat, 
four and a half per cent were Bypbilitic, a number certainly 
lea than hiiK been !in])po«cd. 

However, it may be observed that, in very many cases of 
general sypliili*, the specific affection of the larynx ia totally 
overlooked, Itecansc it often nins its course with euch slight 
Byiuptoms that the patiente do not find it neceSBory to eeck re- 
liof. Hcnco reliable statistics could only Iw obtaimxl by sub- 
jecting every patient in tho evphilitic department of a hospital 
to a laryngofcopieal examination. 

In regard to aye, it is found that in men, thoeo between 
twenty and thirty, in women, those between eeventeen and 
thirty years, form tho boik of tlie patients. Children, accord- 
ing to our observations, seem to bo even less affected than very 
old persona, among whom tliere was otie num of eeventy-fonr 
and one woman of eeventy-two yeoiK 

In regiinl to orcujMtwns, notwithstanding the greet mass 
of materi.i] at onr command, no definite facts conld be gathered 
tending to show that it exercised any in^uonco upon the Rjie- 
cific disease of the larj-nx. Nor could it be pmved that pei^ 
eons who work mostly outof-doors, or those coinpellL'd to talk 
a great deal, were 6&j)ecially liable to this form of dieeaae of 
the larvttx, 



253 PATHOLOGY AJfl) TSEATMEKT OF STPmUS. 



Aeats and Chionlo Catarrh. 

LoTUf vbo has a larg« field of obeervation, recently mtuSa 
the asaertion that the affection of the larynx, as a rusult of 
Bjfphilis, never becomes catarrhal, always remaining crythema- 
toufl in degree Wo can not coineido with his vievf of ttie 
matter, for, not only aro the rarioua degreee uf nxlnosB (hy> 
penuniia) to \>o Keen on the affected mucoiiD membrane, but 
(!Tcn snch symptoms ns are prodtieed by affeetiona of other 
mnooQS membranes ooUectively, and have been called catarrh, 
are present here. 

ThiTO ia found a fliiglit or more marked ewelling, not only 
of the affected etmctnrce, bat, ob Levin himself has admitted, 
of the Bubmucooa tissue also, and an atfcration of the aecrctioa ; 
in &omo easM it ia diminiidied, in othera again consideraUy in- 
creased. Fnrthenuore, the epithelial cells, eepeciany on the 
Tocal cords, arc cast off in some places, in others markedly 
thickened — conditions that arc admitted by all anthoritioB to 
oonstitnte catarrhal diaeaae. 

The duration of the affection, too, \i tctt often greater than 
in erj'thema. Lastly, wo have the fact, and certainly it ignofcHn 
unimportant one, that mch a pntliological condition heals very 
rapidly under an anti-syphilitic treatment, while it most obtti- 
Dately resists a treatment with anti-catan'lial remedies, snch as 
astringents, etc Tliis certainly prove« that it was not a mere 
acddenta] affection, such as is caused by a cold from which the 
sypliilitic patient yeas suffering. 

The catarrhal affection very often accompanies a catarrii of 
tlie fanocB. The phenomena are not more efrious, mwo in »*■ 
mote complications, and generally present the appcanaoeB vi 
subacute and chronic inflammation. 

There are no differential data for distinpniRbing it fmm 
idiopathic catuirh, or from that occurring in conw^iuenDo of 
other affections. At one time we thonght that a frreotcr de- 
gree of exfoliation of the epithelial cell*, especially on tlio \iot- 
lien of the vocal cords, occurred in syphilitic catarrh, than in 
the non-specific affection. 8n1w««]tieut expwienoe, howsver, 
has taught uh that this view was incorrect ; neither does the 
(jualtty of the secretion supply any proof of the character of 



BYPBILIB, 



S58 



Se lesion. TIic itame kind uf tenncioiid mucns occnis oq the 
maiginB of tlie vocal cont&— it a^Jutiiiatcs tJicm ; and, wlieo 
it liocotua dry, forma cnuU as ia tJio idioputliic form. Ifor 
would it bo correct to state that tlic duration and the obetinaoy 
of tho diAeaae furoieii any iiidicationa regarding ltd erphilittc 
cliar&cter. 

Henco tlie dia^oBis can only be confinaed by tlie siiual- 
Umcoua presence of other syphililic evideiieea, whicli are often 
plainly luunifwit by tlie Bwollen eurviail glands ; yet oven this 
doe« not eetabli«h the diagnouB beyond all cavil, for it is quitB 
possible that tiio patient has snfTered from laryngeal catarr!) 
before he acquired syphilis, or that tho a0uctiun was produced 
hy some other causal condition. 

Although it muBt be conceded that tbia form of Byphllltic 
infection, like thu more iuteoise mauifcalationii of tlie epe- 
d6o disease, may be cured by a general onti-lnetic treatment, 
•till it can not be dcuiud tbut local trcdtnicnt ia of the greatest 
Itonefit. IVo do not mean a mrre symptomatic treatment, 
such as, for instance, the inhalation of narcotic remediee for 
the relief of the cough uid the tickliog and ecratcbing aeiua- 
tion in tbe thront, but tho local use of auti-flypliilttio agentfi, 
euch 08 inliaktioQB of iodide of pota^eiuiD, or a vreik eola- 
tion of tlie bichloride of mercury, or penciling with iodo- 
glycerine, etc. 

If we do not spuak of rtdema of the larynx here, it is because 
we do not believe tliat it ever develops from a simple catarrh, 
but is always a collateral mimifegtation of disease of the deeper 
tisaies, infiltration of the submucous structnree; or uilt more 
fretjuently of tliu |)crichoii(Irium. 

Papulks. 

Fupuloit aro a tolemhly rare form of diseaw in the laryux; 
■t any rate, tliey occur leee frequently even than is BDpposed. 
Now and then tliey are found on the margin of tlio epi- 
glottis, over Santorini's cartilage, on the poeterior eurfaee of 
tbe arj-tenoid cartilagoe, and most frequently on the arj'tcno- 
epiglottic foldjt, in the form of oblong or rounded projections 
or swellings, varying in size from that of a lentil to that of n 
pea, am! having a bright-red color. Gradoolly they grow here 



2S4 PATBOLOOY AKJ> TBEATXEST OF STPBtLIA. 



iibofe the I«vel of the liasiiea; 6oineUnws8 tliej are (Ihstincllf 
outlined ; sometiiuee, again, their borderH arc luiliMtiiict. Their 
apper eurfnou, as n rule, nppOBre gnuinlar, becanao the ejrithfr 
Hal cells MOD disappear ; some of them, however, arc corcred 
with a thick, wliiti&h matter. If the cpithvlkl coatiDg is en- 
tircly gone, a fovr miuat^ red pointa ore eecn apon the yel- 
lowish purulent ba&e of the papuk. Theee fomu may alio 
occur on tlie anterior surface of the posterior laryngeal w»U ; 
etill, B8 it i« impoBBiblo to obtain a uti^actory view of thlB 
re^on, nothing dellnite cjiu be said upon that ])oint; for 
hypertropliy or exfoliation of some Inyere of tlie epithelial 
eclls occurs eo frequently as a consequeiiee of chronic catarrh 
alono, that one must be rery careful in judging pathological 
alterations occurring on tlieM pUcea. No poec*iiiorteia ex* 
amination of this lesion has ever been made. 

This form of disease, at any rate, occurs verr rarely on the 
tnie and faltw vocal conis, and it irill scarcely Imi {me^blo to 
diffurcntiato it definitely from other kinds of ayplulitic infil- 
tratioQs, wliich, when they undergo d<^uneratioii, go on to 
ulceration. 

iKFlLTRA-noXB, GCMIUTA. 

Under tliis head, not only the ciroumscribed tntnora, bat 
iniiltrations, euch as often attack all tlie tiisaucs of tlie larynx 
in a diffused manner, occurring in oonfcqucDCO of rrphiliai 
belong. They occur more frequently tlian the former variety, 
and since they often terminate in grave, morbid altenitioDS 
are of much greater prognoetic importance. 

They may ocour on the epigfotttg, partly in the form of 
single or multiple aggregated n(«lnle8 of various sl2ea, partly ai 
uniform hypertrophy of either its laryngeal or lingnal lorfaoe^ 
or both. In the severe forms of the disease the gracefol 
form of the epiglottiii is lost, owing to the thickening of Iti 
enbetance, and in the highest grade the hypertrophy may bo 
BO great that both lateral hordera touch each other, and then it 
bocomoB totally impoaeiblo to obtain a view of the laryngeal 
cavity. 

The same is true of tlie infiltrations in the arifti^\o-tp\^<4- 
^f<3l<U, Here thick callosities aUo form. If the Utter de- 
velop on the ar^^oj^Zoirft^Malso, the entire space betweea 



SYPHILIS. 



355 



them will be filled nj). If tlie gnmniata are located xtboat tbe 
joiiiw of the arytenoid cnrtilages, the movemonta of tho latter 
will be markedly Uiudercd. 

TliC9e hypurtrophitsi are generally ver^ deiuu;, and tlie probe 
maJ;c« little impression upon thorn. 

Tlu;/ occur in Tarious forma oo the trt(e vocal cords. Now, 
ooe or both vocal cord:^ are swollen to Buch a degree that the 
patient is in danger of dying &oin asphyxia; then, again, 
thcru IB only a slight circumscribed ewelling, which generally 
runs along tbe length of a cord, and is cither pale or livid. 
Lastly, that fonu of tumor is of ospociiil interest which hits \\a 
rtarting-point from the lower eurfacc of the vocal cords. As ia 
well known, the border of the vocal cord, under normal oircum- 
ctancc^, constitutt'H a cavity facing dowuwanl and inward. lo 
the iutiltraliong under consideration, %o great a convexity pro- 
jcitirig into the Urynx may originate in place of the concavity 
that the tuuiitrii thu.H fiiriuc<I in the median line t4>uch oue an- 
other, especially anteriorly, and tlius only a small space re* 
maiiis poeteriorly for the passage of air. This b a very fre- 
quent form of laryngeal stenosis. Now and ihc-n a distinct 
hoondary-Iine oripiiates also between encli an hyiiertrophy and 
the edge of the true vocal cord, the infiltration being Iobs marked 
on the connectivc-tusuc lines running between tlic olaetic 
fibrous bands. This often produces a picture, as if the vocal 
cord were split lengthwise; and as this condition may occur 
phyeiologicolly (I>y the origin of the clnetie fibrous band from 
the proccasos voealie), and alao from the olccrationg that creep 
along the whole length of the vocal cord, it is neeeeeai^ to pay 
particular attention to it. 

If these infiltmtiong involve ^efaite rocal rordi, the con- 
ditiou soon manifests itself by the occlnaion of tbe einos Mo> 
gogui, and more or Icks covering up of the trnc vocal oords, 
tlie latter becoming more curved upwardly. This is usiudly 
attended by a marked increase of the redneeSf while on tbe 
true vocal cords the redne^ does not become so intense till 
later in the conrec of tbe disease, when puruknt destruction 
ocean. 

The nodtdar form oocare on the lingual as well aa on the 
hiyngcol surface of the epiglottic— on the latter most fre- 



356 PATEOLOGY AND TREATMEXT OF SYPBIUB. 

qaentlj, ]>erhai>s on its petiolu part, on tbc ary'-«pigbttio 
folds, on th« head nnU posterior nuface of the arytenoid ear- 
Ulago, on tho ceotral part of the false vocal oords, on the lower 
stirffloeci of the true vi)cal cords, and, lastly, iu the trachea too. 
The upper eiirfuce of tlie Docjce, eo long as thc^ do not nlocr- 
ate, are perfectly smooth ; at first they are quite dark, bat later 
beoome bright red. 

AU thew foniia of nodular growths may be 00 completely 
absorbed tJiat not efeo the pUoe where they were situated can 
bo fooDil, or a less or greater decree of degeneration often takcfi 
place very rapidly, reeulting iu a eyjtAilitio ulcer. It is a 
much rarer occurrence for such a ewclliag to terminate in pe^ 
maucnt hypertrophy by an. abundant proliferation of connect- 
ive ti^ue. 

The fatty or lardaceous degeneration of the laryngeal miu- 
cular npparatns mny he considered as still another termination 
of the s^-philitic inflammation. 

It is evident that, under all these circumstances, a number 
of faccon may concur that will cliange the roico from a glight 
hoarseness to total aphonia. 

Uloebb. 

These often develop with anrpriaing rapi(^ty. On ilie 
]>Iacefl whore yesterday a marked rednosB still prevailed^ to-day 
an nicer with partly smooth and partly ragged edges is ionnd. 
It io sharply defined, and Its b«so may be rod and transparent. 
Of corered with yellowish matter. It is generally aUo sor^ 
rounded by a red border. 

In tho ppogpcffl of the disease tbc ulcer may bcoome of hn- 
msnse luze. It may not only extend from tlie free margin of 
tho epiglottis to both its upper and lower Eurfacee, but oven to 
the citrtibge. After the i!om|)lutc termination of the nicer, 
which 18 usually asymmetrical, the cartilage is entirely exposed, 
or projects, at both ends of the nicer, in the form of a sharp 
IHOng. If the ulcer extends to the aiy-epiglottic folds, or if it 
originated upon the latter, or \i\xm. the arytenoid cartilage, tho 
rigidity of tho affected structures will frequently attract at- 
tention. 

Here, u in tdoers npcoi the &lse vocal cords, the borden 



SFPffll/S. 



S5T 



of tiie nicer are not infrequently tliickened like a rHmpart. 
SuL'h ulcers nre very often found u)K>a tlie anterior eurface of 
tbc posterior wall of tlic larynx, and thcec are tlie ones that 
BO oft«n docciro tlw physician. Ae bns been intimated, it 
is not even poe^ible to get a good view of tliia part of the 
larynx, and wlien an ulcer occurs here little nioru tlian its up- 
per border will be seen. If it iB at all tif^surcd, or undemiiood, 
there orij^iuato, a* viewed from above, indentations, wliit'Ii, lo 
those nnfamiliar witb the true nature of tlie l»don, will appear 
to be excrescences, vegetationg, condylomata, poly]>L, etc Ae 
a protection a<;aiust oonimitting such an eri-or, we H-ill incD' 
tlun the factd that ncopta^tic growths ara cxcccdiugly rare at 
this place ; that the lino induntod border of the projection, 
which ia occasionally well defined, is readily recognized, as A 
portion of the ulcer ; and, lastly, tliat the ulcer extenda from 
the posterior laryngcAl wall to the kteral parts of the vocal 
cords. These data, no doubt., will pat an end to all danger of 
erpop. 

Ulcers on the yulae and trne voeal cord*, especially on the 
latter, spread in the directiouof their long axi^, destroying the 
borders and even a considerable portion of tlie conju. Often 
tboy extend bo deep that tlie proocseus vocolls is exposed. 

'Hie ulcer may e.xteud downward into the iarynr, trachfa^ 
and even into tJie hrom-hi. Not infrecpiently extensive iilcera 
occur, particularly at the bifurcation of the tracliea. They 
often penetrate deep enough to perforate the trachea and attack 
the adjacent otgans. 

The (ini-faco of the ulcer is neually covered with, tenacious 
purulent matter. 

The qucetioa occurs vcr>- often, ITow can cvpliilitic ulcers 
be distinguished from other fonna of ulcer, c*i)ecially scrofa- 
, loos, tuberculous, typhous, Inpoui*, or carcinomatous ulcere < 
Tlieqaeetion is easily answered : Tlic elmracter of the ulcer, as 
■ rale, can only be dctinitely eottlcd by the clinical demonstra- 
tion of syphilis, or by tlie exelugiou of other primary die«ae««. 
When tliLn can not be done, the duignodis will remain un> 
certain. 

This will become perfectly clear when wo review the indi* 
ridual Hyniptoms. 
17 



!8 PATHOLOOT AXJ> TREATMEXT OF SYPmUS. 

The site of tbe nicer h no gimie in forming a clifTi.-rentUl 
(Ita^oeis. All Ictmls of nioore oc«ar on thoec parta of ilie 
larynx tliat are rich in glands ; tLii», syphilitic, like tuberculxr 
ulcera, are met with on the anterior surface of the pocterior 
wall of tlio t:Lryn.\, on tlio petiolur part of the epiglottis, on tli« 
borders of tlie false vocal cordfs and, U«5tly, on an/ other part 
of the larj-nx. Notwithstanding oor veiy extensive cKpcriuDcc 
wc hra mulile to imlicate any site of predilection of syphilitic 
ttlocre in the lar^'nx. 

It is tnie that the fharp border and the arched indeBtatioiu 
of the nU-er Bpeak witli greater certainty for ^ri^ilia than for 
tuborenloeis ; biit^ then, ench condittons sometimM ooenr, not 
only in tQbcrculoeis, bnt cren in sloughing carcinoma, in which 
disctieo tliey are Bometinics very prouuunced. 

Tiilierciiloutf ulceni are often n> c«ivure<l with tenicioos pa- 
mlent mutter, and bo enveloped in it, that tlieir luue can not 
be aeen. After the secretion ha^ been removed, hy the ex- 
pnlsiTe efforts of coughing or witli a IrniKli, (he luwo will bo 
found tolerably clean, pale, and slightly granulating. In a 
Byphilitic nicer, the digeUargo is leee profnae, bnt. nevertbeleaa, 
it is so iutinmtely united witii the hasoof tho nicer that it ts 
almost inipo«Biblc to brush it away. 

Tho condition of the tism(t« around the uJcer is a rerv im- 
portant gyniptoni. In nyphilitic ulcerations tho aurronndlng 
tiBBiKS are mostly bright red, while in tttboreulone nicera Dot 
only the parte near them, but tlie entire laryngeal inncoaa 
tnembnuie, ifi pale, often to a reraarknble degree. Still, even 
this lAga 18 not absolutely reliable ; for tabcrcnloas nlccrs may, 
on the one Land, be surrounded by reddened ti^ucs, and, on the 
otiier, all muwua membranes in protracted ayphiliu may have 
an extremely ann^mic appeurance. 

So far wc have only seen om phenomenon, wlnrh waa fre- 
quently pruieiit in tlio vicinity of tuberculous ulcers, bat nOTcr 
in confcqnence of eyphili* — ^namely, a number of yfUt>UfUk doU^ 
rarying in eize from that of a pin'6 head to tliat of a miltetieed, 
which represent m many niinatc infiltrated glands. At fint, 
they aro somewhat ecattcrod, bnt eabeoquently become more 
abrogated. After ttiey ondei^ d^neration, in some oaaea, 
nlcera are seen to form, which grow larger and larger by tho 



STPsiim 



ootlesoence of eoLae of the foci. We have paid particoiar at- 
toodon to this condition for a great many yoare past, and 
always foond it to bo a reliablo dia^oetie feature. These yel- 
lovifili dota Hhould not be confounded wilb the yellowiah gran- 
ules that are eomctimes foond in tho vieinity of a carcinoma ; 
in the lutter case, tboy are lorgor, and distiuctly range above 
tlie level of the normal muc'ono menibrant!. 

The condition of the adjoining nasal, pliarynpeal, and oral 
mncoitti aietnbnunj may be regardtMl oa a reliable guide. It id 
tmo that, in all probability, wbcii the ulcer i« extremely large, 
exTeudiup; from the soft palate, root of the tongue, and the 
fauvial niueons lueuibraao, to the larj-QTc, one will be apt to 
think of Byphilia and not of tiiberculoeiH : it miglit be per- 
fectly 6afe to do eo if a scar v^ found at the same time on one 
of tlic places mentioned. Tet, aside from the fact that tuber- 
eoloufi pereoDB may also bare sy]>hilitte ulccra on tho lancoos 
membrane, and tliat in tiihercnlo6i>i extensive nlcers, reaching 
from the root of the toii^ie to Uie eoft p:date and the gnnu, 
also occur, another difficulty bceome* snperaddod, under thoee 
(sreiinLitnncefi, namely, the differentiation between sypfiiliiic 

. wtroinomaioita it leers. 

"We can recall more than one instance in which, after care- 
fully examining the entire body, we were anable to make a 
differential diagnasia between fiypldlis and carcinoma. After 
euccoeding, in eome inatancee, in bringing about a cnre of the 
ulcers under anti-«yphiUtic treatment, we deemed oursclvea 
jaetiSed m concladiug tlie dittcaM^ to have been t^vpliilis. But 
when, after a ehort time, the ulcers broke out agaio, wc foiiud 
oareelTce in the eamu doubtful potation ai before, and this waa 
not cleared up till tho fatal end. 

SwdUtig of tlio lymphatic glands- in the submaxillary re- 
gion, and lower down in the neck, faraishos no ditfercntial 
diogooatic eigns ; in a milder form, it ooeun in tnbercnlDeis ; in 
« SBveror form, in eaneer as well as in ayphilla. 

Laatly, in regard to typhoid nlcere, it will not be difficult 
to distinguish ihem from 6ji']ihilitie ulecrs when tho wholo mor- 
bid picture U ruviuwed, and ulcers as a reault of lupua are 
foond only when thia affection occure on other placed. 

Hence, from all that has been said above concerning the 



SCO PATBOLOGT AXD TREATMBXT OF STPBIUS. 

dilTereiitiiJ dingnom of Inrytigeal nlcvis, it will bu upfiarcnt 
tlial in all doubtfol cases it will be nocOESuy to carefully oi- 
amine tlie wliulti bodif', aiid miuuti'ly rnvGetigote all lliu circuin- 
stanceB of the case. Tlie 9yviptom» of an ydcer of tlie laiyax 
Taiy according to ite site. 

An ulcer io the larynx alone, a« a rule, cansee no dlGBcnltieB 
In flwaUowiog. This is eepecially true in contradiBtinctioa to 
the wide-spread crroucoiia views conccniiug ulcciB uu tlic cpi- 
gloitiK. PreciHcly a« in tubercaloeiB difiicultioe in deghititioD 
are only present when the alcer spreads from the lateral wall 
of the larynx upward to the pharynx ; but especially t« this tbo 
caeo vrbcD ulcere eprcad from the anterior to the posterior wall 
of the laryux. In the last two instances the pains which often 
radiate to the ear may be eo inten»> that the patients decUixi 
to partake of any nutriuiout. Still, as a rutu, tiic tlttlieiihiuK tu 
deglutition are greater in tuberculous than in inrphilitic p»- 
tionta. noareencgfi is present when the rocal oords aro directly 
aiTuctud or whtu they are lesfi morahle, or when the jxitient on 
account of pain avoids bringing into tension the necessary ap- 
paratus for the production of plionatioii. 

JluBmcrrhtMjra iu 0(jIumm|Ucucc of ayphililic ulceration of tha 
larynx are atwuys sliglit ; genvrally there arc only a few dots, 
or, at the nioet, etreaka of blood in tJio muco-pnmlcnt expecto- 
ration. Wu at luuftt lutre never ecvn any bleediog worth mention- 
ing in H\-phiUtic ulcon) of the hu^'ux, though we have witnessed 
f>ome profuse, even fatal, luemorrhagce in tuberculous nloon of 
tlie fnucca. 

The secondary 8j,-mptomB in tlie lan'ux appear at the eune 
time after the primary infection, aa on the other parts of the 
ttody. Sometimes the phonoinonn in Uie larynx occur for tha fint 
timo BO lato, fio many yi^are after infection, that it is difficult to 
trace any couueotion between tliem. It is neoesGary to remind 
the reader here of t}ie queaiicm tliat has recently been discussed 
BO much of tbe occaeionai late occnrrenoe of hereditaty syphiHs. 

Aldiough there is no doubt whatever that the tfeneral treat- 
ment, whutlicr it consists of tlic inunction of mercury or the 
internal administration of iodide of potawium, cornwdve sub- 
linutc, Zittman'e decoction, etc., is the most importuit, stUl it 
is UAt well to discord the local trcAtnicnt entirely. Jast m 



STPmus. 



Httle aa we are ratUfiod to treat cxtcni^ivo gpccifle 9£>rt» on the 
skill with Zitlnmn'd decoction alone, but employ, in addition, 
lotioDg, plasters, and ointments in the nioAt nctive inunner, so 
little shoold wo 1>e content to awnit tltc efTects of intcmnl treat- 
ment in fljpliilitic Uryngeal olcen, for inetance, on tlie rocat 
oordi4, witlioQt resorting to tlie xim of local rviiit-dies Iwfure an 
iiTcniediable losa of eubstance or erosion of tlio cnrtilflgcs has 
taken place. 

Tlie £oi-ni of local treatment ncecesery in onj given case 
will depend upon dpecial circnmEtancet; ; bnt it will alwaja be 
mora ulmintageouA to treat the affected places, if ])o»sible^ bjr 
direct applicatioiis ; we mcoa thereby that more good will be 
aooompliflhed by penciling the ubors in the larynx with a sola- 
tioQ of nitrate of silver, iodo-glycerine, tinetore of iodine, ete., 
than by inhalations. Of the tatter, those consisting of iodide 
of potasgiam «■ iodide of sodium nro to be preferred, while 
OODOdvQ eubliinate always pives rise to unplcnaant Bceondary 
effeotc InsiiHlationii of finely powdered iodoform upon the 
ulcer have proved to be of great benefit. 

In nleera of the trachea local treatment ia not onl^ nscfal, 
but often absolutely necessary, especially in thoec case« tn 
which there is a marked accumuUtiun uf mucns or crusts that 
adhere tenaciously. 

PEHlCHOSDKmS. 

Tliis Is one of the most freipient forms of disease in sy])bi- 
lis ; and BvphiliR. agnln, is one of the most freqnent causes of 
perichondritis laryngea. It oocnrs on all the cartilages of the 
Lirj-nx, and may start from the periehondriuui ibwlf aa well as 
from nlcers of the mucous membrane that ttprvad to the carti* 
lage. The lesion may t«iniiiiiate in xll thoec morbid alterations 
that follow i^erichoiidritis in general, namely, abecoseeii, spread- 
ing of Qkera, grave destrnction of carious cartilagt-s wliich 
have become ossified, exposure of the cartilage in a snppnrating 
cavity, and forraatioa of cicntricc5, with consecutive disfiguce- 
mcut of the shape of the larynx. 

ClOATBICES. 

Syphilis is the nioi<t frequent eatiee of scare in the larj-nx. 
It ia evideui, from what has ticcu said U]>on tlio subject uf ul* 



362 PATUOLOeT AND TREATUEST OF STPBTltS. 



cers, tliat tliey may occnr on any ]»art of tlie Iwyni- In the 
slightest grades they require the closest inepectjon to see Uiem ; 
in other caMS^ agam, tlicy arc extcmiro and diaracteristlo, be- 
ing met TriUi in mnnuction with nloeni on tlic hard pulate, that 
liJis ulrcatly beoQ partly de6troy«d, on the root of the tongue, 
or l&teral and posterior walls of tho fauoea; 

The disfiguromcut of the romaiiu of the epiglottis may 
be vei-y extendve ; we know, however, that deglutition oven 
in cases of complete Ices of the epiglottifi may be accomplished 
witlioat any ditiiculty. Id acars of tho poitcrior hir^'Ogcut wall 
and the vocnl cords tbo glottis not infrctjuoutly is distorted. 
Thoeo foriUB m which bridge-like Laiidh urigiuate on the ary- 
epiglottic foldf, and especially on the false Tocal cords, are very 
romarkahlo. Further, those sears that are on a level with and 
Itclow the vocal corda, and which eitJivr hriiig about adheedorai 
between them or membranons contractions of the glottis, de- 
serve iii)ecial mention. Theee coatractioiu geneially occur at 
its anterior angle ; souietinin^ bowOTCr, th^ line the larynx iu 
an aiiiiuliu- form. 

There occurs very often from tho contractions of tho cica- 
tricial ttsnne, and tlic couMrictiou of tlio bhioil-Yes^le rMulting 
from it, disturbances of the drcidation, followed by marked 
bnlbcua and cndematone thickening of some parts; even new 
ulcers form again as the rcenlt of thi£ pathological condition. 

Cicatrices on the posterior laryngeal wall surrounding the 
crico-srytenoidid joint will render it immovable. 

Scars often have a characteristic appearance. Still, a thur- 
ODgh exaiiiiuation of tho clinical hietory of tlie cofa is tndia* 
penstthle, for otlier prooeaaefl, especially eschars produced ly 
K^utioDB of cau&tic potaiih, may give rii^e to similar cicatrioos. 

A scar very much like that described altovc occurs also in 
the tracbea. Cicatricial bauds that transveree its lumen in the 
form of a network an; of great importance, for a slight accn- 
mulation of the secretion at this point mar occasion the moet 
dangcrons attacks of eoffocatiou if some of the meabw of the 
network becomo plugged up, and thus tt-duce the calibor ni 
the trachea. 

Cicatricial contractions of the loiynx D»y reqoire varions 
de g ra o a of surgical interfcrcnoc They may be so aercre aa to 



STPsrus. 



2«8 



call for laryngotomy. If tnembranes bavo formwl Iwtwecn 
the Tocal cortb and adlic«ioiw bciwrmi Uio latter, their divisioa 
witU the knife will accomplieli oxc«lloDt reeults. These hloody 
upcntions must be gapplemented by the me of larvngval Iwii- 
f;tefi of gmdiuUy iocrcaeing thicknceece, occordi Dg to Schruttet'a 
method. If the £iUe meuibmnce or ecatv arc not vary thickf 
dilatation by meaos of liougi^ aloue tvill in maiiy cases au- 
Bwor oompk'tely. 

Conetrictioiu of the trachea aro to be treated lq a eiiuikr 
maimer. 

New GBowrns, 

Gmnmata having been already described, thoee growths 
which occur singly or in groups, and rcecniblo pointed con- 
liylomatA. remain to l»c sjwkcn of here. Tlicy are met with 
mainly on the soft palate, apon tlie arytenoid cartilage and 
epiglottic folda, not 80 often on the anterior Burfaoe of the pos- 
terior laryngcaL wall and on the vocal cords. Sometimes they 
fonn sncb bigti cockticunib-Uke excrescences that the probe 
sinks in between them to a depttiof several miIlimetT«& Paint- 
ing them with tincture of iodine will cause thoiu quickly to 
fUnppoar. 

Thew new growth», acconling to published report*, liave 
also been found in the trachea. 

In conclusion, it Is iiuccsKary to aUude to tliose forms of 
disease which, although produced by syphilis, are not lotAted 
in the lai^'ox, aod only manifest their influence npon tliis organ. 
Syphilitic diseased glands which teniporarily or permanently 
interrupt tlie functions of the superior laryngeal iicrvc, or still 
more frequently the inferior laryngeal nerve, cans**, by the re- 
suiting paralysis of tlie uiu»;lce of the larj^nx, not only hoarsft- 
neas and aphonia, but even dangcroiui 6rm]>toms of suffocation. 
In ths«e ca£cs, the natui-c of tbe primary aflection often ro- 
mains an nneolved problem in physical di^oeio. 

SjphilltlA Affeotio&s of the Brooohl and Lub^ 

From the character of tbe morbid Icitions found after death, 
Virehow came to tha concloMon that syphilitie vlfferation, 
with oonsetjiient cioatrizatiim and stenocis, may occur in the 
bronchi, as it docs in tbe larynx and trachea. Syphih'tio broo. 



aC4 FATBOLOGY AJfD TREATMENT OF STPmUS. 

chitis mftj merge into chronic pncamonia, rdi] tbo Inttor tornti- 
nate io liyperplaatic iiiduratiou of the pulmonarj Btniwtures. 
Tliiii fomi u£ inUfrttttirtl jneumonia of eptwific orij;ia is enid 
to occur idiopattiieally aleo, and Ituul to tlie fomution of oUlau 
uoduloft, of strong cicatricial bands raoning tliroDgh the pol- 
monarj tuwucK, iui<] of ciuttriciul retractiooa of tbc pulmoDarj 
snrfaces. Criiminositics in the hiiigs undoiihtciltv' occur in ho- 
reditary BjpUilia ; iu tLo acquired form they have been fre- 
qucntlj ntet with and clc!>crilM.-d. Nuvertlielei^, their proaence 
is not tsajaXy demonetrahle, uitiier clinically or pntholc^cftllj. 
We must be able beyond a doubt to exclude the preeeace of 
tubcTctUoeis, oud for that purpoae talcc into cooaidcntion the 
8ito of the u^orbid depociu. Uummata occur all over the 
luug)^ vrhile tuberculosis, in the vaEt majority of M£w, \6 found 
at tlie apicoe. Finally, the antecedents and coocomitante, tho 
conrec of the dieeaso, and the effeofs of anti-epecitic treatment, 
aro very uti«lul data in diagnoeiB. On tlio jileiira, too, Byphi- 
UticciciitnceH, with prolongations extending into the pohDonary 
tiesoes, are said to occor. 

[Puluioiiary syphih^ is properly regarded as a late mani- 
feetation of tho disease. It occurs uuuuly in two forma, dif- 
fused and circiiniM;ribed. The diffased depoints arv found 
along tlie onunw of bronchi and tJieir ramifications, rcaulCiii^ 
in peribronchial infiltrations, whose rctractioo aabeeqaentfy 
occludes the liinicn of the bronchial tubes, ]>rDducitig collapse 
of that i>orti<m of tlio lung. If the infiltration extonds to the 
sorfaoe of the lung, it will become apiJorent cren before tiie 
pleura U remorod. The circumscribed form occurs as ganun* 
nodes, %-urying in tiro from that of a smnll kernel np to that of a 
walnut, and even larger, which ire fyurnl iuibeddc<l in the |nU- 
monary tifflue. These gummata may undergo absorption, fatty 
di'gencmtion, cheeky tmntfomiHtion, or softKiing and suppo- 
ration, but, in any event, callous cicatrices of dense connective 
tissue always remain. The ditlused and cinmnMcHbed fonna 
are |wt]ioIc^calIy alike, and differ only as regards titeir locatitin. 

This leeioo, us already obserred, presents do patfaognD< 
mcfliio symptotiu. But if dollneaa, on percussion, is fonnd 
over a circiimt^ribfd ^twx^ and dyspnoitt supcrronoe rapidly, 
in a wi-11-duvvlopvd, robust person, nnatteiided by hectic fever. 



SYPBIUS, 



96S 



and some of the ktc evidencce of specific disease arc present, 
tlie dueaec may be oonsiderod pulmoaar}- e^'jiluJig. I'lie traaX- 
tnuntvrittt tliu lodidua, aud tlio alM^ici; of tutK>rclu bacUli from 
the sputa, will, perhaps, iona the most reliable e^Hdenccs of 
tbe nature of the disease.] 

Affections of the Kidney, Bnprarenal Captide, and the BUdder. 

lu addition to other dtaease» of the kidney fuiind in sy]ilii- 
litio paticntfi, wliich, however, caD iu no wuv Ih: di^tiiigitiflicd 
ixcm the pathological Usioiis found in aon-?pccifie iJrigbt's 
dlHNUC, giimninta and dimntc intt^nlitial, nyphilitie, inflamma- 
tofy circmiiscribod dc]wsits have also lieeti deincribed hy medi- 
cal writera. A few instaiieo* of aimilar afteelions of the eupra- 
reiial capaule are alw) rtwupded. 

In a few rare caH>8, pyphilitio ulcerations and eubBcqaont 
cicatrization occurred in the bladder, these proceeees bdng nnt- 
altjr accompanied by gimllar lenioiis iu tbe urethra (Proli^ch). 

STphilitio Affectlooi of tbe Testicle and Spermatio Cord. 

Tile term sijphHUic dl^aifu' '•ftlit; ks(!» {orchitis, albuginitis, 
or sarcocele syphilitiea) 'm applied to an inflammalory affection 
starting from the aibiiginun of the organ. In conseqnence of 
tbist tlie albn^nea and the celliiinr pndottgtttionf) that extend 
from it into tJie substance of the testis, dividing it into small 
lobes, may become mariiL-dly thickened by proliferation of tbo 
connective ti£«nc. In addition to tbis, bowovor, there are mm<y 
timfsa found, under the thickened envelope of tbe ttpeciflcally 
diseased testicle, diiitinctly outlined nodnles, aa big nA millet- 
eeeds, conbtiniof^ a Umi, yoUowieh nucteOB. These have been 
regarded by Virebow and others as pmiraata. Hcueo, a eim- 
pltt orchitis (lypbilitii^ and an orcliitiit gutnnioMi may lie di»- 
dogni^jlied. But whether connective tiesne alone has formed, 
or gunimata bave developed, can not be poeitively ascertained 
during the life of tlie patipnt, 

A commencing eypbiUtic disease of the testicle generally 
runs a totally painless courw, and, for that reason, hardly 
ever attracts Uic attention of tlie patient In excopttimiil iu- 
stasoet, it inanifeets iteelf by tOigbt pains which run along the 
qienuadc cord, radiating towaM tbe corresponding iugulDal 



366 PATBOLOQY AKD TSSATUBST OV SYPBIUS, 

region, but wliich am not ait^rravfttod by pneeurc apoa tho 
cord, a oonditioii wliich LhipujtKQ considered as cbaiacterifltio 
of syphilitic disease of the teetiole. li the totis \& {.•arefully ex- 
amined at the Ikt'ginning of tbo discMC, ono or mora acnttcn^d, 
nodular, hard places, about the eizo of a bazel-nut, are fouod 
on its surface. 

By the gradual enlnrgemeiit in cinriimferenpe of the origi* 
nally indurated places, or by the gradual coalescence of the 
scattered inibuniiiatory foci, the testis uniformly swells op^ 
becomes im Imnl us mrtitage, and twofold or even Uircefold its 
normal size. It thereby loses its oval sliape, and becomes pyri- 
form, witb ittt bade directed downvrard and its apex dmim np 
toward tlte groin. The swollen te»tis is less aeiuitivo to pree»> 
are than a normal one. TJie epididymis, and the correspond- 
ing vas defurcuA, as a mlo, remain oualtercd. In excciiUonal 
ewes, however, tbo epididymis becomes involred in the pyri- 
form swelling and the vas deferens is bypertrophied to two* 
fold and even fourfold its nonunl thictfnes». 

In some cases, a scrons cftneion takes place into the cari^ 
of tbc tunica vaginalis propria. This bydrooele, which has 
been described as orchitis serosa, or vagiaolis, and by Virckow 
termed |K>rioreliitiit syphilitica, does not seem to its to stand 
always in caiiN.it reLiHim to syphilis, but very often depends 
npon a trinsud&tion resulting from a simple passive stasis of 
the blood. 

Like its developmenh, tlie entire cotirse of the disease 
of the testis is slow and chronic. Its duration is oncertaiii ; 
eometimcs it is prolonged for two or three years. During thb 
jicriitd, however, tlie testis may spontoneoosly liccome smaller 
and larger again. So long a£ the swelled testicle is of moder- 
ate size, the scrotal integuiucut mScn no morbid alteratioa ; 
but, when it has attained marked dJmcneiotis, or a oooadcrablc 
amount of serum at the oime time \% efinsi-d into the canity 
of the timicavaginiUi!), the wriaklee of tlie affected half of tlio 
scmtum gndoally become offncod, and the skin of the scrotum 
erythematous. 

Syphilitic inilaiiimation of the tastk generally terminate* I7 
alisorption of the inflammatory products. Sometimes, however, 
the resolution oversteps the limits of a nonmd couditioa; tlio 



SYFmUS. 



testis becomes emaller tlian it was Wfore, anj), linatly, i? atro- 
(ihied fo raach that it is reduced to u more nidimcntary condition, 
rot liifiger tlmn a bean or pea. Further, there are casus in wliicli 
the affected testij ih couv«n«d iuto a uia^ tm hard as cartilnge 
or boue. A syphilitic teifitiH Ktrhlum uiidergoiis on ppu ration. 

As a. result of B^'pttilitic diseaw of the testicle, the secretion 
of fiemen is groatty diminished or totallj arrested. If both 
testta are rendered fuiictioiinllj incffietfut hir specific clifiease 
of a high degree, a tUiuinutlon of ercctione, lot's of sexual ap- 
pedte, and, finally, vith increasing atrophy of the glands, 
complete impotence will result. Kicord eCatee thflt the semen 
cecTOtud by eiich tcelcs id diminished in quantity and changed itx 
quality ; tliat it coutaing no eponoiiitozoa, and is simply a tliin, 
tni&eparent Huid. In the testicles of rdbii^t persoue, who bore 
indications of luiving had BypiiilLt which, however, had boon 
completely cnrcd, Levin found the g])ermatozoa were often ab- 
sent (ill lifty per cent). Those fitatcmcnte a;»roe entirely witb 
the obivrvalioiui made by U. ZeiiwL Ue knew tuauy men 
vbo had eiiffered from syphilis, and, notnithstanding that they 
]KiiAe6ited strong coiutitu lions, be|^t no children, though thetr 
wives were perfectly heidthy. 

At any rate, it is probable that the origin of ey]>lulitic die> 
ease of the toetee may be fostered not only by certain local intlu- 
enoca, such as a fall, a blow on thu testicle, i>r cxccis»« In vcuo- 
ry, but tlut orcii remote causes, such as epididymitis blcnnor- 
rboica, toborcuIoBis of the epididymia, or carcinoma of the 
testicle, may servo to engender a FpeciHc orehitia. Bat ve 
muiit confeH tJiat, although vcr\' many of onr syphilitic pa- 
tients BulTered from gonorrbrea, jet no Farcocele was produced. 

In all cases that came under our treatment tho aSoctioti of 
tlie testicles w:u tlie result of ncqnircd sypbilig. As a general 
tiling, only one testis was diseased — now the rif^t, and then 
again the left. In a few rare instances tlie aecond testis was 
attacked some time aft«rr the tirst. Orcliitis syphilitica ocnirred 
most frc4juciitly in persons who were entering from syplulitio 
ecthyma or i«|>ecific nodes of the skin or mucous mcinbianc. 

The ofluctiuiis of tlie testes, which may be mistaken for 
aypbilitic inflammatory orciiitis, are tubcnoloaie, carcinoma, 
ud gODorrhteal epiUid^-mitis. 



36B PATnOLOQT A2fD TBEATUEST OP STPBIirS. 

Tiilwrciilosis of Uic tvstos, a« \% well known, always bcgtiu 
in (be epididjinU, and ia cither limiteid to this part, or sabee- 
queatlj extends to the entire crgau. The sp^ufie kflection, 
however, attacks the tefltiafiret, the cpididyinL* gcaeradlyremiun- 
ing normal. Tubcrcoloda produces a noduUr, iiaeven cDUrge- 
nient ; syphilid a Ginootb, uuifomi tumor. Aa & iceult o( 
tuliercaloBU, iDflamiiuLtory oonditiout; of uiio of the tostos 8oaw- 
dines snpcrvcno, which gcaerally tenninato in sappnrstitm, 
vrhile eyjihiUtic affections of the testes develop without fuver 
or intlaniniiiliun, aiid vvnr iteldoni undergo BuppontiQiL Ac 
the hegioniag, tubercnloius of the teftes. like the syphilitio 
variety, is paiulc««, but later, when the tubennUoiu affection 
approaches ijuppurution, the patient eiiffum ecvere pain, vliile 
even strong pr«i»ure on the testicle, whicli is greatly enlai^ed 
as the result of eyphilii;, canseB no unplea^nt sensations. 

It b more difficult to distinguish a recent syphilitic cffchltk 
£ron) a oommenoing camber of the tosticle. 

Both affections develop in the teetiw, twitli are at iirst poin> 
lew, and present one or mora circumscribed, hard, nodabr 
placcB. Bot cancerouH nodules grow nnich uioro rapidly than 
the syphilitic node, and iu the former the testis ac^jutres a nod- 
iiUr surface, while the lotter, owing to the fusion of the depos- 
its, becomes uniform and smooth. Tlie longer ihw carcinoma- 
tous growtlis last, and the older they grow, the more elastic 
tliey heocHne; i. e., the loaa faard they are to the saoab of 
touch. Gradnal poftcning and fluctuation of the aircinonu- 
tons kernels en«ne, attended by inteueo, protracted pains, and 
followed by bursting and ulceratiim. A syphilitic testiclo, on 
tiic contrary, almost always remains stationary in its indurated 
condition, or it disappoan ahnoitt entirely, and vet^' ec-ldoiu on- 
dergoee suppuration. In syphilitic intlanunation of the teetis 
the vas deferens usually remains unaffected, and when it be- 
comes diflca«;d it is tnmsformcd into a uniform, tluckeneU car- 
tilaginous cord, while in carcinoma and tuberculosis it, as A 
lula, has hilly or nodular prutul)erances. Cancer of the testicle 
very often extenih) to riio epididymis, and the retroperitoneal 
glands whose IjTnphatic Teasels emanate from tlte testis be- 
come inTolred early (these glands are found on both sidci of 
the vertebral oolnmn on a level with the kidneys [Albert]). 



aypHiLis. 



> lymptiatic f lAndi^ <>n tlie coiresponding side nsnillj do not 
beeomc enlarged tilt tlie carcinoma of tho tostu baa involved 
iLh sldu of the scrotum ; tliey then become exeesBively hj-jwr- 
tropbied and transformed into irregular tumors of the size of a 
valnut or tion'ii egg. In addition, Ricord culls special ittuntion 
to tlie following very imiwrtant difforentiai signs: Liko carci- 
noma of the breasts or of the eyes, which never occutb in both 
breastB or both eyes eimultancously, alwaya lieing limited to one 
Olgan at Best, ao cancer of the tt^ticlu itf alwayi^ aiiilatorol, while 
Byphilitic orchitis may occur on both sides at the same time. 

The difierentiation between gonorrhceal epididymitia and 
epocific inflammation of tlio testis occasiooB no dtftiCTiltics. 
The paiDfol appearance of the afloction in the i;permatic cord 
and epiilidyiiilii, aoctniijianied by febrile movernenl, the ewell- 
ing of the testicle in a few days, and, lastly, the jirf fcnco of a 
blennorrbtea, will be more than suiHuieut to iuditsite the true 
nature of the dtsviuiB. 

IJydroceIc and Liematocele are even easier to diftingniwh 
from sarcocele syphilitica than the other varietieB. 

Ryphililic intlamination of the testis, according to 11. Zoi!<6l'B 
oljservations, is a much rarer disease than specific affectionii of 
the iris. It hardly occurs once in a himdrud syphilitic pa- 
tients, A* a rule, it belongs ti> tlic later period of the disease. 

The shorter time the disease laste, and the sooner raUono] 
treatment is instituted, tlio booiatir& restitutio ad int-rgntm may 
be expected. Like all tho other phenomeiui of sypluUe, spe- 
cific inflammation of the testis pruHentB relapoes. The woret 
that may be feared from a syphilitic orchitis is the impotence 
of the patient. 

Vircliovr, who distingaishes a periort'liltin and opchitia syphi- 
liltca, ascribes the sime role to the tunica vaginalis propria tea- 
tee, in regard to syphilitic aftootion of the testicle, as die peri- 
toneal envelope of the liver plays in Byptiilitic hepatitis. TbuB 
he found not only cartilaginous thickening and calcification of 
the albuginca teatea and tuuica vaginalis propria, but adbcaons 
between tlicm and coitiplet*: Ryneclila. Ta'tIu found the mme 
morbid alterations on tlie testis which Vircbow described, 
namely, hyperplastic thickening of the albugiaco. the eepta, 
and the membrana propria of the tubuli scminifcri, tuigeft- 



270 PATBOLOGY AS'P TB£ATMEKT OF STPOtUS. 

cencfl of tiie veins tliat inosculate around the tubuU scmtnifeH, 
ailliodion uf the naturally Iwtated eeiaiiial caiials hr new hj* 
pcrpla&tic tiasue, ilai-k-brown pigmentation, and, UstW, fatty 
degeneration of their epitbelial celle. Jn this manner a am- 
eidurahlo Duml)cr of the iwjuiuul cuuaU uro duttroyiMl, and id 
tbcir place libroiu stnictore is foond Id tho teaticle in which 
DO tubuLi seinioiferi can be eeeo. 

According to Koldtanslcy, syphilitic inflammation of tho 
tostis generally attncts with great violonoe a few lobnlca at a 
tiuie, and gives rise to Jmnicoee proliferation of tlie albugiuua 
and tlio septa, with olditeration nf the textnrc of the gland, 60 
that at last it is trnDgfonned into on irregular, lurd tumor, with 
cheeej, tubercular degenerated foci in which aoonmuhtiom 
of insi)L'w»ted puB not infrequently are found. The vaa defeiv 
eoB IB here obliterated. In rery rare cjises gnmraata of tho 
apennatic cord are found, while the correaponding tistis h no- 
affected. 

Syphilitic Affections of the Orariei^ Fallopian Tabea, and 

Utenu. 

Virchow baa uo doubt that there is an oophoritis ayphi- 
litica; still, ho ie anablo to state whether it prodocee anythiiifr 
more than fibrous indumtion and its coneeqacnccs. Klcbe, too^ 
is unacquainted with anyotlier lenon in eyphilitio women than 
a chronic inflammat<try proeoaa of the ovariea, wliicli gvoenLllj 
tonninatee in B|>e«dy slirinlung of tho oi^^ and tho formation 
of circnmscribed .■uiheuonft. Gummotm now growtha have beeo 
obeorved by Ricbet and Lecorch^ If both ovarie* are affeotod 
by ayphilis, storility will be the inevitable Hwilt. TIieKKadlod 
oulica Bcortonim, according to Kleba, may sometimes be due 
to morbid proceases in the ovaries. 

In regard to the Fallopian tnbee, we know of a case do- 
scribed by Boucbord and lA-piuc, in wbicb, in addition to 
gtimmous hepatitis and encephalitis tho tubes wero trarut- 
xoriued into hypertropbied cords of th« thickness of a finger, 
and contained tliroo soft teddlah giimmnta of tho sice of a bazel- 
Dut on each side. 

In regard, to specific dlsGowe of the npper section of Ow 
Qtenis, we are unable to speak from personal experteaco. 



BYPEIUS. 



&n 



Syphilitic Affsctioas of the Mueoni Membr&ne of tho Genital 
Orgaoi of Both Sexea. 

An erylhemaious rednem occasionally dovclopfi npon tlio in- 
ternal sarfdce of the prepuce. I n conf^iquenoe of tlii^ a more 
or 1e£9 Boverc preputial catarrh ia produced, whoso secrctloo 
macerates the epithelial ceils of tho iuflainod mcmbnuie. Syphi- 
litic prepiitiul catarrh ie distingmshod from tho eouuiiou balano- 
pofittieitis by tlio fact that it a])peam in n milder form, usually 
cau^iiif; no plUegiiionous Bwctliiig of the prepuce and ekiu of 
tliu }ieiiL», uo aeutu iullaiiiiu'itiuu of the dur^al lymphatic veft- 
sals of the pcnift, and no profnoe dLseliargo from the fo&tui coro- 
naria, as in local Ixilanitis. The diagnoda can, however, only 
be positively decided liy the jjreseuce of otlier syphilitic umui- 
festaiious, especially roseola syphilitica on the gliuis pom aud 
the skin generally. 

Syphilitic trtftkema of tlic vulva occurs even oftencr than 
Bpecilic preputial catarrh, AlUtougli the affected mucoua inoin- 
brane is not }Mirticular1y red nor the diaoharge profuse, BtiU tho 
labia majoro and uiiuoni are ofteu markedly ewollen, and the 
catarrhal redness spreads into tlic ragiua. LrosiouB may occur 
on the mucous niemhrnne of the vulva and vagina drailar to 
those on the prepuce and glans ; tho^ oroeious are liable to bo 
mistaken by iuexperiencod phyfiiciana for the cauaa, namely, a 
soft chancre, iiLiteiLd of Uie efleeb; of iiyj>hiUs. 

Mucous membrane papules in all their phases alone, or ba- 
ftociated with ery(ht:ina of tho mucous membrane of the male 
and female genital organs, occur much more fre(]uently tlun 
erythema of these parte. The papulee, being covered with a 
coDaidcrabIc uuioimt of d£-tritu», may rejidily Ite uiistakca for 
chancroids or new primary nyphilitic iufectiug chancrcB. The 
best te&t betn-een both these alTcrtions is the speedy or &Iow 
production of a pustule by inocuhition, and the prceenco or 
alieouce of other syphilitic aooondary phenoiuona. Alucoua 
membrane papules in the male are mostly situated iu the foaaa 
coronaria, at the aperture of the prepuce and meatus uruthne ; 
ID the female, ueiuUly at the vulvar orifice. Xhcy rarely occur 
higher up in the vagina or on tho cervix ; when they oeenr 
at the latter place they resemble grauubtious that result from 
ateriDO catarrh. 



273 PATnOLOQY A^D TREATUBKT OF STPmUS. 

Gttmmy tumors are found on the inner or mucoos nirfice 
of tlie ]>n:piicc, on the miicoiia mcmbrnne of the labia majom 
and minam, and on the pneterior cutnniifisnro of tho ragiiUf 
uither singly or in groups of three or four. In the latter ease 
they ore a}>t tu becuiuo conflneiit, and form eeiuiliiuar ulccra. 
They occur Iocs frwinontly on tho cervix, where they are apt 
to be mi^aken for a Sbroid or carcinomatous tonior. Now 
and then tltey are seen in the form of urethral or pcri-areChnl 
infiltration in the male urt'thra, the caliber of ivhicb they are 
apt to diuunigti, and as a result of disui^nizittion and Blutigh- 
ing may occasion pn)fu»e hcemorrhage and listuhe of the nre- 
thi-n. ITrethral gumniata have been found tno»t freqnently in 
the pockets of the foesa navtonkris. Oumma of the oervix 
□teri and uf the uretlua can only bo diagnoetic-ated by the aid 
of attending nypbilitic plicnoinena (dlecasce of the toiicfi) and 
cxjuvantiiiis (administratioD of iodide of potaaaiuDi). 

Gaoiniata on the macous incuibrune of tlio genital organs 
of both eexes are very often mistaken fur a chancroid or Ilan- 
teriau printory syphilitic lesion. An ulcerating gumma ie did- 
tingiiUhod frran a chancre by the fact that the latter develops 
and approaobea cicatrization much more rapidly than the for- 
mer, which is always acconip«Qiod by other etyphilitic manifoi- 
tations, and that it U fiomctimos eemtlnnar or Btcklo^baped. 
The ditlerentiation between a gumma of the genital organs 
and a Hnntorian syphilitic primor}- lc«on a only of coDse- 
quenco because tlie latter is the ^Ipba and tho former the 
ome(^ of tlie ttyphiUtio diiwaeo. 

The di^iiganization tliat attacks one part of a gumma 
while healing takes place ou the other, and the absence uf In- 
filtrated lymphatic glandu in the groin, even when tlie nodo 
has existed for a long while, will moke a diffcreutiat diagnum 
between it and epithelial cancer quite easy and certain. 

Syphilitic Affections of the Corpora Caveraou Feai& 

In sevend instancee we have seen, daring the late phaaoa 
of syphilis, cartilaginous indarationa, raiyiog la dxc froin that 
of a pea to that of a hazel-nut, originate iu tho corpora c*vcr- 
noea, in a painlees and apyroxial roaoner. Tbeee materially 
hindered the normal production of erectiona. The nodes vnra 



srfsuis. 



273 



moBtly situated in the poetorior tliird of tlie pendulmw portion 
of tho {wnis, aud failed to disa^ipear entirely uiirJer an anti- 
gpccitic treatniunt. Wn liave never wen these nodeg undetgo 
suppuration. 

STphfUtie AffeeU»u of the Brtutt. 

Sauragee claims to h»vo Iweii one of the first who obeerred 
in the mammary ghindfl of Bypbilitie women cunoor-liko growths 
which were made to difia]i[)ear under mercurial treatment. 
Hichot, UaJEonneuve, Ileiinig, Yerneail, Ambroeoli, and Lang 
have doteribed gummy tumore m tho bnsisUi. The two btt^ 
have also met them in milot. Luncereaiix disttngniKhes a dif- 
fused and a gammonit miuititiM. lie records two ca8«« oIjiB«n'i>d 
by Ambro^oli, aud one by himself, of dilf used ina^^ititis in Kyjihi- 
litic women, which were cured by the odmiiiititnition of iodide 
of potaanum. Boeck met witli Iwo caeee. Uoth patJent^ had 
anffered for tuany years from oomtitutiooal syphilis. 

Syphilii of the Heart and Slood-VuMli, 

As ft nsalt of acquired syphilis, sinijile callous inflammA- 
lion and j^mmata develop in the heart in very rare caeea. 
The callous itifl&mmations may ofFect one or all of tiie layers 
of the cardiae mti»cle, while giuaina almost always attacks Uio 
myocardium. G. Roflenfold published a report of two pa- 
tients who snffered fi-om "asthma sjphiliticam,'* which ffreatly 
reeombled cardiac asthma. In both coeee chamctonEtic evi* 
dencca of syphilis of the heart were preeent. 

Comparatively rare as affections of tlie heart in cniiiie<jiience 
of Bj-pbiliK an?, so frequent are specific diseaaea of the blood- 
ToseelH, and e»pecin11y of the arteries^ Tho gnmllcr arterioe, 
particularly the cerebral vessels, are moat frequently affected. 
There arc, however, reports of many inBtanvefi of larger ar- 
teries affected by syphilis, by M. von Zeiwl, Von Langen- 
beck, Kimdrat, and lADcercaux. Heubner devoted pertionlar 
attention to syphilitic affcctiont; of the artcrieB. ArUrUia 
eyphiUtioa occurs either bb an indcpundont process or as part 
of a local specific affection. In tho former, gtA^-ifh-wbite 
thiokeoiug of the intima and adventitia of the arteries is 
found either in a cirenmscribcd form, or the Tesseb are trans- 



274 PATB0L007 AA'D TREATMENT OF STTmUS. 

tonneil into solid cords of connectire dsene. In the flooond 
case, tbo artery Uea in a itpedfic diseased masfi, and gcner- 
lillj all tlie tliree ooata are involval. Ziegler defloribeil tliia 
process luJmirabl; in the following words: ^The inUma and 
tliu odventitia are apt to be more aSected tluD the titodb. If 
the prcicctis id Btill active in the stu^ of granulation^ the thick* 
ened intima viil abo oontatD a great deal of oollalar ttntUL 
Some of the ceils aro auall and round ; eomc, again, U^o', 
epindle-ebapod, or stcUatc, rcprcecnting rxrioue forms of fibro- 
blastema, Tlio same is tmo of the adveotitia. The modia 
ia only moderataljr infiltrated with cells. If the sjrphilitio 
affection is of utder date; if conncctiTo tisrac liu developed 
in the domain of the indammatioQ — tho hypertrophiod coata 
of the artories will contain more fibrous tissue and fewer qoUl 
The media U either in good condition, or it ts atrophied and 
fibrous in places. There Lt uuttiing peculiarly KpeciOc in tlio 
htitologtcaJ process. But it may be said that in the ordinary 
arteritis of tiie small veaeels, no such enormous accumulation 
of cellular infiltration occura as in syphilitic inflammstioD, 
and, csjiccially, tluit the advootitia i« not altered to SMh a 
degree. The wall5 of the veeseb in Eyphilis often beoooM 
markedly hypcrtrophied, Botnotamcs to sncfa a dt^rce as to 
occlude the lumen of affected vceeols.'' Zidgler very aptly 
adds the obflerratiOD that *'do histological criteria of the 
syphilitic procees ooeor in the blood^vemels. Etcd tlie rich 
proliferation of cells in the ndventitia is not palhognomonioy 
for it is found in the cerebral vessoU in other pathological 
conditions, such as tubercles." Syphilis, then, may be re^iarded 
aa one of the most frequent causes of arteritis and its effects. 
By the occlaaioQ of the Teasels of an extensive part of an 
orgnn, scrioos alterations may be bronght about in it. 

Affections of Uu Brain, Spinal Cord, and Fsnpbenl Nerra^ 
as a Btflolt of Syphilis. 

The central nerroos system and the peripberal neiras maj 
be the site of morbid products eogendere^l by syphilis, or tb^ 
may become involved by offoetioiiB of stmctures snrrounding 
them (bones, meninges, etc.). As a result of spocitic oxo^tods, 
nocroBis, and caries of the bones of the skull, violent paiM in 



STpmiis. 



Uie bead, rertigo, jactitatioti and palaies of the cxtremititf 
nuty cnrae, followc<l by hemiplegia ind secooduy gntve le- 
sions of the brain nnd its mQxabfmn. The ejmptoDU which 
are produced by the exoetoeifi wiU, of ooun^ vary accordiDg 
to tlio looftlity of the brain and Bjiinal cord, whiffh is preeeod 
□poo. The mcningccs may be affected by &y[)1iiliB even in t]ie 
earliest fctages withuat any sypUilittc affections of the boneg 
being present. In coniKqaoDCo of tbu meiiin^ti); i^ypliilitica, 
the cerebral roembranee become thickened, and b*^tiii|>tegia, 
imbecility, and cortical epilepsy may ensue. This kind of «x- 
teoeiTc tliickcning uf tlio mcnliigtis niuy tcnniaate in chronic 
toflainination, and engender a ^cricH of Bymptoms which i^ 
Tory much allied to prograsaiTe paralyaia of the ioBuio. I* 
Meyer rogardit the intiimitc union of the dura matur trith the 
other menbranoa and the surfaco of the brain as especially 
patbt^omonic of the morbid lesion characteristic of syphilitic 
meningitis. 

A£ dxown by Henbner, disease of the baaitsr arteriee, in 
conaeqoence of eyphilia, may bo regarded as one of the nio«t 
fraqncnt causes of cerisbral afFcctiong. It prodnoes grave dis- 
tarboncee in the circnlation in the parts of the brain within 
the sphere of the affected vessels. SometinieA eren large cer^ 
tual arteries are found totally obliterated. This condition, and 
the thromboeia that foUova the constriction of the rca^U, 
nltimatcly result in softening of the brain (encephalitis syphi- 
litica). Giimmata, too, arc found in the central nervous sys- 
tem, ae well as in the peripheral nerres, in the form of large 
or Buall reddish, yellowish-brown, or gelatinous, transparent 
ittURa, witlt cheeky deposits on their margins ; or nodes, u 
big as a pea, with oheeey degenerated centers. These prodaets 
hvn boon only recently reoogniw?«l qb eyphilitic gmnmata, 
throngh the researehea of Wagner, Fiireter, Titmpcl, and Rock- 
linghansen. They are found in the most variable parts of the 
brain, in the cortical and white mihiitaiice, in tlie corpora quadri- 
gemina and corpna Etriatnni, in tlie hypc^hysU cerebri, and also 
in some of the ner^'es. Of llie cerebral ncn>'e8 the ocnio-motor, 
the trochlearis, the abduccns, the optic and the fuc-ial, are cape- 
daily apt to be affected in conserjucnce of syphilis, and are 
foniid infiltrated with the yellowiah-giay, gelatinous, trana- 



276 PATBOLOQY AA'D TREATMENT OF STPEILia. 

parent, or 6rm gtimmatona masses alluded to. On cutting 
them open a fow wliito points can be eeon, which were ionaw- 
\j regarded as undesLroyed oerve-llbers, but which, id reality, 
are nothing more than cbe«8y deposits. 

In r^ani to the fiptnal cordj those dift-ases mngt first be 
considered which arc caused b^ the 8>'pttilitic affection of its 
eoTelopes — the Tcrtobm^ and the mciiingc& Ad the rcsnlt of 
exostoees or inflammatory products developed in Ute rcrtcbne^ 
or maHtecl thickening of the meningee, tbe ccntire thicknee^ 
or only a ecctitm of the ootd, may become incapable of tmna- 
mitting impnwrion^ pArtlj as tbo roenlt of prc^urc, partly as 
tbe result of extensioQ of tbo inSammatioD to it, and the well- 
known phenomena of comprfJttion-myditis wilt engvt. The 
^rmptoms which oppear in snob cases vary greatly, aooordtng 
to the height of tbe vurtolinb or luoningee affected, and w> 
cording as the procesa attacks tin anterior, lateral, or poeteriur 
aetrtions of tbe spinal cord. 

lu »uch casus there occur the so^salled root-eymptoma, L e., 
distnrbancM which originate frvm pressure upon, or inflammi^ 
tion of, the spinal nerve-roots that take tlieir origin from the 
diseased places. In the progre«e of the di^ase tbe eymptom* 
of apostic spinal puralyitis,* or eymptotna of ataxia, or Anally, in 
rara cases, 8(H!alled epinal liemiplegia may ensue, according to 
the part of tbe cord that is compKceed. Later, certain aymp- 
toma regularly appear which indicate a partial or oompleto 
division of tbo cord, sach as ponplegic conditions, nnmsthflriti, 
paral^-Bia of the £pluncters, and bed-aores. 

In two caKi we saw tlie s^-mptomti of trantoetm myditia 
appear at the same time as the Gccondoiy plicnomcna of erphi- 
lia ; they bad reetfitcd all kinds of treatment, bat finally were 
cnred by tbe use of mercury. There are aa yet, to our knowl- 
edge, no deecriptians of nndonbted pathological hucXs pabliahed ; 
still, tbe clinical pictures admit of no other conclusion. lu 
one cai«, Se^^ltgwuller, by active auti^pccific tn-atnicui, curud 
a veiy cxtc-nairc iiiaecular atrophy in a person anffering from 
Byphilia, 



* Tfals tara b med li«t« only for the pwpoM of dMOriUng tbe 
atobgr (onMue lo it, and mi la tbe mbm nuplorcd by ErU 



3YPBILIS. 



Fonrnier and Erb claim tliat & cansal relation exists between 
tates and sypliilia that liiu preceded it. In eighty per cent 
of tiie caBGS wliicli he has ob&erved, Fonrnier continned thoco- 
ineidcnce of tiibeH with Kjrphili^, wlnlo Erb cnred some and im- 
proved others of his cases hr antinpecUic treatment. The 
qneetioa is not jet definitely decided. We are forced, how- 
ever, to Eido with Wcatplial, Lcydon, and otliers, against 
Fonrnier and Krb. In mme 8;rpltilitic cases certAin phenom- 
ena of serious dbeaae of tJte Bj>inal cord have been oljservcil, 
moet fre(|ncntly symptoms of the tHvcullod aKcndiug spinal 
paralysis (Landry's paralysis), an<l yet, at the antoptir, not even 
the mioroeoope could detect any abnonual condition of the 
oord. 

The peripheral nerves very often become diseased in oon- 
eeqneneo of syphilid. They are ailuiiled most frequently by 
the preesore of exodtosetn, or the thickened meninges, or by 
gomoiata of the meninges or bones. Tliickening of the nie- 
nlngea at tlte base of the brain mo6t frequently produces simi- 
lar phenomenH, and for tliat reown paralyiMS of tlie mnKle« of 
the ere are ^ecn bo often in sii'philitic patients, since the nervee, 
for a long distance of their iM-Ti]>lieral course, nm cloee to the 
offbcted port of the meningc*, and are involved in diwni?e3 of 
tibe latter. Paralyeitt of the muKles of the eye ie a complica* 
tioD so couuuoQ in eyphilie that on anti»pecitic treatment should 
be tried in every case. 

In addition to the ocolo-motor, nbducens, and trochlcarie, 
all the otlier cerebral nerveti may become affected by eyphilis. 
Primary affection of tlie nervea oeenrs lc*s frecjueiitly in 
this disease. In the latter, one or more reddish, grayi»h-red, 
or yellowish foci fonn ou the nervee, which eeem to bo ranch 
tlilcker, but sotnetimett tliey a(n)pby to such a degree that only 
tlie nerve«heaUi remains. The gpintU nervet have Keldom been 
fonnd affected ; nsnaJIy they show only secondary changes. 

Tbe diagnosis of cerubral, spinal, and nervous ayphilis is 
all the more difficult, becaose in the majority of oaeee no aymp- 
toms of fiyphilio in other organs — on thu mncous tocmbrane or 
akin— cau be discovered. The sndden appearance of a cerebral, 
spinal, or nerve aScctioo, the ige and tbe history, will form 
important guidoe; still, not oven the good results obtained 



878 PATBOLOQT A.YJ) TRBATilEST OF S7FHIUS. 

from nntupccific treatment will cstalilisb die dtagnoeis be^<md 
a doubt. 

UofortiiDatoly, iioQ-specific nerroiu aSectiuDs engender 
B^rmptunui liiiiiilaj Ui tliose prcKluc«il by sjiecific diieMCB. 
From tlie present standpoint of onr knowlfsdge we can make 
tbe followiDg statement : 

In its first period svpluliii producce aSectloDs of ihe me- 
nii^oe and the b»ilar ci.-relir»1 arteries, wtiilo tlie diseasee of 
the DerTona syBtem that come on htler eometiaiefl ori^tuto tu 
the manner juet mentioned, or are doe to gnmmata derdopti^ 
in tho ncrvom eabetanc« or in the mcningce. In geoenl, the 
following gnnipe of fiTmptonu aro obscired with remarkable 
frequency : Cercliral diseafies, oonsetjiient ii]>on booo-Iedoaiii 
manifent theraaelvM by tixot) violent tfadthe^e t}tat beoomes 
aggravAted al niyht. Tlic painfnl pUces are often sensitive 
to ext«mul proBsnre, and upcm thoae plaoaa, or near them, 
a perioKteal gumiaa is aonwtimes found. Tn quite a oiun> 
ber of cases cfrt:l/riU hem^tgiat enme, trhich are ofluall/ 
earned by points of softeniog that develop in the vicinity of 
a giiniiiui, or as a result of Heubiier's ditieaso of the arteriea. 
These hemiplegias occur either suddenly, like apoplexy, or 
ofteoer gradually in snccewive uttacks. The caaes belonging to 
the fiivt TArictj are almost always the result of art^ial dis- 
ease, and originate partly from throubous, partly ^m oin- 
holism (as a result of the conreyance of fibrinous eoagaJa 
from projecting points on the walla of largo eet^mil arteries) 
resulting in sudden ptngging of a largo resael. Tlie/ thna 
give rise to the eliuii^ phenomena of oereliral emboli. Syplu* 
litio hemiplegias not infretgncntly vacillate in thvlr coutm^ 
sometimes got better and then worse ; often, indeed, they get 
well entirely. This is especially tme of the apoplectiform 
eases wluofa have Inku properly treated by antisypliilitic rcme* 
dies. In many cases, again, only a moderate degree of impror»- 
ment, indeed, sometimea not even this mucli. can bo achierod 
by simihir treatment. In tiuch cases we have to deal with 
plugging of largo veesdo, vhich beeomes pormauent, or with 
aofteniog in the vi<nnity of a gumma. 

In some cases tho inanifeetatioDS of eo-ealled cortical epi- 
lepsy (Jaoksonian epilepsy) ore obdervod in syphilitic pationta. 



STPmus. 



3?» 



^This affection, as a rnle, is eiUicr produced bj morbid altera- 
tioiu in tliu bouc (exostoses gnmniata) or hy spccUic menin- 
gitis. Un<ler encb circunuUiicos Uio procetecs munUonod maj 
bo located in the r^on of tbo central oonvoluUoDs or in their 
immediate viciuitr. AVe then almoet always notice attacks of 
conrulsioiu, eomctimcs with, sometiuies vrithout, lw& of coD- 
wioTtSDOB, bat iu which the spaanift differ from ordinary epi- 
kpay in not attacking tbe cntiro modcular system, bnt only 
groaps of miiRfiles. 

It freqacntly happens tliat iiypliilitic patients, after Buftois 
ing from the phenomena already dei^cribed. or even if they 
bare not ^iTereil from them, are attaclced by peculiar tfe]>1ialtQ 
distarbnnces which are hardly ever obsurrod in any disease 
but syphilis. They fonn the so-called '• drunken " conditions 
that develop in patients guffering from cerebral ayphilis. Thcuo 
pttienta often complain for days and weeks of intonao jmins, 
ntnuboeas, and confosioa in tbo head, before tbo pictare that 
will proaentlj be deecribed develops. They are nnable to at- 
tend to their occnpationa, especially if any mental effort bo 
DeH8sai7, for the least mental strain ajj^^ratcs the trooble 
mirkedly. Having lasted for a while, tliese aymptonu grada- 
tUy grow wonw, nncongcion^ness snpcrvcnes, or tbo cephalic 
distnrbonees rapidly bocumu ag^ravateil, and tben cluingc into 
profonnd stupor. The iwtients lie in bod for days with their 
ejet shut, and can only be nwakoncd from their semi-uncon- 
scions condition by bobg londly spoken to or Kbaken. "While 
this condition lasts, tbey are sometimes perfectly qoiet for 
days ; oftencr. however, thuy tug at the bedclothes, plaj with 
tlieir genital or^ns, become reetlefia, and get out of bed. 
When roused, they will answer slowly and h««itatiugly, often 
mouifoBting loss of memory and psychical disturbance. Dur- 
ing tho time that this condition has been developing, other 
disCorbancee not in^qacntly arise, namely, cortical oonvul- 
siwu and hemlplegic phenomena. In quite a number of caaw 
tlw piTohioal disturbances bocomo aggravated, maniacal i^mp- 
tonw sapervmie, or the patient becomes comatoee. In tbe 
latter event death is the UHital termination. In other eascA 
the condition imprcn-vs. a temporary or permanent cure h 
achieved, but although the patients regain ccnscioosneas, they 



280 PATBOIOOT Ah'D TKEATMEyt OF 8YPmLIS. 

arc frtxinoDtly B£*cted with eomc moQtal troable, sach as loGS 
of meincHj. At die post-mortem examination of sucli caws 
Houbacf asaall^ fonocl morbid meningeal ultcnttoos along 
-with the diHUktcd candititm of tlm artcriots, and softening of 
the brain de^xinding njion it. 

Laetljr, in aome cases of ayphilie peychiccd didurianoM o£ 
various kiud£ liavu \kxu (>lj«cn'cil, nanivlv, hjpochoDdxUf mel- 
anchoUo, diorcA with mania (Wuuderlicb), and oUier pe^- 
chofi«e. 

In regard to tbe time at wludi arphilis of tlic nen-mis sys- 
tem is likclj to appear, it may como on in a Torj gliurt tima 
oftor infection. In the majority' of oaeee, howerer, many years 
elapee hvforo it mamfo:!;t« iuelf. Tlit! jiredinpot^ing uumm for 
tlie developmciit of this fomi of syphilis, as for all tlie other 
grave forma, arc : too earli/ nse of mercnry, incmnpUte treat- 
ment of the diseaae, excessive indiilguncc in wine and ecxiul 
inCurcourac during thu treatment, uwutul woriy, and cxiutioQ 
in bttBineGB. 

A permanent cure con only be toUiovod when tlie norrf>- 
salMtancc remains nnnflcctod. Iniprovonient takos place rap- 
idly, especially when lai^ doeee of mercur>- and iodide of po- 
taBunin avc employed. Syphilitic di&cuoa of tho neiTM nqitirft 
a long oonrso of aftertreatment to moke tbe core penotnenl, 

SypbiUtie AffectLoni of tbe Vom. 

The tltree cardinal fornu of disease already described occur 
aUo in the now, but witli tliis differenoe, that erythema may 
appear on the lower us well as on the upper part of this organ, 
the papnlee more in the lower part, and the nlcerating oodee 
seem to have a preference for tliu nppcr and poeti:riur parta of 
the nasal paasagea. 

SypbiUtic erythema of the nasal mncons memltranc, or 
$yphiUUo nasal catarrh^ develops with phenomena whith are 
similar to ordiiuu-y ooryza. It i« attended hy a scnsetion of 
tickling, bnming, and dryiuM of the portd ; frequent SEieean|^ 
soon eupcrrenee, and tbe Tulble {>art of tho nmcons membnM 
is reddened. If the catarrh is limited to tlie anterior [lart of 
t!m mnenuit membnine the discharge will bo only slightly ang> 
meuted, but if it spreads to tbe mneons membrane of tbe 



BTpmus. 



S81 



higher tiaftal regions lai^ quantities of tliin fluid are secreted, 
caositig tbo patiwt to Llow liLs nose repcitedl/. The dtBcIiargo 
exooriatee the Dual orliices nnd the adj&ceDt parts. Syphilitic 
nasal catarrh ruriufiliea no pathognoaionic gyiuptoins ; its epo* 
ciHc cliaracter can only he infcmxl from the acoonipanying 
plionomooa and the previoti& history. It may occur either 
aloDO or in connection with macous-raenihrane papnlee or 
nodes. In the iimt caee, under U]>pro]>natc treatment, and 
if the patient takes cara of himsvlf, it may di^ap^icar tempo- 
rarily or permanently; in the other erent, it may spread to 
the adjacent nasal paamgoe, cfpocially to the lachryinnl diict 
Syphilitic naeal catarrh, if it la limited to the anterior parta 
of the macoua mcmhrone, cliaiiges the peroeptioa of emell very 
little, while if it involves the snperior R'giotis of Uie nose 
the ptticntd will guffer coDBtantty front a foul odor, altliongh 
the watery naital eeoretion and tlie expired air am odorless 
(fea3co9mia tJih^ecCira). So long its the nasal cafarrfa Is nnao* 
companied by any other affet^ion, the air pasaea through the 
naul poesagee nnhindered. Bat if uiuooiiB-mcmhranc papules 
or gunmiata develop, especially in the higher regJonB of tlie 
nose, the discliarge will gradually actjuire a nmco-puriJcnb 
character. Tluu thickened nuHol discliargo readily dricA and 
forms cniBtB and plugs in the passages of the no«e as the re- 
sult of the action of the air Sowing over then], and thus ma- 
terially Impcdce respiration. 

The pu^ult-s are almost always eituatod upon the lower 
part of the na^al miicoua membrane, on the margin of the 
□aies, partly on the niucous nioinbrane, and xomctimeA bo- 
come m large here a& to actually close up the oriticcs of the 
DOM. We Lave already stated tliat mucoufi-uietnhrane papules, 
which occur on the mucouK i»eml>i-ane of tlie eartilaginoua 
septum, threaten by tht-ir difiintegnitioi) this part of the sep- 
tum (yic3 de inauton of the French writere). But whether 
papules and nloers in consefjucncc of sypliilis occur on the 
higher parta of the mucous monilirane of tlio noec, or tJie do- 
Btmctioii of the oesoous sutwrstmcturc only takes place through 
the disorganization of gummata situated at tliia place, and not 
from the deetruction of mucoua-memhniQO papules, con not l>e 
defiuitely decided, as it is impossible to obtain a view of tlie 



383 PATBOLOQT ASD TRBATHSST OF BTPBlUa. 



affected purt^ The fact Uiat sypHliUo affeodone and d<y 
stmctiom of tho upper parts of the tnacoiw mcmbruiu occur 
diiefly la ounscqtienco of iarotc-rato Bjpbilifi, aud that tbe ul- 
cers fiOToetimee fomid BimoltaDeotifilj on other rejpom of ma- 
coos membrane, or on the common intcgomcnt Ukewiao, on 
thQ resutt of disorgatiized gtunmy tumors, proves eonclusjvdy 
that tlie lualigiiaiit fi|>eoitiu affcvtiou in the upper nasal rcgiou 
is caused by ^mmata. 

likmitia ^yphiHtioa vloenmt ; Corysa atffthUitica vie*- 
Toga; Oztvna typhUilica. Tbe fetid no«« (?a punaisie of the 
Freuch writeis) sometunea lieginB with the pbenmnena of a 
catarrhal cor^'za, or it manifeete itself fioon hy a pomlancnt oo> 
elusion of the Darea. In the course of tbe disease the Sobnei- 
dorian memiinuie secretes a large qnnntity of ydlowiah or 
greenish, thick, purulent matter. Tho lon^r tbe disease laats, 
the more ioliorouB and fetid the di^chorgu beoomcs, the more 
rcpoUivc is the odor that is diffoficd frum tltc no«e (i^akoetnia 
oijectiw). Tho foul odor originatee from tho docompositiiOD 
of animal matter, and reminda one of tliat catued hy fetid per- 
spiration of the fcct^ or putrid flesh. Ae tlie discharge grem 
tldctcer and moro purulent it beoomea dry, vellowiFb-green^ 
Btiokj and fetid, and cnuibi and plu^ fumi from tlie nacal 
mucus, ima, blood, and decomposed tisBQe«lementi<. Theae 
doee np the nasal paaeages that are already narrowed bjr 
the swelling of the mucous ineinbrane, and render reapirar 
tion difficult The patients seek to free theae pawgea by 
'v-iulcntljr blowing the noee often, or to remore the ohstiiHy 
tion with tho finger, which is geucmlly followed by idighi 
bleeding. 

C>a examining the nose, the mnoona membrane is foinid 
swollen, and covered with fonl-onolUog diacbaige. Tbe nloen 
ore generally situated at tho junction of tlic cartilaginoua with 
Uio bony septum, in which aimation perforation of the soptTiin 
nioKt frequently occors. Tbe opening at first b not hlg g et 
than a pea or a benn, and is in the twiny part of the aeptnm. 
Tlie greater tbe destruction of the Latter tlic lees eni^rt the 
bridge of tho noae will hare ; gradtmilr it ainks in, so that ■ 
aaddle-likc deprcotiion forms between the tip of the IMM and 
the anterior lower boniei' of tlie nasal bonea. 



srrmiis. 



SS8 



Tlcew that aro atuatod in the npper rogiona of tlie nasal 
CBrity dv unt beoome visible lill tlie triungnUr luuiul curtilage, 
and tho skin covering it, liavu bci'n dwtruyed by nlceration. 
Oonerally there is only one nicer, sometimes two or tbreo; 
they ere superficial or penetrate to tbc tiono, which soon at this 
spot becomea carious or necrosed. The nccroaid attacks the 
vomer, tbo peqiendicniar plate of tlio ethmoid, the enporior 
and middle turbinated bonee, sometimes the nasal procces of 
the superior maxilla, and the nasal bonea. Ooc&aiouuUy the 
tilcerativo proocse spreads from the eeptum nad or the choanee 
to the bottom of the na^al cavity, and produces perforation 
of the biird palat«, which ntaially takes ])luo« ui tJie median 
tine, and sometimes is so large that the bnee of the cranium 
may bo lit np through the opening, and if an ulcer hap- 
pens til b« there it will become viaihle. Mur^over, even 
ulcbis which originate in the labyrinth of the ethmoid bone, 
fostered by the poroiiB natiLre of it« oeseoua lBmellH>, may 
csoao ao much dL-atructiuu that tho mouth, nasal, fruutal and 
Sf^keno-pahltiuc cavities may form ouo lurgu oi>uuing, hounded 
by eroded bony waUa, and allowing the movements of the c{h- 
glottic to be fteen. 

Oifltna syphilitica heals nndor the following conditions ; 
The pain which tho patient sometimes suffers on pressure of 
the nasal process of the snjierior maxilla disappears ; the hor- 
rible odor from the nose and the purolent di^liargc ^ulwide ; 
no more portieles of bones come away ; grannlations appear on 
the ulcer, and cicatrization takes place by a eellulo-tibrous, 
parchment-like inembraue originating on the place wliere the 
mncoiu mcmbnino has been destroyed. The new membrane 
secretes a yellowish substance resembling cerumen. 

Ritinitia idoeroea develops as a result of acquired and of 
hereditary syphilis; fvtill, it occurs vciy rarely in s\'philittc in- 
fants. A marked degree of deformity of tlic nose, and conse- 
quently of the £kce, is the effect of ozeena fiy|)hilitica. If the 
diseuD is mtnated in the higher regions of the nose, tcmponuy 
or permanent anosmia may result^ tho nerves of smell either 
becoming unimpiessioiiable to odoK for a long or short time 
by the cuntionons action of tlie mephitic nasal dtsclmrge, or 
the perception of odors is permanently abolished, because the 



2S4 PATUOLOOT AXD TRBATifEifT OF SYPHtUS, 

mucous membrane wliich tranBmits it ie deetrored by nlceni- 
tion and repUced b^- ii di^*, parcliuicnt^Uke &luu. 

Whether rfiinitia ulcerosa is a B/mptom of BvplUlia or of 
scrofnia can only be np proximately mottled by taking into con- 
sideiatiuu the coexiatiiig phcuuiuona and the antecedent coD- 
ditiona. In regard to the concomitAQt phcnomeua of ouena 
syphilitica bcreditJim, in the vast majority of cages it is pro- 
ceded by iilcerutiuu uf the soft palate, while in ozsaa scrofn- 
loiu Doitlior ])erfunition of the ban] nor of the eoft paUte 
oocars. Ilowever, oJaetia may also develop secondarily to the 
exttrpation or tearing out of a na^ pol^'pos. 

Syphilitie Affection of the Auditory Paswgei. 

According to Gniber, primary syphilitic disease seldom 
occurs in the external oar. PaptiUr eypliilide of theearazid 
exteruml meatus auditorium diHeis in no tray from that oil the 
skin. In the deeper part of the external ear, and 00 tho tym- 
paauDi,it IB met with in the form of ^^{^u^« m»^fu«f, whieh 
often coo only bcdistingoishcd from an otitis externa by other 
signs of sypliilis slmaltaneouBly pnaoit Exoetoen of the 
bony passages are seldom paiirfalf becaiuo tbcy pftw rery 
slowly. According to our observations, nodnlar i^lulides of 
tho external car and meatus occur in iKitU the ulcerating and 
ibe non-uleerutiiig forms; in tlio former, when it occurs oa 
the auricle, it assumes a lupous cliaracter (Foumier). PoUtser 
also met with pu^tnlar eruptions. 

Of all tliu sectioiu of the car, the middle car, owing to tbe 
frcqacncy with which speci6c dieeases occur in tlto nasal aud 
fnucinl stracturee, is most frequently affected by svpliilis. In 
the limng membrane of tbe tynipannm, cf-pecially in the mn- 
oous mombrans comring the raombrona tympani, ^rphilitie 
tUccralion very frequently causes ecvero pains, which, in ooo- 
tradLsdnction to ordinary otitis media, do not abato even ftfrer 
perforation of tlie ^"m panic membrane has Liken place. Bat, 
so long OS the morbid process is ooufinod to tbe Kustschiaa 
tube, tbe patients complain of nymptoms that specially bckng 
to affections of tlie auditory nerve. According to Lowenbef^ 
iofiltrntioufl and proliferatjons may occlnde the faacial aperture 
of the >ube, and, if foUowod by euppuration, occasion fearful 



BTPmilS. 



n5 



vBn$KfloOn antl retncting scan, tlmt will close up tlie opening. 

'SeVwKrtae regards tlm foUoTiDg ptienoniena as characterietio 
of the Bpedfio nature of cliroDic catarrh of the ear: Tliu 
affection is alwajrs bUatcral« aiid doca not begin for some 
months aftor oUiur syphilitic phciioiiiuitit liavc apt>cared. The 
nocturnal exac^bations of the osteocopic paine in the tem- 
ples, the rapidljr increasing inipoinnent of hearing, and, 
lastly, premature diminntion of cephalic bono-eondnction 
(labyrinth syphilis^ are additional conlirmatorjr eridencoa of 
the spedfic foundation of tlie disease. Tlie eKtenrion of the 
sappurutivc proccse from the lining mcmbtime of the mastoid 
cells externally to the periosteum oi the mastoid proceee fre- 
quently ocours in syphilitic patients, witlioat perforation of 
the tympanum — i. e., without preceding otorrhoea. llyper- 
plflsitB (inflammatory liypertrophy) may be obscrred on any 
part of the middle ear. Ver^- severe infliunmutory procewM 
in tlie niucoos membrane of the middle car are usually aooom- 
panied by hypereemia of the tissues of the labyrinth, which 
catuee extraraaaiion of blood, and in thie manner engenders 
mtddm and nsnalty iii curable doafnes«. 

BTphilitio Affectloni of the Ey«, 

Isms SYi'iiiLrnoA. 

Syphilia per m may undoubtedly occasion iritis, and it i» 
equally nn<jue«tioniible that, of nil the causes of iritis, eyphilia 
beads the list. We m.iy unhe-sitatingly maintain that at least 
half, if not a larger proportion, of all the iuDammatiotut of the 
iritt, iti dtid Ui syphilis; ludoed, there are medical vriters who 
doabt the occurrence of rhi^iimatic iritin, and who are disposed 
to regard all iuetancee of iritis rlieumatica as syphiUtic. 

Iritis not infrequently occura In the early etagcs of eypluli^ 
sometimes even a^ Ita rcry &tei le«ion, and in that ease dis- 
plays its real character by the risible gmnmona nodes tiiat 
form in the irie. Ab these patients were positively treated 
witliout mercnry, wo have the best proof that the jnunnin'O' 
are not the effects of lucreurialiKation. Likeviec, the fact 
^t, although uitis may ap|iear in the fiivt etage of (lyplulia, 
yet a also apt to supervene in the later stages, iilong vrith 



SSfl PATBOLOQy AND TREATJIEXT OF 87PBIIJS. 



gnmcmta. proves that, strictly epeAking, there are no wwaUed 
gecondurj or tertiary manifestations of the disease. 

SypliiJitic iritid ecarocl^ over stUckB both e^'cs (nmoltaofr 
ooety ; frcncrallj, one eye iu affuotod fint, and tlie other afte^ 
w&r<l. In regard to tite eTinptomatolog^j, it maj be atatod, 
first o( all, that the symptoms of specific iritiB can not be dk- 
tiiigiiiHheil, in the majoritv of coses, from the idiopathic varie^. 
liko the latter, it may develop in an acnte, subacnte, or chnmic 
fonu. 

An iritis that Iia^ already devulcipcd often rcmaiiis for a 
long time at it« acme. If the affection waa u^luirt.'d in hy 
violent paina, that radiated into the cyehrov, into the forehead, 
often over the entire half of the corretsponding Hide of tlie 
]iead, and if the aymptonw pccnliar to irilifi (marked injection 
aronnd the cornea, oincity of the anterior eurfaee of the irla, 
eliango of its color, and blurring of the noruul fihera, but c^mk 
cially adhesions of the pupillary border of tlio iris to the ante- 
rior capsole of the lens), accompanied by photophobia, and 
laehrymation hare developed qniekly, the inflammation will 
be voty severe, and may lagt an imreasonnbly \ouig while, the 
pains conttnae nndiniiiiinhed, oxaeerbatiug nt ui^lit, and the in- 
daiumatory product, in the fonn of a membrane covering the 
pTipil, and of ^mnll nodeti Kitunted on the posterior wall of the 
cornea (De^cemet^s membrane), constant!/ becomes more and 
more noticeable. 

In other cai<os the ditteaAo deveJops len nolentlr ; in etfll 
others, there a only a diminntion of the power of vinon that 
indaccs the ptittent to seek medical relief. In tbeee oases irida 
haH (!n;{)t on inaidioiuly, tbo posterior rynecliia, the pnpiilarj 
membrane, or little nodes <m Deaeemct's membrane, oppoaite 
the pnpil, that resalted ^m the disease, have roatoriaJIy dimin- 
ished the poirer of vLsion. 

tjinoD the forma of iritie mentioned, as they actnally origi* 
nate fonn syphilis, are not in the least ehameterigtie, and ditce 
we are unAble, by merely examining the eye, to recognize the 
syphilitic basis of the affection, it is of the atmoot importance 
for the oculist, in every case of inflammation of the iris, to 
seek for evidences of syphili»~bat not in the hweo manner in 
which this is nsuallr done. 



SYPSILIS. 



S87 



Howercr, there is on4 fonn of 63rpbilitic iritia \rhich 
proelaima itself aa bhcIi, namely, iritis ijum-mw'a, bnt wticb 
scnrcely am«mnts to one foartii of all tlie cases of specifie iritis. 
It tscliaroelcrizod by minate grannlc«, of brighc or deep yellow 
(in tlark iridi:*, rediiiMh-brown or black) color, wUldi develop 
on the piipilUn," or ciliary border, or on tlie piano of the iris ; 
they are generally situated in tbe parenchyma of the latter, 
jmijuct with tUo smooth, semieipcular surface into tbe autcrior 
chamber of the oyc, and not iiifn»jta'iitly a fine network of 
Teaaelfl is troven around thorn. Tbey vary in »ze and nnm- 
ber. Tbere may be eoTeral small oned (of the bum of a pin'6 
head and laifier) on Tarioos phtcee of tbd iris, in wbJcb case 
the pupillary border wnll be eurroundcd by them, like a WTcath, 
oronly two or three Httle nodes arc seen. However, these very 
isolated gmiiules are the orieij that winetiuieB display eucb a 
wondorfal tendency to proliferate, that tbey Hibecquontly 
aliQoet completely fill np tbe anterior obEunbcr. WTien thcw 
minate noden exist, the symptuuit) of irttin, as a rule, will be 
severe ; sometimeti, however, only a section of the iris, in 
which tlie jrranidea are found, is inflamed, or there are no act 
lul intlamniabjry pheiiODiena at alt. The micnwcopical exam< 
ination of thc«c ruxlci shows the presence of large nnnibeia 
of flmall cellalar clementu, sach as constitnta gnmniata in gen> 
enl and grantilation-tieeue. The pn»euco of giiinmata in iritis 
proves oonclueivuly that syphilis is the primary dii<e«fie. That 
ao many writen should deem iritie gnmmom to hare eo few 
oharacteristto fiymptoni.% rannt bo due to tlie fact that, in some 
cases, the clinical history ww; not investigated witli that thor- 
oofihnoefl that is often DoceeBOiy to oooilrm tbe presence of 
sypliilts. 

In general, it is <]tiite easy to diagnose the gnmma-nodes. 
But when, in iritis, a lat^ yelIowi»h-gray Imnp of inflamma- 
tory product is depositee! on the periphery of De«cemet''8 mem- 
brane, it may become imjXKViible to ditttiugiiiBh it from a gum- 
ma sitUBted in the etmcturee of tlio iris. In that case, nodiing 
lots than opening tbe anterior cliaiuber of the eye will solve tbe 
qneetion, for tbe depooted matter may then bo removed. On 
the other band, tliat tumor, which is obecrvod withoat, bat also 
with symptoms of iritis, and is known as grantUoma iridis, and 



PATBOLOOY Am) TREATMBST OF STPffTLlA 



which, Ixith in itti L'xtcmiLl ajijicarnnoc nntl histoloj^ical roimeo- 
tions, agrfee entdrelj* with gumma, vrill be leea likclj \o deceiTO 
us ia diagaofiis. Amde from its extreme raritj, and with UiA 
exception of another form of node, which may be looked apcfn 
as X growth of trautuiitic grannlatiom, it can be regarded m 
nothing eltie than a true ^lutnai origioatiug in oonaequcnoe 
of ^rphilis, especially tlie hereditarj- ™rietj. Eijually unim- 
portant, in regard to the diagnoeis of gumma, is trae tuber- 
culosis of the iris, and the circiimEtaaco that, id acato adenitis 
of non-«yphilitic origin, small, rooDdisb tnmore, of rvddi^h 
color and feeble consifiteiicj, are said to occur in iritia. 

Lately, a peculiar, gelatinous exudation, rceembling in od^ 
ward appearance the dislocated lena, has been eeca in tbo an- 
terior chamber, in caaot) of iritift. It nocumulatca with ex- 
treme rapidity and in large quantities, and may disappear with 
equal rapidity. The connection that was fom>crly claimed to 
exiet between thi£ kind of exudation and B>'philiB can not, bow- 
ercr. be mmutained. 

The t^rminationa of IritiB eyphllitica, in the main, do not 
differ from tlione of the idiopathic or rheumatio Tarivty, Un- 
der appropriate treatmout it may bo cured entirely. Some- 
times this bvorabte tennination ensuea even siiontaiieoQsIj. It 
iDay leave come syiiechie, with or witliout a piipilbry mem- 
brane. It may cause total cloanre of the pupil by annular 
posterior synechia), which, since the peraisteuce of eynechla 
faron the tendency of the inihuumation to n,>1»pw, often 
giTee riee to secondary gUoooma, and 16 followed b/ total 
blindncBK. 

Id regard to gnmmata, it ik neccsarr to olxwrro thattiia 
smaller kinds of tlic«e etnicturee gradually difiappcar, and leava 
nothing more than a oolorleea ^>ot in the parenchyma of the 
irie. In extremely rare coses, small gomtnata have alw bcctt 
Bocn to undergo purulent degen«ration. A large gurama> w- 
pecially if situated on tiie ciliarjr border of the iris, may de- 
stroy the eye by attacking the ciliary body. The bulb in 
that case ^lirinks and becomes totally atrophied. Still, ena ft 
vcij large gumma, if it is confined to the iris, may speedOj 
and completely diaappcar, without leaving any injiiriona ef- 
fects. 



87PH1US. 



599 



The prognosis of sypliilitic iritie elionid alwnye be given 
with raution — with mucli greater caolion than iu idioputhie 
inftamniiition of tlic iris. It Is neeeasary to }H->ar in iniiid tlint 
the inflammatory plienomena inay reinain for an nnnsmUly 
long time at their height ; that an implication of the other eye 
is at least to be apprehended ; and that the affection ha« n 
strong tendency to rekpAO. Thnii, it may happen that, althoogh 
tbo patient ia gitaated tinder the most farorable circumBtanccs, 
•nd is uiidergoiug inuuctiou-troatiufiit to the iHfiiit of sali- 
vation, the irilia that wiw already curwl rchipBcs with t^rriblo 
violence, or tlie second eye ie attacked by tlie <llecAf« in the 
form of grave, gammoas ititis ; that the epreading of tlic mor- 
bid processes from the iris to the ciliary body and choroid oo- 
car3 oftcner than in any other form of iritis ; and, lastly, that 
the inflammatory product liecoinee organized into syneoliial and 
pupillaf^ membranes with great rapidity, and that evoQ an 
early Iroalmont often will aecomplieh no comploto cure. In- 
deed, tilts may even be true of the other eye, which hecariie 
involved under the observation of the ph}-flician. 

The treatment of iritis syphilitica rcqnires not only loon! 
bat alfio general mCHHurvs, directed against tlic primary diEcase. 
The local treatment^ however, differs in no respect from that 
of rlicinnatic iritis, A few drops of a eolution of atropine 
(atropia eulph., 005 [gr. j], aq. dcstil., 600 [Sir] shonid be 
dropped into the conjuncti%'al sac, if the inflaramation be ee> 
vcrc, every two hours ; if not, at longer intervale ; imd cata- 
plasms of pulv. semini lini ehoold be applied to the eyes. This 
is very agreeable to the patient, and aseuages the pains ; if they 
fotfiU thcw endf, it will be neceflsary to apply them day nrd 
night If the pupil docs not dihitc under this treatment and the 
pains do not abate materially, six or eight leeches should be ap- 
plied to the templeit, and a subcntaneous injection of niorpliine 
administered to the patient in the evening. The action of 
the latter may he prolonged by gnbsequently giving him & 
dose of chloral hydrate. If the iritis is apparently cured, and 
if no injection of the ciliarv borly can be seen in the daifdme, 
the eornca should be carefully examined when the patient 
wakes in the morning, to ocu whetlior any halo in prcM-nt 
aronnd it So long as this rendition continucSf it will be nccce- 
10 



a<»o PArnoLoor akd tbeatmsst of sypbilis. 

mjy to tue tlie atropine Holution, in order, if po«sil>]^ to gnaid 
against a relapse. 

If gumma nodes develop in the couise of an iritiB STpiiilltl- 
ca, tlie pli^ician will foci justified in tiubjcctiiig the pationt to 
merotuia] treatment There is no local, special treatmeDt that 
can be recommended against the gaimoata: became, on the 
one fa«nd, the Bmall once ore not dangerous to tJio e,TO ; oa the 
other Land, even a large one luajr di^appcnr withoat Icariiig 
any trace ; and attempts made to obviate any impending diD-' 
ger to the eye from a hirge node by remoWng it (excLiiiiig it 
and pieces of iris) hare not been followed by satis^ictoij rc- 
ealts. 

During tbe time tlie severe febrile plienomena last^ it will 
be well to keep tlie patient in a dark room, in bed ; the eye 
(if no cataplasms are employed) should be covered with a linen 
bandage and protected by a green shield ; tlie patient's diet 
and the niorcmcnts from his bowels ithonhl be related* 

if iritis ia ushered in nnder moderate or no symptouui of 
irritation, the local application of atropine, protection of tbe 
eye a^inet k'""'"? ''k''' '*y ^^'^ aid of flinnky fipeclaclo*, and 
avoiding other injurious intinences, will fiufiice. A mercoml 
treatment, however, ia perfectly jortifioblo. 

The treatment of those conditions that may remain after 
the iritis has entirely disappeared belmga to the Bpeeial d(y 
main of the oculist 

ArPGcnoKS op thk Ciliakt Body, thk Cuonuto, axd YnKS- 

OCS UlTUOS. 

4 

Tlie ciliary body scaroely e\'er becomes affected independ- 
ently unless a primary gumma forms in it Yet the oye need 
not neoesearily be destroyed by the latter oondition; on the 
eontrary, gummata of the ciliary body hare been seen to dia- 
appcor, at any rate, under morcorial treatment, without loaving 
any injurious effoctfi in the eye. 

It is scarcely poeeible for the cUiaiy body and choroid to 
become affected by the extension of the inflammation from 
the iris. Acuti irido-choroiditia typAUitica-, which may soper- 
veoe, it is tnte, in Bome exceptionally 'rare case^ attended by 
the formation of gumma in the deeper parta of the eye, bn^ 



STPniLia. 



291 



as a rale, filion'inj: noUiing epcciSc, nianif(>6ts itself in Uio fo]- 
lowiug iiiuiner : A marked evtteitiveness of the cUUry body, 
and remarkable duniuutioa of the teoeion of the cjrc-bull); 
farther, a dimlDUtioD of sight that in no way corroeponds to 
the Tiiiible opacity of the miKJia; although the pupil ia atilt 
partly permeable, yet no rellex lan be obtaine<l by tlie o]»)ithaU 
mosQopo from the fandus of the eye, or the opacities of the 
vitreouB humor pre:!«nt are seen as undulating black maaBae 
in thu dim tiehl of vision. These phi^iiuiueiia usually anper' 
veoe upon a violent iritis. Acute Jntiainmation of tlie irido> 
choroid strncturee Is a very destnietive dlMaa^ aod when left 
to itself will fru(|uently result in atrophy of the eye. 

In another fioriva of caiios of iritle, the attention of the 
physician will be attracted principally by a loea of sight dis> 
proportionate to a complication vhich he will rcoogniui aa 
opacity of the rltrooiu humor. If the choroid is free from 
morbid alterationa (of which we can only convince onrKilvos, 
as a nile, after the inflammation ha^s entirely disappeared, and 
an iridectomy lias been performed), we arc justified in assum- 
ing that tlie opacity of the vitreoiui humor is not an expression 
of a choroiditis, but that it is un independent inflammation of 
the vitreous body—a f»ijal!ii«. Tliiu kind of hyaliLis may de- 
velop in the courM! of syphilid even witliout iritia. BtiU, the 
fact that alterations of the choroid frequently a]ipcar Inter, 
ahowa conclnsively tlmt it was a ca^ of latent choroiditia 
(eeroaa). 

The mo^ remarkable Kperific affection of the cliorold, bat 
which can only bo detected by the aid of the ophthahnoscoinc 
mirror, is choroiditis dueeminata^ of which, in aypbilia, tbe 
cmaU macular fonu ia most frequently Men. However, it does 
not follow that the latter is seen cxcluBively, or that tbe lai]go 
macular form do» not occur in ciyphilia. Behind the retinal 
vesBele, in the fundntt of the eye, tl>ere are seen nnmemua very 
small, rounrli):h, ova] or angular, yellowish or bhiinb-wliite, io- 
flammatory depoeitit. surrounded by pigment-cella, especially 
Id the equator bulbi. Towani the posterior pole of the eye, 
A few large deposits of e-xudation, resolting from the fiuniun of 
a number of small ones, may be seen, or the disease ts limited 
to the circumference of the eye. It may d^o happen that 



PATHOLOar AXD TREATStSST OF STPmUS. 

bright, pathological foci io tlio fundus of tho ©re are entirely 
abftciit, and in tlicir pkce the fundos \s seen covered with 
irrcgnlnr clnnip, or regnlar mng8e« of block pigmont. Owing 
to tho fact that the di^coloratiom in 6y]>hilitio choroiditis, as in 
any other kiud of liiflaiuiuadon of ikva retina, are capable uf 
»auniiiig tigiiruK ttuit Ktrilcliigly i-e(«eiiihlo the ty]>iciU pigment 
degeneration of the retina (so-called relioitis pigmentom), the 
error has signing u]) qoite recently of asdaming that retinitis 
pigmciitona i* a munifustatiou of hcrwliuirj- BypUiU*, or ■ pd- 
suit of constitutional syphilis. In choroiditis dieficininata the 
aght is impaii^ to a variable extent, according to llie de^nxi 
in which tlie exteruaL la> era of the retina are inTolrod in the 
inflanunatoiir procces of tJic choroid membrane. 

In tlie treatment of eypliilitic inflatnmation of the choroidt 
mercurial prc]HiratioiiH u-ill be rtMjaired all the more boOMse 
the beet results are derived from ttieir use, even in tho noa- 
speeiAc fonn of tho diseaso. If the acute irido-ehoroiditis is 
once subjugated, tlie Bight will uiateriully iuiiirovc. If re> 
lapiieit of ojxuntJeH of tlie ritreons humor and exacerbations of 
choroiditis di*«miuata occur, mercury will again be roqaircd 
in tho treatmcuL 

LtrLAMUATiox OF TiiE Ketixa asb Ortic Nebtk 

Syphilitic choroiditis, like s3*ph:litic iritis, may be eotn- 
hined with niinitis; tho Latter, however, also oecore alotie, 
and aa a rale in the later etagee o£ syphilis. Specific retinitis 
presents no patliogoomonic lesions whatever; still, it can not 
bo denied that the Byiiiptonis of intlammatinu in the s\'])hilitio 
fonu generally do not a»t6unie that degree of intensity tliat 
they do in other kinds of retinitis As a rule, there ore foand 
merely light -gray nebolar opacities that center around the 
point of entrance of the optic nerve, cover its mai^pns more or 
leas, and spread in all directions; sometimes they are sharply 
outlined, and even at tlie height of the disease ara veiy allgliL 
Afl tho retinal Tnmiihir symjitoms (vonconitios and dilatatioita 
of the Teiufi) are hot slightly marked in must instances, the en- 
tire appeemnoe of the retina might bo explained by the tension 
of tlMi delicate rocmbrano of tho ritrcons body in front of it; 
bat, aJtheugh a delicate, dust-like opacity ia deecribed aa an 



sTPmus. 



early, mrcly altseot, evmptom of retinitis syphilitica, etUl tlio 
marked diminiittoQ of sight attended by aoniilar defect of 
rision eurrguaditig tlie poioc of tixatiuD, and other strikiug 
disturbtiiciis of the fuaetioiis of the retiua, point to tho pres- 
enee of pravo retinal diaeoMS. In other casw retinitis, being 
attendtti by etrikiiij; altei-ations of the slrnctiires and vesseU of 
the retina, \s,per se, easy to diagno«e, but iU syphilitic fotindip 
lion can only ^ye ronfirineil by the aid of other maiiife^tutinnK. 

As a apccial form of retinitis that lias been met witli, cotn- 
hiDod with s^\-phtli», tlic central ref4ijmtiff variriy may be 
mentioned here, -which m^iiifrnt* itAi^lf l)y suddenly appearing 
and disappearing, and reappearing again in the rame luauaur, 
u opadties to the douiaia of the yellow »pot, attended vriih 
corresponding disturbances of vision. 

If gamma Dodoa develop in the bmin in the oonree of 
eypbilis, or the optic nerve nntlergoes gninnions degeneration, 
ns hag been observed Mveral tiine», the pnwcneo of cerebral 
ByphiliB, or of eypbilis of the optic aorvc, may also declare it- 
self by the (Weurrence of refinilit optica — L e., by swelling of 
the intraocular portion of the nerve of vision, Tliis form of 
neuritis is not in tbo least specific ; it only points to the possi- 
bility of the ppMence of a oerebnil tiiniur, wliicli mny indeed 
be a gnmnm. < >n the other hand, the nse of the ophtlialmo- 
scope should never be neglected when the presence of itypbilia 
is Biupect4i|, bocaujie rieuritiK may come on with Tcrr slight 
difiturbancvH of vision, tiie patient complaining of no faalt of 
hie visual oi^n, and yet the presence of a neuritis will mate- 
riallj support the dia^oeia of ocrehral HypliiUe. After all, 
ncoritLB and atrophy of the optic nerve occnr in syphilis, also 
amblyopia and amaurous, witboot any pathological lesion— 
withont any coexisting aigns of cerebral disease. 

The loenl treatment of retinitis and ncnritis ityphilitica is 
limited to keeping off (jlaring and all kinds of hurtful light; 
»be genei-al irentnient is the same a* in cerebral Bypbilin. 

Arromoxs of tuk Cokitea, CosjcKcrtvA, aki> of the Etb- 

LUtS. 

Both hereditary and constitntioDal eyphilia f ud a fertile 
field in the comca — above all, in the form of kcratitut jxinn- 



20-t PATffOlOOr 4.V» TRKATilEST OF SrPSILIS. 

chjfmataga (ditliiHi. iutoretitialis, profunda). According to tbo 
«icn*d of the Euglbh writei^, tliie is the exprosaion of heredi- 
tary sjpUilie, aud siiualtaQ4x>u?ly is eaid to bo prceent with 
other TQorbid processes dc])onding upon tbc kereditAiy dii- 
ease ; for iustauce, in tUmuet all eaaes with a peculiar C-OD- 
fomution of the teelb (Ilutcbirison), nnd in mnnv cmw mth 
dca&ess. Still, we taay merely xftecrt that pAroDcbjruiatmu 
keratim is perhaps the onlj aifcclion tlmt ui most oates k 
CiiiiBfd b^* exlraocuUr cau«» ; tlmt it especially napGrreDee in 
badly noumhed coruititutionH, nnd tfaoe occars alike in chlorotio 
or tcrofiilons indiviilualfi, or in those living in luisury and wont, 
as wc-lt us iu sYpliitit). 

Tmo keratitis punctata which is characterized by tlio ap- 
pearance of a dim, grayish ejiot, oi tng m a piu'e )ioad, in tlu; 
Turioii£ strata, of the (substantia pn.>^ria coroofp, Iinit pcHiap^ the 
chwest ctmncctiou ^itb syphilis, bat is such a great rarity that 
it only deserves to be meutioned. 

Oeeasionolly vb nie«t in syphilitic pcreons an obetiiuto eon- 
jnnctival catarrh that aometimee precedes iritis for a long time 
Yet it can not bo positively nswrted tliat the catarrh, per w, 
vas prodncod by BypbiUs. Both fiarti and a^t cAanerfSy and 
tevondaiy gummata, are found on the conjunctiva, but all of 
tboin are exceedingly rare. 

In regard to affections of the eyclidg, the mott itopoftuit 
in ayphilitic tji^ammaiion of the Utrml (^rtilaget. Roay vptitB 
or macnlie are seen on tile external akin of the eyelid; the^ 
gradually develop iuto rouodish grannies, and when three dh- 
dt-rgo ilcguiteratiuii ulcvrs origiuato. riccrs upon the adjacent 
Boft partfl may also spread to the eyclida. The Iatt«r may finally 
bccoDie perforated, followed by the formation of scara, vhicb 
caufio thciii to become everted, resnldng in ckatridal dieflg- 
arcmcDt and diitortioo. 

Affgctk>x» uf tub Omim, LAciiBrMAL Sao, axd or tbb 

HiracLEB. 

SyphlUa may oocasioD canee, Decroris, and exoetosia of the 
orbital bonee; fi]>eciilc ulcers upon the mocoaa membrstH of 
the hichrymal duct, like caries aud noeroda of the mrrounding 
bony stnicturc-a, may ]>rodnco marked oonatriction of the dnoE, 



BTPBIUS. 



205 



and thoa estalilUli a clironlc Inclirymal disease. Spocific io- 
Jlaaunati<»l of the musclee of tlio ejo nixy poe^ibty restilt in 
paima of the latter, bat as a nUe i\m legion dupcudti upon 
syphilitic afTcction of tho bmiti, tliu ulTuctcd ccrul)ral oen'M 
beiug conipreascd at the base of the brum, or involved in the 
morliid proctee. Uere we have isolated pareses or paralysee ; 
b6II, palMj' \iM Ihsou obeerred in aiiuo«t all the iDueclcct of 
Itotb eyes, ^ot infrequently, capceially in paralysis of the 
masdee of the eye caused by sypiiilis, it ie poedble to confirm 
the fiimultoncou^ presence of partial or extensive amv^tliesia of 
the filiin of the face ; and it can not be denied tliat tlic coexist 
(■Dco of paral^'eia of the luusoles of tlie eyt?, aud of the [)aru to 
whieh th« trigcminnK \s ditttribtitod, points to fyphilis as the 
primary caiisti of ibe disease. 

STpbilitio Affection of the Bones and their Eavelope& 

Next Co the common inte^iineiit :ind the miicoos mem- 
brane, the bom-i! am must frequently riuhjt-cted Ui xyphilitic 
affections, llowerpr, eyphilitic affections of the bones do not 
appear till tlic morbid alterations have inicriBoly and cxten- 
sirely involved tliu itkiii and mucous membranes. Clinical 
experience luu Bhovn that eupertioial syphilitio disutuics of the 
Bkin, roeeola, and papnies, go hand in hand with {>rnof!toal affec- 
tions; on tlio other hand, the deep and eiippurative lesions of 
the sidn, euch u ecthyma and nipia, are associated with deeper 
spectflc pnrenchyniatoiiti liono-ditMrjRes (wlorous and curies pn> 
fnnda), the gnmmoos aCfcctions of the skin or nmeoiis mem- 
brane, with ^ninmata on the skeleton. 

With tlie cjawptioii of inflammation of the iris, no Bpocific 
ieeiou of any structure mnnifeste itaulf by such violcut pains as 
a&ctlons of the periosteum ; etill, tlie pain.4 vary according as 
the bones are involved from the beginning of the syphilitic 
disease or later in its coarse. 

The great majority of syphilitic [latients complain at the 
banning of tlio disease, at tlie time of tlie emptive fever, of 
tearing, drag^rin^ pains, which appear here and there, disap- 
pear eut la-Iy, and then reappear again, which cnuinale from 
the pcriostcom of eomo of the bone«, mmtly of the head, 
■faonldor, and kno(>-joints, and especially the eristic tibiia 



PATHOlOar A\'D riiFATilSXT OP STFHILIS, 



The painfol pUoce aro noiiher swollen, nor is thoir torapcrft- 
Uire iucreased ; jireaeiire opoii tliem uut onl^ dous ii<tt iiicrL*»»; 
the pain, but generally cnosoe it to disappear. The pains, 
tbcrofore, seem ut be purely neuralgic or rtieniuUoid in cbar- 
adur. 

Tbe pains wliicli occur Uttr in tlie course of invctente coMca 
of gypliilis, as a nile, arc more intense, and do not travel from 
one place to auotber, bc«iii»o tlii-y are due to au exudative 
lo«iou Iwtwucii the puriuKteiiin and bone, or to iullainniatioa 
of tbo oudtwtcuni of lliu bono cancelli. The pstiente generally 
deecribe the paiu as deep, boring (ilolorea oaieocopi^ tara&ranr 
U*)', eomo moiutain tliat ttiey feci as if tJie Lodc wure be- 
ing Hwcd through ; others, again, afi if the bono wore cotn- 
preased in a viec. Syphilitic paiutj iu tho boDce arc panicnlariy 
severe at midnight, disappeiiring toward moriuug, altendtxl by 
profuse ponipimtinn ; bonce, they have nlso boon called dohn* 
noetwni, liicord deniee that an aatrouomical period exercises 
any Influence over tliern, and sasertH tluit he ban found tltat tlie 
exacerbations of the pain are only caused by the wamitli of 
the bed. I3ilumler believes that syphilitic paiiu in the bones 
are suporiiiduced by nocturnal febrile exacerbationH, tJic action 
of the heightened temperature causing the veesels of the pe- 
riphery of the body, tbe periottteuui, and the boues, to boooma 
dilated, a huger flow of blood eneiies, thus rvenltiog in swedl- 
ing of some ports of the bones. According to onr experienee* 
the nightly exacc-rljatiune of pain are not felt by all patieDts; 
sometimes ttte pain in tlie afiected bone is present day ud 
night ; sometimes, again, it increases as twiliglit sets in. Tha 
Utter is alwaye the cose when the inflammatory dt-pofiits of the 
periosteum or medullary spaces undergo tiiippitnitioiL jVlttir- 
nately abating and exaoerhating, the pain lasts as long as the 
exndattoQ coutinuee; it suliBides when the iuflammatorr prod- 
uct becomes o^ified, but titiU continues when suppuration and 
carious degeneration ensue. The cause of the paiu in perios* 
litis is tlie tension of the penosteom by ihe exudation that is 
poured out between it and the bone ; in ostitis, by the eeoen> 
trie dilatation of the medullary spaces, which arc eurronoded 
by unyielding boue by the new deposit that takes place in 
them. 



SFPfflLIS. 



gyphilitio IiiLlUmma.tioa of the Feriottaam; TeriostitU SyphU 

Utica. 

AUeiided by more or lose violent pain, a tumor forms on 
flome parte of Uie ftff«.'ct«d hone. If tlie &agoT ie gently parsed 
over it, tbo peun is iiicrei&cd ; while, if tlie pressure is more 
oonoentrated, it in Miuutimes dimiui^bed. Tlie periosteal swell- 
ing coDfflSts of a gelatinouMi, Bvno vial-like, gninmoiin exndntion, 
wbidi, examined microscopicytlly, proves to be jelly-like em- 
brronal couiicctiro tissue. This periosteal inAommatory' prod* 
net is either abwrlied or traiifunni;d into pUR aiid iclior — 
periostitis supparativa Bire eMilccratira — or, in (^oiiscqacnce 
of a tdiDcly deposit of euflicieat salts of Kme, it becomes oaai- 
fied— OfiHifyiii^ syphilitic puriostttie. In the latter case, a por- 
ous bony thickcniug form?, which, on account of its external 
reseniblauee to tufa, h aleo called tophus. I!ut, if the syphiUs 
has attaincfl a high degree, tlie embryonal connective tissne is 
transformed into a gumma or syphiloma — gummoua jterioa- 
tiiU. 

0»»\fi/ing p^ioeeUlt oceura in a diflfnse form or in tbo 
sbape of a emooth, roundish, plano-convex, circuni«cribod, 
olustic swelling. The Hktn over it generally remains tin- 
atfected in its texture, and may be readily displaced. These 
clastic swellings sometimes become very larp;, bnt, notwith- 
£taudiug their eizc, may disappear without leaWng a trace be- 
hind, BO long as they are not oesified. In mimy cases, after 
abaorption Ikaa taken place, the bone retains a cartila^pnoDs 
thickening, due to oeeiSoatlou of tbo dco]ier layers of the pori- 
oetctim. Ossification osaally ensues only in persons of rc^ust 
ooDfititation, especially if the poriof«tcal swellings dereloped in 
an acuto manner. If the perioetitie runs a clirocie course, 
Ofldfication takes place very glowly. It manifests ittiolf by the 
formation, of omtcophytes, exostosis, and hytieruKtOdti). The 
oev deposits of bony matter, at leiist ut fust, are not inti- 
mately and fmnly tmtted to the subjacent bone. The neo* 
pla.sm lies close to the affected bone ; gradually the part of 
the bono in contact with it likewi»e becomes attuckt-d by an 
adhesive intlamrnatiun, on occomit of which the ossific mat>- 
ter of the now dopoeit and that of tJio bone blend togvtiicr. 



398 pATaoLOor AXD rasATMsyr of sypbilts. 

Mo<;t of tbeee oflteopU^tes, especially ujtoa die intemal or ex- 
terual &tirfii«eB of tLt> boucti of the Hkull, bave a smooth, plano- 
coDTcx shape. Sucb tumore were described by Itokiuiiaky u 
ebony-like exostoses, planted externally apoD tlio BuperficUl 
surface of the bouc. They liave a wdl-niarked border, and 
often are sarroundol by a groove ; in textare, tliey are raan 
dense at the places of contact uritb tbe kooe> wliiob, lioweTcr, 
ol&O ap;>car to bo induratul. 

ricuratiug {wriot^titie usually annonnceB itself by a circum- 
scribed, painful swelling, which fiuctuat«8 from the vcr^- be- 
ginning. Tho Rkin over it eoon b«»race red, and fiuee with 
the tumor, fomiitig one common ewelling. The pas occaoia- 
latee betweeu tlie pcriosteutn und the bone, in encJi a manner 
that tho former U raised up for a considomblo extent from the 
bone, and the Intter, being thng deprived of its envetupe, loses 
Its source of nutriiion, in couHefjueuce of wbicb itA upper rar- 
face di^nenites into a carioiu or necrosed condition. For- 
thennore, the contiguonssoft part* may become involved in the 
suppurative proceaa. Ttiere then originates a huge, aprcading, 
ichorous, phngcdcuic ulcer of the skin, that exlcude down to 
the bone. The pna that has formed under the [icri^Kttcnin 
may, however, also become inqnsiatvd into a yellowisli, caseous 
maes, whereby the perioetent indammatory product may reeetn* 
ble tahorcular di^|x)t«it. Exfoliatiou of necrotic pieces of bone 
occnra reiy mrely. Finally, after the nicer of the boos baa 
laeted a long while, the wound closes by the formation of now 
conncctivo ti^euc and retraction of the skin. Wo have ooTer 
been able to demonstrate the occurrence of rappuration of tbe 
inflammatory depwiti in the parietal hiysra of tbe eudoen- 
nium. 

Guinmmis periostitis fumiBhca, daring life, very few dhg- 
nostic points. It is not possible to assert positively whether 
the turaor, that has its starting-jwint in the periosteum, and Is 
covered with normal int*?gunicnt, is a growing tophns or a 
gumma. Indeed, even the ivt;Il-marked, bony hardness of the 
new growth is no proof agninst thd presence of a ej-philnma, 
bccanse, as Virchuw maiotalus, It is a qnCAtiitn wlivtbcr a 
gumma of the pcriostcnm may not become ossified. If ve 
bear iu mind that oven the ocntml part of a gmiima that origi- 



SYPBJLrS. 



Datee from (lie pcrioetcum may ondci^ <Ie$:enentiotL, and tlic 
contiguoafl bono mnst aftci-wanl Ijecoine carione or necroMd, 
it IB clear that a large Dumber of ciuos of guuuuom perioe- 
titis sliould he recorded tm uloeratiug perioecitu. Ucdoo, dur- 
ing life, it h only puaeible to luiwrt, with apjiroxiinitto cer- 
tainty, after the iwrlosteal swolUng has disapixiared witlioiit 
eappontioti, and a dtipressioii is ft-lt through the ttkiu iu Its 
place, tliat a p:iimnia was abHorbed at thiti ])(nnt, and thnt the 
fonu of boiiK leisiun occurred here which Itertrandi and Vir- 
chow have designated ai carits eicca, or infiatMnaU'nj atrophy 
of the corf&T of the lone. There aro autheotic descriptiotis 
by Virchow and others which prove, beyond a donbt, that 
papillary i>truclarcs origtnuting from tlw poriosteuui, and oun* 
sitting of a transparent, gelatinoas, yet lo wish-gray ealKtanea 
grow into contignons bonoe, and whenever the jierioeteDm is 
torn ofi these neopladms are pollod out of the openings in tlio 
bones. The microscopical exaniination of Iheec papillie sho^^'s 
that they arc real gummata. The ganima that growa into the 
bono givee lise to two apparently contrary proceeen, "While 
the oeeeouB ^ulwtanco disappears from the centml point of the 
affected part of tho bono, in coneequoneo of rarefaction or 
atrophy, and a funnel-Hhaped d&])rt-!«i»u m thereby produced, 
new bone 6ab6tan«>e is deposited on tlie circnrnfercDcv of this 
depression, upon the surface siuTounding it, and tn tlie diploS 
coDtiguons to the aiTecte<l placw, which becomeii indurated or 
ebnmated. This hj-perostottis forms aromid the depression a 
Flightly irregtiiar, hilly wall, which gmdually grows lower ami 
Bmootlier till it merges oouipletely into tho adjiicent nurinal 
parts. Thert) arc fr«<iuently cicatricial retractions in the skin 
OTCr tho affected Imny depressions. 

The eroding gnmmata of the bonc« occur not only on the 
perioetenm of the long tubular and Sat bones, but also on tho 
periosteal layers of the dura mater and on the medullary mem- 
brane. They are met with singly or multiple, in the latter 
caw always in groups. Deposits of these gnmmata aro some* 
times found on tho interfial and o:ctonifll bonce of the sknll. 
Virchow ha^ seen several timett an external gnnmia-nodo cor> 
responding with one intemally, and iu one case the bone 
became perforated. 



800 PATBOIOQT AND TSEAT3IBST OF SFPlIUfS. 



Ostitis Byphilitioa. 

In oOBBequonco of erphjlU, tho modullirj epacoe of tbe 
boDce tany be the eito of intlaniinatorr depoeito, like the gelat- 
iuuae new growths behreea the periottteutu uid buno to peri- 
oedtifi, the tine conncctiro-tissQC mc«bofl that oonlain fat be- 
ooming go&oratiiig places for tbe new growth. So \qtig as the 
neoplastic eonnetUve tissue retain* the geJatinoos composition, 
BO long ii ihe nfTeoted p«rt of the bone eoft, and eaeilv cut 
with a knife. If BbEor]>tion sets in early, tlio diseased bono 
again beconiw jwrfeclly normal ; if not. the condition of tbe 
part grudnallj becoint-s altered. The sheeted part becomes 
sclerotic, like ivory, ehumai^d, or it degeneiatee into a atato 
of itU-iiporoiiii, or Ls dwtroycd by r»j>pMration (caries profnn- 
da, according to Kokttaneky), The favorable temiiDation is 
in offteoHKlerosia, in vrbioh ttiu aflucted bone is both thicker aittt 
heavier, bnt not otlicrwise iinpaia-'l. The case is altogether 
different with oslco-porotic lK>iie ; this i& soft, can be bent, and 
baa a aiarkcdly waxy color. When it uodergoea suppuration, 
the ootli^ and the Apaces in the nie«hcs are dilaicil and tilled 
with ichor. The bone is discolored, brittle, or livid, if the 
granulations cxaborato in tho spacce; it rcsemhIcB a patrid 
piece of flesh, and is readily broken down by the prc««iro of 
tbe finger, and may bo cut with tlic knife. It has liMt itj flrm, 
cortacol gnbstanee, and is permeated tlironghout with pn>- 
liferatinf^ granulations. In other eases, a new bone baa origi- 
nateil from tlio o^ieotis cortical nibstance, which goes on grow- 
ing, while internally it continues to suppuTatu, producing an 
appearance as if the carioos bone had beoume inHatn). Ocea> 
sioiially, a circn inscribed ooIU«tion of iclioroas matter take* 
phice; it is wmictiincs Biirroundcd by a hyi)ertrophied oeaeoOB 
sahetance, and is linei] internally by a layer uf rich rascalar 
granulatiouB. The process of nlcerative dcetmetioci consists in 
the fusion of the b<mL-sahiitAnce with tlic waits of the medul- 
lary spaces and with (be bone-cells, which become dilated and 
filled with a mass of finely granular detritus. The fusion of 
the intercellalHr sabstoncc goes on while the salts of lime are 
being diminished. Tho marrow nndergoM degeneration into 
a ^ty ichor, aa a n»nlt uf the duatmction of its fai^ oeDi^ 



SYPn/LfS. 



301 



Adjoining llie ^upptinttiTe prooeee of the bone, the soft parta 
are nlnrays affected to eomo extent with iutlammation, which 
terminates partly in iievr hyporplastic do]>o#Jts, and partly in 
pumleiit iniiUnitioii. Tlie perioHtuiini liecuines IiypertTOpbied 
and united to tlie adjacent connectIve-t)8i«ne pruUferatioDS, 
fonaiing a gelatinons or tibrons bulbous mass, intiltratad by 
puniloit deposits, iu which tho muscles are agglutUiated. 
The latter grow pale and arc de^troyiH]. Aucorditig to ciT- 
OQiOBtaiioefi, the purulent collection, iii or un tlio bone, will 
bunt cxtenuUy, eometimes a large nicer then reenlts, or one 
or more straight or crooked, eimplc or ramifying long cfltuUs 
(fifitulsD, ainnses) form, in the vicinity or at a dietiuioe^ wboae 
openings are generally tturrounded by a rampart of grannlo- 
tioni*, or tbey barrow their way into a joint. Tlio grannlatioas 
have a cliiracterittic appearaaeo, reeonibling » hen's aiiufl, and 
always indicate the prweucu of dead houe. 

Gnmmata occur not ini'rptiiiently in the medoHary space*. 
Lebert, Ilouget, Gosaelin, Follin, Virchow, and CbJari liaro 
seen tlicm in thia locality. Thus, nocn)Ki» of the boneif of tlie 
skti]!, in the course of constitntiomil syphilis, generates pe- 
culiarities which led Virchow tuaiisumc that thin uecnwia bc- 
lougD to the gutnmous form. The necrosis here goes on from 
vrithin ont^-ard ; the dead piece of bone begins to detach 
ite«ll hy the formation of au indented line of dciiiarkatioa 
from tbo 8tni liviug indurated hone, tho bordero of tho Utter 
frequently projecting over tho necrosed piece. Sometimes 
several points of ue^^rositi ara met with near each other 
or at remote placex ; in tlie former enee they cooJceco and caOEc 
terrible destmction. On ita external surface the dead piece 
of bone hnfl larj^ holes, which coalesce inwanlly, looking very 
much an If the gumma had originated within it ; but the in- 
closing necrotic substance is at the same time indurated and 
heavy, presenting a most ])eculiar appearance. 

Cliiari has observed guiumata In the medullary canal of 
long bones, which, during lifo, seldom prodncod any clini- 
cal symptoms They may be absorbed or cause indnration 
of the oeseoQ? tissues or central necrosis. Syphililio affec- 
tions of the bones not iufrequeutly result in spontanooos 
fractoroa. 



802 PATHOLOOY ASD TREATXEyT OF STPBIUS. 



Cieatiiiatian of Sjphilitio mean of Uie Boom 

Roldtanslcj and Virchow etato tlut a sypliilitio oeecoos ecnr 
poe&c«sc« remarkable peculiarities. Aocordiog to tlio former, 
tlie parts Barrouiidjiig an ulcor of the bone display not tnfro- 
qiieiitly imluraliou coiubiued with byperoetoBia. ViTchow dl^ 
&cnbce the eyjilillitic ofibeoas ci(-jitrioD»i in the followliip wonk .' 
" Eveiy Bpecitic acar in a bone is characterized hy a hick of pr*- 
duotiou of 1x)iie-)>iil)«tajico in its center, while a ttiiperflnltj 
fonxw at itji ciruiimfun'iico." If tlie Iwiie, eayB Vircliow further, 
is totally deetrojred at one place, as is often the case in die 
bones of the paktc, nasal scpttitii, or of the tiliull, nothing, or 
at least no osbific nuitter, will foim in itji place. No^rliere is 
this ao etrikinglj to b« seen ae on the skull, where titc orifice, 
on ite inner surface, is covcn.-«l with a mcmhrane so cajiablo 
of producing o»i1ication as the dura muter. The latter soon 
thickens at the site of perforation, and when the necrotic 
piece of bone is removed a scar fornix, on whose borders tlto 
external skin, and tbo soft parte covering the eknlt, the bono, 
and the dura mater ore ftued together into a common mass, 
and nftcnrard nppcors as a white, amcmic, dense, Uiickooed 
Eubfitance. The lon^r it lostfi tlie deneor and shorter it grows, 
so that the nntnral arching of the akull at this point dtaap- 
pears, the entire scar gradnallj becoming flattenccl. If the 
entire thickness of the bone is not affected with necroais, an 
irregular dcprc^irtn will rcsolt after the dead piece of bone 
has exfoliated. Knt HUlc newly formal cicatricial tissue i* 
found later in this depression, and the \os& of sahetanoe here 
is hardly ever re [ikccd bv r^eaentiTe proe C M e s. The only 
sign of regeneration is foand at tlic matgitu. These, wliieb 
ori^ually were rery abrupt, gradually become thinner, and 
subsequently, by the interposition of a bony mvX, usually are 
tranefonned into a space that is perniCAtc<l by gruoves and 
fismtrw. As induration and bypcroetods of the surronndtng 
bony parts regularly take place here, the places resemble Teiy 
much tbocie that have been produced by inflammatory atrophy 
without necrods or supporatioa. 



8TPSILI3. 



SOS 



Site and Effecti of SypMlitio Periostitii and Ottitii, 

Anj port of the skoletoa may become oiFL-ctcd lij sypliilia. 
Tbc cranium, the palate-booos, the claTiclea, the sternimi, and 
the tibiflD arc, however, meet fraqaoDtly diseased, prabuhly hu- 
caoBo these parta arc more liable to be affected by cstenial 
ctiwee, gach as cbangoe of tompcratiirc, tbo air, and eepedoUy 
nwchanic&t injuries, l^oniw with mauy aiiglei>, tmch as tbc plio- 
langea, the metacarpal and motataroi), are wry rarely aficctc<l. 
Tbofle enlarji^jaentti of the boue« of the pelvis, which at tlia 
tioMof Kilian were deiteribed an acoutbo-pulvis orthoni-})elvig, 
ma; perhapA Bomotiines urigiiiato from syphilis. PcrioEtitis 
tmd osteomyelitis uiay occur in the booee that have been luen- 
tionud. The diaphyties alone of the titbolar hones are ahnost 
exdufiivcly attarketl ; tbc C]>ipliyi«ie3 hecome afiected in escep- 
tioiial csifles only, especially in congenital syphilis. The tor- 
minationii of jn-riorttitis nud oKtitin vary in dllTcrcnt bones. 
,Thna ossifying. ulcenitiTig. and giimiiioua periostitis, oaieo- 
siBf oeteopoi'OBis, cariee, and necrosis, occur on the bonce 
^f the xkitll, while tlic intn-maxillar)* {M^rtion of the soperior 
maxilla ifi |>re-i^niinently liable to suffer from sappuratlvo ostitis. 
Specific caricfl and necrosis eoldom originate in the inferior 
maxilla ; frequently, however, ossifying or indorating perios- 
titis develops hero. 

Some of tlio nerve or vnscabu* tranks may be compreeoed 
by ostoophytcB, whereby nenralp^a*, palwea, and diKturljonoBB 
of circulation will be produced. Thus, we saw the iscliiatio 
nerve compreitsed by an exostosis on the great sacro-ischiatio 
foramen, and the corresponding lirab was paralyzed. PanJy- 
ais of the facial nerve and of tlie correitponding side of the 
face may Itc proihiced by an osteopbyte near the fi^kHnastoid 
prooeae. Again, an exoetoaia or % gumma on the sella turcica, 
on which the optic commiasnro Tcete, will compress the nerve 
of viaion to ancb a degree (hat tlic patient may become totally 
blind. Ofiteophytee and exoetosee in the orbit of the eye may 
give rise to cxophthalmoB. By ossification of the intoruul 
auditory meatoB pormaiient deafness may cnBue. Oesitic by- 
pertrophiee on the inner plate of the cranitmi may, by pre^ianre 
on the brain, produce convulsions, epileptic attacks, and soft- 



804 PATHOLOQr AXD TBEATMEST OF SFFBIUSi 

oning of die braio. If a giimina over the frontal einns onder- 
goee aoftuning, or if a large or small piece of the cnnium «t 
tlue plftce bccomce nocrotic, fatal hajmorrhago, bj oponixig into 
the eapcrior longitiulinal sinns, or mGningitu loaj reenlt. 
Carter of the mastoid pro<.t>ss niaj perforate into the tjmpanio 
carity, thereby catiMng detacbment and remoTal of the OKidos 
of the oar, and this will be followed by deafnen. 

Bifferential Z>iagno«it of Affecttona of the Bonea produced by 

Byphilia 

Many of the extrcioc opponcnte of tlie mercurial treatment 
maintain tliot all the atfcctions of the bont» oocamng in syphi- 
litic persoQS are brought about by the use of mercury, and tliat 
eypbilis, per «<!, is not capable of producing either oetitia or 
perioetitis. Still others, who do not deny the oxiatenco of 
eypbilitio-boDe diaeoees (Mathiae), contend that epeeiBo affec- 
tions of the bones arc a combination of sypliilie and mercnrial- 
izatioD — eypbilis that has been modified by a treatment with 
mercury. Bnt neither Orerbeck's erperimenta nor Kufismaul's 
clinical observations fomisb any evidence that mercurial dia- 
eaae of the bones occura. !&[ercut^- attacks only the maxtUaiy 
bonee with penostitia and nccroaia, and then only in conse- 
quence of nierciirial Etomatitis, when the mineral wax UM>d in- 
jii(Itciou.sly and in oxcesuvcly large doBea, and wii^ followed by 
gangrene of the mucoua membrane, and the perioHteum of the 
mnxitlffi. There then originate thow large, pnmicwttone-like, 
porouB, h^-pcrtropbio growths which are known by the name 
of oetoophytea, and dilTor strikingly from Bypliilitic affeo- 
tjons. 

It is impoesiblo to dotemiine at preeent from an anatom- 
ical standpoint whether any given afiection of the bone is of 
feirf-fu/oiifi, tiff^Uitky or tjouttj nature ; nor will it ever bo pos- 
sible, as £ngle eays, to characterize any form of oeteophjte » 
pathognomonic of th)« or tiiat dyseraela. If the diaoaae of the 
bonce be not of a gmnmonfi ehameter, the eUnieal pliyeician will 
have to rely npon a number of symptonu to funu a diagnoaa 
just as he is compelled to do in apecifie di8cnii4>it of the akin 
and mucous membrane. The diagnoos is rendered all the 
more di^Bcult by the fact that in many casea most of the i^rmp- 



sTpmus. 



80ft 



tome of RTpliUls aro absent, bocnafie epeciSc sffoctionR nf the 
bonm Tprj' tiftoii ooour wUliout aiiy eyphilidc manifcstatioiiB 
oa the skiD and macons membnincs. 

In opposition to this view, Kicord tn&intaJna tliat exi»tOMs 
origtuating from sjk'pluUa ofteaer ail«--ct the up[)cr ciirrace, while 
thoM resnlting from ttvrofuk uffc-ct tliu ]iarcnch^ma of the boiH]. 
Rokitaosky and Vlrcliow aasori that the platio-coavex osteo- 
plijte deposited upon the cranial bonoe ia a form of disease 
peculiar to syphiltH. ^c have already allnded to the fact 
that both of these anthon maintain that specific cicatrices 
of bonca are pocnliarly constituted. In regard to gout or 
rheanmtitfm, wo bciiovo that tliis dyscrasia produces the gonty 
nodes rather upon Ibo small jointa — for example, tlie fingers 
and too«; and, further, that it d«posit3 \U infiaininntorv prod- 
act in the form of a powilcr upon the cartilages of the joints 
while syphilis ailects the iihaft of the bone. 

Syphilis of the Ihmkw occurs more fre<|Hently in women 
tlian in men ; furthermore, it ia a freqoeut sj'mptom of faeredi* 
larj s^philU occurring in joath. 

Byphilitio Affections of the Joints. 

Arthn>]iathie!i originating from erphilis occur very seldom. 
The few joint affcctionfl in syphilitica that came under oar ob- 
scrratiou generally attacked the knee and ankle, mom rarely 
the acromial joint, and nuvst of all the elbow-joint and wrist- 
joint. We have no poeitive evidences that syphilis cxerciae* 
any infiucnec in the production of joint aScctions. Some of 
the arthropatliics which wo noticed on syphilitic pottonta were 
recent, appeared in an acute manner, and were attended with 
Tiolont pains; some consisted of degeneration of the joints, 
hydrarthrosis, tumor albns, and ank^'togis. In most cases anti- 
syphilitio treatment exercised no beneficial infltience over the 
affection of the joint, wliile general and XiVsA treatment di- 
rected against the pre-pumable nmlerlying chlorosis, scrofula, 
or goat, was crowned with better succesfl. But even those 
affections of the joints which get well under antispectfic treat- 
ment afford no proof timt tlicy were of syphilitic nature. We 
are only justified in maintaining that a joint is the site of 
lyphilia when it is pathologically demonstrated that the spe- 



806 patsoioot akj> tbbatment of SYPmU^ 

oific morbid protliict of sypliilU, gumma, is fouDd in the strnpt- 
ures entering into tlie conformation of the joint. Till tlien 
tlie occurreDce of specific affections of the joints will rem&in 
doubtfu], to say tlie lea^ Lancereanx menti(»ifi two caaee 
of s,'ii>hilitic ftiffCtion of tlio knoo-jiiiiit iu wlucli gnmoia-Uke 
tuiuore were foand in tbo ejuoviul CAp&ulo and in the liga- 
mcuto of tlie joint. 

ICoccntly man; antbore — cspccialh X61atOD, Lanccrcans, 
ChassugDac, Archambault, Liicko, and Erlach, Ln Bonio; IScrgfa, 
in CojMJuha^u ; \'ulkiuuun, in Halle ; a]id Taylor, iu New 
Toric — have culled attention to a diecoH) of the phnlangoal 
Joints, originating frtHU B}'}>bilis, wliidi Itaa beoa dtiecribed aa 
dactylitia ayphilitioa. 

Specific dac^litis occiire in llic fin^rs and toes. Tlie af- 
fected plialanges are markedly iiicreaiiMl iu thtcknoaj, so that 
tliey aio unable to retain their position between the Hngers^ 
and lie npon their follows. Tho swelling, moreover, is not 
only notlcuabb on tlie diM^aiied phalanx, but nli«o on Uio ad- 
joining phalangee. Tho akin of those phalanges is hhush Id 
color, the ewelliDg is tenee, and on pressure fult to be ela^tio, 
bat loaves uo dvpnaeion; it ia more prominent on the dor- 
eaI than on tlio roUr Eurfaoe of the affected bones. The 
morementa of the diseased joints are more or less interfered 
with, and on forcible motion crepitatioa may be felt in tho 
joints; active movement is almost impoesibla The pain erea 
on proBsurc ie generally slight. Ja thoeo cases ttint came un- 
der our observation, tho first and second phalangeal joints we» 
moat frequently involved ; ttie motacarpo-phalangenJ joint not 
so often. 

Syphilitic dactylitis is duo to gammons depofuts in the anlh 
c:ntaneoii8 ronnective tissue, perio^cum, bone, and tlte IcjctHTH 
entering into the fonnatiou of tlie joiuL Tho diagnosis of the 
(^citic origin of this affection can only be firmly cstaUuhed 
by the previoua and present htstory, and the result of treat- 
inent. In most caaee an appropriate treatment will bring 
abont comploto recovery ; somctimec (here rcoulls a PJMT- 
throeis, or the disease teraunates in atrophy of the diaeawd 
phalanx, while the int^^ument, joint, and teudons remain 
norm&L 



SYPniLia. 



807 



SfpliilitLO direction of the Cartilages, 

The caittbge.'t of the nose, eyelids, and laiynx, in conse- 
(juencc of sypliilis, m&y iindei^ the same fciDd of morbid al> 
tcrations, attended by tmppiimtioii, oa are observed ou tlw: cow- 
tipiom bluD and mucous uieinbraue. If only n, cinall pi«cc of 
mncous membrane overlying tlie perichondrium is destroyed, 
the affected cartilage will be perfoiated at that point, as is tlw 
oasc with the cartilage of the eeptum nasi ; or if the cordlago 
itself 13 attacked, a piece of it will slough away by cariou* ul- 
ceration, as lA often even to occur on tiie opiglottid. In either 
event tlie reet of the cnrtilaj^ nulfei^ ikj textnml ebaiiges. 

The cose is altogether different with the thyroid cartilage 
— here perichondritis and ogeification of the eartilago likewise 
take plaee without inflammation. The lurynx \osai iXs iiatumi 
elasticity, and pnsunire on the Utenil Kurfaces of the thyroid 
cartilages canaes pain. A^ide from the fact tliat in perichon- 
drltiH the mucous membrane of the larynx is markedly swollen, 
tlie arycpiglottic Itgnmenttt degencratu into Hbrom wclb^, the 
Tocol cords become thickened, and thna lose so mnch of their 
mobility tliat, on account of thu oAHirirjititm uf tlit* tliyroid car 
tilage, the laryngeal cavity it; no lunger niirronnded by elaetio 
hot by teiue walls, thus causing marked interference with, 
phonation. Caries or necrosii* of the thyroid cartiloge in con- 
seqnoncc of syphilis occnrs very seldom. But if ulcers form 
in the broad part of the mucoaa memlinine, cqrrcspondiug to 
the cricoid fartilagt', tiie part of tlie cartilage tlint has liecorae 
denuded will bcc/)mc ORsitied and cariouH. If the caries tlien 
attacks Uie upper border of the cricoid cartilage itaelf, the 
joint connt'Ction with the arytenoid cartilage is destpoyed, the 
latter ossitiee, and tlien UkewiBe becomes necrotic. The adho- 
dons on the cricoid and thyroid cartilages then become eo 
feeUo that one of the arytenoid cartilages may bo coughed up, 
or an aliecess forms in the vicinity through rrluch the cartilage 
is expelled. If the aheoess encroachea upon the coniua of the 
hyoid bone, the Utter will also become necrotic and expelled 
throngh the aperture. This kind of degeneration and destrno- 
tum of the cartilages of the liuynx may also originate from 
laryngeal tnberculusis. 



«08 



TOLOOT A.VD TBEATUEXT OF STPmilS. 



SfphUitlo Aff&ctioos of Kosclei, Teadou, and Sheatlu of 

Teadons. 

Disease of aomo of the tiiuscles is a paiiLfuI and not infro- 
qiientlj^ a grave affeetioa tbat uocurs in the later stagea of 
^ypliilis. Specific dUease of the miucleti is Boroetiinee aoeom- 
panied hy pains like tLose of mascalar rheamatLsm. The paina 
graduollii' increase iii severity ti!l thev atlaiu such an intensity 
that the inuaclcs bocoiiio perfectly rigid am] iiDm<)va)>lc. Tlicy 
are then in a state of constant contrnctioa. The pains in some 
parts of tlie inuficlci5 will be considerably aggravated hy oon- 
tacL They often subiiidc, but itiercaao in ecverity when at- 
tempts are made to extend the limb forcibly. 

The diseaae of the musvle resulta from a chronic local 
iDflommation uf the muscnhir abcath, in which a circom- 
aeribod Iijpertrophy caused by proliferation of connective tia- 
Hue eueueK, m> thai tlie primitive muscnlar fibere are dcetroyed 
and ab(%orbed. At the places where tliu mojiciilar flmctlire k 
destroyed, the connective tiseae that proUieratea from the pari- 
mysiuni may, under certain circnmstanc«8, according to Xi^*la' 
ton, increase to the size of a hazel-nut or hen's egg, and con* 
stitute a gumma. Contraiy to ^^^laton'a statement, liow«r«r, 
vru wuro soldom ablu to discover a mosculur node by the scdk 
of touch ; nor, as a rule, did wc find any duuigc in tlio color of 
the akin over the affected parta. 

Thu morbid altorotiou is nanallr situated in the belly of tlie 
mnsole, but is said to occur likcwiso in the Ccndinona part. 
According to our obserratioos, syphilitic contracture* took 
place in the vast majority of ca«» in the biceps bwrhii, next 
ID the biceps foraoris, onco only in the left Rtonio-clrido- mas- 
toid, iu ccmMMjueuce of which coUum obetipuni orlglnatod. 

There are aomo oases of strabiamui occurring in aypldlitle 
patienta which may not be dao to peripl>era] or central affeo* 
tioR of the nervM of the ocular mnecles, but to gnmmoia 
alterations in tho ocular muscles tbomsolves. N61aton baa 
Been gummata in the biccpo biachii, pcctoralts major, nua- 
aetor, in both gemelli, in the lectna abdominis, ant] In tho 
umi-membmnosos. 

Vfo onoc saw a patient in whom gaiumoua tumon ionnod 



BTPBIUS. 



809 



in tlie peroneus of tlie riglit leg ami in the tibulie posticus of 
tho left leg. The tumor of the tibialis poeticns (limini^hed 
markedly iu size after the internal use and lucal appliciLtion 
of iodides. The guiriina in the pcroiicus degenerated and 
broke througli tbe ekin, spreadiog downwanj till it reached 
tlio eorreeponding malleolna. 

Sypliili^tic muAculor disease, when ren^iiscd earlj and 
treated rationally, lasts only a short time; left to iteelf it will 
Wt a mnch lotigor time. If tbe connectiro tisenc wtucli pro- 
liferates into tho muscular tibrilliu is abaorbod, the atTectcd 
mosclfg niav bo completely restored and capable of jxjrform- 
ing iboir f unctiou ; but if the morbid Xemux baa histwl for 
a long while, tlie muscle Iwconies atrophied and forever re* 
maim contraotured. Sjiecific muscular tumore mjiy become 
soft and break through the gkiu above tbem. It is claimed 
that restitution of the muscle iit pontiblo even after the skin 
has been raptured, if the morbid rhangos of the mitecle do 
not exieud too deeply. In the latter event, the moscle iu- 
variably atropbicf. 

There is no doubt whatever tliat the shfftiAs of the iendtmn, 
like any otlicr orgau or part of an orgiin, may become affected 
by syphilid. 

Diseases of the tendinoua eheatbs are, however, very rare, 
few inatancea being recorded in medical litcratnro. In the 
year 1868 Verncuil reported tlie occurrcnco of serous eSnsion 
into the tcndiuoug ehoath^ of the extenBurs of tbe Sngcra in 
STphilitic patienU. Iu Vymeuil's four caMe,all of winch were 
observed in women, the affection of the tendinous sheaths 
occurred simultaneoosly vith the outbreak of secondary mani- 
festations. There was considerable exudation, but it never ex- 
tended to the forearm ; it finctnatod distinctly, nnd the bwcII- 
ingwas sharply ddiried ; the skin was not changed. Foumier, 
commenting on the report of Vcmenil's caacs, says that he baa 
M?on laix ca&Ofi of tlitA kind, and thinks tho ditHMSO is of fro- 
qnent occurrence. This author met with syphilitic affections 
of the «inewe and tendinous alteaths on the extemor mueclce of 
the toes, on t]ic tcndo-AchiUee, on the biccpe of the upper and 
lower extremity, on the enpinator longus, p«n)n6as, etc Ac- 
cording to Foumier, " pamless tumors witb marked exudation 



SIO PATBOIOOY AX£> TS£ATMEyT OF 8YPB21I3> 

occur; huL aouictimca iiiSamnmtorv pbenoineoa, attended br 
redness of tlic tikiii, arc prciH.-jit. Id otlier casoe, Uttte or no 
ftuctaation is felt, the tumor is dooj^hj, or the affectioD can 
only 1)0 recogmzod froin Ike impfured functioD of the miuclo 
and poinfulncss of a tondoD oii prossnrc. Gummnta haro aleo 
been olwen'«d ou the ^uatba of tendons. Thus, BSrUinler oien- 
tiunH B GUHo rv'prirted by Nuiiii, in which a ]>al<>, yvllowish tu- 
mor, half the size uf an orange, fortnod in the tendons ou tlio 
dareiim of the foot, in n person forty<firo jrcnra of age, who for 
twenty years had euilered from Byj>Uilia. It wm expvUed by 
siippiimtion throngh the nkin — a tuniihir one having been ex- 
pelled in the tame manner, some lime prerionsly, from tlte 
sinews on the side of the knea" Chonet, in bia TaJnafalo 
vork, oltw dracrilicd a ca^e of a gumma wliich developed in 
the tendinous ehcath of the oiiterior pcroocnft miucle of the 
right sido. The gumma nndonrcnt degenention and eloogb- 
ing. This leeton appeared fifteen or sixteen yean after the 
pereon became infected. We kiw in a person oifeotixl M-itli 
B^'philia bilateral hygroma of the forearms^ corrcepondiag to 
Uie common oxtooEore. 

Syphilitic Affection of the Bursae. 

We have nuver had an opjMrtunity of seeing an undoabtad 
ttteof syphilitic Hllection of thebnnse; hence, we can only 
refer to the writings of other ppedalists npon tJiLs «peciSc 
affection. Keyos, for the eake of analcgy. divides sypliilitio 
affections of tlie Inirato inUt tlx- eecondary and tertiary forma. 
lie has never seen a caae of eecondary baniUs with or withoat 
exudation into the harea ; still, be thiiik.i the existoaoo of this 
lesion, comparing it to other Bimilar affections of the joints 
and of the tendons, is very probable. Allnnmu to the oecnr* 
renee of secondary gj-pliilitie bnrritis withont effoeion aro 
found in tlio writings of Jutes Voi»in, Fonniicr, and Adoljtbo 
VafBer, GoBsolin, Foumier, and Vomcnil have dcarribod graph- 
ically influntmation of the buraa with etlu^on. Secondary 
syphilitic iullammalion of tlie bnm canaett hUle inconTentenee, 
and may tlicrefore easily be overlooked- Trrtiary affectiona of 
the bursa, on the contrary, arc not ao nonfiiial. Aeoording to 
Kcyce, it ia not posaihle to divide them into tlic gununous and 



SYPBIU8. 



8tl 



hvperjiIaBtic fonns, as thero is no proof of the occnrrenoe of 
the lattvr. All tli« knovn oases ure of the Snt fonu. There 
are no poet-mortem ubeervatioDB of thn diseMO. From a 
dtmci] point of view, however^ two kinds of g^nmons bnr^ 
sitis mny Ik duttiuguisliod : One occurs \>y the cxtenRion of 
the disease from adjaotmt ti.»(nic« ; tlie other originates in the 
barsa itself. Koyee relates fourteen caeee— fieven of which arc 
not yet reporttd — of tertiary, specific hnraitis. In twelve tbo 
bnraic were primarily atfected. The bnrete in the vicinity of 
the knoe were affected eight times ; those over the patcllft on 
both 8i{tc&, in thi-co cams; on one ude, in two case« ; over the 
tuberosity of the tibite, in one case; between the insertion of 
the Mmitendinoitu* and the lateral ligament of the knee-joint, 
each one— upon botli Bidea ulil:«, nnd npon one wdo alono. In 
Uie other four ca^es, tlio barsn, was affeetod on one edde only 
over a ninlleoliiti, under a com, in the pahn of the Imnd, and 
over the olecranon procesB. Botli Bexe* are cfjually affected 
by El; but, in all of the six women, the bursa! of the Imee 
only vera diseoaed. Tlie average age of the patienlJt waa 
thirty-fivQ yeare. The shorte-gt time that elapsed between the 
oocurreuce of tb{! chancre and that of t)ie Imntitu was one and 
a lialf year ; tlic lotigcdt, eight and a Iiftif yaire. In half of 
the cases, an injury waa found to be the cansal factor tlmt 
started tlio Imon. In all caaos tliu diecase mn a ])(uii1cm 
conrso till tlio aVm became involved. Kluetnation roald only 
be detected in eoiiie caj>e;!, and then indistinctly. Antieyphi- 
litic treatment gcnemlly brought abont a rapid recovery— in 
all, marked improvement For further information, we refer 
the reader to the works of Choiiet and Vtday. 

Endemic SypkillB; Leproid or Syphiloid Siieaae. 

During the last eenturv, and nntil quite recently, attention 
WM attrat^ttv) lo a peculiar form of disease that appeared like a 
pert in vai-ions parts of Europe and America. Sometiraes ihia 
was regarded us a modiiication of leprosy (lepra sen olcphanda^ia 
gracomm), and then again iw a di-gc-ncmted nyphiliK; and, nc- 
cording to the rplativr i,Hew of the matter, was described either 
as leproid or sypliiloid." Theee forms of disease were popn- 
larly designated according to the place or provinco where they 



313 PATROLOQY AXD TREATXBXT OP SYPBILIS. 

occnrred most fn-<iiiontIy. TIiii*. in Norway ai»d Sweden it 
was called *' Jiadcft/rje '*' [from rada, bad, miserable, and tyge^ 
post) ; in othor placce— tlic Holstein, the I>iimarHaH, or 
mw«ft — iiuiJutiamidiscaee; in the Aiutro-Hungamn Empire, 
Skerlvejo or Sclt'^rlitn^o, after a village iu Fiumaner Counter. 
There are etill other syiion jma : mal di fivme, di F«ein«^ 
mat di Ragutm^ di Jireno, }'''atcadine. It was aXm epoken 
of a£ Lithuanian or Courlaudian snd Hessiaii syphiluid. la 
Senria the (liiteuHe belouf^ing to tliis group was called Fmnga j 
in the Itukowinn, in l.iubciiburgen, in Itonniania. Buala; in 
Greece, " Sj/irokoloti^ orchidoy and Frani/oy In French Can- 
ada it waa Icuu^'n by the name of mtd de la Bay do St. Patd, 
mal Aagiaigf mahdie den clouicm^nts, the Otiawa dueaae^ 
and aa Canadian syphiloid. In Scotland s}-pliilt8 occnrring 
enilemically was dc^Tibcd as »iavifin^ fHhtn, or gQMna, owing 
to the reeemblance of the moi^t cutaneous nodes, which the 
eril engendered, to a cluster of Scottish strawberriee, which in 
the Celtic dialect is called »iwin. On eloeer investigation 
theite endemic diseauee proved, iu the vabt uiajoritir of cimg, 
to be hcnxlitorj and acquired li^-pliilift; but eejieeinllj the in- 
reteraUj and neglected variety, the eo-called tertiar)' manifeata- 
tioDS. In addition, many other ordinary chronic dlseaaes of 
the skin, such as chronic ecKoma. lupus, jmoriafiis, etc., were in- 
cluded. These cudtmica of nypliilis were soon &nbjugated by 
tlie sanitary rcguktiooit tliut were established for the control 
of the patiente, and by hot^pitoU, where the dieeoeo w(u treatod 
by antieyphiliLie remedies. 

[Kalignant or Galloping SyphiliL 

By the term nudi<fnatU or galtopiiuj syphilis (already al- 
luded to on page 173) is meant a form of eyphilitic dinMo 
that runs an excce<lingly rapid conree, but which diffen veny 
littlo from ordinary syphilis in the eseentlal features of the 
fundamental malady. Tfao lesiona of the different manife** 
tatioits pretient only the characteiistio trait of ruuning an ex* 
tremely rapid eoume. Ordioarily, the mgrbid pheUDmena, 
alter the acute stage of the eruption baa pawvd. lapee into a 
markedly chronic condition, hut in the galloping fi.tnn tlio 
dieeoAC retains ite acute chaiactOTi and the eruptions that toV 



8TPBILIS. 



818 



low euooeed one anothor very rapidly, eo that tlio lesiotiG com- 
utonly dcnoniiiiHted tortiary a)i]>car witlitii a fen- moiitlia from 
the time tbc ]>atieDt Itcciiiiie infected. Tlic Bc<xindary period, 
which ordliiarity lasts two and tUrao yean, is bore only of alHtrt 
duration ; inJued, m Konte cases uo eccocdan' plienomona are 
noticcabli' ut all, tho very tiret cniption being lortinry in cliar- 
actor, the diseaAO aumctimee overleaping the secondary aud 
lajMing into tlie tertiary ntugc in jierliaiw three inoDtlu from 
tilt! tiniu iufuctioD took place. 

}Jone of the coniititntiutiul phenomena of malignant ayphi- 
lia, iucliidiiig tlio primary initial loeioii, display any inurked 
devitttiuu from the oorreepondiug manifeetations of vsuKt that 
ran an ontinar)- coiu«u. Neither the site nor the fonnatioa of 
the initial intliirabwl lesion, neither a panpn-noiw, nor any other 
peculiarity of the chanerc, haa any eifcct in prodncing this 
form of syplulifl. Even the lirei eruption usually presents 
nothing pecnliar, thongh tbo one fcUowinf; niay assume a ter- 
tiary character. lu some casesi, again, iha first general mani- 
foetation of the disease may be a puetnlar eruption and the 
effloreeoenceci, iobtead of dewpuunating and healing, aro rapid* 
It oonvertcd into ulcere. In that case the ulcerating tertiary 
eyphilides differ from their prototy|H) of onliuaiy syphilig by 
appearing in f^eater niimWn, the entire liody being covered 
by them. They vary greatly in form, and are more confused 
and irregular in the caees tliat run a rapid couree. Gupiiiiata of 
the skin are addom or never aci-n e.-irly in malignant sj-philia^ 
a circnnwrtanco that h eafii!y explained by the rapid coarse of 
the disease, anil by the great tcTidenoy of the inorhid jtroduet 
to uodel^ suppuration. Specific affectioua of other ergauc^ 
of the mucous membranes, Umea, vincera, ete., present as lit- 
tle diversity in malifiimnt eyphilis as the morbid products 
of tboBO organs in ca.'^w that ran an ordinary course, differ- 
ing only fifi regards tlie time of their appearance. There is 
but one symptom that ia patboguouionie of thii variety of 
syphilia, name)}', the occurrence of febrile phenomena pro- 
rtous to tlie outbreak of each snecessive emption, while in 
ordinary cases the several empUous are not guueralty ushered 
io by fever. 

Tbe most important rpatnre in the oourse of galloping 



3U PATSOLOOr ASD TREATITEXT OF STPBJUS. 

s^pliilis, as alruaJy intitnaUHi, is tbe carl}- a|t[M?arai>ce uf what 
hiB been donominatcd tertiary pbeaomcoa, and tLe total aU 
^euce or brief ilumtiuD of tlie ttooondar^ stage. But an the 
leeaooa of B)-|)]iili« liuvo beun arlntraril; cUffiiliod, and no 
B^mptom or group of e\-inptom6 ie indicative of the t^tage o£ 
tbc diecase, it ]& impossible to draw a line bcturctin the cues) 
that mn a iiomial and i\\me that nm a rapid niatignaut cotm^j 
actwding to the period that lias olapecd from the time infeo- 
tiou occurred till the appL'arance of the first eruption. Still, 
it will not bo amiat to coiisider tlioso cikps in wLicli tertiary 
manifestation g appear in the course of the first jear as Wlong- 
ing to the gallujiiug or malignant varitfty. It will alKt he self- 
evident tlint, when the disease rnse socli a rapid course, the 
varioos manifestatiooa will he conipUcaled hy preceding and 
subsequent morbid plicuoniena. Hence we have in galloping 
nypliilis new outhrealca of eruptioiw before the preceding onetii 
have been cured, and thene eruptions or the lesions of the Ti»- 
Cera alwura manifest the late chameter of the disease. 

Notwitbataiiding the rapidity of Uic conr»e and tlie eCTerity 
of the vnriou.4 manifestations that cbiintcti-rize malignaDt ftypbi- 
lis, instanced hare been known in which the subseqtiezit otit- 
hnieta of morbid phenomena oecnrred at longer intervals, tho 
eruptions were less eerere and fewer in nnmhcrs, the succeed- 
ing efllorewencefl being piipuliir and ee^n^alcd iuetcad of ul- 
eeniting and aggrcgnting ; and, finnlly, even thin galloping ma- 
lignant syphilis M!cms to have mo its course, and the disease, 
like au extinct volcano, han ajipiLrcntly diud out. 

In regard to the diagnosis there is nothing in the plie- 
nomena of galloping syphilis that is likely to render it nioro 
difficult than in ordinary easw. Indeed, tlie multiplicity and 
profuseness of the em prions, and the severity of Uio ulcei»- 
tions an; apt to render it all the more easy. But in regard to 
tho prognnnin the case is altogctlier difft-n-nl^ It is evident 
that the terrible and frequent eruptions, tho intctttity of the 
ulcerations, the reourrenee of the febrile phenomena, must nlti- 
mately exhaiuit tltc pntii-nt uud tcmiinatc in death. Another 
circtunstauco thiit adds to the gravity of the prognosis in ma- 
lignant syphilis is the danger to the internal organs, e6]>eeiatly 
the bruiu, which may be attacked oarly in the disease; some- 




STPffTLIS. 



m 



times, indeed, before tho expiration of the first year. Such 
caatM ueoaUj- tcntiitute faUlIv (Foiiniier). 

In regard to the catues tliat will produce galloping «Tp]u- 
liftin a cert^ti claeeof pfttiente, little defiiiite is knowQ. Tbere 
is good tuthority for eaying tliat tlie maligniint or gallopiug 
fomi "VtiB quite conimoD vlicn eypbilii! first nppenrefl fpideiui- 
oally; it is now, however, quite rare. CTnquestionably tt de- 
pondit upnii ccriuin cuuditioiis nf tht-eonKtitution uf tbu jKitient 
for ite production — cacliexiu, aleoliolisiu, depraved liiibit*, or 
the like— Hnd wbicb render the system leee able to nmt the 
vinileuey of the syphilitic poison on the one hand and lew 
amenable to treatment on the otlicr, Stil!^ T can recall two io- 
etanouA whon: nuDo of theev cniidttionii olitolucil, both patients 
hcing entirely free from any dieooverable taint that could have 
serTcd as a camo for tLo production of this form, since they 
were middle-ogod, well-developed men with good prerioiu 
lii£torio3. 

The results of tlie treatment of this porticalar fonn of 
eyphiliii may bo rendily infeiTcd from its cliaractor. It is ex- 
ceedingly obstiuate to traetmeiit, and EtnnneAiful n»nlts are ob- 
tained in exceptional cnsos only. Tho oxIiaoBtion oonseqnent 
upon the cxteiuiro drain upon the syBtem from tho nntnerous 
and severe uloent, the debititnfing interenrrcnt febrile attacks, 
or the speedy cnerotichment of the dleeaee li))on some of the 
important viscera, will nullify the pliyKtvian'a eiTorta and 
Laateu the fatal end.] 

Hereditary 8yphiU». 

By the tcnii h'^r&Iitanj ayp/tUis is meant that species of 
eypbilis that id inherittil from s_'^-i)hilitic parents by the prof^ny 
b^Otten by them. Hereditary fiypbili^ ig mainly cliaraoterizcd 
by tho fact that the indindnol^ nScetcd by ic noTtur pruent 
any primary sjieciflc locion. In the majority of eases heredi- 
tary syphilitic children are bom with tlie eWdencce uf the dis- 
ease, or the mnnifestiitioTi^i develop during the first few weeks 
of extra-utfrine life. Gouerally, the eigus of beroditary eyphi- 
lia appear during the first tliree montlibi after birtli. In vety 
rare eaeee the symptoms do not come on till the time of pu- 
berty of the unhappy victim, this form being designated by 



818 PATffOLOOT AXD TREATMENT OF STPBIUS. 

tlic term s'jphiih hefclilaria tardi. nerwIitAnr Bjrpbilie maj, 
therefore, Iw biibdividcd into two varieties, viz. (1) ayphUU 
h«r«dititria pra&KB (wliich ajipeiira a sliort time after birtb), 
mhI (2) fiji'hilii Jwrr/Huiria Uirthi (wdiph doi* mrf. appear til] 
n long tinio after birth, iisnally at the periud of puberty). 

In regard to the theory of inheritance, we may, relying 
upon our experience and tliat of other aatliois, la}' down the 
f oUoffing aphorisma : 

1. If one of the parents is svphilitic it the time the child 
is procreated, it may be Kvpliilitic. 

S. There are «i»e8 in which sypliHitic parents, ctch while 
still inauifudting evidcncca of rcoeut ^ypliiliit, procreate healthy 
ciiildrt-n. 

3. When a mother, healthy at the time of procreation, 
gtTes birth to a child who has inherited the diaca«c from Uie 
father, the mother n-iU Bufier from latent rrphiJis at the moat, 
because till now only three cases are known of motbere bo- 
oomiog infected by the hereditarily erpliilitic ehiklreft whom 
they suckled. (The infection of the mother by a fij,*philit]e 
cliild, tliruiigh the placental cinmlation, according to Rieord 
and Bidny, is called cfti>c en retaur.) Tho eircuraatanee that 
ntotliera never, or very seldom, are infected by their own 
children during w^-t-nnrwng. iw now Icnown as Collea's law. 

4. If both parents were sound at the time of procreation, 
and the mother actjuirea aypliilU diuing pregnancy, tlie child 
nuiy, after being begr^ttpn, l>ccuinc ityplniitic. The later io 
Uie i>enod of geatatioD the infection of the mother occnra, tlie 
more probable is it that the child will remain well, hecatne 
the contagium of syphilta ha^ a shurter period in which to CX' 
erciiw its effect npon the child. ThiA kind of infection of the 
children is called irifecth in ui^i^ (KaE^owitx), or, According 
to Vajada,,po#t«>n<?//»(w»fl/ tumoral i7iferlt4>n. The placenta 
is no obetacto to the paeeago of the contagium from tho motlier 
to the fcBtus, or the rcverae. 

5. The more recent the e\'philis in the parenta, the tDore 
pTohablo is it tbut tho child will be infected, and the graver 
the manifeetaiioiia in the latter are apt to be. Generally, the 
infant!? arc (rtJU-boni, or oome into the world hearing spoci&o 
numifesCationa. 



SYPBILK. 



817 



6. li tlie diseaao in the parents U Intent, the cliild will de- 
velop sjifliilis a long time after iu birtli. Gmvo forms of tlie 
dises^o arc then rare, still they arts tiot always al^seut in chiU 
dmi of such parents. 

7. The longer the time which liaa elape*d after tlio specific 
Bjmpton)8 in tlie parents have dixappearecl, Hm letw probable 
is it that they will beget syphilitic children. 

8. In till: uiajnnty of cutHfs, syphilis in tlto pan^ntx gradu- 
ally grows feehler, m tluit, after licgcttiiig some sypliilitic chil- 
dren, they finally procreate healthy onee. 

Tliufic aphoriumB are the concliieiona of our oxpcn'onco. 
No infallilile do^ta for hereditary eyphitlK and its disBcmi- 
nitioa, boverer, can be laid down, and we and others hare 
ccrtatuly mot with exceptional cases, which will aiford food 
for thought concerning the dissemination of tlio disense. No 
doubt that, by closer observation and more aocarato knowledge 
gained coiieeming ht^rodity in genoral, the myfitfry tliat Btill 
envelops mnch tliat \» i^trange and hiddun in the Ktudy of tliis 
chapter of ^rphilis will be solved, and the prepress of science 
in the fnture will find the key to these problems. 

In K^rd to tliiB influence that nyphilut exercises upon preg- 
wmcift it may be premised that the fcetns very often dies m 
■uUro very early, and then the macerated ffftws {infantet «cmi- 
eocti), prtiw-nting tlic apiKamnce of having been ecaldod, b 
aborted. Whether the death of the frntoa is tiie result of dis- 
eue of the Untm itself, or of the uterus and plaecuta, hu not 
yet been definitely decided. Pollnow regards hydrops tangui- 
noltntua a? an iiitra-uterine disease of the foetoe, and heredi- 
tary ijphilie a« one of the most frequent catiecs of it, Barnes 
thinks that syphilis oiigondcrs a morbid condition of the uter- 
ine miicouti tuemlirane — a ehrutiic inflammation — and Kince tlie 
placenta which develops from the latter is tlie organ through 
which the fcetufi derives it« nntrimcnt, the latter mnst natu- 
ndly die «'hun its fountain of nutriment is diwHiscd. Vireliow 
found morbid altcmtions in the maternal part of the pla- 
centa that reminded him stnjngly of giimmoiis tnmors («»• 
domefrUiM pfttLyniaris ^urnmoaa). Fnmliel has alo demon* 
atratod, in the fetal jmrt of the placenta, a dcgencrition pro- 
doced by cellular proliferation of the placental folliclee, which 



S18 PATUOLOOY AXJ) TttSATMSyT OF SYPEJUS. 



may caneo compreseton and oMiti^mtlon of the follicrillar vee- 
Bela, asd fioally terminate in fatty degeneration and atrophy 
of the placental folliclee. Oediiuuuon foand, in firo com* of 
nbortions prodoeed by nypliilis, alterations in tlie »t?ibilic^il 
veitels and in tbo plaiwnta. Tlio tuubilical t'esele presented 
atlMroruatouH inflamnuition of tlieir walls ; in tbe miun lirancbeft 
tlirombi wuro found conetitiiting tbe picture of intcntitial pU- 
ceutiti*. H. Zeissl noticed that tbe placentas of sypbilitk 
women are comparatively nniillcr, fcebli^r, and will«d, fatty, 
pule, and friable; tlio snrface facing the atoms pretKDtA small 
or large spota of 8»called bcpatizadoo, which, in tbe npper 
strata, are infiltrated with calcarcouB incnulatunis. 

Children, who are overcome by the syphilitic diathcris 
dnriu|; iutro-uterine life, are either bom with the niaoifeet*- 
tiona of tbe syphilis, or the latter appear in the tir»t few days 
after birth. Uowcrcr eren ctdldrcQ begotten by fathcn suf- 
fering from latent syphilis may come into tho world npp«reiitly 
well, and remain well during early infancy. Ijiter we notice 
the gradual formation of infiltrations (fatflely called tuptu 
tJfphUU hereditaria) n\)o\i eome ]iarts of tho elcin, with simol- 
tanooos destruction of tho soft palate and the naeal bonee 
(fisama typhffitica), tho occnrrence of hyperplasiie on tiie 
ontilal or tubular lionet, etc; phenomena which fonnerly, 
even more than now, were deemed eridencea of ttcmfnta. 
Hence, aa haa been remarked, a congenital gyphilis may be said 
to occur wlitch raanifoMlit itsrlf in vtera, or a few days after 
birth, and an in^rrifni tiyphilin, whictt oasts off ita mask Inter 
daring youth. If syphilitic pbenomena appear in a nuraltng 
eerer^ ntoutlis after birth, euc-h as vre see in the first pbiflM 
of acquired Ayptiilis, tlioy eliould not Iw regarded ae the rasalli 
of inherited eypliitis, bat of syphilis acquired /vr partum c* 
po«t parfiiTTt. 

In regard to motliora who give birth to diildren with he> 
roditary syplillia, we wish to add, that Itntcbinson' IwUeves 
that repeated liuaring of Ri,-pbiHtic frptnses gradnally engendeni 
a Rpeciiic |>oiHoning of the mother, and tlut the conseqaeneea 
of tliiit poisoning often appear rety late, in nliich cane they 
manifest themselves at once as tertSarj* phenomena. ItAren- 
spuog luaiutains that tbe sooien of a sj-philitic man, wbicfai 



STPBIUS. 



"319 



under ordinary circunuitancea, is Iddocuoiis for the womui, 
witt infect her m sood as he impregnates li«r. Womeii who, 
at tlie time of oooception, are affected with recent Byphlli*, 
Reldom give hirlli to a viable ftetns ; the^ generally alwrt or 
miscarry at the l>egiiinh]g of the ui^ith montli or L-;u-lior. Ao> 
conllng to Whitehead, four per cent of syphlhtic infected motb- 
cra ahorL AVo can not confirm the viewa of Mayer and Bcduar, 
that all mothora afTtMttod with ccHUtituUoual Byphilifi aro abso- 
lutely sterile; Btill, H. i^i»sl met nnth tn^y cases of women 
soJIeriiig from intonuU syphilid n'ho were unfrmtfuL Uc saw 
vomeQ wlio had no signe of syphilitic primary loeion, or any 
epecitic exanthema, affected with pcrioetitia and falling oat of 
the hair, and with intense anieiuia, which phenomena disap- 
peued apcQ antiBypbilitie treatment. lie bolierw that in 
theee estsat the &cmeu of the Byphtliiie man was the medium 
of infection of the -u-oiuniL 

Uanlfeitatlons of Con^eaital Syphilia. 

Congenital flyphiii-s ungxnidt^rs morhid altenitiong (dmilarto 
those produced by tlic aw^iiired form. Infanta affected with 
marked hcre<Iitary fiyphili« iit iha time of hirth are, as a mle, 
b«dly nourished ; the skin generally, ntid that of the face espe- 
cially, ia wrinkled, ^ving them the appearance of a wcazcued, 
morutnatie old man. 

The morbid alterations of tho general ekin resemble veij 
mnch the analogous eni|)tions of acquired syphilis in tho adult 
According to our experience, however, congenital syphilis of 
tho elrin appears only nn^cr three main formg, namely, macu- 
kr, papular, and bullous eyphiUde. We never saw rupio, ecthy- 
ma ami cnlaneouB nodes in iufanls. 

As a sign of hereditary syphilis manifesting itwif in the 
earliest period of iufaney, Hutchinson mentions the peculiar 
curving of the upjier incinor teeth; this lesion U auid to W 
due to a ^ulty development of the dental aocx that kecjiS pace 
witli the general atrophy of the body. As a consequenoe. the 
permanent inrifoTn romahi short aud iiaxron-, being wide at the 
hue, ami their ,ingle» rounded ; their lower honlors aro deeply 
indented in the center ; they have a dlrty-yelloni&h color, and 
«eem to he eemi-tranaporcut. Similar ngn^ if they appear on 



830 PATSOLOGY AND TZEATMES'T OF SYPaJLTS. 

the other t«e(1i, are eaid to be of do diagnoetic raiae. Wo an 
not inolincd tt> atUicii uiuch importanco tu tUcm. 

MaciJar STphilide in the Znfimt ; Erythema Kaddo-pspulatom 
Syphilitioiua Heonatorum. 

This gyphtlido generally develops in the first wocks of in- 
fancy, if tUc new-born child does tint coine into Uie world with 
it. A \atti Mj>]wanuice of macular syphilide in the iofsnt altmjrs 
indicate.') that it vrn$ not infected in vtero, but ontsido of it,poti 
jMXTiitm. or -per partarii. Macular syphilide of the ncw-bora 
presents the satuo cIiaractc-rieticR as itti prototype lu \ha adalt, 
originating tliroiigli accjuii-ed syphilis. Most of the spots tlut 
attract attention are situated on the stdee of the tbomx, bo- 
coniiug sparser toward the nlcmutn ; tlit-y ore never seen on 
the uuck and face ; a few occnr on the forehead where the 
hains cease to grov. 

II the aficcted child is not treated promptly and jndiciooiljr, 
other syphilitic phenomena quickly make tJieir appeanaee on 
different p(Lrt« of the hoAj, Flat, oopper-eolored iiMlnlos, as 
big: ns a lentil, then form on the palms of the hands and bo1«0 
of the feet, and on the heels, and ^uou become covered with 
ydloviah walce, which may bo easily pulled off, or excoria- 
tions and fiasoros (rhagades) cniglnatc on the places mentlonod, 
eq>eda]ly on the heels. Frequently the grooves near the aba 
na«i are remarkably red, and covered with Qne, whitish sealet^ 
vhile mncous- membrane papules are present at the anglee of 
the mouth aud nasal orifioes, upon which the mucus has dried 
and formed crusts. These kiuds of liuraid cutaneons or intt< 
coufl-mcmbrane papules form in tho folda of (ho buttocks, in 
the hollow of the knee, at the anus, Krotum, and in the gcnito- 
croral folds of both sexes. The papules Ihut arc mot with on 
the Utter places soon Io«c their caniDcnlar conditiun, from 
caufiofi already mentioned, and are then likely to l.>o mistaken 
for intertrigo. The denuded eoriom on tlicw places secsretH 
a yellowish, gliitinons fluid that speedily pntrofios. In many 
infants, erythema maculo-p»pulatum eyphilitica appears, at in 
the adult, on the internal Hurface of tlio prepuce, on the glans 
penis, and on tlie labia minora. Or drcnmscribed tlark spots, 
varying in size from that of a lentU t4> that of a bean, occur on 



arpmua. 



381 



tlioee placee, wliict become excoriated by catarrb of the glans 
or of tho Tulra (that is frequently preeentj, aud *ro trunefoniied 
into bright red abtadotu. 

In some ca£«e, a few eolitarr leotienlar papules are found 
among tlio roAQOla>f>potii, mostly on the elbov and on the in- 
XQTaa\ eurfacos of both tliigtis. Wc never nir macular e^bi- 
Ude on tho new-bora or nureling without the suiultaucoiw 
prefienue of moist i>a[)iil6M on Boiue ptitcus, for histaoce on the 
anas, Ubia majora, angles of tlm nioiitli, and between the toca 
The cnvica), axillary, and other glands eeldom swell up to 
such au extent in conaetjueuce of aypliilis congenita in the in- 
fant as in the adult. 

So long as no phenomena of anppuration snperTene, macu- 
lar Byphilide in tho new-born child runs an apjrexial course. 
~Wo can recall hut one codo of recovery of a child affected with 
syphilis congenita maculoea. All the others became antemicr 
and terminated their miserabie existence in about two or throe 
weeks, from comjilicationa with exhausting diarrboDO, bron- 
chial catarrh, or pneumonia. 



Papular Byphilide in the In&nt. 

UTe fonnd that papular eypbiUde, in its various metamor- 
phtMce, occurs leae fre(iUL'utly than tho niaoular form in the 
new-born, uud, in rcgurd to location, suucceis'ion to and combi- 
nation with other e^'phihdce, it beharea precisely as does ita 
prototype in ibe adult We have rarely doen the »o-eaIlod 
papnlo-milinricfl or lichen mtliarics syphilitica as the rcenlt 
of congenital syphilis. In children who do not bring papnlea 
into the world with them, the eruptiou wilt not develop siraul- 
taneonsly un all the places wtiere they naoHlly occur; this 
acconnts for the liudiiig on such infants of young and old 
papnlee. 

In rare casea, the papules are grouixxl together so closely, 
on Bomo ploccK, that their scales fonn an atmoet unbroken 
coat-of-mail. Most of the scales, in the (wo caaoe that came 
under our obderration, occurred on the bade, sidee of tho 
chest, on the palms of the handjB and soles of the feet, and, in 
part, on the forehead and nape of the neck. 
SI 



8Sa PATnOLOQT AND TREATJilEST OF STPBIUS. 



Piutal&r, Oammoiu, and HeBmon-bagic SjphUide ia the In&at. 

We obeerreil poiatalar or bnlloos ctitaneoiu affection in the 
new-born more fVe^jiiently than papular Bvphilide. Ia£uib 
either bring it with thum into the world, or thc^ become 
affected by it during Uio firet week mitex birth. In the latter 
caso, browiiiali-red spots or papnlee, raryiug in etze {rom that 
of a lentil to that of a pea, elightlj elerated above the lei-el of 
iho skin, ore found on tlm furolicod, oepecialljr near the ej^ 
la^es, in the face, now and then on the chin, oq the bnttoeka, 
on the extensor and flexor liurfucce of the extremJtiM, and, in 
p-eaieot nuinWm, on tlio jMilnu ctf the hands and wlee of the 
feot. Within throo or fonr dnjB, most of these B]>ot6 and Sjit 
papulee are changod into flabby pusttJeB, oontainiug yellaviah*. 
green, thin pus, of the fSsxs of n pea and larger. The pnstule*^ 
are not perfectly round; here and there, especially on the 
palms of tbo hands and eoUct of the foot^ they are indented , 
and irrcguUr, as the result of the coaloscenco of sCTcral ^j^\ 
gregated etllorescenceB. The center of the poiilulus colUpeoA' 
epeoJily, whereby tho umbiHcated depression ensoes. fiat, 
while the central deprcesion of tho cover of the ptuitnle drloi^ 
and forms & thin oraet, the remaining pnmlcnt contents nuMl 
the contignooa cpidenuie, and the poetulnr wait that has not' 
yet dried ie thereby increa«Mi in circnrnfereucc. Tlie red- 
dened cutis beneath the thin cmet te found eomowhot injured, 
as in varicella and impetigo of the nursling and adult, bat b^ 
no means very scriuunly. Tliis is a somewhat hastily skotelied 
morbid picture of the entaneona dieease which is gesefilfy 
described aa peuiplugus syphililJcus neonatomm, a synonym, 
which H. Zeitail deems incorrect, idnce neither trantpar<t$U 
resicles form, nor, as in pemphigus foliaoous, do the oootenls 
of theae blebe, that speedily become opaque, wash awoy the 
epidennal covering, resulting Bomctimea in tlio exposure of • 
large extent of inflamed culia U. Zei«dl therefore deenu It 
more correct, in accordance with tho htwe of analogy, to do- 
scribe the eruption tmder consideration as varUvila »i/philiiiea 
eof^ufnr naonalorum, because in the latter, am in the confinent 
varioloid ii>-philidc of the adult, an mnbilieated d^VMiUia of 
eome of the postolos conlainiog thin pns, reeare. 



STPffTUS. 



323 



Severe excoriations generally occor on the beels w an ac- 
oeaaory pbenomenon in the bnllous or pustular sypliilidfa of 
tbo now-bora. The tiaaal caviticfl of nioet of tltoeo iofantA 
gradually become occtudud by Uio drying of the secretion of 
the Sclmeiderian aicmbrane, in coiiee<~jaeDce of which breatb- 
ing tUroiigli the oode beconieu diiHcult, If not impossible — tbo 
little ]xiticnt being obliged to goiip for breath, and anaUIo to 
Huck the breast, if tlio preearioua existunoe of a new-born 
diild affected with pustular sypUilide is prolonged for u fort- 
night or more, paronycbtal HwyHingn will form on eomc of the 
ungual joints of the Sngere and toes ; moRt of tbeee swelUnga 
b^tn to supparate near the muttix of the nail, whereby the 
latter id Rubi»e<jucutly cunt off. AVe bavo never xeen onychia 
ncca in children afflicted witli hereditary sypbib's. The same 
is true of the falling out of the hair and cyebrowa as a result 
of 8)'plulifl congenita. 

PuEtnlar (typbilldc iB attended by a rapid palm, and for 
that reason Iho patients arc very r««tles3. All infanta afiected 
with this syphilide that came under the care of H. Zeissl (most 
of tbcm foundlings) died before they attained the age of two 
or three weeks ; tliose that were bom with the eruption seemed 
even more wrct(*he<l, and succumbed in a week. Those that 
are attacked by the bnlloiw fwrni fn'tjnently die t'n u&vw. 

It Is very difficult to di8tingtn6b between tlie pustular 
cypliitide andpemphigua cac/ieciicorum of the new-born. The 
only sign by which, according to our nWrvation, tbe-se two 
cntaneons diseases can be distinguished from each other is, 
that in pcmphi^iid cacbecticonuQ the bulhe dry, form crustB, 
and exfoliate much more quickly than in i>cmpbigus syphiliti- 
cnfl. After pemphigns cachccticonun has fonned crusts and 
exfoliated, the former effiorescence qniekly beoomee covered 
with a new cpidemial layer, while tlie pu.<itules in tbe so-ealled 
peiaphigufi sj.'philiticus are more pcreji^tcnt, and after thoy have 
Qzfuliated new akin very seldom forms npon them ; nor do any 
new puKtnlcs originnte in the former on the plaech where mme 
had already been located. While idl die new-bom children 
dieted with syphilitic peraphigns that came under our ob- 
aervadon died, tbo.sc suffering from tbe cachectic form some- 
tunes recovered under gixid nursing and care. 



S24 PATHOLOOT ASD TRSATXBJTT OF STPBIUS. 



Id iiifaiitit we very rarely saw impetigiriouK or tlie wxalled 
crtLiiUiceous «ypbilidc in the form of sni.ill, itn]x;tiginou8 cmsta 
OD the Bculp. We bave not met vith acne syphiltde, octtijni&, 
or nipia in the Dew-bom as a resaU of Byphilie ; on the other 
liind, iu tlie few amm of rupia in grown-up cliildren tlut 
came under our observation, ve could always detect the spot 
wbere tlie infection took place, and thus prove tliat the child 
ac<inired aypliilig after it was bom. From personal experience 
we feel equally jiigti&ed in denying tbc statement that vesicu- 
lar sypliilides, euch as bcrpos and eczema sypkiUtioi, ever occur 
in iiifautfi. 

We have repeatedly seen nodfdar XifphUide, orBupporat* 
ing or perforating tubercles, t» a symptom of hereditary syplu- 
liSf but only in children several years of age, in the fonu of 
nodcd that beoaiuc tranHfonntd into conflocnt iierpiginous nU 
ceiB. This lesion never ocoub In the form of ecsttcred nodea 
in the new-bom or nurdiugs. 

So for wo have mot with no casoi of nyphUia h<emor- 
Thagica^ such as have been reported by Caltx, Behrcnd, I>eah- 
na, and otlietB. Iltemorrhagic Byphili«, according to Cehnsnd, 
is a peculiar morbid tUteration in the circulatory appuBtaa 
which occurs almost exclusively in inherited veDcrtttl disewe; 
Bult2 is. the only one so far who liaii detvcriltt^ a few cases 
that have lieen observed in tlie adult. It is eliamcterizod by 
OGthymous eruptions on the sldn, in thosnbecrou^ tisEnesand 
the uieuingeii of tJio brain ; and proliably aUo in the paren* 
chyma of tlio organs ; f urtlicmioru, by hiemon-ljago from the 
navel, after the cord has fallen off, so that we may have pur- 
pura and oiupbalorrhagica syphilitica, in eombination or sepa- 
rately. Either may occur with profiific bleeding from an acei> 
dental injury, or from Uie apparently eoand mucoiLB membnue 
of the mouth, uoee, or inteetinal canal. 

Bchrend r^^rde the marked fragility of tbc blood-vessob 
and dinnnishcd coagulubitity of t)ie blood as eaoGcs c^ the 
bleeding which is prodnocd by syphilis. Uiemorriiagic ityphi- 
lis is not identical with hiemophiUa, for the latter represenit 
ft permanent diathexis that will last through life; tlie fofftner, 
a transient litcmorrbngic diatbesu. 



8YPBIUS. 



8S5 



STptiilitio Affeotions of the Hacotii Membrane in the Xnfiat 

In oongenital sjrpfailu, as m aoquired Hypliilis of the ndult, 
tlie mucous membraQea are aSoctcd mostl}' in tlioee parU tliat 
are viable. Accuniitigl^', Uiu iia«a] miicouit niuiiibranu, espe- 
cially at t]ie margin of ttie name, tlio mucous membrane of the 
mouth from the red bonier of the lipe to the faucee and 
larynx ; furthurmorti, thu muc:ou8 mumbrone of the aaua and 
genital oi^DR — where it mci^cs into the common intogumcot 
— ^will be affected. Of all tlio places the lipe, efii>eciimy the 
an^es of tlie moutJi, are the niotit fretpient rates of specific 
affections ; next to tliift tlie istlimujR fniicium, tho tongue, the 
inteni&t surface of tho checks, and the Ups; furthermore, the 
nraoocB membrane covering the carlilagiDon« part of the nasal 
septum. We have iie^'er seen any B^-phiUtic diseases ou the 
posterior wall of the faucti*, pharviix, and the higher regiuDS 
of the Da&al passages in Infants and older children. Very 
favqocntly, on the cootrar}', the mucoua membrane cofering 
the vocal corda and Jklorgagnl^s cavity of tho lan-nx ia ewollea 
and diseased — a condition which, owing to tho inacceneibility 
of the ports, is only detected by tlie cr^-ing of Uio infanta, 
Tho thoD omit peculiar piping-ehrill tones. 

The morbid alterations of all the parts just mentioned 
manifcBt tliemselvw by permanent rednefw, cTTthemn, or by 
the formation of M-attcrcd or confluent pnpnlar intlammatory 
foci. The epithelial cells on tlie papular inflamed epola are 
either pearly-white, Uie 0}iaeitiofi diMip^iuaring if the piipnlutt 
are abaorbed, or if they degenerate and euppumte the epithelial 
celb are destroyed, whereby the affected places are transformed 
into erosions that bleed readily or into auperficial ulcers. Sup- 
puration ensuo! on the plaet^ ttiat are meet exposed to press- 
ure or friction — thus, on the lips, nt the aiiglee of tho mouth, 
and at tlie margin of the anus. At these places tho dennded 
swollen cutis gecerally cracks, and then quite deep Hesuree and 
illigades form. These bleeding crevices become covered witli 
cnuts compoecd of blood and matlcr, and render sucking and 
tiefecation i)ainful. T\m proovfis recurs on the tonsils, avnla, 
and palatine -Aivh. 

In the nil rifling we have tteeii vegetations (pointed oondj- 
lotna) occur only on the mucous-membrane papules at tlic anus. 



SfiC PATHOLOGY AKV TREA72IEST OF SYPniUS, 

Wd liave ouly eeea giimniala» and deep ulcere rcealting from 
ttiem, iu Uii! niucoiui moinlirano (>f ilie luooUi, fauces, uul aasal 
caritjr — corcr in tLat of the reduin or external geaital orguu. 
Once we oWrved deep tilc«re id tbe toDsils in coexifiUog gum* 
ma of tile tongiie. 

Hvpliiliiic lUToction of the tia«al mooous membrane — coryta 
ity^j)kitUuM monatorum — Drigiiiatee in Lhe following maQQer ; 
Tbe nasa] nnicou8 metubnuii!, espcinallj tlmt of tbc riutilage of 
ike iia»U eeptuni, liecomce markedly rod and aliglitly swoUvii. 
Ooca^ionally the epithelium eveu liere ia opaque or abraded, 
and at fimt nwretw a pmfuse but thin mncns, wliicli gradu- 
ally becomes thicker^ jellowi^, purulcDt, and iiuajly ichoroiia. 
The mucous membrane of the nasal tractals eroded hy tLo 
irritating diechnrgo and bleeds uusily, the di^ihargo becom- 
ing streaked with blood. Like the mucous membrane of the 
septum, the margin of the nasal oriticea and the akin oi tlie 
upjicT lip become excoriated. The thicker tbe diadiArgc, the 
lai'gcr the amount of blood that exudes, and the greater the 
number of blood-coagula, tbe more will tho alroudy ewollen 
nasal poseagcs bcoMno narrowed, eo that the little patient b 
aliaoet totally unable to breathe with the mouth ghat. Sock- 
ing tlie breattt then becomes au unepeakabte torture, aa tho 
occasionaUjr coexisting afFi>ction of the tocidU i(«etf renden 
that process exceedingljp- difficult and laboriouK. We have met 
but one case of the Kinking iu of tbe bony na^I framework by 
preceding necrosis of tlic vomer or ethmoid. No cose of stink- 
nose {puttam:) in the iicw-bom came under our obeervaliuo. 
Some years ago J. ^ieumann published tho rcj>ort of an an- 
topay on an infant that died from congenital syphiliB, and bt 
whom tho ethmoid was destroyed, and the bony framework of 
the nose had coUapeed. 

All or aome of the morbid alterationg of tho miicoos mcni- 
braiice, just deecribed, very i^tduui occur alone ; in most of tbe 
ciu%s, tlicy aocompany the morbid Ivbiouii of the oommoil integn* 
ment, already d««cribed above. 

Syphilitic AffHrtiOQ* cf the Bones and their Tonics. 

The skeleton of children snflering from hereditary sypliilia 
may not only be attacked by those discaacs of tlie bonce with 



BTPBIUa. 



337 



wliich we became acrjnainted in shidying ttie lesions occorring 
iu pcnoua witli acf^Tiired s^'philis, but iu additiou it is aubjcct 
to moet rctuftrkahlo and cliarnctoristic uioHiid ultcratJonA. Tbo 
latter conBiBt eeeentiallj in a dieturbanco of the normal growth 
of tbo Imnca of the infantile skeleton, and repreecDt Mmetimes 
atrophic conditions of the prc-formed cortiluginoiu and osecooB 
iabMaace, and again of new growths of tLo bony etrueture. 
The moet frequent, and probabl}' the earliest, bone-affection 
which is caused by hereditary syphiUs is dueaae of the epiphy- 
sit uf the tubular bones, gneb ns the rartilaj^bone junction of 
tho ribfl. Wngiier, WaUlyer, and Eubner maintain that thia 
procen i« especially pntbognomonic of tlie intra-uterine origin 
of qrphilis. KObner r^ards it even aa a new pathological dif- 
ferential sign between the htter and aciiulred »ypbili8 of young 
children. These authors invuriabiy found in uU the oongeni- 
tally s)*philitJc children dissectod by them, even in al)ortiona 
of the seventh month, tlio alierathng of the os»'{^cati(m bound' 
arw of the tuhul^ar homt and rlh«. Even when the altera- 
tioQs seemed to be maeroscopically al){ient, which was soldotn 
die cate, dioj eoold be positirely diagnosed micnMen]>iciilly. 
In mo«t CBMB gnmmats, were found nmnltaneoiuly in the io- 
tenial orgaua, and mnooos-membrane or cutaneooa eyphilide, 
and syphilitic lesioiia in the placenta wero lAs^o preoont; bnt, 
erm when all tbceo were abeent, the bone^jartilaj^ b<3nndary 
was snffloieutly niarkc<L Tliese oliservem saw macrrvcopically 
all the Btages of tho«e altomtions from tlio simple spreading of 
the cartilage proliferation-zone and the epon^ layer of Gn6rin ; 
from the ifregular, ehaggj encroachment of the omification-zone 
and of the cartilage up to tlie U>t<d detaf'kment of the epiphygig, 
by a widened yellowish rone between the calcareous cartilage 
and the grayiah-red, pulpy eubstaivoe developed from the epongy 
portion of the bona The microficope ehows, on tlic carlilagc- 
bono boandaricl^ that the young medulfary spaces are chohed 
up with ^ranuintion-tisfitf, consisting of small, ronnd, or angu- 
lar and spind]c-phapcd elements, mixed np and attached to one 
another by prolongntions. In addition, wo find Bonwtimce a 
thidc, sometinioB, again, in ease tlie ^Mphy»ia heeom/t d*- 
tadied, a semi-fluid etilwlanee like a KuKpRnosteal gnmmata ; it 
never bccome» pumlent, as Wagner claims, nor is it devoid of 



828 PATHOHOOT A.VO TRBATMKXT OF BYP3ILTS. 

Tucolari^. The second diaracterisdc whidi tLej digoovered 
Is tlie extremely imperfect devdopmaU qf tke osUellofU, de- 
scribed hy Grt-geribmicr tod WaWycr — lai^ multiplo«haped 
cells rvady to t)eooinv oeailicd, irliK^li in tlie normal bone&re 
found in a continuous larer like epithelial celld, hut occur herc 
siiigl r and Ytny imperfectly' developed. lu their pUco suulII 
grunulattou-ccUj, or Icntj, tpmdl^^Maped elemente^ ore present. 
Iq addition to thc£D constant tltcrationa pertoetitia oeaiScuw 
was fotuid itt the vicinity of the epiphyeial boimdwr, though 
only in tht! nKist a(]vati<-e<l cases. Waldj'cr tnd K^bncr dc- 
«:ribe thiH lesion an KyphUUic gramilaiion-yrowtfi. 

Tlie inrtammatory discflse of the "growing cartikgo," ao- 
oording to I'arrot, ])roduei?fi tlioae jteculuir piuiuiio-jMiralj/»e$f 
wliich sumctliuuit ocL-ur in ihe extremities of children afflicted 
witli HyphiliH con^nita. The cavMs of motor distuyhatice* are 
the sappurating processes resulting from an atwceSB situated 
above or beluw tliu joint, and whii-h eeparatvB the epiphysis 
from the diajiliysis, though the uerves and tnuMrles remain 
totally uninjured. Id addition to the epiphysial detachment 
mentiouc-d by Lowin, C. PvUizzari and Tofatii gpeak of fract- 
ures and infractiotia in the diaphysid of the ribs, aod Pkr- 
Tot deecribca oroaone and perforation of the skull {cranivta^ 
and plaffio~cfpk<Ui<t). 

New growths of bony Piibetaneo and oeteoj^ytoa occur 
oftpcciatly on the lower epIpbyKial ends of the long bones, and 
on the cranium in the viciui^' of tlie anterior foutaueUe (Pai>- 
rot's Ufltifdnn tikull). 

It [& esifiy to comprehend Itow the di^turbanres of nutrition 
in the growing bonejLj caased by bcnditaiy syphilis, may be 
one of the cau»^ of mchitlB. 

Mectiona of the Eye in Conseqneuss of Hereditary SyphiUi. 

Ophlhalmo-blennorrhcca very often ocenra in children who 
suffer from congenital syphilis; iteometiniei originates when 
the catarrhal process of a syphiUtic coryza is transmitter! through 
the lachrymal ducts to the conjunctiva of ono or both eyca. 

Wliether tliat lesion in wlucli the remuants of an iridic 
choroidilU tbnt Ims run its conrse in ubrro — niinioly, the unioQ 
of the iris and contca, the latter being ooTeru*! uiure or lets 



arpmua. 



839 



with orfpinized mafcruJ, ami intcpcalar staplivloma — ore fonnil, 
shuuld l>e described as the effects of herediur/ syphilis, ia & 
mooted c^iiostioD evea amoug oculidte. E(j[ually uufcrtaiii is 
the question regarding tho cooticction of keratitis paniQchy- 
matosa in infancy and yonth with bcroditjiry gyphilia. Oca- 
listA epcak more positively regardiup the oecurrenco of iritt't 
«e 9yphilid0 hervdiiaria. Th« diagiioais is hnu^ \\\Mn the 
DiArasmatic condition of tho iufonta, upon the protracted char- 
Mtar of the difleaae, its tendoncy to form Ryneehia and oecla- 
sion of the pupil, and niwu the extraordinarily rare occurrence 
of ordioary iritis in childhood. 

Morbid Alteratloni of the Internal Organs rcmlthig; firom 
Hereditary Byphilia. 

The mn«it cvtimtimt and frequent alterations resulting from 
hereditary iiTpIiiliH are found in the liver. Schott deeoribes 
the lirer in ej'philitic new-bom children as follows : " It ia 
ttSDflUy enkrgod, dense, reddish, or ycllowi^— bcuRC, on in- 
oisiog it, it i« seen to be speckled in some plaoos ; the ontUn«« 
of the acini are obUteraced in most cases, but the incised ttaae 
was found unifomi ; the moro dnnse and doaghy incialoos weK 
glossy and Urdaceoiu. In another caee there was found, ia 
the hepatic parendiyma, over tlie large vuRAela, a rouDdinh, 
ycllowigh, white, dense nodo as big as n pen, around vhich 
trhitiah wclta ramified in different direetiona" 

In regard to tlic forms of syphilitic affectionn of tlie livt-r 
in the infant, Schott nays furtlicr: '* While the fomw of he- 
patio syphilis in aiinlts vary, perihepatltia, accompanied by 
lohahitioa of the hrer, or interstitial hcpiititiR, or, lahtly, guiu- 
mous nodcd being prcectit, iu children widi hereditAry syphilis 
tro find hardly aurtliing bttyond indnration, seldom any nodee ; 
stiil, even when nodes are present, wo can not always safely con- 
clude that the ease is one of syphilis, since other proccescti, euch 
IS effoBioQ of blood in the Itvcr, may al^o oecaeion them.'* 

We, too, have seen repeatedly in the liver of ayphilitio oliil- 
dron, sharply outluied, yellowish-white node« b/« big ai^ a hazel- 
aat, proliferation of comiective tissue, and cicatricial retractions. 

Many phymcians look upon an enlargetl spleen a^ an ini* 
portaut clinical symptom denodug hereditary Byphilltt. Klebs 



880 PATS0L06T AJW T&BATMBST OF BTPBIUS. 

foutiil, in tbe panerea* of a ftetus six niontlm old, a namber of 
gumitia.-no(lEN, and FypluHtic ludotut in the lungs, liver, and 
kidneys. Fartlier^ lie mentions a case of sjrphilia in the infant 
doBcribed bj CraveiUiier, io wUicb tlje paDcrcas vae trans- 
formed into A vhibu, dcoAC, lardoL'CouA mate ; at the Bamu time 
gamma-nodeB wcro prceont in the thymus gland and white 
eypliUitic pneamonia ttu notic«d. In twcDtr-tbroe cases of 
disease of ilie epiphysial ninrg:tD of the bonoe and enlarge- 
ment of tho Bpleen, Birch - Hinchfold foand tho pancreae 
affected thirteen times. The morbid luaon cuusii:1ed of pro- 
liferation of the interstitial dseiie and atrophy uf the glaiidn- 
lar pai-cnchyma. 

Olivier, Cmveilbicr, F^rster, and T^agner saw, in tlie Imigi 
of infant)! who died froui HypliiliB, lolxilar indurations whlcb, 
wlien cut into, were found to he yellowish, red, or gray in 
color, the center being cheesy ; theee indorated depoeita were 
pronounced by tbcni gommatjk or ^^'philoniatu. We, loo, have 
eeen similar ind)initc<l t^potA of tlie size of a lioxitl-nut in the 
parcDcliyiua of the lungs in the cadavers of syphilitic infanta. 
DifiDMd eyphilomatouB infiltratioa may extend orer both Inugi, 
or affect half of one long, or even leas. Tho intiltratod plaecs 
are deetitato of air, reddi^-gray or yellowish -gray, smootbt ho- 
mogeneous, and necrc'ting a nifagt-r ammmt of opui|ue fluid, the 
bronchial tnbcs nro normal in width, dllcd with air and para- 
lent mucufi, the mnooua memhrane is pale and thickened, and 
the bronchial ghuxhi hypertniphied. ITnder the microaoope 
the inter-alveolar tisene is «oen to be dilated by a dopo«it ot 
atrophied or fatty degenerated cells and grannies, albnmen, 
and fat^molcculea ; between tliew is found a idight amonnt of 
homogeneoQ» basement enhetance. Tlie mucous membrane of 
the noall bronchi is uuifonuly infiltrated with a deposit ol 
celk and nuclei, and in some places there orccleTationa with 
broad hosof. The ploune of syphiloniatons lungs are gen- 
erally normal ; the pulmonary tieene is fiim, heavier, and only 
slightly dilatable. Kobner and WaJdeyor have aUo noticed, 
in the lungs of hereditary syphilitic patients, namerous nodu- 
lar guniuista and diffused, inter-alveolar, smaU-eollcd granula- 
don-proliferatious. 

Klebs thinks that intnt-uterine renal ttfphilit b not tnfre* 



SYpmiis, 



331 



({oent, and lio describes a case of tlits kind in -wliich g:nminoii8 
dopoeits, oontaiQing granaUr tissue thtt hod been traiisformcd 
into spiudlc-cclk, were foaod in ^e Iddnej. 

Tireliow claims that ho has bood WTcral times, in oongeni- 
tsA Bjpkilts of tbo Dcn'-born, entargement and fatty dc^nera> 
tion of tile supra-reniil caj>tuh. 

In tlie oadarer of a boy six days of ago Pureter obssrvod 
fibnnd degeneration of Peyer's infe^tinjil rjlnndti, wbieh he 
prasoiiiee was the effect of liereditary sypUilis. TlieM glands 
projected above tlie level of the inucoiis innnl>Tanc, tlie pro 
jection increasing toward tlie center of the plaqae; tlie color 
WAB grayish-red, the upper enrface dense and glossy. On soo- 
tioo, the tUickcned patches were fonud to lie hard, glotsy, and 
gray, and cunM not bu tom off fn>ni thv unaltered muMular 
coat. The ulcers extended to tbe Qpper end of the ileum. 
Hi^er up aloere in groups of twee and threes were found of 
fear to eix millimetree) in length, while those in the ileom 
were mostly eight to twelve millimetres in length. The ul- 
oeiK were oval or round ; here and tbere they displayed a tend- 
ency to form a ring. There were no normal Peyer's patches 
to 1)0 seen. Simjilo inflammatory swelling of the solitary fol- 
liclM, but no ulcera, were found in the colon. The mesenteric 
glandB. and the small, firm »p!eeii, were imrmal. The mlcro- 
ecopical appcarancee were as follows : The hypertrophied pro- 
jecting plaqucscoiiHistcdonlyof a denae network of connective 
tiame, which extended ns a uniform layer from the upper 
BQrCaee to the mmcular coat, and was quite poor in celb and 
granules. In the center of the plaque, whero it appeared 
rough, the connoctivo tissue broke down into a dues of finely 
gnmtilar dclrituB. The villi ecaecd at the borders; the eylin- 
drical and lenticular glands wery entirely absent 

Roth defscrilies Kimihir apptamnces found at tlio autopsy of 
a ebild five days old. 

Schott states that he found, in the cadaver of a cliild that 
died with pustular syphilide, tumefaction of the inteetlnal 
glands, similar to tliat observed in scarlatina, typhoid fever, 
and, in rarer casce, in Icukeemic oonditioDS. 

Mra$ek found eypliilitio afiections of the email intestinee 
in ten out of nearly two hundred caaca. There were cither 



333 PATHOLOGY ASD TRBATilRIfT OF SYPBIUS. 



ditfiLsed inflamniiitory ur t;k-i>ical sjrphililic Icsioo?. and tlit lat- 
ter were partlj in the form of infiltration aronnd Pejer'a 
plaquos, partly in the form uf irrvgulmrlj scattered uodci uul 
, granules. 

In both forme there were infiltntionfi of email ccUa into thfl 
intesdnes, tbe li^vperplasia starting from the adreotitia of small 
aiteiiee. Tlie occlasion of the caliber of the eann], cnoBed by 
tbeae inHttriLtionE, interfered with n proper blood-rappty (o 
the part, and resulted iu the de^neration of the deposits and 
□odes by ana>mie necroids. 

In the brains of the cadavers of children that gaccnm'bed 
to coDgenilal syphilis, and vrere examined by Sehott, only one 
kind uf altcralious waa found, namely, gelatinous tomora ait 
big a« a hazel-nut bent^i botli anterior Io)m9. A microscopi* 
cal examination proved thitt their structure was similar to that 
of the tnniors described by John Miller, and which Wagner 
fotrnd in the vicinity of the corpora quadrigomina in a perron 
who died from puerperal fovcr. Jiroodbent eeldom found the 
brain affected iu infantile eyphilis, and he beliertis that some 
casee of tnhercular meningitis were mistaken for infajitilo 
syphilis of the brain. 

IIutchiDson lias obecrred nervous affect ions in ooniieqneDce 
of hereditary 8y])hiliii, which inaiiifeKted thenuelvea by eon* 
vulsiona with aiinullaneons kerato-iritis and atroj^j of tbe 
optic nerre in a child eighteen mouths of age. 

Hughlings Jackson *avt a ca^e of facial puralysis ond pars* 
pl^ia in a syphilitic child snfTering from licr^Klilary eypbili*. 

We found in a hereditary syphilitic cliild numerous gom- 
mata in the brain, and marked thickening of the right facial 

nCTTO. 

Henoch eaw several cases of afiectiun of the fftttt ia cod- 
aequericc of Iiere<litary sypbilie. According to Uenning, mor- 
bid alteratioiiB may also occnr iu the Itnaeta of children sai- 
faring from tlie hereditary dtwaee. 

In consequence of congenitil syphilis, morlnd altoratJona 
may occur in the thymu$ gland, in addition to those orlf^nat- 
ing in the permanent oigans. Paul Dnboix frmndaccamnlatiotu 
of pns in the thymas, especially in those infanta who 600- 
cumbcd to a ctmgenital pmtnlar eyphilide. In the year 18S8 



STPBIUS. 



S33 



'Widertiofer dtseectn] a female infant tliat died from a pustn- 
Irt nypWlide lefreral hours after binb ; after tlio removal of 
the sternum tlio Uijnnus attracted atiuuttou bjr being almost 
doable tbo normal sizo. Its cxttiruul eurfaco contained f-everal 
Bpotit abont the size of millet-seeds, which, owing to its tluD cor- 
ering, permitted the purulent conteuta of these plaeca to be seen. 
They appearud like small cavities. A longitudinal inci&ion laid 
opoD a cavity of the size of a hazcl-aut, whose apparently 
Bmooth. walls contained a thick, yellowigh, purulent fluid. Yel- 
low, Byphilitic nodes were imbedded in the eiil^tance of the 
U<rer. Wedl's microscopical examination corrobonitod the ox- 
iatonce of a true absccse of tho thymus gland. 

Diaf^oais and Prognotii of Congenital SjphilU. 

Congenital syphiUa in the infant can no more be recog- 
nized by one nymptom than it can iu the acquired variety in 
the adalt. A positive diiigiiCKiLs can only be made by passing 
in review the whole train of eymptoms and studying the en- 
tire pathological picture and all the phenomena present. 

The prognosis of congenital Hyphilis is extremely mlfavo^ 
able. More than two thirds of the casea that die from eyjthilia 
belong to the congenital variety. The morbid Icsiona origi- 
nating in xUcro, or shortly after the birth of tho infant, ob- 
Bervod by U. Zui^el, almotit invariably lerminated fatally. Pus- 
tular eniptiouK, grave catieo of coryza, afTectiona of tbo viscera, 
arc tbo most dangerous symptoms. Infants in whom syphilis 
breaks out at birth, or shortly after, die sooner than tlioee in 
whom the disease appean after tlie Vi\mi ut several days. 
Those who are brought up on artiScial food die sooner than 
those who arc nnraed by a healthy mother or wet-norse, and 
propurly cared for. Congenital syphilis usuaDy put« an end 
speedily to the prcciiriuus life of these new-born children by 
lobular pneumo7iia and exhausting diarrhoais, accompanied by 
bloody stools and vomiting. lufants, whoso life is prolonged 
by judicious treatment, usually remain backward in their do- 
velopmcnt, and retain marked indications of having passed 
tlirough a scrions disct^c, meh as tho caving in of the bridge 
of tho nose, prominent frontal protuberances, opacities of the 
cornea, cicatricial lines radiating from the angles of the eyes, 



S34 PATB0LOQY AJfJ> TREATMENT OF STPEUIS, 

monUi, nares, and nnn« (llutcliineon). Lftter marked pecnliari- 
tic3 of character develop, and special tendendee to ncaroMt 
sod mental didturboiiooB. 

Syphilis Hereditaria Tarda. 

Id mre cases Fyphilis that ts inherited from the parents does 
not appear till niiojr months, indeed, aometiniee eveD manjr 
years, after birth. This form of inherited sjphilig, described 
o£ AarediUtriii tarda^ appears ulmo^t exclusively vrith the phe* 
nomcna of tlic gnnimatoim pcriwi of Bjphitis, which differ in no 
respect from that of aoqoirQdejrpbilis. Aa an effect of inherited 
syphiliB appearing late in youth, the mneous membrane of the 
check, mouth, and fauces, especially, is attacked, and the hard 
palate becomes perforated. Similarly i^.rpIuh'B hereditaria tarda 
seems to have a special predilet-tion for the mucoiiH mtmiltmoe 
of the nooe, and not lofreqaently terminates in deetmetkm of 
tliecartilaginoiiB, indeed, even tlie bony iiawil franiewnrlc. Gam- 
mata of the sltin are comparatively rare, while periostitis, ei»pe> 
dolly of the long tubular bones, oecars quite often. The dta;^ 
nosis can only be established by iwwertainiug carefnlly tl*o 
hiMory of the patient, and by excluding acquired syphitta. The 
Bymptoma mentioned by Hntchineon — the pecaJiar indenta- 
tion of tlic permanent incisor toeth of the ecoond dentitiOQ 
period— in our opinion, is of no great valne. Wo have nerer 
Been a cafle of hereditary eyphilis M'hicb appeared after the age 
of nineteen ycare. 

Treatment of Sypliilla 

"We will now de*eril»e in detail onr views reparding the 
treatment of pyphilig, which are eorrolwrated by Diday, IL 
ZoifiBl, and Biironspning. Like any other diseasBi Kyphilis 
may get well spontaneoosly In a long or short time ; and if a 
Bpontaneons cure takes place, it is likely to bo di'tinite. Allow- 
ing syphilis to run its course spontaneously under a carefully 
regulated diet is called the ht/gUnic or txrf>e<^ttt a*eihod of 
treatment. In addition to the expectant method, there is the 
treatment of syphilis with mercury, iodine, and ve^uble retn^ 
dies. There is no doubt whatever that mercury will eaoBO the 
symptoms to diaappear very rapidly in the majority of caMt. 



SYPB/IIS. 



886 



Dut it ifl eqniJly pcrfain tlmt when mcrcnry is employed very 
early — as soon as ihc priinarj Icjgion is deteewd, or tlio first 
eniptioii appears — d)« H^-mptoms then present will, it h tme, 
speedily d^ppear; but obetiiiat« relapses are more Itkely to 
follow than when djrphilis ih firet allowed to spend it« fury, 
lu otlier words, merc«ry, if employed in tlie first few weeks 
of syphiliti., wiU^ it is true, soon dieeipate the aymptonu, but iit 
DO more able to annihilate tlio syphilitic diatliceia in. a short 
time thaD the expectant or iodine trentinent — en the con- 
trary, if need too aariy, it retarcte complete recoTcry. hx oar 
opinion^ mercury ehonld not bo used till eight or tco weeks 
after the first eruption has appeared, anloss the latter is too 
slow to diiappear under cxpeetaut or iodine treatment, or dan- 
gorotu pheuomona l)ircatt;ning some of tlie organs of sense, 
the viscera, or the oeiitral Dorpoos system enpcrvcno. We 
coincide in the opiutoQ of It. Zeis^l, " thai it is not the mer- 
enry tlint in injiirinuK, Imt the improper time cliosen for em- 
ploying it against syphilis." 

True to the precepts of H. Zcisars school, our method in tlw 
treatment of iiyphilis, briefly sbted, is ns follows : In patients 
aSected with an initial primary Iceion, but who are still en- 
tirety free from specific phenomena, such oa glandular enlarge- 
meat or eruptioiiB, the treatment ts confined to the local Icaon. 

If the first eii'phiiitic phenomena appear upon tlie common 
intepm^ent in the form of a macular or papnlur cmption, we 
proBoribc DO auti-epccitic remedies for the patient, oven when 
Buppnrating papules are present in the nioutli, on tlie h'ps, or 
on tlie touMilii, but seek to expedite tlieir involution, and to 
render tliem less jjniinful by prohibiting the aec of tobacco 
and cantcri^dng them with the solid nitrato of silver, or by 
pencilinj^' tbeni with & solution of tanno-glyeerine (tannic aeid, 
S-OO [3iv], to glycerine 20-00 [3H8., 3iv]). If the emption 
hsA not entirely disappeared at the end of eight weeks, or if 
no improvement is perceptihle; we tlien prescribe the prepare- 
tioua of iodinck 

If tlio symptoms of tlie diocase have not entirely disap- 
peared after tlie expiration of eight weeks more, the treatment 
with mercnry may bo resorted to without any fear eonccming 
the futorc coarse of the disoaso. Our favorite romcdice arc 



336 PATnOtOOr A.VD TREATMENT OF STPffTUS. 

Zittm&n's decoction luid tlie inunction of btae mase. B^v pur- 
suiug tlie course nientioaed, a smaller number of inuucLkms 
axe noccHsar^' to ckiuo the ffpnptonu of the dleeeflc to dUap- 
pear titan if a m<;mirial tn.iitnient h inititutoil fnun tlie ban- 
ning. We seldom emploj mcninrjr eulwutaiioously or admioifr- 
ter it interDally. 

Another importaut <jueetioQ tlmt prctonte it«clf to Uiq 
gypMIologist is, whether the troacmcnt of tho dieease ia com- 
pleted when tho symptoms that verc present at the time the 
patient came^ndcr observation have disappeared. This (jace* 
tiOD can only be answered by tho Htatcmont that the dieappear^ 
ancc of the symptoms is no proof that the diathesia has been 
eradicated ; for othenrise no relapHo would follow after a 
longer or nhorler interval. We agree, therefore, most doeided- 
Ij, with the French writei-s, capecially Founiicr and Marti- 
neau, that the treatment of syphilis eliontd be continned u 
loog aa pos^iblo. Tnic, it is not necestiary that the patient 
be constantly auder the eye o£ the physician ; the subfieqacnt 
treatment may, in fact, be left to himsulf, it being neceeaary to 
instruct hint to apply for medical aid ag^ as soon as any 
6ym]>toni8 recur. 

We think it is very important for the patient, eron wbcn 
it]t the s^'mptomfi of ttic disease have disppearod, to continao 
the treatment with iodine for a long time, at least for a whole 
joar. If a patient deiures to l>e treated with mercurial prepara- 
tions, M is now and then the case, a cycle of ten to twelre in- 
unctions may be tried during the first year, albeit no ^rmptoma 
of syphilis manifest themwlves. We know, indeed, from 
experiments which TTelim and II. Zelssl instituted, that even 
healthy pei-socs tolerate large nnrabere of inunctions of mer^ 
cnry witliout tlio least Injury, Taking this fact into consid- 
eration, we allow the patients, after the symptoms of 8^■p^uli» 
have disappeared under the above-dawrilicd method of trcat- 
mont, to rusort to the iodine baths at Ualle, if their means and 
tb« season will permit. As soon as they return from the baths, 
iodide of potassium or sodium is again employed, with intervals 
of longer or shorter dnmtion, depending njwn the appearance 
of symptoms of iodiera. But, if the circumntaneea are eucb 
that the patient can not travel to the baths, he sboold drink 




STPffiirs. 



837 



hwator at liomo for a long timo, and then go Ijack to Oi« 
Suh of we of tlm prepanUiom uf iodiue. 

So fw we liave boeii jjcrfcctly siitielied with t!ie result* ob- 
talui>(l l>y the metliod of treatnieiit descrilied, the pi'dunged 
u»e of tlie ii^idea Dever having proved iojurioiis to tbc patient. 
Bat) in view of tlio etotcineut of Foumior and othor authora, 
who assert tlut grave eyinptomB of alTi-Ttiuti of the ceotral 
ncrTODfl Bystom eosae in those casee of eypiiilia tiiat have not 
bcCD treated at all, or only insufficiently, we always prolong 
the treatment as macb as possible. We arc conviacod that 
mercnrtal preparations play only a subordinate [lart iu a oonrao 
of anti-speci6c treatment caiitinued for n jti^ir or more ; bnt to 
treat syphilis with merenry for full dve jeara, as some of the 
Fretich phydeians do, is hardly jnstttiable. 

It is not siife to declam a [Wtieut permanetilly curvd if at 
least a year has not elapeed after the last symptoms disap- 
peared. 

We will next eay a few words r^iarding the prophylaxia of 
syphillit, aud then describe in detuil tho expectant and olhor 
methotls of treatiiK-ut. 

Prophylaxis of SypUlls. 

We (Ustinpiish poneral prophyUris, embracing wbolecoon- 
tries, aud oue that has rcferoucc to tho individual. Tho for- 
mer belongs to the domain of nuiitary jKilioe, and tlie student 
is referred to tho literature on that subject. 

Since sypliiliu Iua tteen better known, reinetlies have been 
sought which would afford protection agnin^ the abi>or|)tion of 
the syphilitic Wms, and would make the absorbed virus in- 
nocuous. 

Quacks often pretend tliat tliey liave many Pcraedics capa- 
ble of accomplishing this purpose ; but none ever proved effect- 
ive. The bt»t protection, comparatively epeaking, ia derived 
from the use of tho condom. 

If a person apprehends that the syphilitic contagium hu 
gained an entrance into hia system tlirough any point on tho 
skin or mucous membrane, the physician can only snggcet to 
him to take ench measures of protection against tho further 
elleoLi of the virus m are employed against tlte ahwrptiun of 

23 



339 PATHOLOGY AXD TSEATMBSTT OF STPUrUS. 

other pcniicioviH matter (glnnJt^nt, rabic*, aitd i«ofl-cIuuicre rf-J 
ms). Strong caosticH, Buch ae {Hinetrate cl«!pl>' iutu tbe tis- 
euiia, iiuy be used for Uie purpose uf deetrojing tlio poifiou st 
thv pliicu of cntraDCC. 

Wo know, from conntlcss cxpcrimonts with tbo viru of 
the soft cliaticro, that it van be tuiido banulcee to the Bysteni, 
if tho plaou where it wia <lop08ito(i ia thorooglilj destroyod 
with cQiifiti(» within tliroo days. Bat the time iu nrhieh tbe 
Bvpbilitio riniH caa be roodered innocuous by doKtroyinfj it 
with cauiiti<s hu not yet been deSniluly a^tcert^ned by similar 
experiments It was snpptwed tluit, since eertoin excoriations, 
tliat origiuatc during intcrconrsc, through which the s^'phi- 
lidc Tims may take effect, were etfectively cauterized within 
thrw> days, the ^irus oonid certainly be dcBtrwyod by caustioa 
irithin a few homB after it was abeorbed^ and thus rendered 
hariuleae. Unfortunatelvi most of tbe patients fail to notice 
the place of entnuico of the poison into tbe eystem, and dO' 
not become aware of tbe fact till the specific primary lesion u ' 
fully developed, and is undet^inf; molecnUr degonoratioii — a 
process wfaidi, as a mle, XslVvb jikce three weeks after infection 
has Dcenrred, at a i>eriu(], iberefore, when the blood is alroadj ' 
containiiiatod. Tbe Ixst a^uts with which to cauteriie tbe 
place where the vims penetratvd is caustie potaak and VieDom., 
pa8t«. 

Mercnnal treatment will not protect one against the origin 
of ey]>hilis, for oven perscnis who arc engaged in punniitH where 
a great deal of tbe mioezal is need — for inetance, mirror-pliitecB^ 
gilders, and others — are not proof against the diseaee, as baa i 
Imh:« found liy experience 

An English physician (Wilks) propounded tlie qno£tion 
whether B^'phills conid be aborted The delibentiooa of %.'\ 
c<Httmiaaon rcetUted in tlic coDcltuion tliat it wag totalljr n 
less to mnovo a Quntcrian primary indnrat«d lesion, «ine« mo- ' 
ondary symptoms would noTertheless appear. 8igmnud and 
Hieonl came to tbe nune oonclnfiions; the latter mys tbe Endn- 
ration in not to be regarded as tbe came (origin) uf sx-phiUa, 
hut as tlie effect of the conittitntional affection. Quite n> 
Mmtly, tnany- pbyEtcians have again taken up the subject, and 
stated that they have obtuiucd good reaulta b^<xciain<; thepri' 



STPRILIS. 



mary Utt'on; ihtd is to eay, no eccondary Bj-philitie phenom- 
CTiA CDsncf). Of th(i autliora referred to, Auepitx aiid I'lina, 
Kyllikyr, Hnetor, Chtdzynsl:!, wMi Ferari are the mo«t pratni- 
neot AuspiU and UnnadeBervecredit for having lately givoD 
new impi^tus to this queatioiL 

But we have ccmvlno'tl Murvelves, by a great many expert* 
mentft, tJiat extirpation of tlio indurated primary lesion, how- 
ever earlv perfonned after infection, does not prevent the out- 
break of sfctmilary plicuomena. Quite recently, H. Ztrissl had 
an opportunity of otwcrving u etriking Inetancw, in whicli the 
initial iudurated lesion vra^ cxcificd nith apparent i^ncccK, ao 
that, according to the etatement of tbe pntient, eome of Cho 
moet pTomincnt of the French eyphilogmphcrs, BaEscrcau, 
Foumier, and Iticord, considered tlie infecting focus as having 
been completely destroyed, and yet, iliroo months after tbe 
operation, BccoDdary phenomena appt-iirv-d in ilie fonn of ery- 
thema {Kipulfiisum on tho gcnorol skin, although theiv was no 
posaibility that tlie patient Lad been reiufiicted. At ihe time 
tlie patient presented himself to H. ZeimI, theerytliema was in 
fall bloom. Tlie striking case reported hy Mauriac Is espe- 
cially convincing: A patient contracted a primary legion which 
was excised fifty hours after it appeared, and, although no In- 
guinal glandular enlargement was present at the time of ex- 
cision, yet general svcondar)' eypliilw cni;ue<l. Tiiis and other, 
facta have ted na to doubt thu effectivenesa of the abortive 
treatment of eypbilia, and to assert that if there is such a con- 
dition OS an incnbatioii period of ^ypliihs, it u of very abort 
darntion. The cxci«on of ttio specific primary lesion will 
not prevent the development of constitntional manifestationa, 
wlietlier the adjacent lympbatio glande be swollen at the time 
of the operation or not. 

We will alao remark that it is doabtful whether even the 
earliest cauterizations of the infcctiug initial lesion (Hunte- 
riaii induration) are of any use, as a preventive measure against 
constitntional syphilis, becau^, in the couise of an extensive 
pnotioe, we have seen repeated inetancee in which, acconling 
to the Btatcments of roliahio physicians and pationtft, tlic Mroe 
were cauterized within a few hours after coitus, and yet the 
. initial indurated lesion with all ita couscquencoa followed.— 



840 PJiTBOLOOr AXD TRSATMfiNT OF STPmUS. 

The im[)orative duty devolves upon tho pbysician of exercising 
the utmost caution in prociiring tlie purest vaccine Ijmpb for 
the purpose of Taccinatiiig infant« anil revacdnating adulta, 
and tlie Bume precautiooH eliould be employed in Eclectiug a 
wet*niirse. T1io(k> about to luurry, too, tuiglit Iw uonc tbe 
worse if they Bubmitted tliemselres to a carcfal oxaminatioQ 
hy Ute pbyiticiaii. 

Trsatment of the Initial Fhenomenft of Syphilii ; tbe Eonterifti 
lodunttd Chancre; and Indolent, Kalttpl^ and Stmmona 

BllbOMl 

The trentment of the initial lesions of syphilis is eimflar to 
that of tlia other monifeilAtione of tlio diBCASc. Bometimtc, 
however, they reqniro epecial mea»'«ree, be<»n» they frequently 
canBO (local) diKturbances and complientioiis that vtui not be 
relieved spoedily enoagli by tlie general treatment. 

Tlio eite of a »tjphilifie infetiing ebanere requires a diffop- 
ent local treatineut according aa it ia ako tbe niie uf a soft 
diancit) or not In the former cane, the cliancrct »bould bo 
treated in tbe same manner and n-ith the eame nmtedieB, re- 
gardlcM of tlie iadnration, wt if it were situated upon a lujo> 
indiinited base ornoD-«ypbilitic person, lo tlw aooood ouSt 
the local treatiiieut is onl^ int«ndL-d to aid the cieatriaatioa of 
Uio Hore, which i» Jct)iruble, liccauee tiic lluntvrian cluuicrei, iO 
long as it 18 nncicatriz&d, carbm more or lees pain ; and, in caM 
it ie contaminated with impurities, it is apt to aaBumo a owdi- 
tion of phl(^;nionons infiammation that may upread to tbe adja- 
cent skin and lynipb-itic glands of the vicinity. Ecpeciolly ia it 
desirable to caase those Unnterian chancree to cicatrice tliat 
are situated upon the tntomnl Hitrfnce of the nincoos tnem- 
brane of tbe prepuce, in or near the foesa corociaria, and in 
feioalee at tbe introitne Taginn*, becanse they freqnently giro 
riw to protratited bakno-blenorrluBa and vulvar bIpDnurrhwa; 
further, thoae on tlio Jipn, at tbe anns, and nuatus of tbe 
arothn, because they occasion pain in speaking, defocatioil, 
and uriuntiou. Tbe cicotrizution of tlie initial induration i> 
expedited by keeping it clean, by thi* npplii-ation uf iodoform 
drc«dng, or eEupla^tnim liydrargyri. If tbe Unnterian efaaBcn 
on the raucous membrane of the prepuoo baa occniotiod phi* 



STPEIUS. 



mofiie^ M)nio toleniltiv strong Ritirnngimt, or slightly eanstUj 
preiHUiatioD, euch as a eolation of carbolic acid or clilorato of 
potash, lihould be iujected between tbe foreskin and glans 
pcnk Eereral times daily. After tliia, biM of tntutlia, dl]>ped 
in the rame prefmratiou, filunild tie iiJAurtMl undor tim funnor 
for Uie piirpoee of keeping the InHaincd pirts asunder. li 
this does not answer, oiroumciaion will he required. If the 
Huntemn chancru is situated at tlic lip« of tliu urethral ineiL- 
tiu, it eltould be tonclied daily witli nitrate of tllvcr, and a 
small wcdgo of cmplostram hjdrargyri inserted between tlie 
lipa. The same method ahonld bo poreued in chancres at the 
tnoe or rulra. ilunterian indtmatod leuons situated on tbe 
skin of tho peDi», labia majora, or lingers, eicatriiie qnicke!>t 
when thoy arc covered with adherive or mercurial plaeter. 

ludulonl htiljocB of llit> size of a hazel-nut require no loeal 
treatment. Tlie treatment directed against the gooenil dixeaNu 
osaally sufficed to reduce tlicin in size or to britifc ahrnit reso- 
lution, if the indolent buboaccompanjringtlicsjpUilitic initiid 
lesion undergoes suppuration, it ehoidd be treated, cata'ia pari' 
bus, like any otlicr Mippuritlag glandular abBcess; but if llw 
syphilitic, indolent buboea, fostered bj the ecrofnlons or tubcr^ 
culous tendency of tho patient, or by tilocmtlug or moist pap- 
ules in the Ticinity, gruduolly increase, notwitli^tauding tbe 
genera] treatment already institnted, on eSort should be made 
by appropriate local treatment to prevent suppuration, bccaose 
of the fistulous pa.'««i^8 that usually result from inflammation 
of the hyperplastic enlarged glands (^trumoua buboeu). Tho 
reader ia referred to what has already been »iid U]>ou thia sub- 
joBt on page 141. In eoine co^es we succeeded in gradually 
diminifhing tlioi^ adcnopattiics by MTornl subcutanooug injoo- 
tions of a few drops of tincture of iodine^ A concentrated 
solution of nitnitu of silrcr, or oomprei!«e» dipped in a oonoen- 
trated solution of basic acetate of lead, or iodide of lead-plaster, 
tincture of iodine, belladonna^ or gallic add, will be found 
useful. The following is one of Uie best preparations : 

9 Aqna aesta, 20-00 [ f aa., 3 Iv] ; 
Nitr. atf. orvBt, 5-00 [3 i?]. 
M. 8. The fflandiilnr ■welling to be pcDcilIod tvioe HiiXy with a nuu- 
el'a-baEr bnuh. 



Si2 PATnOLOQT AND TBEATMEXT OF BTPmUS. 

EniptaRtnim de Vigo cum Ii^rdrargjTl ^tiD imullj cause b 
diiuinution of etrumonti btiboes. 

If the atruuioufi bubo, per «, does not prevent the paUcnt 
from walking, it is not abeolatelj- nccraeary Umt be should re- 
main in bt'il ; indi:i,-»l, u modv-rate Buiount of cxcrciec out-of- 
doors eeeme to hapten roeolntion. 

If fluctuutioo hii£ beoD detected at any place, the efforts to 
bring about aliSorpLion should not yet bu abandoned, nor the 
abecoM opened inuncdintely, hccauBO experience has shown tliat 
even indolent buboes that flnctuiited distinetlj' were ncverthv^ 
lees made to undergo resoliitioQ bj the cnntinuouA apj^cation of 
tincture of lodliie, leiid-plaitter, etc Not til] a prulonged trial 
of tlie above-mentioned remediex causes no diminution of the 
swelling, on tlie contrary, eecms to increase it, make it more 
feusa^ aud give the patient mtvltu ^suu, way the afKintiincoiu 
burtittiig of tlio abscess he i^xpedited by the application of cata- 
plasms, etc, ; or it may be incised with a »har]vpoinled bi»> 
tojuy. The part of the ftkio that ha« beoiiine thin, red, nod 
tmdennined may bo removed at once with the scieeors. Tlie 
opened indolent bubo ehoold then be treated in accordant 
with the rules of antiseptic eiirgcry. If fiatula; form, the 
laeoeurcfi advocated on page 142 may be udoptod. 

Treatment «f Becoadary Pheaomena of Syphilui 

(A.) Exi'taTTAjfT METnoD. 

The expectant plan of treatment coiiHibbi In regnlating tbe 
diet of the patient, and in the local application of remedies to 
the primary lesion, none lieiug admiuiHiored against the gi'nitm) 
specillo disease. If the primiin' lesion has begun toeuppunte, 
tlic patient should be prohibited from taking active exercise, 
in order to avoid tlie ri^k of can^g suppuration in the in- 
guinal glamht; if it lias eicatxizt-il, or did not enppurnte ut all, 
the patient fiioald be in the open air as much as possible. He 
should avoid catching cold, abstain from the oso of tolMWWO, 
and partake of nutritious food, especially meat Uo may be 
allowed a moderate amount of u-iuo and Iwer, but lobaooo 
should Iw prohibited absolutely, beeauw the uritation pro- 
duced by its use will occasion the formation of syphilitio 



SVPffTUS. 



343 



efflorescences on the mnconit mcmltniDe of Llic mouth, tongue, 
and fmicee. It is liigbly import&iit for the patient to lit-iieh the 
aniU rrgioQ with water after each etool. In corpulent perBona 
conti^oiis parte ebould t>c kept a£undor l>y the iutcrpositioD 
of bita of lint. The constant contoot of two opposing sar- 
iaiotB, 18 at the anns, groio, ete., iJways produces oondderable 
moisture, and tLie rcsiiltti in the development of |npulea. 

li xeondary phenomena, in the foriD uf n macular or |mpu- 
br sjphtlide, have itually appeared, the phTsician ahoald etill 
content himself with carrying out these hygienic measnrea. 
SypMlitic phenomena la«t a variable length of time in di&r- 
eut persona. Roaeola audcrgoea resolution without medication 
<]iuto rapidly. In one caac wo saw it disappear withiu seven 
days. Papular syphilidca often rCKiniic a long time to nndei^ 
go inTolDtioQ. r^oria^ia palinaris and plaiitarb fmiacntly re- 
quire, if not treated, tea to twelve months before tbey dis- 
appear by roiK)lutioD. An e<iaa\ Ictigth of time often elapees 
before tbo syphilitic initial iudnration completely eiib&idce. 
Bnt it ahonid not be forgotten that similar oooditioiM are 
(rften Been in perBous who niuU-rgo aeiive inercui'ia] treatment. 
Wc have oheerved that the indii'idiwUly excreiiMje oonaidorable 
influence over the rapidity with u'bidi the tiyphilitic eymptomi 
diiUippenr. In gcnpnd, it uuy be said that the cure of s'ki>hilia 
in ansemic and weak persons takes a longer time and is more 
difiicolt than in the robust and weU-Douiished. In regard 
to puKtular NTphittdi^K, tht-wj, Uto, oft«n re<pnre, under ex- 
pectant treatment, eeven to eight months to disappear by 
reeolution. 

The ex|)ectant treatment has taught us, on tlie one hand, 
that constitutional syphilis will follow even if not a particle of 
mercury ia nscd, and. on the other hand, that the assertion of 
the anti-mercnriali^t^, that the »o-calIc<l secondary and tertiary 
syphilis are only the mnnifcetntions of the mcnmriatizatioo, is 
not tme. Ke1ai>«es and the gravest forms of syphilis (symp- 
toms denoting lesions of tlie central nervous system, of the 
viscera, etc.) may supervene just as well after a strict and scm- 
pulonjily oarried out expectant plan as after an anti-qiecific 
treatment. Wc only wish to say that these phenomena occur 
oorapamtively rarely after expectant treatment, and that re- 



34+ PATUOIOGY AND TItBATUENT OF 8TPSJUS. 

lapses an; apt t^r occur li*^ often tliaii nftcr on eari'j inercarial 
Ireatment. If Beriuus sypUilitie e^'mptirtud bavc appeared, eueh 
as affections of tbo brain or eye, tiio oati-epocitio retoodiu 
ehould be employed at once, and tbe life of the patient or the 
iutogrity of on important organ sbouUl not be CDduQgcrod bj 
delay. 

All recent cnsefi of ao([Utred secondary Ejiibiliit are well 
adapted for trenttnent by the exi>ec!tiiiit metliod. If a fL-brJle 
di asMO poeomoaia, dyeontery, typbiud fover, etc. — Btiper- 
ventw upon tbe a[}eciflc pbeuomeDa, mercury, iodine, and all 
depreuing remedies moiit tie diflcontinned, and the Rypliilido 
dbeue treated with expectants for the time. In very severe 
fomui of puetular syphiiide similar indicatloDB prevail. Littlo 
can be bo]M.*(l for from tbe expectant mctliod in coeoain which, 
after a long or eliort luo of specific remedies, eopeciaUj mer- 
cuiy, a relapse ensues. Caaes of congenital eyphilit) irLioh ap- 
pear in youth, and arc likely to cause destruction of aoino of 
the eoft or bony parts (lupoa Eyphihtica), aro not adapted for 
the expectant method of treatment. 

If the phenomena of the eecond |H>riod have resisted this 
method for ctglit or ten wceke, tbe tn.'fltuiciit with iodine may 
be commenced. The treatment with prcpantions of Iodine is 
adapted to ail pKate* oi !«yi)1ii]t!t, nnd, according to IT. ZeissPs 
experienoe, the resalts derived from it are second to those of 
the ex])eotiint procedure, muce relapsea occur leas oft^m after 
an enrly treatmeJit with iodine than with mrrcnry. 

Iodine in proper iinatititiee, in conjunction with a csrefoUy 
regulated regimen, are sufficient to eauM the tjfrnpioms t^ 
»t/phUus to dtmpjyfar, or at /«w/ to le wcakat^d m that only 
a fevo marcurial inuncticnt will be ntcewory to complete the 
curt., -mihovt fear qf a tvlapte OMurrmg w y^&n to cont. 

In pregnant women the aymptoms of syphilig recdAt treat- 
ment much more than in non-pregnant women, ORpcdnlly if 
pregntncj Is aa old as the infection ; they do not disappear en- 
tirely till the oontcnift of tbe uterus have U^n expelled. Wo 
were, therefore, always obliged to eontinne the treatment with 
the prejHiratlons of iodine after tlie confinemrat^ and, where 
this reniiHly proved insufficient, a few inunctions of mercniy 
completed iu 



BTPBtUa. 



ats 



Therapeatic&l ApplicatLon of Iodine and lodlne'Saltt against 

Syphilil. 

(B.) Mkwcin.vl Tekatmkst. 

Since 1322 iodine luw boun dmhI with gtxKl rtsnita inRyphi- 
lifl bj Fonney, Drura, Lagol, OiUIorier, and Uicord ; but it 
bccaruo famous as an aDtinvpliilitic rcmctlj mobljr through 
the writings of Professor Wallace, of Dublin, wlio, in the year 
1836, put>Ii«hc<L n. report of one liumlreil and furty-ln:u cases 
treated with iodide of potogsiuta, in which be obtainud most fn- 
romble resnlu. 

We employ mainly iodide of potan^um, iodide of todincn, 
iodide of iron, iodoftmn, and iodide of lithium. Pure iodine, 
whicli, owing to itn corroaivo action, is not adapted for iiitcma) 
use, may \w given in the fonn of tincture. Of Llic latter wu 
prescribe l-OO {gre. xvj] to lOO-OO [ | iij, 3 tijj water, and allow 
tho patient 1o take two tcaeiMouf uIb a day. Of iodide of potas- 
atim or M>tlitnn wo order 100 [grs. xvjj either iu eolutioD or 
pin. The latter is preferable, becauM the bad t&sto of the 
medicine is tlins aroided. ^ pawant^ we will state that iodide 
of eodiom u lees disa^eable than iodide of potaMinm. We 
nso iodide of iron, either in tlie form of pilla or eirap, as 
follows : 

Q Ferri io«l»(., 10^)C [g riij] ; 

£itriict. ft pnlvu tnColii flbrbt U 
t\. s. nt ft [>ilQt» Ko. 100, 

CoDiiperee pulvore eodem. 
S. Tea piiU. to l>o taken duUy, 

S ^jr. ferri lodat., 2-00 \gn. txx^l ; 
8jr. mororum, SO-OO [ 5 «., 3 IvJ. 
M. 8. To be tAkea In one dar. 

Iodide of iron is especially adapted for tlio treatment of 
eypliilitifl i>atieuta who aro markedly anieinic, A gramn>c 
[grs. xvj] of iodide of iron daily, in pills, is very "frell t^^Ieratvd ; 
we have often given as mach ns ^'50 [gre, xl] without daaeing 
any digcrtivo distnrbanoca. In very weak patients, whose di- 
gestive organs aro not strong, the uirap of tho iodide of iron 
may lie preMxriljed, but only in qnantitics ncceeearv for each 
day, as it easily deconaposes, and tho free iodino tboD prodnoes 



3i6 PATB01007 AND TREATMENT OF SYPBILIS. 

])fiin in the atoinadi aud Toniitin^. Tlie decomjKwition of tlus 
iodide of iron i^ prcvcotod in Blancard's pills which are 
wrapped op id buleoiu of Tola. Each pill contains 0*07 tH 
gr.Jt of which the patient tatw four or firo oaoh daj. Moch 
bonetit is denvixi from the internal use of todofortn, accurdiii^ 
to n. IaAsaVa metliod. It is pre«cril>t>d in pill-form : 

B fndofonD., 1-50 \gtK zsUJl; 

Est. ot pulr. trifolli fitmal U at ft. ptl Xo. 20. 

S, Flrv piUa to bo token <l«i];. 



Good results aro obtained from iodoform, optKrially in 
casett of iiouralf^ cauitcd hj R^itlulia. In addiliou, vrv onljr 
wish to tncntion huru tlmt patJontfl, after the intcnuJ nse of 
iodoform, eomotimee enffer for a long time from unplesaaat 
cnictatioQS. It sLoald not be preecrilied in large do«ee ; Mime 
phjtticiana have seen in1en»c cxciU!n»:nt aud mental distorb- 
aocee anso in patienti to whom large q^uautitioe of the drag 
were adrainuitered. 

Iodide of lithium, vhioh till now bas not been mneh noticed, 
may be given in do^ca similar to those of iodoform. Wo have 
used it for ecTcml montJis, iDJoding it xubcutauoouslj. It 
foniis a perfectly clear wjlution when disrolved m water; 1-50 
[gre. xxiij] may be injected hypodermically. The patienH 
complain of pain at the site of injecUcHi, but it soon BabMeiL 
In this mamicr the prepanitioii \a very well tolerat^'d. pro- 
dncing no otlier unpleosaot effects? except a moderate iodine 
acne in some casea. The inrolotion of the syphilitic pbe- 
nomena proceeded as mpldly us after the ii% of any other 
praparation of iodine. Iodide of lithinm may also be admini»- 
tcred iDteraally in pitU from 0-50 [f^ra. viij] to 1*00 [gn. xvj] 
per day. Thin preparation aeeomplislies an few miraculous cores 
as any other. Eeccntly TIioiiulod, of Gratz, and J. Nenmann, 
injected iodoform in aolntion or emnkion hypodenniealty with 
good effect. As already said, all phasea of syphilis are a<:lapted 
for treatment widi the preparations of iodine. We hare eecn 
Domoroas caaea of iritiH cnred by the adminiatntion of iodine 
and appliratton of atropine to the eye, not the least impoirmuat 
of vision remaining in a single patient. 



3TPmUS. 



347 



tliat mcrcurv causes tlie s^^Tnptoma of nypbilU in 
all cases to di(«ipi>car tuoa* rapidl/ llian aujr otlier antj-etiecilic 
rcmedj, lins but a limited »]i|>li<utioii ; in eonie oases botb mer- 
cury mil) iodine act quickly, in otlivrs tlieir effects npon the 
patient oro vcrj elow. Too inucL tXrceA uuii not hv laid upon 
the fact that ercD io the gravcet ionoi of eyphUin tho prcpa- 
nttioue of iodine alone will often bo found euOleient. 

In regard to the subcwlaneona otnploympnt of tho prepa- 
rations of iodine, it may bo used with iidran(ag« in porous 
troubled Hith weak difi^i^tive orf^an^ ; but tliis method will iio 
raoro take the ptac« of tlie internal use of tho drug than the 
hypodermic injection of mercury has till now enccoedcd in ro- 
placing mercurial inunction. Howctct slight tlio paius may 
lie, the pattunts iieelc ia avoid them If not ahoohitvly lU'cetutary. 
Besides, it }\w the additional tlindvantage that in piirate prao 
tioe a Byphilitio patient can not be seen eveij- day. 

PattctitM, vrhoac health, and othi.T circuuiittuiiCfH pcimit, 
ehould go at tlie proiier mkibod of tho year to iodine min* 
end springs. There are aevvral placea in the Auetro-Hunga- 
rlaii Ein|>irc where rolimble iodine springs are found, encli as 
Hall in l'p)>cr Au:stria, Xvonicz in tialida, lippik in Slavonia, 
Lubatscbowitz in Mahren, and Darkau in Silesia. In these 
pUoe-6 the paticDts not only drink iodine- water, but ako bathe 
in it. Frofesaor Koeenthol, of A'ienna, under the direction of 
Profeeeor Schneider, faafi shovn, in a pa])er presented to tlie 
Imperial Acadi^niy of Scleneeti in ttie year 1602, that iu<]ine ia 
absorbed into iliu blood by the tikin. 

It is a mistaken idea to prohibit the patient from partaking 
of articles of food containing starch diiriug the iruiiiuient with 
iodina Starch alone, without the Kimultanoons intervention 
of an acid, is not capable of separating the iodine from ite 
com[>onndB and forming a combination mth it. The acide of 
tho etouuich arc much too feeble for that purpow; and udmit- 
tiag tliat a partial dccompoeltion of tho iodides takes place 
from an ercceaa of starch in the stomach, then ouly an iodide 
of starch would form, which is the very Biilwtanee recom- 
mended by Buchanan against syphilis on account of its non- 
irritating action on the gastric mucous membrane. Equally 
little injnry resulta to the patient, according to our experience, 



MS PATHOLOOY AND TSEATXEITT OF STPmua. 

from the dccuii]pi«iti(m of tlio preparations of iodine, owing 
to the use of acids dunng tLt) titoLtmcut witli iodidca Ite- 
contl^, EugUah pfa^oians have actaallj soaglit to tocreaae tiie 
actiuu of tJus rcuiedj', aod obtained favoralile results from tbo 
combined nse of toienbly etrong acids (ozoaizcd water, nitrio 
acid) witli preparations of io<liiie. Tbo powerful action of tlie 
salts of iodino, in bringing alioat u mutmnoriibofiiii of llie ti»- 
eoes, is resfion cnougli for allowing the pstiont, during tlic 
iodiiuHjiire, to ]xirtako of ob iqiipIi nourigbiog diet, wpociaQ^ 
aniinal footi. aw p(ie«i1ile, Btill tbe cure sliould not be made uu- 
neoeEBuiljr ii-keome b^ prohibiting tbo ingeetioii of Invad. 

The prepantioDa of iodine, as already stated aboTe, are 
adapted to all fonu« of syphilitic disease. 

The iodides have proved ofipocially efficacions against gum- 
mons periofititis and 06titi«, gunimala of the skin, tongue, 
roepimtorj organa, etc; in inoseular contnurtiona, garcDado 
sj[)hilitica, ppccilic eye, hrain, and nervous affections, inherited 
aypliilifi, appearing in tbe 6hape of ecrofulous DianifesTatkois, 
and in easea in -which ecrofitla and Byphitis are comhined. 

Still, there are cases in which all the morbid fomif) men- 
tioned ohstiuately reetat tlie action of the iodine remedios ; in 
mcb, if tlie condition of the patient pomiitB, wo rewHl to tlio 
mildest of all iiiorGiirial preparntionK, Zitlmann** deeooticn. 
The mercariiil*! geiienilly aohieve more if they have been pi» 
ceded by a conree of treatment with iodine. 

It follows, from what hae been Htid, tliat the nita of iodine 
are the chief remedies fur eo-callvd tertiary syphilis. StiU* It 
can not be denied that all the other speciHc phenomena may 
lie made to undergo involntion by die nsc of iodine; but it is 
equally true tliat there are exceptional caeea, wluch can not be 
foretoldf in which mercury may bo advantagcoiuly sulMtitoted 
for the iodide. 

AVhen iodine preparations are lued in appropriate caaea and 
In proper doses, the appetite of the patient increwiea, and nnlri- 
tion improves proportionally. Sometiinra, however, the appo- 
tito inereaaee to a nvenoos hnnger. Oeeafitonally the iutenial 
use of the lodidoa emuM ringing in ths ean iind inUiHnal 
aUarrh, wliieh Kometimee is attended by louee stools, then again 
by oooatipation. Tho pathogeoio action of iodine aumifests 



STPBIUS. 



itself most Btrikingly opon tlio misal mncoua mcmbinne, i 
violeat nasal calarrb origiuating in most patients after tliis rcm- 
ed; h&s tieeo used fur two or ibreo days. Tim pliouomeuon 
is gcnerallj accompmiied by an irritated condition of the ma- 
ooua raembrane of the faucra and pain over the froDtJi] ginns. 
Tbi3 catairiml aJlectiou of Uie luacoua memhnuiee mcntiuDed 
extends to the laclirynuil apparatua and £tutacLiaii tube. 
More or lees eerore febrile movemont, according to the senei- 
tiveocea of the p«tieot, ensaes. lu nioet caeee we noticed, iu 
COtwequcnoo of the continuuiu UM of the iodides, tnarkvd red- 
neas and looeenaas of tho (;t)in& of tho upper incisor te«th 
(gingivitiB), which peraisted for maiiy weeks, along with ob- 
stinate eolivation, Tbc pathogonic action of iodine &alta loani- 
festt itsi'lf jttst as frequently npoD the geoenl ekiD aa upon the 
naso-faiieial niucoua raembnme. An acn^ike eruption occara 
in some persons, especially tlioee having a tetider ekiu, on the 
&oe, nape, ghouldore, and nppor anna. The iodiue catarrh 
oud a«ne may indeed oocur simultaneuusly, but, as a rule, thewe 
two afFections exclude eacli otiier. lu some ptitient« the use 
of tlie salts of iodine produces sIcepleBsno^ In rare cases we 
have obscrvixl, in vonseqaciicti of the inturnal iiiiic of the prepa- 
ralioHB ander oenaderation, ejpUderal ecchymuees and nrnnt^- 
IUm telcangiectaece, as big aa a pin's head, on die general integu- 
ment. Iu eomo caecfl the <uAi<»i of the Kcart itt aeoeleruted to 
Euch a degree, by a prolonged use of this remedy, that the 
rapidity of the puUe ia iuereaeed to one hundred and forty per 
miante, tho patient being at the game time cscoedingly irri- 
table and exhausted. We also saw pleurodynia occasionally 
in cone^iueiice of the ose of iodine — a phenomeurm tirst point- 
ed out by "WalUee. The pun, which is usually limited to the 
left dde of the thorax, is bo Tiolent at times aa to hinder the 
patients from breathing, resembling rery much in sereriiy 
■that occurring in tnie plenrigy. 

Iodine catarrh and iodine acne disappear when the iodidea 
are discondnnod. For the relief of the gingivitis, the aatrin- 
gcot moulli-wa^hen nMiuniiiiendod against mcrcorial stomatitis 
may be ufed. Tlie ravetioiis hunger and sleepleasneBB, the 
ptcurodynia, and increased action of the heart are markedly 
diminished by ao active purgative (&ud£chutzer or Pollnacr 



350 PATBOLOQY AXD TREATMEyX OF 8YPS]US. 

bitter-water), and disnppGap (•ntirely after the uso of ft few 
ilosoa of q^uinioe^ 0*3 to 0-4 [grs. v to vijj daily. 

Tlie Tre&tmeDt of STphilU by TegetaUe Semediet. 

Of tliu vegetable remaliett, we will oul_j' mt-iitiuti Uimva, pi- 
locarpine, and Zittmann'fi df!CocHon. Ta/u^a-tincttiro has beeo 
reoonmicnded hy tbe Ubicini brotliere. It is prepan-d from the 
root or bulb of one of tbo cucurbitacca plauts, Tlii« rcmodj 
■WAS Dsed in tbo form of 8ul>cutaucau« Iiijocliuii, and alno inter- 
nallj iu U. Zoisel's hospital di^iEioo. The results were mch 
tliat it mav 1)0 sold tliat time aiid not tbe remedj aoconipUahcd 
the cure. Ilowerer, it exem«s no injarioiw effect tipoo the 
sjrtem. I^win mado numorous erperinictits with^'/octrijnn, 
the alkaloid of jabonndi. He tised the muriate, aiid treated 
tb!rt_v-two women with it hy h^^podtnuic injections; twenty* 
live of the patients Trero cared. In tliree of the ecrcn tlat 
verc Dot cured, «ich violent ayniptonis of collapse appeared 
(lut the treatment bud to be diacoutiimed. One patient wu 
attacked bj hfenioptTtn's — in another eiidm-aTditiA supvrrened. 
In two others the sj|-pliilitic manifestations did nut disappear, 
notwittistandiug the large dtMes of pilocaqiine ciuplovod. 
The longest time roquircd for a cure wu fort^-threo daja, 
the shortest foarteeu. Lewin thinks that a cure ootild be 
acliicvcd in a still shorter time, if it were not uecesfaiy to suft- 
pend the treatment, ctoti wlieo no accidents oocurred, on ws 
count of tlie patients' being frequently very much affected hjr 
it. The average (juautity of pilucarpiue required for a cure is 
0-3Y2 [gre.vw.}. 

The relation of pilocarpine to tbe different forma of ajphj* 
lis ia pretty much the same as that of mercury. The relapm 
in tbeae twcnty-acvcn patients amounted to only bix per cent) 
against dgfa^ per cent after a vegetable cnro or previous t»a(> 
nJent with mercury. NovcrtheleeB, Lewin tpve* the preferenos 
to hypodermic injectioos of corroeive sublimate over tbe treat- 
ment with pilocarpine, for, although the percentage of cures 
with the latter is decidedly jcroator, yet the use of the remedy 
ie attended by such unplcnHint eymptoma. In some ooaeain 
which we employed hypodermic injections of pilocarpine tluj 
unploaeant effects were so Tioloot that we liad to abandon all 



STPBIUS. 



m\ 



fmthor trcatmont with it, eKpeeially sintw tlie curative effeots 
were by do iu«iiib eatisfactory. 

Rut frum Zittiiiuitii'ii clecoctum wu Ii&vu ticen very Tmlttaat 
results. It is difficult to say wbtillicr lliin remedy should be 
classed aoioag the vegetable or the mcjvui'ial prcpaialtoiis. 
Ill prL'i«iriiig this decoctioD, 08 \a well knovrn, l-tiO fgre. xvjj 
of wiiito mgar, a like qunntttj of powdered alum, 0-8 [grs. 
xij] powdered calomel, and 0*3 [grs. iij] powdered cinnabar, 
are boiled m a little bag with eanaparilla. Mitecherlicli waa 
unable to detect any mercury iu tbe decoctJon, while Znotcti^ 
Wiggers, and Winkler found traces of it in large qnaittitioa of 
the prvpiLration. Skoda found Zittniaim'ti decoction lets efDca- 
oiooB wbca calomel and cinnabar were omitted. For the»e 
nasona, we bare to a^ign to Zittmarm'a decoctiou a hybrid 
positioD 1x;twecu the vegetable and purely mercurial remedies. 
We order the patient to take 800*00 [ 3 ixss., 5iv] of decocL 
Zittmanni fortioa every moming, and tlie name quantity of the 
weaker decoction In the evening. At tlie eame time the diet 
must be etrietly n^:ulated. Uu should dritik no liquor, beer, 
or milk. Fruits, ealaii^ alt kiiidA of vegetablu and fruits — in 
a word, everything that is likely to cause diarrhoea and fiatoa — 
mtut be strictly prohibited. At 7.30 a. u., the patient takes 
Ids breakfast, consisting of a cup of black tea and toast. 
Ualf an hour after, he begina to drink the decoction, which he 
finishce in tbe course of half an hour to two lH)tini. Generally, 
from one to three cvaeuationa from the bowela then occur in 
tbe conne of tlie forenoon. At one o'clock hu takes bis din- 
ner, oonsiating of Boup, roast beef, and rice, with a glaaa of 
wine, and, if tbe weatlter la pleasant, be may take some exer- 
cise out-uf-docjnt, and, at 4 v. u., driuka a second bottle of the 
(weaker) decoction, likewise consuming it in tlie courao of half 
an boor to two boars. 

If the patient hoa five or aJx evacuationa daily, he may oon- 
tinne to take the decoction ; bat if titey become too frequent, 
and perceptibly reduce him, or vomiting cn£ncs, the remedy 
moBt be immediately dificontinned. Id the majority of cafies, 
not more than three or four evactuitioDS take place daily, the 
decoction agreeing very well with most patients. The effects 
of the remedy usually become niouifeet after using it ten or 



352 PATHOLOer AXJ) TBSATMEST OF STPHIUS, 



twelve daj's; it ha* nu cxcLt-dingly faroraWe effect npon ftll 
fonii8 of M-j)liilm, but i& capcciull^' ai>|iUcablo iit iMtiontft wbo 
are aomcwbat exLauetod b; t eovoro coarse of mcrciuy, and id 
whom the sjphilitic diseue ob6tiiiat«ly reetBt^ the preparations 
of iodine. Jt is on iudi^putnlilc fact tliat, in paticoU who bad 
boon treated carljr and for a long time with incrciii7, obstjoBte 
lelapaes of the eyphiliiic diseoee, in the fonn of peoriosis pal- 
maiis or plantari^ will aot disappear at all, or bat yery bIowIj^ 
under the ut« of the iuilides^ die malady iiopruvin^ oaljr when 
mercury is again administered. But, if it \x not dc«inc<l proper 
to give such patients more mercury, hecanae tJiey are already 
reduced by the prccediiif^ active treatment with it, Zittinann'a 
decoction may be preecribed. Truly wonderfol efiecta may b« 
expected from it, though mch an expreesiou ongitt not to be 
used iu the practice of medicine at the present day. it ren- 
ders excellent eervicc in diffused pa»tu)ar eyphilides, and in 
sappQrating jpimma-nodee, whether situated npon tlie comnioo 
intej^ument cr the mucous membrane. If the decoction ficca- 
fiiona violent colic-pains or profuse diarrhcEa, and ita furtlier 
employment if indicated LotwithstandiDg, it will be well to 
omit the «enna-leavb« from the preparation. 

[TheformulagiTCD aboTufor the preparation of Zitbnaoa'e 
decoction being incomplete, tJmt described in the ruiCcd Statu 
Dispensatory is here appended : Take of earsaparilU twelve 
ouDcee, spring-wftUir ninety pounds; digeet for twenty-four 
hours, then introduce, inclo^d in a small bag, an ounce and a 
half of sugar of alum (consisting of c^aal porta of white nigar 
and powdered alum), half an onnoe of calomel, and a dractim of 
eionabar. l^il to thirty pounds, and, near the end of the boil- 
ing, add of aniiio-aeed, fennel-Heed, each half an ounce, Banna 
three ounces, liquorice-root an onnoe and a half. Fut atude tira 
li<pior under the name of the strong ihcocHon. To Ujc reaidue 
add »ix ouneee of eareaparilla and ninety ponndfi of water. Boil 
to tlurty pounds, and^ near the cud, add lemon-peel, cinnamon, 
cardamom, litjtiorice, of each three drsclunE. Strain, and SAt 
adde the Uquur, under tlie name of the weak ddcoethn,'] 

Thtr&peutlc Use of Xarciuy. 
MorcuTj inay^ bo introduced into the system ni two wBy»~ 
tliroDgh the mucoua membrane of the digestire and resplntory 



arrmus. 



353 



oignnn, and thmngli tbc gunen) »kin. Now, if iu the pationt 
who is about to be tn^atixl, oim of tbc«u ways become nnav&il- 
kble, in coDfieqacDce of evpbilis itMlf, or because of eome 
morbid alterations or coniplkatione, it wUl be necessorj- to Und 
eoino olhor oourso whereby tlic mercury may be introduced 
into the system, Kurlhor, if it ie tho iuteotiou of the pbyd- 
cian to prodiioe a mild and gradual therapeutic elTeet, aud if 
the digestive organs of tlie patient are in a grxid condition, 
ttie latter may he employed. Ijut if bo doeires to iiitrodacc a 
large qiiantily of meniiin' into the syxteiu in a atiort IJuie, the 
externa] gkin is certainly best adapted for tliat purpose. If it 
in deaircd to produce a direct ejwcific effect upon tbc respire 
tury organs, mercury may be iuIiaJcd in tlie form of vapor. 

Kerouiial Preparatioas which are best adapted for Xntrodadioa 
into the Blood throngh the Digestive Organs. 

Althongb we entirely apree with Miallie in his tlieory that 
all preparatiouB of mercury introduced into the a^nstem must, 
before developing tiicir theraiieutic cffcctis become conTerted 
into corrosive sublimate, and licnc© tluit it would seem to be 
more advanttigeous to use the bichloride at once, ncvcrtbclefis, 
wc muat Bay that the other preparations of mercury are by no 
meane to [k diecardcd. E?cpuriviicu has sliown that eome per- 
fioufl are apt to auffcr from gastric pain after taking oorrooivo 
mblimate, while the protoiodidc of mercury or calomel agrees 
with thorn very well iudced. It therefore BccmB as if some 
peiBOus tolerate better the sublimate that forms n-ithin tbeir 
'Bjatems from the protoiodidc or calomel than when it is ad- 
ministered to tlicm directly. 

Most flennau physicians at present prefer corroiave Rubli- 
roate to any other preparation of mercnry, becatue it so seldom 
pfrodoces ptyaliem, while tha unpleasant by-effoct almost always 
attends the ui!c of the protoio<li<le, calomel, and mcrcurius soln- 
bilis llalmcmaniu. The Hali%'ation which sometimes miperrenes 
very rapidly upon tlie use of mercurial preparations Beenis to 
UB to be due more t:0 individual idiosyncrasy tlinn to tho 
chemical propertiun of tliu drug; liuni« the niason why noma 
of tbe most accampll»bed pbydcians differ eo mnch upon tbiB 
point. 

28 



Sfl^ PATSOLOOY Ayi) TREATMSST OF STPUIUS. 

llydrarjfvri protoiodurctum, iodide of nicrciinf, a greenish 
itwoliiblu coinbiuatiou of todiue vritb mercury, is esi>tx:UII^v' 
recoinmc'iidcd b^ Ricord, aiid adnptod in cu&ee tn wliich the jtri- 
mary induration still exiata, in recent crythcm&tuus aod papu- 
lar eyphiUUt^, and iu peoria^i^ polmariti aud pUataris diaaouii* 
nata. Ad a nilc, the inroltttion of the epecifio etfloreseenoM ' 
on tho ekin and mucous membrane begins after odng tho 
protoiodide for two or three weeks. Tbe papules on tlia 
[Miltns of ttie hands and boIcs of tbe feet offer tbe most ob«ti>l 
note rcustanec to tlie uctton of the remedy, and local upptiva- 
tions will almost always be re<juired to asuM the protoiodide 
in dtseoasing thetn. 

The dose of tlie protoiodide is 0-02 to 0-04 [gr. \ to \\. 
Generally, patients who take O'lO [gr. If] of this remedy in 
twenty-fom- hours hare two or three liquid eTacuationa, at* 
tended by colic-paina. To provcnt the latter, the mercurial 
t^bould bo combined viUi extract of lacluciuia or opium in tho 
following manner : 

B Protoiod. h^drarg^: 

Eitr. Inctnoaril, U 1-00 Igra. xr)]; 
Opii pnri, 0-50 \^%. riijl; 

Extr. ct pair. rati. Uqoiritia, U f|. s. nl ft. fil- No. 50. 
S. One pill to bo token in the Diorniiif and tvro in Uie cTpning. 

So long as the protoiodide exercises a perceptibly favonble 
effect over tho iudiiration or tho other syphilitic inanifestatioaa 
present, and tlie mucous niciubrano of ^e tnoutb remains tm- 
affected, the duee reeummended above may be oontinuod. Bnl, 
if tho improvement of the syphilitic lesion k aneated, two 
pills should be given in the tuoruiog and two in the eTcnin;;. 
Should the patient's giiius Iwoome red and bwolleo, and lua 
breath ac<juiro a repulsive odor, tlic ivmcdy will have to be 
diftcontinued till the mncoQS membrane regains ita nomuil 
condition. li the protoiodide, despite the addition of tlie nar* 
ootic, causes intunee coUc-paiite; if profuse, li<piid, or, Btill 
worse, bloody stools take place, the iDteraal nae of all kinds of 
mercury should be suspended, and the patient objected to an 
iumiftion-cnre, or tho iodidce may bo prcacribed. 

Chloride of mercury, being soluble, is a more UBcful rem- 
edy than the protoiodide ; still, it con only be used internally in 



87PniU9. 



]>or8onB wbo hoTO pcrfectiv bealth;' digestive organB and wmnd 
nwpirntor; apparatus. There lure patients in whom the hm of 
eorrodve eublimate occasions f^astnilgia, and for that reason 
tlic remedy must he repliuH^d hy uiie that is lees oeefuL In 
persons who hnvo nlrt'jidj* HiifTereil from attaoks of htemopl^'- 
08^ nioreury id gcnemi, btit especially contuuve Biihlimatv, 
sliould be nsed cautiously. If albuminuria ia present, large 
do«eft of tlu; bi<rhl(jriclL' act f<|ually imfavoraltly. No corrosive 

■mblimate, and, still lesw, other drastic mercurial preparatioiid, 

^'■hoiild be preecrihed for sypliilitic pregnant women. The 
irLiitment of ftvpliiliK with comieivo sublimate waa introduced 
into W't-stcni Hiimpo by Van tiwicteu, from KuMta. The Rus- 

Isiana take tliis mediciue in oom-whisky (liqnor Van Swietenii). 
Adult pativiits readily tolcmtc a dose of the sablimato of 
0005 to 0-02 tgr. Vb *<» t] PC day. As a rule, it is best to 
continue to tlie end of the eublimate cure with a doee of my 
0-010 [gr. J] per day. But if the syphilitic pheiwniona re- 
main at a BtsndgtiU for ecveral days, and there are no coatra- 
indicationa in tlie consdtution of the patient againet larger 

[doses of mercnn.-, it nuiy be increased gradually at tlie eud of 
three or fonr weeka to 0'012 or 0015 [gr. ^ to J]. It is better 
to administer It in the form of pilU thati di^Kolved in water 
or alcohol. Tlic following ta the most convenient method : 

t( Mur. hvdrsrg. (-jr., O'lO [kt. IJJ; 
Solve in paaxillo lether uilph., tt ailde 
Pulv. uQvli q. B. ut ft. pU. No. SO. 
D. S. One pill to be ukeii murniog and evening 

B Mur. hjdrarg. cor., ChlO [gr. If]; 
Aquft liwiiL, SOO-OO I fliM^ 3 iv). 
M. 8. Oiitt tutlvupouarttl to tie Uk^n morning and evening. 

For the purpose of preventing tJie gnstralgia and tbo coUc- 
paios, the patient ehould avoid taking the roedidoe, eapeci&Uy 
bid morning do^, <m an empty stomach ; a bowl of broth or 
milk ehonid always precede it by about half an hour. If the 
patient is in the habit of drinking tea, monung and evening, 
then the following may be prcecribod : 

Q Rtium. optinii, 20-00 [ J ss.. 9 iv] ; 
Snblimat. c«r., O-IO [gr. 1)). 
IL D. 8. Tvtotjr dropa to be taken In tbe tea, BoniiRg and eTODin;. 



35$ PATEOLOOT AXU TREAT^EST OF S7PBILT3. 

'^\'c seUlum prpHcribc ealotnel or sii1>mariatc of luenmtj ; in 
fact, only in eucli cases in which wc dcsira to adminieter lar;^ 
dosi^ of mercury through the digc«tivL' svetciti iu n aliort time.' 
In dangcrouR iritis eopecially, and in specific offectiong of the 
faaces, cnlomel has proved to be one of tJie qiitckeet rcioudiM to ' 
produce good effects. In aduJte it ma^' bo givun in the foltow«J 
iug form : 

S Citlomol lipviirati, O-M [gm. TiijJ; 
0|>ii puri, 0-10 [kt. 1}). 
Siocfaar. alba, £-00 [^ it]. 
11. Div. indcMuHo. IS. 
D. 9. One powder to be taken morning, nooD, aiiil ti\^\i\. 

Od the wliole, tre have iiKd vcty Uttlo sahlimatc or sob- 
mnriiite of mercury for mnny years past, I)ccauee wo liave cou-J 
rinced oiirselvei that no other preparBlii>us will produce sac 
peculiar and obstinate alterationR of the epithelial cells of the 
iDUC(.)nii membrane of the mouth and tongue as these, wpeciallj^ 
if the patient lb addicted to the use of tobacco, lu then pa* i 
ticDts there are foimd most froqocntly ou the mueoiu mocn- 
hriLiie of the tongue, lip^ and cheeks, especially on the pljira«< 
that <-omo in contact with the angles of the tcctli^ pearlv-white^ 
opnleecent opaoititw of the epithelial oclla, varyiog in m^e from 
that of a pin's head to that uf a heaiu which may be either 
Bcattcrc-d or aggregated. Those places look as if tlioy had been 
touched ^s'ith nitrato of eilver. They are distitiguiehed from 
muooua-membninc papules hy tlio abecncc of diphtheritiej 
alough upou thorn ; they do not ulcerate, display no local jiro- 
liferatiou of tbc papilla, often tormiualo iu rulracrtioiis of Ibct 
affected plaout of the mucous membrane, because, in oonso- 
qucnce of the pressure of the epithelial tliickcning upon the 
aiTected papillie, the latter retract, while the epithelial opacltj' 
is so persistent that it remains nnalterctl for tnaoy yeutL Id 
accordance v'ith an article published br Wicniiky, a RnsBlan 
physician, vho on injecting cinnabar into the blond of aatmak 
found it again encysted in tltc epithelial cella, II. Zciael fi>els 
JDetifie<l in asserting that the opacities spoken of arc nothing 
more than cpitlic-liiil culls containing mercury. In proof of 
this view, vc can fay tliat vre nover eav these persistent opad- 
tioa in perMtis who were not treated with corroiive BDblimato. 



8YPBIU3. 



857 



As an additional proof, we may point to an annlogoiw alteration 
of tlie epithelial cetla aecn in tlie blue color on-tlieguuu ot 
perFwiiii wliu haudto luul, mid in tliu hronziug nf the itkiii and 
buccal mucDOs membnuic pr'uduced \>y the internal adininietrft* 
ttuu of oilrate of fiUrer. Ad tlie internal cmploymeut of mer- 
cury is f^cncrally adopted In the troitmeut of recent manifesta- 
tions of ejphilis, that \» to say, at a timo vrhcn the indurated 
infecting plaooa are £tiU fluppuiating and the indolent bulxiea 
ore BtiU progrce^ng, it will Ijc well for tlic patient to avoid all 
active exercise, though it is not necessary that he slioold stay 
in bod. Furthermore, as the patient frequently auifcns from 
rlieuniotoid pains at the beginning of syphilis, he should not 
expose himself unnecessarily to sudden changes of tempeiatura, 
anil aHp(!cially ahuiild lie pmtect hiinKelf againitt cold and dnmp 
night-air. It ia even bciielicial for hira to sweat »>nic at night. 
Under moderate diaphoresis, the disease not only runs a fa- 
Torablc oonree, but the internal use of mercury in letter tol- 
erated. J'or this rcawn, most ph^Tiicians order the patient 
to take a larger dose of mercun' on going to bed than at other 
ttmoe. 

In re^^ard to the diet, the patient may be allowed to take a 
moderate amount of nourisbment; it is only neccesory for him 
to avoid ail kinds of vegetables and fruit that eaitse flatus, and 
bU artieles that contain regetablo acids, leinonadcd, etc., vrhieU 
are incom[>atil>le with tlie reniedie<t, and readily give rim to 
nansea, colic-pnins, and diarrhoea. If calomel is used internally, 
the patient aliould not be allowed to partake of very Kally food, 
mch as salt herring, or drinks containing soda ; nor of am- 
monia, because the composition of the calomel is thereby liable 
to ba dianged, and, it ia claimed by some physicians, that 
sodden doatlui liavc resulted from iL Ho should icnounoe 
tbe use of tobacco in every shape absolntcly during the treat- 
ment with mercury, especially when tbe snhhmate is need. 
How long a time is rcquin-d to accomplish a cure with mer- 
citry, and how much of the different prcparatiom ia nconsory 
to completely annihilate syphilis, depends upon the individoaj 
oosc. As a rule, the merc-uriolit nhould be administered to the 
patient, if he tolerates them, till all the symptoms liavc disap> 
poared, which will seldom occur in lees than two or three 



85S PATBOLOOY AND TREATMEST OF SrPmLI& 

montlis. Aa;<^r(liiigly, n -patient will wmBumo about 4-00 
[gra. Ixij] of the ppotoiodido, or 0*5 to i-OO [gr% viij to xvj] 
of corrouve iubliiuate. Tite treatuieut mast be aaiqwnded, 
at least for a time, an Mxin as ttie trtiicoiiit lueinljraite of tlui 
mouth ia affected, am! the patient eliould riiise Iiis moiitli with 
eome astrinj^rent pa-paralion cfory half-IioiiT. 

Extdraal Applicatioa of Hercory aad it* Frep&ratioiu. 

TUc Bb«orption of iiiercur)' luto tlie blood throngli Uie skiD 
can be acoomplishod in tlic following manner: 

{a) ]ly re|x^ated iniinctione of »ilve, coDtaintog tnercniy, 
over a Urge portion of tbc skin (cpidermatic mcreiirul Ueal* 
mont). 

{b) By iojeotioDa into tlio subcutaneous tissue (bypwiennle 
mercurial trcattncut), 

(0) By tbc action of vapor of mercury throngli the skio. 

(rf) By the ust of mercurial baths. And, lastly — 

(e) By the local am of mercury in the form of suppodtortet 
upoQ the mucom membrane of the rectum. 

(a) Mercurial Inunction TreaimerU, 

The method of treating syphilis by means of merrarial 
ointment came into vogue at tlie vuy buginningof lhecpid<tnic 
of syphilie in Europe; hot even the sptematio dircctioua laid 
down for ita application by Louvrier and Rnst at Uio b^t"*- 
ning of this centur)- led U* m much misuse, that all seaslbla 
physicians denounced it. 

Onr method of employing the inunction-cnre ie tho follow- 
ing : We begin the innnctioos without any ppeoiiil preiiarationa, 
simply allowing the pftticnt to take a lukewarm bath. Wu 
order from two to five grummes [ 3 as. to 3jsa.] of blneoiot* 
meut for ench inunction. The inunctions may bo performed 
by the patient himself, or by an attendant with leather glow* 
upon liitii handa They may be roAorted to daily, or erory 
second or tliini day, aeoonling to tlie intensity of tbc flyphilitic 
lesion and the oonBtitutton of the jalient. and are carried out 
in the following order tipon tlie variotu purta of the body: 

On the first day of the treatment the ointment is rubbed 
in on the anterior sutfacee of botli anns ; ou tho Kcond day, 



STPBIUS. 



8£0 



on the anterior surfaops of borii tliighs ; on tbo third day, oil 
the uiU'rinr Burfu(!0!i of iKitli fonuiniifi; on tiio fourth daj, on 
tie anterior eiirfaorn nf hotb I(^ ; on th« fiflh dar, on hotli 
loina; on the sixtli day, on the bnck; on the sevcntJi day, 
the order r)f arrau^muut is begun aiiewr. The patiuot ahonld 
tbomughly rub iu tlio whole dose of tho ealve, taking care that 
none of it tvinaiiis iu lumps uptin hia hand or u])OU tlio body. 
Tl)c hairy parts of the body idioald he avoided aa rouob as poe- 
sihlu, iK-caiuK: th« iuuuctioug urc there apt to produce on erup- 
tion of finuill postales, an. indatnmatioD of the apertures of the 
hnir-folliclcs. If itio iiiatient's liandfi nre tough and callous, he 
should put on a pair of tight-fitting leather gloveti wliorewith 
to perfonn the iDunctioo. 

In iinploBSant weather tlie patient nhotild rumniii in hiA 
room; but when the weatber is favomblo, ettpccially during 
the trann season of the year, ho ahuuld spend the greater part 
of tlie day out-of-doors. During tho cold Maara, the tem- 
perature oif the room should bu 15* or 16* Ji^umnr [60** or 68^ 
Fahr.}, and, if possible, the apartment should be tliorougfaly 
Tcntilatcd twice a day. 

The phydciaD eliould pay special attention to the oondi* 
tion of the mouth of the patient. From the very beginning' 
of tltc treatment, thu latter i-bould be instructed to rinfiv his 
mouth repeatedly during the day with pure water, or vrator 
containing some astringent remedy, eucU as ohlorato of potash, 
alum, bomx, tannic acid, laudanum, etc, 1-00 fj^rs. rvj] to 100-00 
[Jiij. 3viij] of water, in addiliou, he elwuld prevent the 
fonnatiun uf tartar on hif) teeth by brufibingtliem several times 
daily witli a soft tooth-brush and water. 

In accordance with the views already enunciated, we only 
resort to tlie iuuuclion-treatnient iu the advanced stages of 
tha diseaw, and eopecially in those cases which resist the action 
of less powerful remedies — the iodides. All relapses of the 
first phase of syphilis, auch as rvtajiaiiig papular syphilidcs. pso- 
riasis jMlmaris diEFosa, impvtigo, and ccttjyma syphilitica, and 
partly, aloo, nodular e>-philidee, are particularly well adapted 
for treatment by inimctiou. In some casea certidu special 
philological and pathological conditions that may obtain will 
More to determine the physician in preferring the innnction 



3C0 PATSOLOeT AJfO TRSATMENT OF STPmUS. 

method orer xay otiier form of iDLTCiirial trentinciit. Tbtis, it {» 
vastly preferable to sabject fij;philitio ptvgnuit, and pnerpenJ 
women to ao inuDcdon-cure:, than to iwtmiDuter mercurr to 
tliem internallj, Penwiis luvuig foelilo digcriivc or^gniui, tboao 
buHuriug froiu mifipiciiiuB lan'ngoalimd linrndiuU naUurlui, from 
freqacmt gastro-inteRtinal catarrh, or those wlio ooly recent!/ re> 
coTered Irom typhoid fever or dysenterj-, are moro advan- 
tageously treated by tntmctions thao by tlio intenul admin- 
istration of toercnrj. Furtber, tlie morbid syphflitio coodi- 
Uoufl best a«Iapted for the inunctioD-trcatincat are those wliieh 
are oompUcntcd with constitutional or other iLtfiKtions chat 
also requiro internal treatiueut — fur iuBlance, tcrwfula, tuber- 
cmloKiB, chloroeiK, iutennittont fcvor, ete. In theiw cases, cod- 
liver oil, iron, and qninino, may bi- employed in addition to 
the inunctions of mercury ; but tlie iimnction^ are principally 
applicable iu chose caMs in wblcb dan^rous symptotua hd- 
pervono, bccauso Ihcy afford such rapid rvlltf : thus, in anp- 
puration of tlio nasal paasagos, in iritis syphilitica, iip«ctHe 
affections of the bead, brain, and nervi«, especially those that 
depend up<jri extni-cerebral morbid cLangas. 

The nuniVier of tnunctious that may be ncoeoary Tarie«, of 
ootirsc, according to the form and intensity of the disease; tbe 
individHal condition of the patient ; and, hetly, whftlip-r ilie pA- 
tieot had taJceii mcnnirj shortly befurt! beginning the iDonctian- 
treatment or not. 

The treatment of syphilitic nlm.TR. nodalar Rvphilidw, and 
largo tophi, will nxjuirc! mona tQutietioUA than ihat of a papnlar 
Byphilide. In regard to the individuality, experience hasehown 
that there are jier^ns in whom tlie employmcot of this method, 
and the mercurial treatment generally, oxerciec a favoialilc in- 
flnence upon the involntion of tbe morbid plieuomena in a 
veiy few days, while in othera the lesions obstinately rwiat all 
kiuda of mercurial medication. Fewer innnction* will bo ro- 
quirod if employed in conjunction with Zitttnann's deeocLioD 
tlian without the aid of the latter. Wo have seldom foiwd 
lose than twelve to wxtuen inunctions snfficicBt, nor more than 
thirty required iu the patients that camo nndor onr ofawrva- 
tion. If the number is not capable of snbju^^itiog the most 
eeaeoti&l fcaturos of the disease ; still mora, if an aggravatkuk 



arpmiiB. 



831 



of the svpbilitic sjmptoTnti, or of tlia genrnl poiKiitiijn nuper- 
veoes, tlie treatment nliould be niKpended for the time being, 
and an effort made by a proper diet and mode of lirjng (aomc- 
timeB hj tbe intercalation of a roodcrato gnido of oold-n-otvr 
cnre) to invigoruto the sj-stein. "When tliio lias been achieved, 
the inunctions of mercnry maj be rdBomed. 

Sometinica it becomes necessary to enflpcud the immction- 
curc for a time, owing to Ibo enpcrvention of certain pbyaio- 
logicai or patliological coDditions. Tlio physiological condi- 
tions refer^d to Iiere are uieaati'uatioii and ooniiiiement. The 
acDte, ffbi-ile, coTitagionti exanthemata, mcneica, scarlet faver, 
variola, acute iuHajumatioiis of Eome of tlie organs, intenso 
catarrlul or tntlainmatory aflectious of tJie intOKtinal canal, ao- 
companied by exliausti%x> diarrliwa-s miiy be class<^ among llio 
pathological conditions. Above all, however, an intercurn-nL 
livmoptysiit in tuberculotia aypbilitic patlentti will require tbo 
immediate iiu«pen»cm of the inunction-treatment. But the 
application of the nifrciirial ointment per e* not iiifreyucntly 
giree ritse to morbid phenomena, whieh neccautate a Kuspen- 
siou of the procedure. Stomatitis mereuriulis is one of the 
most fre<iot'nt pathogenetic effect* of murcurj-; next in fre- 
qaeDcyareeczematoits affections of tho^kin, occnrringin hairy 
individoals on the places where the ointment i^ rubbed in, and 
in blondes with a tender akin over a larger part of tbo intega- 
ment. 

During the innnctiotttroataaent the patient shonlJ be nonr- 
ialied with easily digeettble food in quantities pnijwrtiomite to 
his age, habits, and bodily conformation. We allow the pa- 
tient in the morning either a cup of tea, coffee, or a bowl of 
l»«lh or milk, with one or two slices of wheatcn bread ; for 
dinner, nntritions bccf-soup, from fifty to seventy grammes 
[ 5 j**-* 3 iv to 3 ij, S vii j] ; veal, or chicken, twenty grammes 
[388., 3 iv] J rico boiled in milk or water, or Bomc other di- 
gestible farinaccons food, orapinach in tbo fiamo quantity; even- 
ings, the patient geta another bowl of cooeenttated broth, with 
vheatca bread and coffee, chocolate, or milk. Special condi- 
taoDfl, fioch as pregnancy, contincment, seorbutns, convalc&cenoe 
from typhoid fever, and intermittent fever, re<]aire special 
dietary rcgnlatious. Pure eeld Bpriog-water is the bett drink 



sea PATffOLOGY AXD TREATJfSXT OF STPBIIIS. 

tbat cnn bo rocomnicDded, In tlie liot eeason of tLe y^ar the 
paticiitis ivpcciilty scorbutic cnuvali^ccnt^ ma/ be pcrniittcd 
t-o drink lemonade or water flarored vitb Eomo fruit-Binip. 
TLoee irbo liavo boon greatly reduced in strength by a pre- 
coding typhoid or intermittent fever, low of blood, or viciooa 
mode of life, uiay bo allowGd to drink a proper qoaotitjr of 
good wiiie. During tlie iniiiivtiou-treaun«nt tlio patient's botr- 
cU elioald move at least once a day, because eiqierience bu 
gbown thnt tho^ snScring from constipation are mors liable to 
be aiTectfd wilU salivation than those who are not coMtipated, 
If tlio UmcU are duggibh, catbartica or aomc mineral water 
that contains sii]plmt« of magnesia or tilaulier'a »iltA, sncb aa 
Saidschatz, Piillna, Ofner, Elizabeth Spring, or the like, eboald 
be ordered. During treatment we often give a email ijuautitjr 
of ZittinuunV dccoetton. 

If no eontraiudicatioQ againat the contiQuatioD of tlte in- 
unction-treatment supervene, it sbonid be prolonged till tlie 
physician ba» good reason to believe that the diecaw ie cntiroljr 
cnred. The good cffeeta of an innnctlon-earo, and of tlie 
internal iitio of mercury, eoon manifest thcioselvea by tbe fiiet 
that the patient loses lug former eaehcetic appeamnoe, g*^ 
perceptibly in weight, acquires a healthy color, and tbe evi- 
dencea of the Rypliilltic diatbera's cainble of nndergobg raaoln* 
tion dtnappear. So long aa the circumscribed discolored gpota 
have not totally diMp{)eared, m lung as tbe eyphilitic ncua 
liare not become [H;rfi-ctly pale, ao long oa tbcro is falUng oat 
of the bair and fragility of tlie nails, tlio paticnis coo not be 
deemed entirely cured. 

^Vlen tJiti inunction-ciirc ia completed, tlie patient ahonld 
take one or more nann batbf>, protect hinuelf agaioat cntcb- 
ing cold by remaining a few days more in a warm room, and 
then may grudiially refinine his niiiial mode of living. To 
avoid nil possible riske of the ctfccta of a lowering tctiipomtnra 
upon the Eyetem that may have become aeDutire during the 
treatment, eeveral hot vapor baths, witb fiulweqnent colil douch- 
ing, or a modcmte grade of culd-watur treatment, may be reay 
ommended to the patient 

[The problem at the outact iu tbo troatnient of syphilis li 
to free tbe ayateui of a poisoTi tbat poasewea tbe pruporty of 



STPBIITS. 



363 



tonacioiislj clinging to it uml of iindemiiiiing it for years, per* 
meuting all tl>e tissues and tliiitU of tlie hod}'. We most tiear 
iu miud that bo long tut tliu (Miison i^ active tliu nutuntl reca- 
perativc pow-urn of Uic ImmIv arc insufficient to orercome the 
diaeaee vbicli Las a lendencjr in many cases to he aggreasive, 
pragreeaing in it« morbid changes, an<U wlien k-ft to it«elf, 
causing serious damagtt to maii^v important organs. If the Hja- 
teni ie to be fiaved from [>ertnancnt injur)', if it is to bo freed 
&um Ibti 8yi)MUtic poi^n aud cured {lerfcctly, tlio phrnidiui 
and patient must unite and continue their work together per- 

mtlr until it iu bruugiit to a Imppy tvniunaliou. 

The witidotw lo tJie nvphilitic poinon anj mercury and 
iodide of pota8«;iam ; upon that point there ie no longer any 
question. Tlit- bu^t autboritiat are now agreed (hat tbo disease 
can not be cured t-fft'ctiially without them. Hut they are only 
antidotos when properly bandied. If given in insufficient 
dost-s, the disease soon obtains the uuutery ; if u»ed in ex- 
ce^ lliey become poiKins tlienioelvca. To hit tbe exact and 
Iiappy medium, to avoid both dangerous extremes, we must 
not confine ourselves to strictly arbitrary doees, but admin- 
ister thera in quantities not only suificient to control, but to 
eradicate the disoaw, in acoonlanoc witli the rcquiretnenta of 
each individual case, (wing ever ready to reduce the quan- 
tity or ditwontiime it entirely as eoon as any untoward symp- 
toms manifctit thc-uisclves. At the same tiiuo we must avail 
our»?lvc« of such other agents as will aid in bringing about 
the transforuifltion of diseai«jd into healthy tissuea, by ineroaR- 
ing their uutritiuii with healthy blitod, and removing effete 
matter — ^i.e., by a generous diet, diaphoretics, tonicB, ete- 

To VoQ Sigmund belongs cbo credit of Iia\ing pointed out 
tlie fact tluit iu the tmiittueut of Hvphilid with mereuty we 
mast not only not pnKluce any signs of mercnrial poisoning, 
but the more jierfcctly we guard the system against the toxic 
effects of this drug the surer shall we be to cure our ]ialicnt of 
Lis Byphililic disease In t!io >-ast majority of cases the inimo- 
tion method is the best form of employing mercury, and, hav- 
ing obtained the most satisfactory results from it, I seldom 
itBO any other. Id regard to the fear of patients taking cold 
dtiriog its employment, all 1 can say is that I bare repeatedly 



8«4 FATEOLOOY AUD TSEATMEST OF STPBIUS. 

seen patienbi come to nij^ clinic in inclement weather wltli ■ 
considerable amount of inorcarial olottiietit etilt frosli upon 
thctr persons, having n^lectecl to wasU it off for d&jt to- 
gether (Ihongli thpj were e-aiitione<l agniiist pnffh n e^>m8C) — 
[uuny of thcui being insufficiently clad at tliat, withont auffer- 
ing any ill cfTcctit from iL 

tu the inuDctioTi -treatment, the following addittonal prao 
tical sn^imtione luiy be of value to the pracdtioDer: 

]. Tbo body should be prepared to aljeorb the merciiiTr, 
iind a quantity of bluo-motsK uited sufficdeut to pniduoo an e0i-ct 
upon tlie (syphilitic legion. 

The prc-pafAtion of the body dimply oonei&ts in tlie patient 
taking a 'narm-watcr batli before rubbing in the ealrc; he 
RtioDld remain in tbe batb from a qoortur to balf an hour. 
l*oor patient* who can not procure theee hatha should waah the 
part of the body upon which the ealvc is to ho robbed with 
diluted alcobol or vinegar and water, and afterward rab the 
part dry with a coarse towel; in f act, rimply rubbing the 8kin 
with a conr&e dry towel aecompliebce the same object — of stim- 
ulating the alieorljcnt jiowers of the ekin — u tbe use of hot 
baths. Somcdfnes, however, varions obstacles nuy intvr- 
Tene, mch ae inercurialization and febrile phenomena, caused 
perhaps by a local affection, which have Lo be rcmuvcd before 
the ]>aticnt ran l>e subjected to tbe inuncljou method. Para- 
doxical as it may seem, yet it k nevertlielcM true that a ^ 
tiant may be brought to a slate of mercurialization and sti>- 
matitis without being bcntifitcd in the least, and it will be 
neceasary to core him of these complications before it is poft- 
able to adtniuietcr any more mercury to him, If the fcbrilo 
phenomena are due to an interonrrent acute difca^, or the 
patient baa been intemperate, and indulged in excceece, it wQl 
be necessary to defer the intmction-tTcatmcnt till his syvtem 
has bad an opportunity of recuperating eomowhat, and been 
improved by propnr restrictionB, batbfi, tonics, etc, 

I deem the manner of rubbing in the ointment of the at> 
moKt importance. Cfiually the patient takee a lonip of salvu 
and rubs it in upon his person without care or attcniion, leav- 
ing pcrlmps half of it in lumps on the skin or on bin fingeiB. 
Katurally^ little or no good is derived from «uah inunctions 



STPBIUS^ 



ses 



ibo duoasfi romaiuing unaffected — nar* more, often prognssM 
unchecked. I ibercforc give hii» explicit instractions tomb 
the ealvd into }iis groias, thighs, or nxillie, in such a man- 
ner that tlto whole niastj of oiutment is thoroogUy rubhwl 
' away — oonaomed, as it were — and none remaiiiH on hiti Hngcra 
or in lumps on his body. If possible to employ a trninod 
nuRRC to do the inunction, better re:«ult« wUl, of course, he at- 
tained tlian wlten tlio paliiiiits do it themselves. If time per- 
nut«, [ order die patient to ruh in the salve leisurely on oii« 
side tint, and then on the other; in tliis manner he is nuns to 
mb it in more thoroughly Ibau when ho rubfc it on l>otli sidce 
Bimoltaneoiisly. In order to avoid irtitatin^ the skin, I caaee 
tliB salvo to bo rubbed in each day on a different part of the 
body, as rccoinmgndcd above. The amount of unguentum 
hjdnrg}-n necessary for each inunction varies with the size of 
tlie body and snsceptibilJty of the individuality — from 3*(K> to 
5'00 (gra. XXX to Ixxv) for nn adalt, and from L-00 to 2*00 
(gra. XV j to xxx) for a child. 

A very good method I have found i& to order the patient 
to Tub in the required amount of the ointment jnst before go- 
ing to bod, driuk a pint of hot milk, get into bed, wrap him* 
ftelf up in blankets, and ttvreat. In the morning he Kbou!<t lake 
a bath, or at lca.^t wa.sh tlie part where the ealve was rubbed in 
with warm water and eoap. The hot milk is Iwth niitritiona 
and fiudonlic, and ii* an invaluiiblo adjuvant in bclping tlic 
eysLem to get rid of the syphilitic Tima. One grrat advantage 
of tliis method is that no imtieut is so poor that he can not 
provide hinuelf with the agents necessary to carrk' it out. The 
rabbing in of the ealvc before going to bed does not interfere 
with his vocation, and hii! remaining in bed tlie wbole night 
obviates tLe danger of liis taking cold. For the sake of greater 
cleanliness, I sometimes nee tlie otcatc of mercury, but the 
o1>jection to uugueiUtiin hydrargyri ou tlie ecore of utidi>anli- 
ne«8ii) obri»tt>4l if the patient uecs the same night-diirt wbilo 
undergoing the course of inunction. 

2. The body must be maintained in a good state of health 
during the treatment. 

Above all things, it is necessary that the pai.'cnt should 
breathe plootyof good air. The lungs most work in a good 



see PATffOlOQY AJfl) TREATMENT OF STPBTllS. 

airfwftjihrff, wltilu tlto skin U imprcsMMl into service oiid com- 
pelled to absorb the aotidote agaitut the syphilitic poisoo. 
The patieutd ithould be out in the open itir u much u paflBiUe, 
and 6lc«p iti w large a room as tliey cau obtain. In Pinall rooniA 
more or Icee of tlw Tapor of mercury actiimnlfttw in the air, 
and a tainted ntniospherc is thna tulialed. For this reason, 
ol^o, no ono should shore tho room with the iiatieiit. The 
physician dhould ioBist upon the ])fltieritit* taking ratncletit 
out-of-door exerciHo, and pn>perly ventilating tbo room thoy 
sleep iu ; the fear of taking cold Is so great that tboy often 
go to the 0]ipo«ite extreme, i4iuttiug tliem»clTei; ap in i^mall, 
poorly ventilated rooms, and thus do thcnieelvcs great in- 
jmy. 

In regai-d to nutrition, it is only noceaeary to eay that M'pln- 
\ii tubers Id an acuto amemio, whicli sajw and vittalu the sys- 
tem of tho pnticnt in proportion to the severity of tbi> diseue ; 
the debility is proportional to the loes of bodily weight. Henee 
tlic ncoetjsity of placing the patient upon tho boet poeublo diet. 
The brilliant results which the inimotion-cura and low diet 
achieved in fonner years can not be net up igaiiiBt tliis pnjp- 
oettion A eufBcicnt amount of good and nutritious food 
slionld be allowed ; I am even in favor of according the 
privilege of ]>an.ilcing of a moderate amount uf good wine or 
malt liquor dnjly, for the pnrjxiee of ntimnlating digortion 
ami aA»milatlon, and thus expediting the metamorphoeia of 
the tl8d£8 by a b(;ttcr and riehcr bloo<l-«i!i>|'Iy. Uowi^vcr, 
owing to the gluttonous habits of Bome iudi^'id^al8, it will be 
well for the phyaician to preacribe for the patient the amount 
of food and drink m-ct-mnry for him. It id of the utmost im- 
portnuce that he shonld not overtask hie digestive organs, for 
upon tho ability of tho latter to prepare a proper pabuliun will 
depend the recuperation of the entiro system. 

It ifl highly e«eential that the muoona mcmhrane of tho 
mouth bo niaintajned in a good, liealtliy state;, and the tendency 
to mercurial stomatitie be obviated by appropriate local troat- 
ueut. There ia great divereity aracmg patient« in tlib re- 
S[>ect. Sorac are very prone to suffer from mercurial atomft- 
titis, and others remain exempt from it throngliuut the whole 
course of the disease. But whenever the temlency manifeeta 



SrPBJLIS. 



867 



{teelf it Blioald be counteracted bv the ose of eomo of tlie 
reniodies mentioned alwve. If niccrs fonn in the monUi, they 
should be CAtiterizcd with nilroto of silver or ciironiic 8cid — 
tbo latter solution being oniptoyed one hDndred grains to m 
diadun. In addition to thi^ treatment, Utu juitiunt niURt be 
enjoined to keep Iii« mouth [lerfectl^' clean, and renounce the 
nsc of tobacco abeolutelr. 

I wish to nay Iiero that it la poBsflile to habituato patieiit« 
to tilt; ««; of iiicrciiry, however suoHitive tliejr nnijr Iju Ut it^ 
and, if anch a person oomce under treatment, it is best to be- 
gio irith a small (jnantity of merctiria] saJye and gradually 
inerekse it. If pcrcliancc ealivatiuQ has been produced, lUa 
innnction should be snapended altogctht-r till all the symptoms 
of mercuriftliiatioD have disappeared. 

Sometimes it u difficult to distingimb mercurial tnm 
ejphililic uloerationa. Both occur on varioug parts of the mu- 
COUH tticnibrane of the mouth and rewmblu each other very 
doeely. This is especially tnte of mercurial nlccrs that oc- 
cur on the tonsiU and palate. Here the matter can only bo 
decided by time, watching the oase carefully, and, if necessary, 
SttBpending the innnctioitg fur a while. If the ulcere are mer- 
coria] iu origin, they will get well by the u»e of the ahov^ 
described lotionn for tliu nioiitb, hut if t^yphilitic tliey will 
oouBtanlly become aggravated. They ah>o act quite dilfferently 
in reference to canterizationa. A eyphilitic nicer will get well 
^Hi morcnrial ulcer bccomee aggraTated by cauterization. An 
Inereascd Sow of saliva may also cause uncertdinty in re^rd to 
its oripn, for Bometimes casee axe met with in which this con- 
ditJOQ is simply due to irritation of the ncrvce of the mucons 
mcmbrano of the mouth and of the salivary glands by the 
syphililic virus. This point, however, cim be decided bv the 
history of the case and whether the patient has boon subjected 
to a treatment with raercur)' or not. 

Another objection han l»eeu urged against tlie inanotion 
method, namely, the production of aleepleasneta. Itnt, on io- 
Tcadgation, I hare found that it is not of sufBcieiit conao- 
qoenee to cansc u sui«])(.-tuiluu uf the tnratmtmt. It occuni 
very eclilom, and its eSects arc tranrtient I am, moreover, 
of the opinion that it Ls due to the general nervoua irritaticn 



868 PATnOLOGY AKD TREATJtSST OF STPBltta. 



of the system caiixcd hy thu i^pliililic viniii, as U niiuiiri«t by 
the loss of aeosibilit; of the catis, aod bj the dilated pupils, 
and i& therefore & etill greater iudJoitUon for pereevxtiug witli 
tlio ttULtwcnt. 

A word or two in r«forcnce to the local treabnent of syphi- 
litic losioas doriug the imtuctioii-cure. AUhoagh tlie latter 
will almost always prove sufficient to caiuc uloemtione of 
tho skin and other parts to heal, etill a proper local treatment 
will he found of tliu utraoet advaiitu)y:e. Ahoi'o all, tLe aorea 
are to Iw kept scruputotudy cleaii, in nhnlerer stage of tlie 
disease and upon whatever part of the body tliey may he. 
Solutions of bichloride of oiercury, of carbolic acid, nitrate oi 
silver, iodoform, boracic-acid ointment, etc. — any one of tliem 
will render efficient service. For the nose, vagina, or iBctutu, 
K6march''a irrigator will be found indispensable. 

3. The innnctiooB must be continnud long ODOnglu 
To cnoM the morlud led(ms to heal, and prevent rclapeee — 
that is OUT tA^k. The earlier the syphilitic patient i? taken in 
band, and subjected to a thorough anti-»pecitie treatmeDt, the 
milder the disco&c will nm its ooune, and the more rapidly 
will the symptom* di^ppcor. I have Bcen so many hard, iniiial 
sclerotic nodc«, or hard chancres, attended byindarated plnqnea 
of ingiiiiml g]»nd.s dii^ppenr, niolt away aa if by magie under 
the inmtction-treatnicnt, tlic paticnls retnatiUDg ffabaeqneady 
free from relapeos, tliat I no longer hesitate to pnt a patient 
under the specific inunction-treatment as soou as I have 
eatigfied mywlf of the true nature of tlie Icsioo. It is cod- 
ceded by some of the best authorities that it is easier to core 
a fuUirnt radically of his M'philin while the infecting virus is 
etill localized in the initial (iclenisiis or even if it has affected 
tbo inguinal 1^-mphatic glands, than when it has permeated 
his entire tgrstem, lct<«> modiciiio and a shorter time being nccee- 
eary to coimleract a poiH>n confined to a limited space than 
when diffused throughout the ti^«ue« and 6uids of the body. 
I prefer the inunction method for this purpose, bccnnse I can 
aeoompHsh more with it in a given time than by the intemnl 
•dmintiitrBtion of mercury. Beeidee, it poeeeesea the addiiinnal 
advantage over tlio htter of not interfering with llie pnlieot's 
digesUoD. The oomplicatioos of the inunction-care ppoken of 



87PSILI3, 



zm 



above are oilly seen in exceptional t&fcf^ and liare been referred 
to at length because of the greater value it possesses orer other 
metbodfi of trcatnunt I quite agree vritb Von Signiumi in hie 
statement tliat there will warcely ever bo seen a case of Rj-phi- 
Ue wliidi the inunctiou method, if continued long ooougb, 
will not coro effectually. It is well to Rtnte here that, to cure 
a patient radically, and render him proof ngmni>t relupxes, it is 
Decessary to prolong the iuuuetiotu of mercury for from eight 
to ten dnjre after the K^Tnplonui of ayphilis have entirely dj^ 
appeared. 

One of the mmi uHcf ul adjuviuit^ in the tnatment of aypbi- 
lift U ttie hot-air bath, RuHi<iau or Tiirkiah. The uee of topical 
bathiiig before and after the nibbing in of tlio mercury has al- 
ready been alluded to. The bot-rapur bath for tJie purpoee of 
causing profuse diapborcsis U an invaluable rcuicdy. I cause 
my patknU to take one and often two a week. It i« well to 
caution Ihcm ag^net remaining too long a time in the liotair 
chambers, fiflten or twenty niinute« being sufficient to cause 
active turgeecence of the ekin, attended by a profuse flow of 
pereplration. A longer stay will relax the ej'stem too much 
and prove debililAting. The pbysioU>gical action of tlieae 
batlis is that of a derivative of the greatest power, and their 
good effect* are atx)n maiiifi*t. 

A word or two more in reference to the use of tlic iodides. 
Kverything that has been eaid concerning the auKeptibility of 
pertain imtividuflU to the use of mercury U applicable with 
etill givjitvr force to the pn^pitrationn nf iodine. Often thoy 
are tolerated badly« or not at all, even when talten after meals 
and largely dihitcd. Thus, in one patient, it waa inipomuble 
to adnunister the remedy unlcet! it wan preceded by a teaspooo- 
iul of brandy largely diluted with water. The individual wae 
not of inteiiipenite IiabitA. In other patient*, again, the dose 
required to produce a physio logical impression upon the eya- 
tcm, to bring about a state of iodism, may vary in amount 
:&om 0'60 to 400 (grs. x to 3 j) every three or fonr hours. 
Many pliygiciana preecribe small dofice of the iodide in com- 
bination with mercury, even for Oie early nianifeeCatioiis of 
the disease, in what ia deiiomiuat«] tlie " mixed treatment," 
each dose containing about O'Ol (gr. •^) of corroeive sublimate, 



PATJIOlOOr AXJ> TRSATitByT OF STPUIUS, 



and 0-80 (gn. v) of iodidu of potasfiiutn, pro{ier)/ dilotofl. 
When an iniport&Dt organ ie inrolrcd and ia in daiij^ of be> 
log Irrepajably damaged, full doees of tlie drug— from I*Oft 
to 4'OU (grs. X7 to 3 j) three or fonr times a daj — nil) render 
efflclont »;rvicc ; likewise, vlioa tho use of the mexciiry ban 
to be BUKpcuded and h U necceeary to prolong Ita speeitin effeot. 
On account of itj* rapid action, it Is espedallj nseful in those 
terrible night-pains that sometimes threateo to drive a [Kitiont 
to distractioD. I'lnullj, tlie remedy !b often iiervici^al)!^ in d^ 
ttictiug the true nature of an obscure STphilitic ledon. The 
manj cases of nt-rvous affection whose etiology is eo difficult 
to elacidate, and in which curca are reported to have been 
achieved, arc doubtloes of oyphijitic origin. Paticntii ara often 
met with who form their own diagooeis by the etatemcnt that 
iodide of pota^um ha5 repeatedly reliored them of tiieir di»- 
tn»8ing ailment, thos affording the physician an indicatiott 
of tho trac nature of their disease. Tbns, one patient infora]«d 
mo that he liad been suffering for five years from tbe moat 
violent pains in his atomach and freq^uent eoions, wbif-h waa 
always coutroUed by iudide of potaeeinm; and, on inquiry, I 
found that he hod had a chancre eome eight yean bofor^ All- 
lowed by a slight syphiUtie erujition, but snppoeed bitneelf to 
be entirely cunxl of his diseaae. 

Il insy be remarked en, ptmant that the remedy Is often 
abneed. Many of the morbid lealona of this disoaae gel well 
imder ita tute, and thus tbo patient becomes accuntomcd to 
resort to it whenever anything happens to him. ]n the 
cotireo of time be finds, greatly to hie sarprisc, that the 
remedy makes no impression upon tlie disease, the aymptoms 
rcmaioing stationary, or even hocoming aggraTotcd* A condi- 
tion of tolerance having tokeD place ; not only has tiw lodUa 
lost its power over tho diswiao, bnt it may happen tliat, wlien 
the patient fmbroits himself to xadical treatment, mcb as may 
become necessary upon tlie ntperrantion of some acute s[>eeilie 
lesion, he i» extremely nnimpreesiomible to the action of the 
remedies. A longer or shorter interval of abstinoDOB from all 
medication will tliun bo neoessory before the remedies can ex- 
ert their power av«r the diaeue.] 



SYPnrus, 



(J) Hifpodermie Jlm-urlal Treatment of SyphlUa. 

Lcwln wue tbe Hrot physician who systematicdly practiced 
Jijpodormic injections of vumxiive sutjlinuite in tlie treatuMnt 
of siqvhilis, tliougli miuiy hiu) einplujud voxioua prcpiLralioiie 
of merenry etiboiiTaneously before liiin. 

Before we reUte tlie reauluof our e.\]ieriencB with hypo 
dcniiic injections, we dcHire to cay a word coaceming tbe 
i«chui(|Ue stid llic prt-caiitioiu that are neccsBuy. A liniad 
fold of skin fihould bu piuctied up and made as tense aa pa«- 
Bitile, because the ]ioint of thu Iiypt)dcnnic needle will then 
penetrate tlie ekin mncsh more eaaity, the pain will also 
be leaaenod, and a vacuum is thereby created over a com- 
paratively large enrfaco for the absorption of the iujoctcd 
Aaid. These factors obviate, to a groat extent, the danger of 
tk« formation of an abwc«s. Tbe oiling of tbe needle b^ 
foro injecting tlie niodicinc is enperfluouA, bat tlie entire in- 
strument sboiild lie cleansed in water and dried before ooch 
operation, so that tbe cannin does not bccomo rooj^ and 
doftged up, aiHJ particl(.«'of corraelve sublimate for<^ into 
the akin. The pirion Khoiild work ^mootbly, failing in which, 
and if muoh force has to be used, there Ss, danger that tbe 0|)- 
poeite fold of sktn M-itl bo punctured, and tbe injected fluid 
peoetrate into, instead of under, the iikin. In injections with 
corronTe rablimate, eiich an accident is liable to be attended 
by onpleaaont reeulta; tbe puncture becomes inflaint-d, Hup]>n- 
tatca, and cauiiod Mivere pain. The Kkin should lie punctured 
and the cntiro injection performed a» (juicklj- as poegiblo. In 
corpulent pereons the injections, it is true, are made with more 
difficulty ; still, they con ho performed if a fold of skin nuf- 
ficicntly broad is pinched up. We have never seen any bleed- 
ing from ptincture of a blood-veesel. 

In r^ard to the frwiiiency of ealivntion, wo mnst say that 
gringlvitis and stomatitis did not occar oftener in the |witientfl 
we treated by hypodermic iiijeotions ttiao in these treated by 
inunctions with mercury. Relapses and etiocc»dvo outbreaks 
of syphilitic phenomena occor jost as often in the injuclion- 
treatmcnt as in that by inunctions. It is a carioaa fact that if 
gingivitis develop during the mercurial inunction method, the 



PATEOLOar AKD TREATMEST OF STPBTUS. 

{^Tsmidfi of the inciet^ir teeth of tho lower jav, as k rule, are the 
tiiBt to Bwell up, u-liilo in tbe treatment by hjpod^mitc unbii- 
mateinjecUimit^ngiv-itinof tlie upper iiicisoni ut^uuJIj derelops 
tint If the injectione are tnndc in the vicinity of the pri> 
mary mduration and indolent absorption bubood la the giutn, 
tlie latter will l>e the tint to disappear ; ulcerating pa[mles offer 
tlie greateet dcgrcu of rc«istBDcc to the hypodermic injectiona. 
The niaximuni of a total dose of 0-3 [gm uj], either of cak>* 
mel or of bichloride, vim needed, only iu tJie uiocft obtttinito 

OfiCH. 

Iu regard to the choice of the meroorial to be tued, wa 
prefer corrosive sahliumto to calomel, althoogh, u a rnlo, we 
have Bccn tho eyphiUtic pheitomena diaappear eoottcr from the 
use of calomel injections. But this adrantage which c«lo> 
inel ix)«su6smi is greatl}' offset by the fact that tbo injevtiocu 
are almost alwayis followed by boile, despite tlie atjnost care 
adopted. Altliuiigh t)iey did not ahvuvd suppurate, t^till they 
were very painful for a long lime. According to the statement 
of the patients, t!ie pauu la«c longer after injectiona with a 
purely watery solution of Hublimate than when the watef7 *^ 
lation IB mixed with glycerine. Oingintia, aa a rale, oontea 
on later in iujeclioua with corrosit'e Buhliioate than witlt 
calomel. 

We QBc tbc following formula: 

B Sublimst. porroriri, l'OOIirr*,XTJ]; 
6lj-c«rini purl, 70-00 [ 5 y, 3 Tiyjj 
Ai]tiad6BtiL.S0-O0fSJl. 
H. S. For tojectiona 



A s}'ritif^ful of this solution eontaine 0*01 [gr. |]. The 
injections eiljould be made into the back and aides of the 
thorax. 

Some phywdans — Legeoia, for instance — fearing tlic corro- 
Kive effects) of tho sublimate, have injected a tiiinimain doao^ 
0*005 [gr. ^r], oombjnod with muriate of morphia. Dr. 
Stanb, of Stiafibni^. employed for that purpose, a |)rcparation 
of oorroeive sublimate free from acid. He diseolvcd thefub- 
liiuatc and chlorate of amraonium in distilUMl water, aiKl ftl- 
terod the solution ; next he diasotred the white of an oggin 



STPmiis. 



878 



distilled water and filtered it ; lastly, be mixed both solutiotw, 
and filturod for the tliird tune. CulUngTCurtli found Staab's 
solution, anide from tlie trouble of preparing it, exoeedinglj 
liable to become decompoeed, and injectioDa mnde with it were 
followed by jjidurationa tliafc disappeared very slowly. No 
indtirations,liowovcr, followed tbo ntMiuf Mjlutions obtained by 
tlie method described by Von Biunbergor, in 1870, and many 
patienta treated alternately witli Staub^s and Bamberger's aoln- 
lions laaintained tliat tho luttCT preparation ii much lct*s pain- 
fnl. In Bamboi^r's eolution peptoa is used in place of 
albamen, which BimplLflc-a ita preparation, and renders it 
more permanent. Ho di#^lve<l 1*00 [grs. xvj] of mcut- 
pepton In 50 cem, [ 5 j, 3 v] diatilled water, and filtered the 
solution. To this he added 20 ecm. [ 3 v] of a fivL'-jM-r-^-ent 
aablimate eolution, and diasolred the r»*nlUng precipitnte \riih 
the requisite quantity ( 1 5 to 16 ccm. [ 1 iv]) of a aolotion of tabid- 
ult, poured till! liquid into a graduated glass, and added dia- 
tilled watrr till the whole amoitntt-d to 100 ccm. I5iij, 3ijJ. 
Every cabio oentimetre then contains exactly 0*01 [gr. ^] mer- 
cury combined with popton. Tlio liquid ebould be covered 
and allowed lostaiid quietly for several days. A filight amonnt 
of white flaky precipitate settles, from ivLich it ia finally sepa- 
rated by tUtcring. This preparation keqw better than the al- 
buminate, and injections made with it only caueo so much pain 
as is experienced from the sadden tension of the aubcntancotu 
connective ti«sue. Otlier physicians (Boulton, for instance) 
inject iodide of mercury in a solntion of iodide of pota^mn. 
Still others have tried various otlior proparationa of quick* 
silver for injections, especially hydrarg. acet., bydrarg. ioda- 
tnra, ajid hydrarg. biniodatnm rubmm, and, lastly, a watery 
Bolation of iodide of potaaaium contaimiiji tlie protoiodide. 

But the laitt'Uientioncd injecting fluid is now abuost co- 
tinrly abandoned, as it ia liable to be precipitated and act aa an 
irritant Lately, the chromate of the osyditl of mercury and 
the methyloxydhydrat have boon tried ; wo have bad no ex- 
perience with tlicfic preparations. Cullinpworth, Von Sig- 
mund, and Gurtr. re<:omineQd hydrarg. bicyanetum. 

Quite recently a oue-per-eent eolution of m^eurt/ fvmuk- 
mid was rocommcDdcd for mbcutanconB injection by Ueb- 



U PATBOLOOr AXO TREATMENT OF SYPffft/S. 

reJch. Wc luivc tno<t Uur prnpajiuion i|aiti> exrciiflveU*. Id ite 
oqUod it diffors in do rci^poct from otlicr iDcrcurioI ootupoutid* ; 
it wiflGB the (tvuiptoDiu of 6j,-ph)Ii« to dieappear just aa qtdvklj, 
and ibo prcMlticeft ttalimtioa an readily va otbvr proparatiotu of 
roercuiy, and t!ic r(!la|i«us, too, occiir just aa often after Its 
uae »» after an; other. 

The main advantage of the bjrpodcnnic mercurial treat- 
mttit IB thiit the dtnsc of tliu modictnu iDtroduced into tbo bj»> 
tem is not onl; veiy niiicb enmller than that which ia adnitn- 
iatered \>f the mouth or in the innuctioQ method, but it can 
also be measured nccnrately. Fartherraorc, it u also a moch 
eleancT and 1<«9 cxpcusivo metbivl than tho inunctioD or in- 
temul treatiueut, cirenintilancca whtoli, in private or even bo«- 
pilnl praptiw, c?an not bo ovcr-e«timnt«l. Ncvertlioloni, iro 
iwldoni rv«ort to this method now, boeaose it is br no moans 
palnlew, is aa Uttle capable of preventing rulajwea, and jtut 
as often oc'nfiionii mercurial stcimalitiif, oa anjr of the utbvr 
methods of administration. 

(c) Treatment <(f StfphUiit htj Jlerourlal J^umigatWM. 

For many years H. Zeiwl and others treated their nyphilitie 
patients in the Vienna General Uoepital by mercorial Aiiulg>> 
tioiiB, according to the method described by Dr. Jlenry Lee, 
of London. Tlic* patient, entirely nude, in placed upon a canfr- 
bottom cliair and wnipi^td in a cotton gown provided witli ■ 
hood, the face only being cspoeed. A fuoncMike veeK'I, opeo 
ImIow and perforated with holes all around, ia placed under 
the 8cat. At one plncc it te cut out for the idmiirion of a 
epirit-lamp. Above, the roaBcl is shut oS by a pinto which 
is depressed iQ the middle, where a mnall enueer ia placed. 
The depreMion in the plate is filled with water for the porpMB 
of generating Rtcam-vapor, and in the eancer 1 *50 [gn. xxtj] 
of calomel i^ placed. On ligliting the lamp. Ttt]ior. impr^ 
Dated with the fumes of calomel, ia gencrutetl and deposited 
Upon the skiD of tlio potient. Host patients feel voiy com- 
fortable during and after the fumigation, the refqiiration bchtg 
in no way interfered with by the pixKiec^ Din.-ctly afior tlie 
fnniigation they must go to bud, to avoid taking coltl. 

The fumigations may bo made crery day, or every oUier 



STPniLIS. 



87ft 



day, or even at stm greater interviila. Tlie greatest nomber 
of fuiiiigatioDfl neceseary to perform a care wag fifty-five. 
Sail ration occurred iii ten cases. Itelapeca eometimee utuued 
after nQraerous fumigatiuun. Ko syphilitic [Kitioiita, who ure 
llublo to uttacks of hicmoptyniis, eliouit) bo subjected to the 
fnmigatiou-lrefttment with oiercury. We never employ thiit 
method now. 

(it) Treatment of SyphUU wUh HathB coniaming JJcivuri/. 

Corroeivo sublimate ib tlie only pr^parutiou u^ in treating 
Bypliilitic patients with hatJifi containing mcrcnry in eolution, 
and by tlic addition of mnriate of amioonia it is rendered more 
soluble. Tlic following is t}ie fonaata we use : 

U Sabltmat. eorros., 15-00 [ % m.]: 
llur. anunonis, B-00 (3 ii-j ; 
Attn dMH, 1<M'W i S m. 3 n\i]. 
iL 1b ritro b«ii« obtumto. 

This solatioD ifl poured into a hatb at a tempenitiire of 

Sr to 28" Rt-aumiir [92* to 95° falir.J. TIic pativnt remains 
iu it for about an hour and a half, daring which time it is cov- 
ered BO that only hi« head u exposed. Corrosiro-fublimato 
baths arc a<:lnptcd for individuals whose ekin will not bear in- 
unctions, whose reapiratoij orfjans do not tolerate inhnlationn, 
and whose digestive organs rebel against Uie internal admin- 
igtration of mereurj-. They are especially useful iu patients 
fiuiltiriug from pustular and ulcemting fiyphilis, and those io 
whom mercury when internally administered produeoa on- 
l^easant digestive diitturbances. But thoy should not lie em- 
ployed if the pustule!) are dry and exfoliate, and leave beliind 
perceptibly hard penfoUicuIar iufiltrations — a phenomenon 
which we often had on op[iortunity of ob«crviug in variola 
sypliilitica. 

Willie the Bnhhmate hatha are being o^d the ume die- 
tary meaeures ahould he enforced as ut any other method of 
UKrcurial treatment. These Itathe likewise are apt to occasion 
aalivatiou. It is not poeeible to presi^ the exact Dumber of 
bathe that wilt be nccc««ary in any gircD case. 

As the ab«orbiug power of the skin its undoubtedly differ 



3T6 PATaOLOGY AS'D TREATMBST OF STPBtUS. 

cnt 10 different persons, It is not posdble to sa^ how much Kub- 
limnte of mercury — which, as is well knowu, is a very actnw 
rcmodjT — in ftbeoriio(), and buuco thio method is not likoljr to 
foe eztensiTely Uficd, 

(*) TrMlment qf Si/j>^iiu hy tf*a Apptwiiion ^ Mrr&urial 
Stippotiiorw to the Mitcom Membrane (jf th$ Jfect urn. 

In many eases 11. Zi'UsI has DBed euppoailories of nngaen- 
tnm hydmrgiyri by way of exjwrimcot, in the following form : 

B Vt>g. hydnns^ l-fiO to«00 [gn. xxUj Lo xl»ij]; 
Vug. ooli., 5'00 [:> iv], 
M. KLmp. K<x ]V. 

The pstient inserts one of the Btron^r Bnpponlorieft in the 
evening into the rectum, and of the weaker mppontoriee one 
in the morning and one in the evening. By this method of 
applying the merciuy we have often canned recent reUpaea of 
popular eruptions to disappear. In sorno caeca cnridunrea of 
bediming diflcOKU of the mucous menihrsnc of the month — 6to- 
matjtis wcTQ prodiicvd. The mocouB membrane of the rectniu 
wu not directly affected hy the enppodtories. 

Fatliogenetio Effeoti which Heretir; and it* Prtpara-tiotti may 
produce during TreatmenL 

In (tome personB, the [vepaiatious of mercary^like the puie 
mineral, when introdnced into tlie eyRtem, priKlnoe in a re- 
markably ehort time, in others after a longer period, certain 
morljid efTeeta. CoUeotively, the phenomena prodoced hy the 
toxic cfT(«t of quicksilver have been dii4crilH-d by the name of 
mercuriali^m, hydnirg^To«<i8. or (juickeilver-disease. An acuta 
and chronic hydrargyroeis is difitinguifihed, and accotding aa ifc 
is produced by the iuduntrial UK of mercury or by medicinal 
application it ie known as induetrial or medicinal h;>'drargy- 
roais. The latter manife^te it«elf by a peculiar affection of ths 
mucous membrane of the month, namely, etomatitii) mtirtn- 
rialifi. ^e have never seen any nlceration of tlw akiti or diji- 
ease of the hones, or jMinUvBia, in oon£e<]nence of the thcro- 
pentic ase of merRnry, eveti iu cusee in which its misuse wm 
carried to the extreme. 



87PSJL18. 



877 



mam> 



Mercurial affection of the oral mocons mcmljmne 
fefib it£ulf usually by an unplcasaut metallic taste io the moutli. 
The patient Lua Che scoeatioa u if the tvotli ore blunted 
Mid elongated, and of dr^'nc«« in tho month. An effort to 
chew solid £ood causes piiin and slight bleeding of the gunu. 
Gradaally the pAticnt finds that he wante to spit often. If at 
this time pressure is made upon the submaxillary gland, pain 
will be experienced, boeauso the gland is eomcwhat outat^ed. 
Tlio gUDu, 03]ieciaHy of the lower incisors (leen of the up[>er), 
the lips, the mucous mcnibnuio of the cliodcijeepeciiilly oronnd 
the mouths of the inucnui; foHiuIee, are of & bright-red color, 
Bwolien, and in places ecchymotic The etlgws of the gnn» are 
lind, tumetied, sorronnd the individual teeth like a wall, and 
separated fi*om them ; and for that reason they seem to tlie 
patient to tie ulongatud and ItHwo. In the xpacuii between tlio 
teeth the secretion of ttie gUindnlje taitriona accnmnlatee, in 
tfae form of t sticky, yellowi^-green, ofienaivc substance. The 
•eeretioQ of saliva incrcoaea more and moie, and botxHOCB an 
actuaJ salivaiicn. Lastly, tho tongue swells, and becomes cov- 
ered with a dirty, slimy coating. The p&tient experiences dif- 
ficulty in moving the oi^n, and it eometiracs attains to such 
a ase that the month is not largo enough to contain it, eo that 
the apex protrudei; Ijittwueu thu ineisur teetli, and the lateral Bur- 
faccK beiu- the indentition of the rest of the teeth (lingua cre- 
nata). Tlie patient eulTera from thirst, and the lai^ quantity 
of Bilira which he swallowB soiuetimeii caaaee iiauwa and vom- 
iting. If the action of the mercury is not arrested, and if the 
patient in addition is subjected to snch influences as will nat- 
urally occasion stomatitis and soorbutuai, the entire nmcous 
memhraiie of tlic moutli will berome coated with a grayish, 
diphtheritic layer, which can not he bniahed off without caus^ 
ing loes of substance. The mucous meut)rane finally also be- 
comc« iuliltrated and t^Iouglis form, particularly on tliose places 
that arc prcsEod upon by the teeth. When the elouglu are 
oast off considerable bleeding takes place, and then irregular, 
excavated, painful nleers covered with a gmyieh coating origi- 
nate. The quantity of sdiva Bccrctod Bometinioe amomits to 
ieveral kUogratiimea [many pounds]. It is a remarkable fact 
that the saliva, according to some of the most eminent chemists 



878 PATU0LQ67 AUD TREATMENT OF SYPSIUS. 

(Schneider), eontaing very little or no mercuiy; on the other 
hand, according tu Kletzintfky, sulpliohydratc of ammoDiji and 
tmoesof nrea ore found in it — the formur ap[iarQutly being tlm 
oanae of the offeomre odor. The teeth maj ultimately become 
M looM tliat tliej fall out In oon^quenco of tLo niercuri- 
alization tlio soft ports of tlic lower j&w ore somctimu de- 
stroyed by filoTighing, periostitis onsaos, follovrcd by depontt 
of porons, pamio&«tone-like mihstance, which are known by 
the name of oiteophytes. 

CanoUB teeth, or other morbid conditioiiB of the moath^ 
neglect and nncleanlincaa of tlie tueth and gums, oold and wet. 
and foul air, promote the development of stouiatitift. In some 
petsons salivation enRnes after they have nndergoiie a mild 
course, in othen after a severe course, of mercory. It hatdly 
over (Hu^urv in infants and old, toothluNs pcreoQS. 

A slight mercttrial affection of the moutb, and tendornesB 
of the gums, is of no con&equoiice. On the contrary, even 
the opp<Haeni6 of the salivation-cnro do not t/bjuct to it« becatuo 
they deem it a favorable prc^ostic ugn in regard to the euro 
of flypfailia. But acvcrc stomatitis, pKMlluced by proloDgod and 
exeenire use of mercury, may be followed by \tixj sad rwaha. 
ijy the toughing of the lips, mncous membrane of the cboeks 
or toagne, irremediable loM of substance may ensue ; the mo- 
coos membrane of the lips may become united to the jawv, tlio 
tongne, or floor of the moutl], so that, on the one hand, the 
opening of the mouth, on the other, the movements of tke 
tongue, may he prevented (liamborger). 

In order to prevent the occurrence of mercnnal stomatitb 
the patient should Ik; infonnod at t3ic aommcncement of the 
treatment of the prodromata of the disease, so that be may nift- 
pend \\& use as soon as they appear. Furtbermore, the palioats 
should be imtnicted to rinse their mouths several times ereiy 
day during the time they are undergoing the mercnrial treat- 
mmt ; they should bo cautioned against expoong tliemselvw 
to a too high or too low temporAhire, and the room ihey oc- 
cupy Bhould be carefully ventilated at least once a day. If 
the stomatitis is already fully developed, the patient slionld 
be removed, if poasiblc, from the atmosphere that in Impregy 
oated with ])articlQs of qnicluilver into a purer one. His 



8TPSILIS. 879 

clothes, nteosilB, etc., to which mercnrial ointment may ad- 
here, should be removed, and he should be immersed in a 
warm bath. 

The local treatment depends upon the intensity of the 
affection. If the mucous membrane of the mouth is only 
catarrhajly red or loose, the patient should be instructed to 
rinse his mouth every half-hour with one of the follow- 
ing lotions : 

S Tr. opii, 600 [3 iv]; 

Aqua fontan., 600-00 [ ? xv]. 
M. 8. For gargle. 

Q Gljoerini pari, 20-00 [ J jsa., giv] ; 
TaDnini pari, 6'00 [9iv] ; 
Aqna font, 600-00 [ | xv]. 
U. S. For gargle. 

Lotions for the mouth, consisting of solution of alum, bo- 
rax, tincture of rhatany, salvia, tormentilla, etc., are equally 
eflScaciouB. When the salivation is severe, use — 

B Tr. iodintB, 500 [3iv]; 
Aq. fontan., 600-00 [ S xv] ; 
Aq. ciDoamom., 

8yr. dnnamom., &&, 60*00 [ ^jsa., ^iv], 
H. S. Uoutb-wosh. 

Lotions composed of chlorine abolish the offensire odor of 
the mouth very rapidly. The following niay be ordered for 
this pm^ose; 

Q Chlorin. liquid., 10-00 [gviij]; 
Decoct. althEe, 60000 [ 5 rv] ; 
Mel. rosarnm, 60'00 [ | jas., ^iv], 
M. S. Lotion. 

? Kalichlor., 600 [3iv]; 
Aq. font., 60000 [ S 3v] ; 
Syr. nioror., 2000 [Jsa., 3iv]. 
M. S. Gargle. 

If diphtheritic or gangrenous slonghing of the mucoTis 
membrane of the month has already taken place, either of the 
following may be ordered : 



880 PATBQLOOT ASD TSSATUSNT OF BTPatUa. 

B KxL llKiii. coinixcliiaaL. £O-O0l2i>S si*]* 
A4- funtiB., 

U. S. A loCioB for the nwatK 

^ EnnU-eomnon., ftO(MH)[SixK, i)hr); 
Cuapfaora^ 8-00 [gn. xJtijI, 
M. S. A lutioa for movUi, and for paintiitg th« pignmooi wanm. 

If Uicee remedies prove inefleetaal, pyroU^iDOoni Mod or 
eliloride of calcium should be tried ; mixed viib an appropri- 
ate amount of water, tbcy may be nsod as a m»b for tbe 
nioatb and Application to tlie ulcciv. The diphtheritic patdiei 
may alao lx> touched witL uiLrate of silrur, or pslnud with 
tiucture of itMline. Narcotics, eepedallj opium, maj be tued 
Jocallj and internally for the relief of the pain. If tlie bovela 
are cooiiiLcd, aoiuc luxattvc idiould be adniitiisiared, aad water, 
actdulated witli some vegetable acid, may be given ae a drink, 
la cachectic persoiiA who are greatly debilitated, circ fihould be 
lakcD to iuvigoiatv them tm much ae po^eible. 

Effects of Cold>Water Treatment, Sea-Bathj. aod Salpbnr Tlier- 
mal Baths on Syphilis and Hydrai^yroiia 

In regard to hydropathic trealment as a cnratiTe remedy 
of ^philis, most authors are now agreed that it is an excellent 
adjuvant to other therapeutic moisaic& Bat tlie bydrupathie 
treatment a<>complitilieii uo quicker nwnllB in syphilis than 
tJie expectant method- Cold-water treatment and te«yh<iUis 
are especially neefal in thoae pattente who become greatly 
enfeebled by Byphflis, or wlio suffer in consequence of the 
injudidoua adminbtration of mercury. Sulphor-batlui gtn- 
onJIy hare an excellent elTect npon syphilitic patients. Under 
tlie use of eulphur Ihcrraa] baths, the intense puns in the 
hones, OBpccially, are greatly relieved. If the pattents are wai- 
fleiently careful, some of the most obstinate syphilidee, sneU as 
psoria&ia polniaris, eto., will diappenr nmrc quickly with tlio 
UBo of the 8iil|»hur thermal, if appropriate aiiti-spccifio treat- 
mont is simiJumoouBlv carried out, than without the latter. 
Martineaa leoently asserted that Bolphnr-baths were a test of 
the perwgtence of latent syphilis. Still, should a rdapce ensoe 



SYPBlltS. 8S1 

in a syphilitic jxiticiit who wan under treatment witli sulpIiDr- 
batUs^ it is no \n\v.>i tliat the b»tlui occasioned it. 

For a lotig time the nee of eulphur inlernalljr and snlpbur* 
batliH were highly praised ae remedies agaiost hydra r^'-yrosis, 
especially incrcuHul truiiior. All wc cnii say its that wu have 
obtained good results fmm sulphur-lmttiA in pcrAon« wbo have 
not Buffered loug nor very severely from the tremor, uid 
who, during the use of the baths, abstained from handling all 
loads of mercurial preparationg. It is powiblo that wg would 
hav« obtainod the kiidq results from onlinary bathi), but it is 
also probable that, by the D«e of the sulphur tliennal, the ti«> 
Bue8 are stimulated to greater mctaraorphofiis, and tbuE tho 
quicl^silver ia mora rapidly elimiuated from the eyitora. 

Byphilophobia and Kcicuriophobia or Hypochondria Meicn- 

There are pcnwiLH who, having euffi-rcd from syphilis or 
some other venereal dieeaee, become a prey to feelings of de- 
spondency, which ia beat described by the term eyphilopbobia. 
They fear tliat thi:y arc still alHictod with syphiHts, though not 
one eyuiptom of it or any morbid alteration can be detected on 
thoir person. All ratiomil attcmpta to coQTinoc tbcm that 
they arc free from tho disease are oecleas. Day aud night 
they busy theuisolred with their imaginary diWBW, and aetuully 
hunt for symptoms upon tlieir persons, or conjure up eome 
in Bupport of their statenicnt. " Thus they go about," eaj-B 
Ricoid, correctly, "abm^eu to thenuielves and the whole world, 
min theminelveB by all siirtji of cures which they practice ujxtii 
CbemselveH, or are iudueod bo tu do by ignorant or dishuneitt 
physieians." 

Ou tho otlier hand, there are also hypochondrioo persons 
who, liaving heanl of tho injurious effects that may be pro- 
duced by the improper use of mercury, imagine, when they 
aacertmn tliat they took some of it, oven tlie minutest quan- 
tity, tluit they will forever suffer tlic most dire effecta. Theie 
persons think of nothing but their imaginary disease, neglect 
their atlairu, and Xo^ all tntereet in life;. Any sensation they 
experience, any rt^ihie^s or swelling noticed by tliem ; some- 
times, indeed, perfectly ooi-ioal elevations on the joints, bones, 



S83 PATBOLOOY AJfD T&EATMEST OF BTPHTUS. 



etc., sucli as tbe crUtse tibiie, wTticli tltey accidentally discover, 
are attributed to the merciir)', taken perhaps maBj vetura b&> 
fore. All tho argutneitte Umt muy bo D«ed to siich }i«v'(:hiaU 
patientfi are in rain. Tho delusion tliat they are eiitfering 
ftxim uercuriol poieooing, and the iiatred they entertain for 
the physician \iriio gave them mcrcory, cling to them all the 
tnoro if they hare read nicrcorio-phobie writings, or an eon- 
firmod in thoir views by murcurio-phobio physicians. We 
hare Dcrcr yet found thi^ psychopathy in persona botunging 
to the lower order of people, bat only in those of the mora 
afQuent eluas. 

Sypbjiu&tion. 

The treatment of ejphilia by tho method crroaootuly 
styled sifphUization^ faaa, since tbe death of Boeck, )>eeD entirely 
abandoned. Auzioa Torenno lirat aaggcsted it in It^H. He 
oheerv-ed that, if a potion is luoealiUcd with the virog of a 
Boft chancre for a long timo, he will finally octjiiipe an im- 
munity agoinHt the poiuoii, and the mtlMOquent inoculationa 
fail to take. Such persons are Hud to he syphitized. Bnt, as 
we know that the soft chancre and the ByphiUtic primarf le- 
aion, or, as the French j>hy8iciauis call it, the infLxting chancre, 
are two different morbid processee, like pncnmoniu and pleu- 
riay, we must, like Have, call this method amply "cunCiTe 
cliaucroid inoculation." But a healthy person who ha« been 
inoculated with the matter toJccn from a eyphilitic primorj 
lesion and lias had syphilia, may bo eud to he proof a^ast 
syphilitic infection a second time, because we know tliat rein- 
fection with syplulitic virwa is one of the meet occnrrcncca. 
X prophylactie and a M^m/h-ufteeyphilizatioaisdistingaiahod. 
Tbe fonner, it is claimed, oetit in tbe same manner as Taodnar 
tion. In regard to the effect of tho soft chancre upon a 
pereon already affected with eyplutia, Haye aaya that the in- 
oculated cliancroids are derivative foci, " exntoria," almllar to 
tliOBc that may be pnKlnced by inocnlations -writh croton-oil, 
tartar emetic, etc. These methods of treatment liare been 
tried by Langenbeek, Hjort, and otlicra. As we have al- 
ready said, this kinil of pntphylaxie and treatment of syphi- 
lis is not employed any more, and is only historically inter* 
ceting. 



STPHIUS. 



Treatment of aome of the Local Syphilitio Affectiont. 

AiQon^ tlio morbid altcmtione that mny be occosioDcd by 
syphilis t)it>re ara somo wliicli, partly owiag to tbo dUttirbaDces 
of MiiHitioii, partly uwiug to tbe inutUation aud diMfigui-emeDt 
tliey prodiic«, reqnin; local trt-atinoDt in addition to the treat 
ment of tbu general constitutional disease. These are a£f«c- 
tioDS of tlic organs of »ight and hearing, the moist papulca, 
mucooa-membraiie {xipiik'N around the anus, on tho genital or- 
gana, on the mucons lining of the tnouth and faucra, syphiUtio 
affectionB of thu larynx and trachoa, peoriatis palmaria and 
plantam, deep ulcors of tho skin and of tbo mnooDS mem- 
brane, solid aud suppurating p«rio«teaI aud osecoufi nodes, ab- 
fioeases of the soft part«, caries and necrosis of n part of a bone, 
e^iecially oztena, porionychta, sa^ooce^3 ayphilitica, stricturoe 
of the rectum, etc. 

In regard to aflFections of the oryan of ftffht, we refer tho 
reader to tho section ou ayphilitic affections of the eye, by 
Professor ^raiithner. 

Sj-pliilitic afTectionn of the ear require local treatmait in 
aooordauce with the principlee of otology. According to the 
statenientH of tho most experienced otologiittA, tlio local treat- 
ment requires a long timo before a cun* can be accomplished, tlie 
general treatment being anable to acJiieve a satisfactory result. 

In regard to the local treatment of ej.'phililic uffuctiona of 
tlie larynx and trachoa, we refer the rcatlcr to the therapeutic 
recommendations of Profeuor von Schrotter, in tho eection 
on thoee diseases. 

llucou* • membrane popules require different local treat- 
ment according to their site and metamorphoeia. If they are 
flituatad iu the luouth, and if, u-hun tliey undergo degeneration, 
they assume only the form of erotiioiii*, itimply wntJiing them 
with a mild, ai*tringent lotion, will often biiIBco to bring about 
dcatriiation. But If they have lieeome traiiafonned into deep 
nIoerFi, it will ho neccwtary lo touch them oticp or twice daily 
with lunar caustic, or tliey Hboutd be penciled with a solutioa 
of iodo-glyccrine like the following: 
R Glj-ccriiio. JftOO [3viij|; 
Kali hrdroiod., 0-50 [gr*. viyj; 
Iodine i>ari, O-M [grs. IJ. If. 



884 PATBOLOOT ASX> TREATXEilT OF SYPBIUS, 

Vcgctaltonii groviug tipcfu ])rulifcrattQg pft|>ulcB of tlio mu- 
cous membrane of the moutli, if tUcy do not Bbriok after tbe 
application of astringent or caiutic remedies, mtut bo rczooTcd 
witli tbo Bcifieore and the n-ounde cautrnzed. 

Pa[>u1(» on tii« uiucvjm inombrano of the gonital organs tnd 
rvctnin sliould he trfuLtoil in tlte suine manner, except tint 
thej may be cauterized much more v!g«»roiiBly. 

Moist papales around the anni> and genital organs reqolrv, 
above all, tlie ntmoet cleanlinese, which can onljr be Micurvd hy 
frequently butlilug or wseliing the parta. By iuKcrting pledg- 
ets of lint botwoon an affected and a eonml part, tbv opposing 
Burfaces ai-e kept asunder, and tlie diseoBc ie prerented from 
spreading or infecting a nomiul part. Proliferating grovtliB 
that froqacntly dovelop, and the fetid o<lor of the moiiit pap- 
ules, (should be destroyed as speedily as possible. Fortlm pnr- 
po«e a modified PlenkV paste is used now, wbidi is oompoanl 
according to tbo following formula: 

B Hublimat. oorrpA. ; 
Oun|>bon» ; 

Alamioia ; 

CeroMft alb, ; 

BplriL tIqI ; 

Aoeti vi&i, KB 6-0f> [Sir]. U. 

These ingredients, being portly or entirely insolnblo in spirit 
of wine and acetic acid, are precipitated and form a soft psetu; 
tbe eapematant flnid is poured off, and the jxute is applied 
witli a small brosli to the jxirt which is to be cauterized. It 
causes little pain when tirst applied, but it soon becomes reiy 
Rovere ; and for tbe purpose of relienng it, and of preventing 
tbe swelling of the parte, oold-watcr cxtmjirc^sui should be 
applied. Care should t)o taken not to allow the paste to get 
upon any part of tho skin covering looee cellular tiasae, such 
as the labia majora and minora, the glnus penis, ccrrix nturi, 
ote., as it is apt to occasion intent) inflammation of tbe parts, 
which swell np cxccsaJTcly and may become gatigrraoos. 

Lab&raque*8 paste;, niodilled by IL Zeieel, is very w^ 
adapted for cauterizing moint papules. IjilHira*jae cnnM« the 
papules to be nootstened with a solution of tablo«alt, and aftor^ 
ward he strews calomel over them. H. Zeissl xutm diluted 



8TPBIUS. 



88jt 



liquid clilorine inst*-**! of «iU. The calomel, when H comes in 
(xtiitact witli the chlorine, is probably coDTerted into corroaire 
6ubliuiat«, ftcd this eublintatc in at^u na^ctnti causes Uic v»r^ 
growths to shrink alm(><i;t paint&i^^lv, while a concentratod solu- 
tion of corrosive siiblimiLte tlmt wili ecrre the purpoee of de- 
BtToyiDg the adventitious gruwtlis occasions the must violent 
luins. 

Sublimate ciollodion is anuther caustic used for the pur- 
pose of removing papiUaij inflltration and proliferatious, and 
is prepared in the fallowing manner : 

3 SubUinnt. corm!!.. l-AO (^. xx|j]; 
OxUotiii, 20 00 I 3 Bs., 3 ivj. 
M. S. Far cxb^rnnl use. 



Tliis preparation U carofallir applied to the parts with a 
oamel'a-hair brush daily, or every other day, and afterward 
they oro covered with wadding or charpic. If ecrcrc inflam- 
mation ensues, cold-water compresses slwiild bo appliod. Ow- 
ing to the intense pains which this cauatio preparation occa- 
sions, wo only nae it in ploeee where the epidermis is very 
thick. 

We use local applications in addition to general rcmedioa 
only ID those forma of peonaj^is pahnarie et plimtarie in which 
Dnmeroos deep fieetiree anil epidoroia] uclts develop in the palms 
of the hatidi* and soles of tliu feet, accompanied by intense 
onychia. In mild cases we Bimply pffscribo an ointment of 
fat and spermaceti, or ungucntum diachylon in oleo-coctom, 
or paint the palms and aolea with a lotion containing tar, and 
then dnst tlic parta with powder, or apply emplifitmm hy- 
drarg;>Ti to the diseaacd ])tacefl ;* or, lastly, we use white pre- 
cipitate ointment, 4*00 [Sj] to 35-00 [5j, 3 iv] of cerate, 
of 'which tlio patient may rub a piece as big as a hazel-nut 
Dpon the palra of tlie hand and sole of tlie foot Painting the 
affected parte witli embiimate otjllodion or tincture of iodine 
aUo promotes dc^qnamation and nbwrption. 

L'leere oripnaling ai; a result of (Mironychia fihould bo cov- 
ered with adhesive plotiter, niervurial plaster, or traumatietu. 

Deep vlivrv nf (he skin fOiould be cleansed as often as poa- 
nble, and then covered with emplastrum de Vigo or eapoua- 
2fi 



886 PATUOIOGY AND TBBATMBNT OF STPBtUS. 

turn. If ncatrizatioD doe» not ensue, the olcera ohonld be 
covered with pledgets of lint smeared witb the ioUowing 
ointmeiLt : 

B Argvut. iiitmlitcrTtt., 0'10[gr. T|]; 
Cng. «ropL, lO-OO | 3 ij". & ul ; 
Bth. Perov., I-Ott [gr^ xyjj. 
IL Ft.iuig. 

loiluform, too, baa rendered exoellent £ervice in torpid sad 
proliferating ulcers. 

If sup2>urating ffummata urc ttituutud upoa tlie soft psUle, 
aDd if the kttcr is in danger of perforation, tlie nurgins of 
tbo ulcer should be touched with lunar caustic everr dsj. 
If general treatment is eimultanoooely instituted, iimall per- 
furutions of tiio palate Mill often become nnollor, so that it u 
barely possible to put a fine probe throng them — a matter 
that is of great uii]Hirtanoe in ptionation. The porforatioiig of 
the mucous membrane OD the hard palate may likewiae be r» 
ducel in aze by tJie use of nitrate of ^itcer. 

The lucal treatnu'iit of iixifua svphililica has for its object 
the speedy exfuliatioa of the necrotic ]iiece of nasal bona 
This U hc^t pn>iuiiti!d hy Injtrrtiug dilute aolatiooa of muriatic 
acid or chloride of calcium into the nasal cavities. lu ihew 
caeee we prescribe : 

B Acidi mnr. diU BOO (D \r]x 

Aqna 4^0., 80040 ( I 'a«^ 3 I*-] ; 
Aqoa anlvia, 10000 [ S 1^. 3 <n% 
U- S. For cxlemul dm. 

B Chlor. cfllcisS-OOiaiTl; 

Aqaa d(«tiL, SUO-OO [ % ism, 9 ir] ; 
A(iaM rtwarum, K-OO f § m.|, 
it. To Ue pnt in n liladc butUv for eatcrnal nse. 



The nasal cantiee Bbonld be injected with cither of these 
solntionfi four or fi\'c times every day by meane of aeyrloge 
provided with a loop; ooszle; or, if a fonutain-OTriDge Is aiadt 
the tube is iueertod into the noee, the {mtiout boing directed 
to hold hiH licad backwani for n few moments, when aotne of 
tlie tluid will flow into the naaal pawages. 

OsiBiia 8\fphilUtea frequently is the readnnm of «^-phUis 



STpmus. 



887 



that has already readied its cud, tbo prolonj^ed nlceration of 
the nasal buiKs: aiid muiU luucouii nienibniiie, and the icbor- 
oiu di»cltatfre, being kept up b^ the irritation wliich the ne- 
eroNLii of tbo bono exercisee upon the surroiuiding structDres. 
Qeoeml trvutinent m onl^' luditatud m oui-na'wbi'u nuvr iivphi- 
Utio oatbreaka occur on ditTerent partj> of tlie btxl^, or if thotie 
tliat abcad^ exist do not disappear. In theee cases reliable 
proof of the ApectKc charucLer of ttjc luuon witl be necessaiy 
before treatment vrith mercury or iodine is resorted to. In 
most oEfcna jMlients scrofula will bo foand to play a great 
port, and tbiry will require ood-Uvcr oil and tonics uoie than 
anti- specific r«medic^. 

l'Deypbi!itic«</''0(?iv^<i Fricke'ei compression bandage may be 
employed in addition to intoniid general treatment, or tlic af- 
fveted lialf of the eorotum jiiaj bo covered with mercurial 
plarter. The coexbtring bj<Jn)('ele disappears ejwntaneously 
when the swelling of the testis has stilisidod ; if not, the drop- 
sical tumor may be tapped, and a diluLu solullun of iodine in- 
jected, or tlie oiK'nition for the radical cure may he performed. 

In pains of tbc hones :ind joints, vrhich somedmea do not 
yield to either nicrciiriitl or iodine treatment, nor are assuaged 
by narcotics, we found in tniiny caiics tlie local trenbneDt ret> 
ooimended by Uicord to bo of ^^roat benctit. He rccom- 
mondi! u bliiitcr to be applied upon tlio painful part, and 
after the skin luu Ikicu rcimtrcd the place is eitlicr oorered 
with ccratc-pliister, or morphino is etrcn'cd npoa (lie rav sur 
face. 

/rt perhsti-al thiekeninga an attempt should bo made to 
bring about rauolutioii hy paintin^j the part with tincture of 
iodine or inodemtely eoncentrated iodo-glycerinc. E^cn if 
ducluation is deteetod, the swelling should not be Iiaetily 
opened, for abeorjiliou may aoinetiines take place. Shonld the 
pain, however, become aggravated, anil the tumor larger, it 
should be o[»ened by a valTnlaT incision, in oixler to prevent 
the entrance of air into tbo cavity of the abecesa. In very 
intense, ininfiil periosteal oweltings, Bicord and other physi- 
cians recommend deep crucial indaioQe and acarili cations of 
tbe bone. 

Ulcois of the rtctum diould be washed several timce a day. 



PATBOIOGT AJfJ) T&EATMEXT OF STPJIIUS. 

especially after each rtool, and ii tolerably strong solatioo of 
iodo-glyoerine a]»plicd fonr or tiv© times i tiay, or ihey may be 
cauterized witli nitrate of silver. In ease stricture of the reiv 
tuiD is apprebcndixl, in consequeDCo of contracting dcatrioeif , 
enniprcfiFed Aponge-teuts or coneii of laiutriaria digitata. shoold 
be inserted curly into the gut. If stricture hfl« already formed, 
an attempt sboold be made to diUto the rectum by tbu aid 
of hougli:!! ; uufurtunately, the rcsuttft of thui truatmi-nt tumally 
are only tenijioniry. Tlicra is no other Iherajieiitic resource^ 
in euch cases than to promote evacnatioas from the boiveb bj 
tlie adminisCratioa of oleagiuou« clytttcra and pur^atira rcm»' 
dice. 

The Fnniag of the Byphllitie Child and tha Trcatnatnt of C«b- 
g«nital Syphllm 

So long as no evidences of nyphilia are obBerred on a child 
hegotton by syphilitic parentu, it Rhonld not be loibjoctod to 
nnti.->yphiHric treatment, though it requires careful attention. 
The question arises, now ebould a child be nureod that h Inito 
urith mnnifeKt evidences of pyphilig, or thiit In enspected of 
being afllicted with hereditary syphilial Should it be enckled 
by its mother, or by a wet-nurse I That the milk of n. hejillhy 
vct-nursc b the \ic»i iiutriraeut for mich an unfortunate creni- 
urc ftdmit« of no qucBtion. Jf the niotlier wiw affectisl witli 
oonetituttonal s\'philiA during preie^ancy, and yet gave birth to 
a child free fn>m all cvidctifca of general in'philiB, as la ofton 
the case, euch a child, if possible, rIiouM be suckled by a 
healthy wet-nurse. Kven admitting that tlio mother's ttiilk 
doea not serve as a vehicle for conveying the *ypJulitie virus, 
and although no morbid alteration can bo di*covereil in it 
diemically or nitcniBeopically, Btill It can not he deemed 
healthy nutriment, coming ns it does from a diseased, fcchhi 
constitution. 

Hut, if the mother and child are manifestly affected with 
eni-phil>s, it will be «>i«Kiliitcly necowary to procun< a healthy 
veb-nnnte for the child, because tlie debilitated mntlu-r will be- 
come still more enfeebled by uursing, and the infant nil) not 
tlirive upon the anhcntthy milk. But such a child should 
only be given to another woman after &bo has bccu fully in- 



8YPHIU3. 



389 



cormetJ of the risk she ruoa of Tjeing infected. To hido the 
trac nature of the cbild'N iUiiuK, to pcnuadc a hcaJtlij* woman 
to nndcrlake the DureiDg of a syphiliUc child, would he an 
nnp«irdonahtu act, becuase the health of the woman '\s thereby 
endangered, while tlio saving of tliH child in doubtful; in- 
deed, iu our opinion, higtily improbable. However, if after 
thu woman vms fully iufonucd she m disposed to undertake 
the <lutie8 of a wet-Dureo, she «liould be inrtructcd to beep 
hewclf and child ecrupulouply clean. On discovering any 
tieson on a nipple, ehe should not put tlie child to tlie afluctud 
breast, but nuivo it on the sound breast only. She dionld 
not allow thy child, as ia customary with wct-nurecs, to lie at 
her breast by the hour, for then the nipples, being in coutaot 
with the li[w of the diseased child, are eiirc to become injured. 
Both tile nipple and breast elionld he washed clean every time 
the baby ban been suckled. A sure protection for the wet- 
nur^e is the uw of a nipplu-t>liield during tlie suckling of tho 
infant. 

If the mother displays no evidoncee of constitutional syphi- 
lis, it will he far more judicious for her to wct-iiuree her own 
child. So far, only tliree instances arc known in which syphi- 
litic children infected their onii mothers. The circuniatanca 
that mothers arc never, or tardly over, infected during; wet- 
nursing by their hereditary flvphilitic oflepring, ia now known 
by Che name of Colles*8 law. 

Still, eiueo it may happen that a jwrfectly healthy mother 
may bt-oome iiifi?cled by lier own syphilitic infant, it will l>e 
well, a« Behrond suggests, to allow her to wet-nuree her child 
only m lutig ua no evidencea of aypliilttic manifBRtations are 
observed on the muutli and faucet) of the nursling, d 6 goon 
afi any spccitic symptoms appear on the infant, aud tlie uiutlier 
remains apparently well, she should be advised to dificontinna 
wet-nuning it, aud bring it up on artificial food. 

If no wct-nur»ocan be procured to suckle eucli a child, and 
if the mother u not very much rcducod by tlio syiiliilitjc diatbe> 
ei«, she, being put einiultauuously with the infant upon an 
uitieyphilitic treatment, may be allowed to put it to her breiut. 
But if tlw mother already showd evidencee of the eyphilitic 
dyscraaia, it will be preferable to bring up the child artificially 



800 PATB0LO6T AND TREATMEXT OF STPttlUS. 



DjKiii good, fresli (ww's milk, or tlie milk of a vot-nurao, ob> 
tainei] \iy a tiiirKiiig-tiilie. 

Til tlie trunmifiit uf svphilitic infants kdcI Qtinlings, the 
care, clean IiQegp, and attention iJiejf will reqnire doserre special 
ooustilunition. The moiitli of the uundiiig. Mpccbllv, afaould 
be clciuiwd prcry time it i» nursed, aniJ, after pact stool, tbo ox- 
coriatod places at and aroniid the aniifi ahould be waelied clean 
and vriped dry. Tho medical treatiuent ia both li>cal acid 
goneroL 

The Iwal treatment con^iets in the application of slightly 
cauRtiR remedies, mich as tlic nitrate- of -Bilvcr stick \n the door- 
ating ]>lac<w on the lips and anas, for tbv purpose of lutettming 
their cicatrization, of assuaging the paiu duririj; sackling and 
during evHciiationn fnim the bowels, luid, aliove all, by tho 
productioQ of an c^Uarotic ulongh to protect tlie nl<vr» on tUo 
mncoiu tiicinltrane against irritaiiun and inic1eanliDe«. 

For the purpo*© of promoting absorption of tite niQCDQ*- 
membrane papules situated on the lips, angles of the mutitli, 
on tbc anus and genital organs, and the moist papnlcs on con- 
tignous parts, Labaracjne*^ pnste, or a weak solution of iodo> 
glycerine, may be nscd. 

Tn regard \n the t/rnrrat treatment, it luu boon auggeslcd 
that, in view of the tender constitution of the nursling, to ad- 
minifitcr mercurial remedica indirectly, namely, through tho 
milk of the wet-nar?e. who la trcatvd with autisyphilllic medi- 
cine, or mercnry is adminirtcred to goats or asses, wid the 
syphilitic chUd u then fed with t^e inilb from these animals. 
But DUmerotu examinations of the milk of wet-nmsve tmated 
with merenry, and that of animala in whose fodder niercruy 
waa put, have xhnwn timt but very email ijunutitiee of the drug 
are fonnd in it, and only after it bad been adminisierud to 
tbem for many days. 

In view of the fact tlmt the dme nf the medicine girea to 
ft child in thia mattoer can not be properly oontroUcd, » ako 
the fact, often observed, that nurslings in many respects toloi^ 
ate uicrcnry better than adulta, wo prefer ibc direct to tie 
indiri-trt methodB. 

If no diarrltrea or oilier comi>Iicationa rontraindtcate ft, 
calomel should be need, tlus preparation being beat tolenled 



SYPHILIS. 



891 



hy infante, or the -protoicxlidc of moTOiry mny bo prc«cribc<^ 
aucurdlng tp tlio fullowiii)^ foriuuk: 

3 CHlonri. Inrignti.. or protoiuO. bvdrnrg., O'LS [gn. iJM.J; 

SooclLidlM^&'OUOiv]. 
M. UiT. in lid*. n»qaiil«H No. rlj. 
H. b. Une powder to be given moriting tnd «reiiinf. 

If [irofuFe evacuations of the bowels, with or without colio- 
paiiu, enfiae, oitf. drop of tlic tincture of opium should bo given 
dtuing the tntervalaL If the dinrrlKca diKS not diminish from 
the TUe of tliis reined^-, tlie fthovc-named prcparaUou« ihould 
l»e discontinned, and, aft<!r tlio iliaHmu hna l)fcii chocked, 
oorrofiive sublimate should be reeorted to, ae follows : 

B Sublim. MMToa., (HXUi [f^. ^J; 
Aq. fvut.. 0O-0O[$jM., 3lv], 
U. S. To bo tAkcn io on* d^. 

As Is well known, adults uol infrequontljr complaJn i>f gsa- 
tralgiA from the use of comntive Kubliinale, but infants are 
troubled with voiuiting. If that he the c-Ase, small inunctions 
abould be ordered on eomc parte of the bud^v, provided tlic ekin 
ia not profusely covered with pustules, or the bodv is not ex- 
teofiively denuded of epidermis, or the infant is not too feeble. 
From 0*3 to 0*5 [gn. v to viij] of hluc-iuftBB may he ujm;<1 
daily. The inunctiood should he omitted every third dn.v. and 
the infant pliiccd in a tepid or warm buth. If, on account of 
numcroUB pustules (pcnipliigaa i^vphili liens) and excoriated 
places on the body, it in not |)oi>»ib]e to use the inunctions of 
mercury, llie child f>ltould be put once or twice daily into a 
bath, containing corrosive sublimate, ond prepared as follows: 

B Sulilim. corros.. 200 to JJ-OO [{ra. xxxij to Ixxx] ; 

Mur. uitimuii., S-OO [([w. xxiUJ; 

Aq.fonU. lOOOnfJiij. gviijj. 
H. To be adi]ed tn t)i« bnth. 

The child sliould he kept about half an hour in tins both, 
and afterward carefully dried with warm towels. The in- 
temnl use of mercury and inunctions act much more rapidly 
than corrosive-sublimate baths. 

The prejiaralionB of iodine do not eeom to ngree well witli 
infants ; tliey appear to promote marasmus in siekly children. 



392 PATHOLOGY AND TSEATMElfr OF SYPHILIS. 

The disappearance of tlie external manifestations of syphi- 
lis, however, does not by any means prove that the child has 
been cured of the disease. But the administration of mercury 
inay be suspended for a time, the child meanwhile taking the 
lactate of iron, 0*15 [grs. ijss.] twice a day. Several days aft- 
ci'ward, the mercury may again be administered in smaller 
doBes than before. Unfortanately, however, our skillfully de- 
■^Tsed cures and plans freq^uently miscarry, for, contrary to all 
our wishes and eSorte, the little patients often succmnb to the 
disease. 



IITDEX. 



Abscess of l;mph&tic resseU &ad glands 

of labia raajora and minora, 65. 
Acne-like sypbilide, 202; differantial 
dlagnosla from acne valgaris, SOS. 
Acne^ustular, HTphiUde, 160. 
Action of cbanoroua tItub, 109. 
Acute catarrb of tbe bladder, 70, 
of tbe laryni, sjpbilitic, 2B2. 
of tbe trachea, s;pbiliUc, 2aZi 
Acute gonoirboea, 18, 19. 

hjdrocele, S4. 
Adenitis, multiple, 128, 131, 174. 
AfTections of the bladder, 265. 
of the bones, difFereo^ diagnosis of, 

S04. 
of the eye in infants in congenital 

sfpbitis, 328. 
of the joints, sjpbilitic, SOB. 
of the kidnej, 260. 
of tbe lymphatic glands in gonorrhtea, 

01. 
of the Ijmphatic vessels in gonor- 
rhea, 51. 
of tbe lymphatic glands in tbe begin- 
ning of syphilis, 109. 
of the supra-renal capsule, 200. 
Age, influence of, in syphilitic disease 

of the laiynx, 201. 
Air-passages, cicatrices of the, 261. 

new growths of, 263- 
Albuginitis, 20 S. 
Alopecia areata, 22!1 ; senilis, 22S ; vol' 

garis pnematura, 223. 
Alteration of the blood, patbol<^cal, 
167. 
pathological, of mtde urethra, 2C. 
Amyloid d^cnet«tion of tbe kidneys, 

250. 
Anatomy of the syphilitic hiitial scleco- 



Angina syphiliUca erythematosa, 288, 

gummosa, 230. 

papulosa, 284. 
Aphthe, syphilitic, 228, 
Aura gonorrhoea, 14, 

Bacilli, syphilitic, of Lustgarlen, 168, 

of Doutrclepont, 166, 
Balanitis, 46. 
Balano-btenorrhixa, 46. 
•postheitis, 46. 
-pyorrhea, 46. 
BartoUni glands, disease of, 8S ; of the 

ducts, 88. 
Baths, mercurial, 870; snlphor, SSO; 

thermal, S80. 
Black gonorrhoea, 18, 28. 
Bladder, diseases of the, gonorrheal, 69. 
acute catarrh of, 70 ; cbroDic catarrh, 

71 ; treatment of, 72, 78. 
syphilitic aftections of, 260. 
BlenorrhiBa, chronic, 92. 
Blood, pathologlcAl alterations of, in 

sypbtUs, 167, 
Bloody seminal emissions, 60. 
Bones of infants, syphilitic aftections 
of, 826. 
syphilitic affections of, difTerential di- 
agnosis of, 804. 
syphilitic ulcers of, 302. 
Brigbt's disease in syphilis, 173. 
Bronchi, syphilitic affections of, 26S. 

ulcers of the, 267. 
Bubo, constitutional, 131; idiopathic, 
181; deuteropathic, 131; proto- 
pathic, 131; resolution, 131; stru- 
mous, 187; virulent, 132. 
differential diagnosis of, 137; prog- 
nosis of, 137, 
site of, 13C ; shape of, 130 ; size of, 18S. 



^B ^^^ ^^^^^^^^H 


^^^1 Suho, Imtoial vt Iko opened, 141 ; of 


Chorda vvoen^ S3. ^^^^^^^^^^^^H 


^^^H the loMpc&ml, 1 S9. 


CbordM, S3. ^^^^^H 


^^^M daarrultl, 13i; Blao of, ISS; iliapa 


Clmaic oatanti of ibe fatodder, TL. ^^^^^H 


^^H 


hplTOMl^, M. ^^^H 


^^B BuboBuii. lai. 


Cbronio (jpbUhio oUrrb of At EaiTU, ^^^| 


^^^1 Buniii, >;philiiie fttfteUou of, >10l 


^^H 




Cfnhoait of Uie li*«r, ijiildlUk, 219. ^^^H 


^^H Ou^bexla, the tnililUtle, ITO. 


CIcacricM of llw alr^posaagn; Ul. ^^^| 


^^^H L'ulilaj;i4, flrjiliilitk oOcctiotu of, SOT. 


of tiM «|rig)M(i«, va. ^^H 


^^^^1 Oai^irfa, Anile, «f itic bladder, 91. 


of Ul* lartnx, SBI. ^^^^ 


^^^1 Df tLe laorni. «.Ti>liiliUc; tSS. 


of (he Uncbcn, 242. ^^^| 


^^^H diraiiic^ of ibo bhildcr, 71. 


Cold vvtsr in tlM IiwUbwH of iTpblll^ ^^^H 


^^^L of (lie glMw penis and prepuc*, 48 ; 


^^H 


^^^^^^L lUffereniiol dUgamJaaf, 4S; UuU> 


0o*9ttta of (uuui'ibma In mrn, tt. ^^^H 


^^^^^f ll>Mlt of. 


Colar, pceoUnr, of sjjiUItilc mipUaiM, ^^^H 


^^^^^ briutii«. 


H 


^^^H nani, cmirgc of, ^1 ; tnKBCOt of, T7. 


Coatbinathni of phaaca of t.vphlUt, 1 TI. ^^H 


^^^1 venamil, it. 


Oondjlotna laliun, lfi9. ^^H 


^^^H T«>k«l, dmsic, 71. 


CusdrlotMta, IMi notat, BT; Iraat- ^^H 


^^^H of TBgina, r[ilihttiftl, 00; nrooooa. W : 


mentof, lOa ^| 


^^^^^_ paruli-Dt, 80; Mrotu, (tO; Untt. 


Ceagenltal iTpUlli, BnlfoMulou ol, H 


^^^^H| acnt 


■ 


^^^^^^ Tulrar. ^S ; crcatnicftt of, 79, 


dtagnoiia ml prosMiIa of, US. ^^^M 


^^^H chronic goBonlMetil, If. 


tnaunmt of, ISK. ^^H 


^^H chroDic of ib« iRwties, iTpUUae, 2S2. 


ronjimciiritit gnnloHi M. ^^^^ 


^^^H chronic t4Eiiul sonutrhara, 81. 


CuitUglooa, the namnti, a. ^^^| 


^^^H L'ktarrhal n«^mlM, ^A. 


CoiutitathMuI boboci^ 191. ^^^H 


^^^H Cantrrimtio pravuMCorift of Tatnomilu, 


sjphills, 178; ooorw of, I7XL ^^H 


^^H 


deretopiMM of, l7Si duratiiui ti, ^^^M 


^^H C«i«hr»l diwaao, ^hlKUn, ITS. 


^^M 


^^^H Cbanciv, hurd. ISO; duradon of, 1117 ; 


moruliiT i&, in. ^M 


^^^^^_^ rfm of, UT; iUlI>)(«Bilal iHapiori* 


ConairuttioD uf Ibe Male* aad crwH 1> ^M 


^^^^P 


tjfMiut, ira H 


^^^^^^ p&rctii-iiiliife, Blcord, IM. 


CoraMTiaerta, IM. H 


^^^1 ClukM-mld. lOH. 


Corpora CBVormiH penfa, fTpUaUo aC> H 


^^H atouic, 


f««tMRa of, in. ^^H 


^^H diiihtlwtiac. 111. 


Corjia sypbilltlca neoMloraiB, HO. ^^^| 


^^^1 creibellsdt^ Hi. 


CourM of conadluiiunal (Tpbilb, ITl. ^M 


^^H But, IIS. 


Coirpcr'a i^aada, laBanmMtloa of, W> ^^^^ 


^^^B iBiqireDan*. 114. 


CraneoubM, SSS, ^^^H 


^^^1 |iluiee4*nlc, 114. 


^^H 


^^^H PLTpiginona, 114. 


D«i> (TpbUitir MlaDeeM nrdM, IM. ^M 


^^^1 Krpl^no-phag^cnlc. 114. 


DAftntilM Md daarilouiwof ijplilllik H 


^^^H GDonc of, 113; (iifleKAtiat diagnada 


■kiiMliaoaae^ 18a H 


^^B or, 114 1 duntloa of, 119. 


Dcf<rdatio or actlMWcii wagahimt, 3SS. H 


^^H Imlxi, 132;alupeof, ia«; ttae«(,isa. 


lteiiiro|«[hic bulMxa, ISl. H 


^^^H ChMMnna and ■yphititie rim*, earn- 


D«*eJj>|>n)«ni of IrtnpkMio ^udnltr db. ^^^M 


^^^1 UbmI vttixtt uf. lao. 


oaac b aotl AaiMtv. ItS. ^^^| 


^^^1 viroul actkm of, lu«. 


io ajv'i'^ ^^ ^^^1 



^^^^^^^^^^^V ^H 


^H DiMhesU, Kn>l>°ltl«. I'fi- 


EreptioB, lime of appoannm In g^citei'sl ^^^| 


^^H DIbntDtbl dUgnoM* of (Tpliilis from 


nyphili*, IitO. ^^H 


^^H trjlbcnw nificiirialr, !»&] tnaa 


Kniption, ciiuunecribnl form of, I7d. ^^^H 


^^H inariiiU, IM ; plijirluls ^'erekxtlor, 


Eniptko ToTft nt HTphilii^ lOH. ^^^| 


^^H 188; nMcnl* Ixitminic*, 164; nwv- 


Bxoorialiias, dilfervDlial diaj;no«iii fi-um ^^^^f 


^^V «1a tjpbwo, ItM; nboola, 181; 


ctuncTotil, ^^^1 


W nrtlMfiM, IM; tearlatint, !))-<. 


Eilialatloiw and irumdatMM pooulla* ^^^| 


1 in iwmpblmoaia uiil pliiiiio«i», 48. 


toayptiilii, i?9. ^^^H 


1 Diw«M, k-pro«cl ar nyiihiloid, Sll. 


EspMtaut loctbod of UcaUiHnil i>( an*!)- ^^^| 


1 «f tin kJiliMjr emiMxl by gunurrha-o, 


^^H 


1 •a. 


£skiiial appllcaUoD of iDorcury in a^pb- ^^^| 


^^H Dteasw of the skin in snitillta, I'H. 


■tu, SttS. ^^H 


^^P ifphiliUc, of the r*UMi, sua 


K70, airMtlonic of, ia heradtMr; afpbUia^ ^^^| 


^^ in^lliile, of Ibc nxMih, S»8. 


^^H 


1 DmUoa of if phlD*. ITS. 


gonontomof the, VO; iiMtneuof, ^^H 


B EcihjDM pustular aypbilldc, ISO. 


m EahjmA lyiiliiliUcuiD, SOI, 800; differ- 


Faolara farorbg gaiii>rrha>al Inkolloa, ^^H 


^^^ eaiSal dtftgnont friaa fellkiUHi* 


^^1 


^^B bubML, 108; froM MUBa i-ubruia, 


TaUe rocal oonla, uImtb of, 2s7. ^^^H 


^^^H SOV : from Dclhvma Tulp&r oach(.'i.<- 


Falla;>ian tuboa, ajrphilUlc alliwliuM of, ^^^| 


^^^H U«nnin,Sll; f ram impcti^DMUm, 


^^H 


^^"^ H>6 ; rrom sTowis. 80*. 


FaucM, Kjiibilidc dlaeiuo of, Ut, US. ^^H 


1 EosHiiK rnbnitn, diffcrmtiRl <lU([iKniiii 


Female^ urethni gotmrriuva In, W. ^^^M 


^^K frtm>,*])litliticccttiyin», S(i9; Troiti 


i'vmr, eniptin-. of *]rphilif, 1C9. ^^^| 


^^^P ronfluenl molRt pnpulca, iitO. 


i'lru period ot InmbaiJon of iTpUIia, ^^^| 


W Effects of ■vphlliili.' and cliMDoralil vlnu 


laa ^^H 


^^^ ambliicd, \by 


FlsliUa(oUowlBi;eunp»mtti«tH)bo,I4S; ^^H 


^^K Blt|Auuuiaala anlituta AiKun, St. 


tmtniait of, 148. ^^^| 


^^V tralinm podmidam, H. 


Flat condjrknula, IOC ^^H 


W D}Uttla pnpukHtt, 61. 


pnpulcis IBA. ^^^H 


^^- l^tMiiiiM»ri>hiiiiiai, 182. 


Florcc, or metidaCBa ungtilutn, ttH. ^^^H 


^^^P Bnluloni, amiliMl bloody, 66. 


FoUIculilia barbta, differentia) dtagnab ^^^| 


^^^ Endemic KnibiliB, Sll. 


from (ypUlldc G«ili]niia, 20O. ^^H 


■ EnloamTtlia plAcvniari^ ^mmom, S17. 


Fod, looUiBlImi of *]:philltic, 1II9. ^^H 


1 Ei^dtdf^Dia, inSammaticici of, 68; neu- 


Frwricb'a ohwrvkliona on «;r|>liilitic dia- ^^^H 


1 tnl^K of. DO ; tr«aCii)fnt of, 34. 


mw of tliv liver. US, ^^H 


1 E)ildiiI}^iiiiUi>, B7mt>t(>iut of. ns. 


PiiDctionnl ilbwaaa oC tlic Mmlnal reil- ^^^| 


K^^ E|^heUal conmr, dittcrential diagnub 


^^M 


^^K itvm cbascroid, lil. 


Functional disease of llie te^licle, 07. ^^^| 


^^H Epilbe<ial gDnorrhira, 18. 


^^H 


^^^^ BrMinu of m itieri, SS. 


Oallopni^ or nuitlgnant •Ji'ilijlifi, I7S, ^^^H 


^B Bi7llieciia vleruain or papuluuat, 180. 


31-J. ^^M 


Ilhbruni, M. 


Q«nenil ifphllls, Uido of erapiion ot, ^^^M 


iM>outo«uin, IW. 


^^M 


maculosa pulntn ID ■jpbilitKum aoo- 


Glanda of Qartolln], diica*c ct.Si; of ^^H 


BMomia, 220. 


the ducts, ^^H 


ajpkilitiaiiB mcnbraM? tsuooMt, 990. 


Olaaa poua, oaiarrb of, 4fl ; dHn-rvntUI ^^^H 


Ennbonttoua ai^lM,aTpUHtle, 19^ 


dlagnodiof, 48t tn»uncot(rf,4S. ^^^| 



^H 896 /A7>£X ^^^^^^^^^B 




HiMnorrhag!« (TpMKds in Uw IdChU, ^^H 


^H •i&lb.iMS. 


^^H 


^^H GhNUilU HXphilUiFm diffnm, S42. 


goaorrbnoi £S. ^^V 


^^H gtmtDmtwt^a^tt, 341.942. 


Hair, e/pfalittic tfMttou of, 33S; dif- ^J 


^^M }t«iuntin,m,m,%li. 


fetcntial dUfpiotla from atuiada ^^^| 


^^H utwinr, M2. 


■onilta Tulguls prnmutiiint, IS; ^^H 


^^^H popular, M. 


from kcppei UtmOtatt^ ia$; tnm 1 


^^^H pivfundk, MS. 


phjto^JopodA, SIX. ^^J 


^^^1 Qunutwucua, NelMer's, 10. 


tlud ebanert, tnatmtat of, HO. ^^^M 


^^^B Gcauin>KDa,*«itt«, IS, IS. 


u<!r«l(u(7llyplll^^ll^. ^^H 


^^M bitOty IS, 28. 


lIuHdiiAty ■]r|>hllilk> ilbuwg of thp 1 


^^^B dirouicvU. 


ImwUt 832; lolM, SSS; tfajMoa ^^H 


^^M ofitiMiu, IS. 


^and, S3S. ^^1 


^^^V liMurrlusic, 28. 


BeniiB ■qaosa, l&, ^^^M 


^^^^ iDneoaa, 13. 


hhlaiyi, H. ^^H 


^^^H pujukat, IS. 


Hort>«^. differential iliafQMU (lom dian- V 


^^M Biudin, U, 2S. 


crold, IIA ^^B 


^^H Mnxii, U. 


BrrpM lonileiia, ISS. ^^^| 


^H liUi ol, IT. 


Uiuiild or lualrt patNiki, IW, ItS. ^^H 


^^^1 titmnc, 8a ; oompUoatSou o^ 8li 


lIaMcriulMdtinuioa,*)teuC, 108; fonn 1 


^^^1 ilnilrat, 10. 


of, l&S. ■ 


^^^1 «f ftiSwiG unthnk 78| 89. 


QatchlBMb'* STiiUltilc alTmiuB of tfaa ■ 


^^^1 td nutlu uraitam, 19. 


tOBgvo, 344. 1 


^^^1 <0«fFMti of, S9. 


Hfdnwie, aoui«, M ; ucaOMBt of, it, M 


^^H cain|iKraiiinw of, 81. 


cbronJc, A8: traaUncaiof, OH. ^^fl 


^^H iMtbolc^oal ■ltMBtloruaiiM4 by, M. 


HTdropo wagiilnoleittiia, BIT. ^^^| 


^^H piqgBocLi «r, 30. 


Hrpo<liondna mereumSa, S01. V 


^^H inoplqrluh *giilii«i| SI . 


HjiMjeradc laJecUoiu of taennj, 8TI. 1 


^^^1 if Biailb Bad nual cavhiu, 90; of 


UjdrugTTwia. uw of cnM waior nd 1 


^^H ■VC4UIII, 89 i Inatncnt of, VO. 


•«l|>lior Ihtrnul iMths n, 890. ^^M 


^^^1 of vulvn, Idkipnlbii:, 78. 


^^H 


^^^H of vuItb. pnipaiciUd, 78, 


IiSapatUe bubop*. isi. ^^^| 


^^^1 «f vulva, IndixKl, 49, 


Lnp«bgo-piuluW«rt>killdo, IROl ^^^| 


^^^P of vaJTa, inurraBl, -13. 


B7p'>ili^o>> !MM i ^fctmlial ''hBiiPtf" ^^H 


^^^H tmtRlCBl of,SI. 


ftoni Imptllgo *«)pita, SOS. ^^^| 


^^H of Itw ejc 00; tFvnl^icnt of, 92. 


ItnprlieiixHH RTpUUdck SOI. ^^H 


^^^M of Tig[liK,SO; e|>llliclial,0<i; laucona. 


InombailiM, fint perfoil of, in ijidillb, 1 


^^H 90; purulent, BO; kdmih, 80. 


ISU. ■ 


^^^H GuaonbcMl ibGumotUm, 91 ; imtacut 


Indirect trcoMHni of cotiorTb(c«,42. H 


^^M 


IflilmttM aail hjpertropfar of Ij-mfAuk 1 


^^^H OrutuUtion* of n* nl«ri, SS. 


veaMli aad gtutib la aTplilila, ISft. H 


^^H GummXa, 313; of ilia ttftchea, SM. 


IiidurBlIgii.HuMiiuii,108;ii(c«f, ISI; 1 


^^^H Oummk of the niiomui moi&bniM>, SSI ; 


fonn of, 1st. ^^^M 


^^^1 of tbo LuTTit, S&(. 


lufanUi, pimiBoaii aj^ilhleaf, S21L ^^^H 


^^^1 QoinniaKMn pbue of oouiiiutkunl sn*!*- 


bnoonbagjc ^phlUde lo, S2L ^^H 


^^H iiffi, ITS. 


DMBtaranAlUdoabsSSa ^^M 


^^^B Cwunou* i^liilUo in Ibc Intut, BtS, 


i7plinHlflaffc(ttniofUMWiaMaiM»> ^^H 




btu(*i>t,SSa. ^^M 


^^H Basmionltk am 


lufuiea MBloMlt, 817. ^^H 



^^^^^^^^^^^ INDEX. ^^^ S9T ^1 


^^ bftott^ VTpUIWb nurtlni of, US. 


L« Itirtte, tmiolo of AmuMM, 70, ^^H 


laTwdon, iMWn (avartng soodrrhaMl, 


lAt^-Qi, (fphiliiic ttfcciinn* of, 3^1, ^^^| 


IB. 


dcalHNS of, fiOl. ^^H 


liifcctitin, fjplillitic, melliwl of iraiu- 


•yphiKtio loltllnitluiia vf, 8H. ^^^H 


niiitia^, MO. 


gwntu of, Sa<. ^^^1 


Itifcctiuti, »jr|>hilitle, unidlj of, 1D8. 


MW growili In, 9081 ^^^| 


tnfllmtlaa of tfac lanria, vjpUlitJo, HA, 


Mcnosia of, 9i>plulitic ITS. ^^^| 


of ihe tradtca, U4. 


ulcer* tiL, 'i&<i. ^^^1 


laitUl ifphilitio l<sion, dilTirNatiid diag- 


La r«<itde A Uelonao, 71. ^^^| 


umIs (roKi eluucrolil, 1 IV. 


Lcaiou, marlMd, of tits ikln la ijpbUli, ^^^1 


Initiftl muItipK' uxA ■UuDious bubws, 


^^M 


trMtmoQt of, SO. 


LepnrfdoriTphiloid dl«cue,Sll. ^^H 




LsatlcuLirpapu1(i,]84, 184; (BSeroUiil ^^H 


oy, a IT. 


diOKnoaU from lupiu, Xlft. ^^H 


lafiuuuo* (TphnSs «urda«it on bioiImm, 


LontlgenM •jrphiliiU*, lliS. ^^H 


SL& 


LeuaavThiva, 81. ^^^| 


iTiSammaiioti of lh« ciMiUJ/inli, S3. 


Udum Kcnphntawmn, raMnDhltncB ot, ^^H 


ot Oowper'a gbaib, 00. 


to pspukr typhllldo, ISit. ^^H 


of pchU ot the kidnej', 7d. 


^^1 


of smiliud tcbIcIm, OS. 


IJrer, lypUlillo dlMuc at, HI. ^^H 


of v\» dolcivni, it. 


LomI >jpbilillo kScctioo*, trMtnciit of, ^^^| 


of gluds of Birlollnl. 03; o( lL« 


3S8. ^^1 


ducu, 88 ; trualmi^iil of, 80, 


UxMlkuiKin of ajriibUMo fnei, 109. ^^| 


1 luQamuiulviy vAtatrh, purulvul, 13. 


ofeipluJiiioemptloiu, lit. ^^^| 


^^K gonnrrhuM, unte, 19. 


Liin];H, Nj-phllitic alTcclicm* of, 808. ^^H 


^^V InueuUhilll; of ib« RcIorailB nloer, ISA. 


Lupuj «7phUl>leit4, »iQlo«ratifiu, SIB. ^^^| 


IntvruMlvri^niiti, tnurbid alt«r»tiouswf,!ii 


tiyporttapUco*, 219, ^^^| 


bcKiliur; njpiiilia, 82*. 


B?rpJldiioiiii'. SIS. ^^^1 


IntMtinw, ifphJlltic dleeaiics of, 119. 


^phillit«uii,dtir«n-nilaldiii^otUrram ^^^| 


laiMtlsal gluda, syplulitio iUscuib oC, 


ifotiailu papulM, ^Vj; froiu Daal- ^^^| 


luilie fa>tu», XSl. 


jiumnii, ni>; front nam tuMwa ^^H 


Iritrfl-ulcrinc niiaI Bjpblllt, Ul>. 


tulMTDsa, 3S0: from rhI&a-iK'ler«- ^^H 


Jutroductloo, 1. 


no, %iKi ; f locn Ivpiu Tulgarii, S31 ; ^^H 


ludiuo Aiul loUine-ulu, tKcTspetiilc uc 


fram multiple enviaoma of il;e ^^H 


of, ill aj^liilia, 313. 


akici,S21 1 frMii uroaina flnd me- ^^^| 


Irritnlirp otiarrlu, 14. 


lanoela, 331. ^^| 


Iculiiug of lite kkin in ajri)!!!)!*, 17fl. 


Bjrphilltica bertdilaria, 318. ^^H 




Lvstphitlc gluida, ufTcMiaiw of, in gan- ^^H 


Joints, aypbililic afftctloua of, SOA. 


urrliu-B, Bl ; tn pyphilin, 17-1; in ^^H 




•uft xHuatn, ISS^ ^^| 


Eidncjn, ftffectipiu ot, SftS. 


and vcmpIh !n pmorrfoi**. Bl, tSS. ^^H 


Majh4d dogratntlon ta ajpUUs, S50. 


of l>bi& nigijnm aad niiaora, iaflaoi- ^^^| 


diMue of, aiiaed bjr gunorrtwca. It. 


Tnatjon of, U. ^^| 


Clotu'* obiKirvatioiui on iiyfthiliiic duou* 


Lfmphftiio (•Inoila, dlMuod, Uvctment ^^| 


ot IIm lirer, 348, 


^^1 


Kolpltif, 8()i 


LyiDphttlD Byvteni ot •ntmt/iM, sffee* ^^H 




tioo of, In Ixgiiudiig «yplt))ka, 159, ^^^| 


1 Laocnuiana, diffcrcDtliil dlignooti from 


LjmpluUa ayslom, Uuluralion of, 10V> ^^H 


^^L ehsiuroid, lia. 


LjinptungiuLlU, I3£. ^^H 



^H 898 ^^^ ^^^^^^^^H 


^^H MMTOgbmla *n>l>IUtlM< US. 


K>n<, im-^rpMUte iUmm* oI; W. ^^H 


^^H VaouUr ptooritta, tit 


«n>tiiltde dbMM«f, Ut. ^^^1 


^^^1 srphiliilc In infftDls, am 


N'aluTv iif tbn ivtihilUic rirui, ItB. ^^^^| 


^^^H liiAeiij ciKuinKritwd fonu «( ffpltl- 


KciMor'a fooucociMiB, IIL ^^^^| 


^^^H lUlccniptJoiui, 179. 


Kffplnitia, MUrriial. tft. ^^^^| 


^^^H ■■!« UTVlhni, j,-unorrtii>« of, 19. 


New pwrikM In btym, asS. ^^^H 


^^^H UkllgnaDl »|>bni*, IT!, X13. 


ill IIMluM, flftS. ^^H 


^^^H HoiiTiiuiiuiu of o>i)giJili«l sjrpfaUU, 


on TOMloords, 203. ^^^^| 


^^H 


Kux il0 iDOUUm, S30. ^^^^1 


^^^H MuiuaMprUloti, H. 


NoJw of tbo «Bik, •^uBUe, 91L ^^^| 


^^^H HodualaBof fiworix**' 1nf(<4iani IT. 


ol IIm tnuenof incmbnii«, UL ^^^^| 


^^^H UeUnMb, dlfferciitUl dlagiuMda ftoai 


of Um ubnitaDewn lian^ 313. ^^^| 


^^^H lupM iTplffllieiM, UL 


of tk Mft palal«. MA. ^^^H 


^^^H StcMlaiou mieulaip, SflC 


KoJaUr fipkUfcle of tlw flttn, 918. ^^^H 


^^^^L^^ Uunurf, L-slvnul ow of , in •j;]''''^ 


KutaliiB 1^ ayiihUklr oltildivii, SSS. ^^^H 


^^^^^^^K SAS; !nuDCt!i>iM of, iSd; bfpoil«r> 


^^^H 


^^^^^^^B mir iiijcctiunn of, X71 ; fimlsMiniu 


OoMfiaUoii. [ttAiMinec of, ]o an>hQi^ ^| 


^^^^^^1 lU ; buhl of, tn ; nqtfNUdlo. 


illafiTi of ih« JBTTna, Ul. ^M 


^^^^V Hm dC, 379. 


(EMpbagna, (jpluUtic 4iMaM of, 94L ^| 


^^^H^ Mercurj, patbogcndc nftertt of, 8TI. 


OoycUa alcca, XSS. H 


^^^H therapcntje qm* of, 8^ 


*7I>UBlii!*, SSI. H 


^^^H Utivarlophobla, S9I. 


Opened ba^ tnMtnnil ot, ML ^| 


^^^H Mwcurial pnipantiaiw btot wliiptMl for 


Opbthaimin fuiiDrrbaka MeaooRkuis, ^M 


^^^H IntndiMhNi into ilw Uood, SU. 


^^H 


^^^B UilhiT iwpalw, IM. 


OcfifaitiB STphUian, SU. ^^^| 


^^H Klllarf B]rphlIM«^ tM, I9t • dIfferartU 


Oatlila indilHiiM. «Wl ^^H 


^^^H dik^noaU fmn Mftbica, IVl. 


0* uieri, eroslona of, 0S. ^^^^| 


^^^H Molnl or humid papnlcA, ISOi IflS, 


paiHiUtkBi af. a, ^^^H 


^^^H Matin, 97 ; trcaUniiit of, KNX 


Onri<«.f7IiUUtiaAMaaaof.»a ^^H 


^^^^H Uoriiid lwi<iii» of tlie ticin, l?S. 


OnOa Kabodii, M. ^^H 


^^^H Horulilj ID trphilivi, 112. 


0(Kna ■jiibDIikk, SIS. ^^^^| 




^^^B 


^^H 


Palat«, Mdt of aoA, 1S4. ^| 


^^^H Houtb and nud mrttiea, papnlar an- 


Paiiiirt«s cypblUtic afllMlDH of, ttO; ^^^^ 


^^H gtDB of, 


•rUaMw of an^UUtlo dlaau% MOl ^^H 


^^^H Houtb Boil luml cftvhiM, »n>Ulilfe di*- 


PniMlar anchM of ^ iMMlb, tM. ^^H 


^^^H MM of, 233. 


glonrilla, iU. ^^H 


^^^H MuMtia nMoibratMB o( laf tata, npUUUe 


•tpbllMc. IKS. IMS, 1*2. ^^H 


^^^H tStOiaaa ot, tn. 


■jphiUdc IcDltcula', 183. ^^^1 


^^^H Uuooti* meinbnujaa, ajphilltk erTtbeiaa 


ajpUltda In ibc inhai, SSI. ^^H 


^^H 


Papalaa In antbilllic latTogitia, SHt ^^^| 


^^^H HneoDS meiDbmiM of genital o<Tgua, 


nMln, IH. ^^H 


^^^^B ■ypltiUlic altoction* af, III. 


Pnpahv, ariililHtiiv of IIm aiaeoM ■«»- ^^^| 


^^^H lliiMti* mombrwHa, a«d«a of, til- 


brans, S27. ^| 


^^^^B HuoMU Kanuirtim, 1ft. 


[1npUia»Mia,47:<Bff««tI^<°''P°^ ^^| 


^^^1 MooMia pbqtiM, lT<t, lU, MS. 


of, 43 ; baaumit of. 48. ^^^H 


^^B Xnlt^le admlOi, 174. 


ParanTchla an^dliiiea, 114. ^^^H 


^^^K^^ llT«*a obncrratUiM on •jfAOdo dl»- 


latenlkSS*. ^^H 


^^^^^H flase of dw Uw, US. 


hinilaria,»4. ^^H 



mDEX. 



399 



Fftrrot'B iwUfarTD skull, 8S8. 
Fftthogeaic effects of mercary, 876. 
Pathologies! altentions of the blood In 

sjphilia, 168. 
Pfttholo^cal alterations of the msle 

urethra from gooorrhcem, 20. 
Pathology of the soft chancre, 110. 
Peculiar fonn of the sypbiliUc uloer, 

178. 
color of the eiupUons, 176. 
Pederastj, 89, 

PeWis of kidne;, inflamnuition of, 76. 
Pemphigus cachecticoruni, differential 

diagnosis from pustular sjpliilide 

bt infants, 323. 
Perichondritis ayphilldca, 261. 
Period of incubation, first, in sjphilis, 

160. 
Periostitis and ostitis, site and effects 

of, 303. 
Pharynx, ulcers of, 288; cicatrices of, 

262 ; new groirths in, 268. 
Pharyngitis ejrphiUtica, 288. 
Plumosis, 47 ; differential diagnosis of, 

48 ; treatment of, 48. 
Phyto^opccia, 323. 
Pigment syphilis, 222. 
Plaques muqueuses, 170, 183, 808. 

opalines, 228. 
Pollution.-!, red (bloody), 66. 
Pollutio tUumt, 67. 

Polymorphous form of syphilitic erup- 
tions, 178. 
Prepuce, catarrh of, 46. 
Prognosis of gonorrbiea in men, 3'). 
Prophylaxis against gonorrhtea, 31. 

of Bjphilia, 337. 
Prostate, morbid alterations of, in gon- 

orrhiea, 61. 
Prostatic catarrh, glandular, 62. 
mucous, 61. 
purulent, 61, 63, 
serous, 62, 
symptoms of, 62, 
treatment of, 6B. 
ProBtatorrhisa, difTerential diagnosis 

from prostatic catarrh, 63, 67. 
Proetatorrhoea, differential diognods 

from apennatorrbwa, 64. 



Protopathic buboes, 181. 
Paoriasia syphilitica, 178, 

palmaria et plantaria, 180, 186, 198. 

Ungus, 239, 

nigricans of Cazensve, 17S. 

of the tongue, 239. 

differential diagnosis from aphths, 
240. 
Psoriasis syphllitlctt of washer-tromen, 

196, 
Pulmonary syphilis, 264. 
Punaise, S26. 
Purulent gonorrhiea, 18. 
PustuU fistida ani, 1B6. 
Pustule plates, 196. 
Pustular syphilide, 201, 

in infants, 322; differential diagnosis 
from pemphigus cachecticorum, 838. 

Quantity and SDccessiTe form of syphi- 
litic eruptions, 177. 

Itacedo syphilitica, 233. 

Bectum, gonorrhica of, 89 ; treatment 

of, 90. 
Relation of vaccine lymph to syphilitic 

virus, 147, 
Renal catarrh, courae of, 77; treatment 

of, 77. 
sypbilis, intra-uterine, 380. 
Rhagades, 229. 
Rhi-umaUsm, gonorrhceal, 94 ; treatment 

of, 96. 
Ricord's division of syphilis, 171, 
Roseola syphilitica, 180. 

evanida, 182. 
Rupia syphilitica, 180, 801, 211. 
differential diagnosis from rupia ml* 

garis, 212. 
Russian gODOrrbiea, 18, 28. 

Salivary glands, syphilitic affections of, 
250. 

Sarcocele syphilitica, 86S. 

Sarcoma, differential diagnosis from lu- 
pus syphilitica, 221. 

Scabies plstorum, 196. 

Scabrities unguium, 226. 

Sclerotic ulcer, inoculability o^ 16S. 



^M IKDEX. ^^^^^^^^^V 


^^H SdoiMii^ i^tial patbalo^p at, ISI. 


SuptMwUmix, tDOroariul, in *«phnh, ITA. 


^^H Be* hftth* iu tk« irfAtinral of t^jibili*. 


flttpM-naal capBuk>, atTtclioiia of, SKA. 


^H 


Suppunuiaf bubo, Ikula irf, lUj lica^ 


^^H SeboRbcu rieck conipKliTi, IBS. 


ini>ol of, US. 


^^H BeOAtitUt; |ilirai>iii»iia, ln«lnicnL of, S4S. 


S^MMi", JiiFpiMitial ili&{,iiu«U tvom «fpU- 


^^H Bcminal ritiiulnf, in&imnmtiun »(, ti. 


littu BCtlijnia, 3iX». 


^^H funciUmal dtsoMe of, tt. 


S7phllonia. li:ii Wogner^ 314; VIn 


^^^ 9cmbwJ pmiMloo*, Uauiljr. flA. 


diow'a, 314. ^^ 


^^H Si-qackc i>r goiiorrliiv* In mrHi, i9. 


iV;>tiUlpbot>l*. 36t. ^H 


^^H gentnU, «S. 


Sjpliili*. US. ^^B 


^^H £c(|U«Iic ol unidiral gonorrhiD*, 98. 


tquititk. Its, 1 


^^H SeraoB gonarrlKPA, IU. 


cougeniial, SI9; nanltlBaUISaBi Afj^^J 


^^H SbMthi of lendou. »ypliilitie iUIeeii4su 


4I1I; lUa^ooiU and pnifMMia O^^^l 


^H 


^^M 


^^H SliL-cp-uoM, S3i). 


«idaokic,Sll. ^^M 


^^H Sil« and sffficU tt pcrioDtillii ud otlUia 


itnSiMTj, mofbld ■ti«ntioiti of tn- V 


^H (jpbJUtim, tin. 


tcrnal orpui*, 139 ; beroJiwria, H«. 1 


^H F3dn, noduUr nrphilide af, Sia. 


beredlUrU tarda, M*. 1 


^^B Snuktl p^iiilar <iy[)hUld«, 169. 


tnaU(niMit orgalloplsg, ltS,311. ^J 


^^H Soft oliuicrc tOS; •tonic, 113; erathb- 


hounorrlia^GK, 9!1. ^^^ 


^^H tic, 113; gsngrrauiu, lit; phage- 


of theooniM, 192. ^^fl 


^^H dcnie, IU; Mrplgtiioiui, IU; mn 


of the fautwa, XSX. 1 


^^^^^B pl^no-pliagcdcnl^ IH : devdop- 


oonmltnikKMl, 113; eog»« of, ITa ; 1 


^^^^^H ineirt of, IW; diffemitial dia^cuu 


tkfdofitnHit of. 172; dumloii of. 1 


^^^^H of, 118; pntbologfof, 110; tiKot, 


I7S ; t»0TuKl7 in, 1 TS. ^J 


^^^^^P 1 10 ; prasniMti of, 131 : cnvlmnu 


covbifiBtJMiaof, ITO. ^^H 


^^^^^ 


«nifiti«* f««r (jf. IM. V 


^^H SpenuUc cotd, luAuiiRuUlon of, M; 


tftot period i>I iinToballoB of, 180. J 


^^H trntmcnl of, Afl. 


lafliHBor on pKfftuincT. tl1> ^^H 


^^1 ■jpUlitie tlfixtJon of. !Afl. 


'Inflnenoe on iho moUior, SIflL ^^^| 


^^H &penBfttan'lnva,&Ti<lifIvrtntJ>ldllBMrit 


«f Um ntoinb, XM. ^^| 


^^H from |iro«ttttoiThii«, A(, AT; treii- 


papnJoaa imtkvlaria, lAO. ^^H 


^^H mmt of, SB. 


pt|Mlura l■iltart^ 1»\ IN; dlferan- ^H 


^^^1 8p«niutotrh<ca cnxnU, tH. 


llal dUgnoM* from ««aMe«, IH; ^^V 


^^H SpllK or mulnl wirU, 97 ; tminient of. 


fmm (Muriaib TulgalU, IWI ; frora 1 


^^M 


lidHB •CTofhuloMMm, 181; from 1 


^^M 8plocu, arpbtUlIc affectiqnf ot, H^ 


beniMdrrinalMa, 1*3. 1 


^^B iBiM^U-riiip >ifiN!Uow of, sn. 


pl^enWM, KfS. ^^H 


^^H SqiufDou* *yphilido ttl tbc tiMul* and 


proph^luU of, SST. ^^H 


^H feet, I9i. 


p«IiDcmi7, HH. ^^H 


^^^^^ Sirictura of tbe tirelh.u, 101 ; faiflaio- 


raoefonnt*, SIS. ^^| 


^^^^^fe HMtoiT, 102; 0(g*nt«, 102; «pa>ti«. 


irraliuBt of, 8X4 ; of lh« InlUal ph*' ^^^ 


^^^^V IQl; inwtcncnt of, ICH. 


numciM, t40 ; o( llio Mouadaij ^^1 


^^F Stomuili, inrpUlltlc dlwuo of, MO. 


ptieDuamui, 841. 1 


^^H BuDotavion and pbM«a of (jpUUtie ai- 


Inalttwit «l l6Ul AffMdon*, SSI [ of 1 


^^H fcclloDii, ITI. 


1 111^.1 bIiiI. SBS; etpMtaat aictb- J 


^^H Sulpburlliermal iMllia in bvauncoi of 


0(LU9: nwdfcial, MS : t? regeu^ ^^ 


^H «j|i)iilii, 8$<). 


bl« nnMtSM, UO ; by lanedoni O^'^H 


^^H Suporfldol ctttaaraui ucxln, IML 


mcrcwT, IM; bj b/podennk i^'^^l 



^^^^^^^^^^^ ^^ ^^m 


^^^M JoMloM, S1I ■ tf tvmiptitm. S74 ; 


gtoMlda, gntDHMMM, tW, Mt, M2 ; ^^^| 


^^^K b7b»th»,l7E; b7MppMitorie«,816. 


indiu«t«d,S38; nia«nlar,S49; pap- V 


^^^H iimnnlidiMi oC, I7 nodnatiao, t-i7. 


ulaT,>4l fl 


^^^P (niumbaibililr ot, 146; In wann- 


5j)ibilitic inftction, maUiod of trsnii- ^M 


^^ Mooded wiiiwU, l-(9. 


nilting it, UA. ^1 


H ^phlUdM, 17S; acDotilu-, 208; pun- 


iinkitj' of, 136. ^H 


H BtMU, SSa ; bvowrtliagle, S'2'J : Int. 


S}^falltilc Initial Klerodi, uutomy of. ^H 


H peli^oous, 201 ; lenticular, 188 ; 


H 


^M iMCokr, 320; nodubr, 113; papu- 


Sni^'I'^'c TlniR, Daturaof, N8. ^^ 


H br, 18B, 1B9, S9t ; pnatulBr. Vil. 


rvlatlon of, to vaediM) Ifiophr I-17. ^H 


H <1S : squ4inou«, W ; TKm'«llii' 


and chancroid virui, comUocd cficcU ^H 


■ llk^ I0« ; veaicular, SOI. 


160. H 


H E(n>UKtle kffectioiu, Ricord'a duniflcn- 


Sjiihilipliobia, 381. ^| 


H lloovr.171. 


Sjrpfailiutloo, t»i. ^M 


H &lM]'a dsMifiatiioa nf, 171. 


^H 


H of Uw benM la luTuiU, 816; la ftdclu. 


Tnndnnc, vrphilitie affectlonf of, SOH. ^^t 


H SM t of th« broncU, 343 ; vt ibv 


TveticlM, Ivucllooal <iis«aM «f , 07 ; tnat- ^| 


H bun*, aiu : of the canlbgvi, 807 : 


moot of, A8. ^1 


^M Mipon «aneTti»u p«oU, 973 ; hair, 


Bvphiliilc alTcctUnu of, 205 ; horwU- ^H 


H . tiS ; FalloplaD iub««, STO 1 intca- 


larr, Ui. ^M 


H tiaal gl«^d^ Ul : Jalnta,- 90S ; 


ThenpeuUc qm of lodldea tu qrphUia, ^M 


^M Urjnt, ml; lun^ SU; niicoUB 


■ 


^M membnata, 320; raocGfl, 387; of 


Therapeutical nsc of meronr, 852. H 


H Inhrna, 823; gentul organ* of 


ThrmuB glands, hcndliai? ajrpbilU of, H 


H botl) tesea, iTI ; nalla, 288 ; Urpx, 


332. ■ 


H Sal, U4 ; rnuMltn, 3M ; panonu, 


Time of cencral crnption ot ajphSUa, IM. ^| 


H SiO; Oililh, SOO; orarliw, HO; 


Tongue, qrpbUltIo dlauaae of, 238 ; gum- ^| 


^^^^ aalivarr filuitb, !tSO ; Mpeniialic< 


muta of, SI2, 244 ; qilthcUal catarrh ^M 


^^^K oord, £03 ; tplrpit, ^OO ; tnuWa. 


ot, 211 ; HutdiiniuinV otnerratlona ^| 


^^^^r 231 ; (oapie, t44i ulccraof lion«e, 


of, 244; macular, 2SS; p^tibr, ^M 


^f S«a -, dcalricc*, 999 ; loMiclci 8G3, 


SS& H 


^^^ 863 ; ulorua, S70. 


Tracbca, dcatriom In, KI!; gmniDau ^H 


^^H ■phUitt.SSB. 


in, SM ; bifllintloDB in, UM ; new ^M 


^^^H oovtbliiatiMM aad phnAin of, 17t. 


CTU«1bt In. SOS ; papulcfl b, 8S4. ^^^^| 


^^^B coTthcmB, 12«; of Ihu Tii'iuth, 233; 


KXpliilitlc alTectloos of, 201. ^^^^| 


^^^^ oalsnliBl inSamtnii'.iAn of, dSii. 


OKUrrti ^^^^H 




chrouic cntarrh of, 232. ^^^^| 


H drrbofia, HS. 


ukeis of, ja*. ^^^B 


H fod, lonatian of, !M. 


Trachomk, 92. ^M 


^1 goDDia, Sll. 


TrBiiMuWou of eji^itiUU bj racduatioii, ^| 


H lUdea o( llie oalU. 213 ; of llic (ul>- 


^^B 


^B eMaoenu tiunc, 313. 


TtcatiTicol of catairh of glint penia, 46, ^^^^H 


^^^_ papiUoa of tbo muooua mcmbraac, iSI. 


of KancirTh(r« In men, 81 ; iiidiroct, ^^^^H 


^^B diMbMb, US. 


IntcniBl, ^^^1 


^^^^ diaoaM, definitiona and oUatlllcittion 


of p&raphimoaia, 48. ^^^^| 


^B of,ISO;o( tlefatlC«^S37,^^f); in- 


nf pliimosla, 4B. ^H 


H IMioea, MS; Uvor, S47: maiiih. '^38; 


of dvphiliA, 834, SSR; hy mpnniTlal ^M 


H Uila, tU ; aaoph^;u», I'll ; nkin. 


bailu, 37G ; by lauoctioDH, SfiS ; hr ^M 


H If3i Btamadi, 840 ; tootpw^ 8X0. 


(uiuigaiinitt, 374 ; ti; Iijpodaraiic ^M 



musx. 



Injections, STl ; wHh enppositoriea, 
876 ; of initial pbeDomeoa, S40 ; 
of Hnnt«riui induntioo, 840 ; es- 
pecUnt method, Si2; medidtul, 
84B ; by Tcgetable remedies, 860. 
of oonKeniUl ^rpliiliSi 8S6. 

Tripper, IS. 

True Tocal cords, nloera of, 207. 

Tabcn ijphilitica, 218. 

Tubercola sfphtlitic&, 21S. 

Tamowakj, cauterisfttio proroc&torio of, 
171. 

Ulcers of bonea, Bjphilitie dcalrizAtioQ 
of, 302. 
of bronchi, 2B7 ; of pbarpii, 238 ; 
on fftlse vocal cords, 'IVi ; on true 
voc&l cords, 207 ; in tmchea, 2S6 ; 
Bymptoma of, 260. 
Ulcer, eclcroUc, inoculability of; 166. 
Ulcus eleTBtum, 111. 
trambceaoides. 111. 
fuDgosum, 111. 
Unidt; of syphilitic infection, 106. 
Unopened bulxi, treatment of, 189. 
Urethral gonorrhoea of wale, 19. 
hi female, 86. 
sequelcB of, 93. 
Urethritis blcnnorrhoica, 28. 
granulosa, 29. 
membranacea, 29. 
purulcnta, 19. 
Urethra, stricture of, 102 ; inflamma- 
tory, 102 ; organic, 102 ; spastic, 
102 ; treatment of, 104. 
Uterine gonorrhcea, complications of, 86. 
Uterus, syphilitic affections of, 270. 

Vaccination, transmission of ayphitia by, 

147. 
Vacdne lymph to syphilitic virus, rcla. 

tion of, 147. 
Togina, gonorrhcpa of, 80 ) chronic, 81 ; 

treatment of, 62. 



Ta^nltls papulosa, Bl. 

Varicella syphilitica conflaena neona- 

toiiim, 882. 
tike ^phillde, 204 ; differenUil diag. 

noBis from rarioella rolgaris, 206. 
postolar syphHide, ISO. 
Vas deferent, toflammatJon of, 62. 
V^etations, 97. 
Venereal eatarrb, 13; epithelial or mn- 

ooos, 12 ; purulent, 12; serons, 12. 
contagions of, 3. 
Vesical catarrh, chronic, 71. 
Vesicular syphiUde, 201. 
Virulent buboes, 182. 
Vims, ^philitic nature of, 140. 
Visceral syphilis, 178. 
Yirchow's obserration on syphilitic dis- 
ease of the liver, 247. 
on nodes, 214. 
Vocal cords, new growth of, 263. 
Vulvar catarrh, epithelial, 79 ; mueona, 

79 ; serous, 79 ; treabnrait of, 79. 
Vulva, gonorrbtf a of, idiopathic, 78 ; 

propagated, 78 ; treatment of, 79. 
Vulvitis pumlenta, 70. 
Vulgar lupus, differential diBgnoeis from 

lupus syphilitica, 221. 
Vulvo-vspnal gonorrhma, complications 

of, 83. 

Wagner's syphiloma, 214. 
observation on syphilitic disease of 

the liver, 247. 
Warm-blooded aniroab, transmission of 

syphilis In, 149. 
Warts, moiat, 97; treatment of, 100. 
Wctzler's observation on syphilis of the 

liver, 248. 

Xerosis vnginffi, 81. 

Zeissl's classification of syphilitic affec- 
tion, 171. 



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■I Ikilcviic llo^plta!. on midwifery, ihc pucrprml, uiil lli« olhcr ui^icnitci ufwoinFi). This volume 
U made up iiatntontully from phonvgiiiphic teporls of ibe teclutrs wliicU I )ui>'g si^'Cn ud the 

fDCrpcrnl diiMsc*. Haritig hiul tnlliei cuccpltonal upportunilin W the >ilu<))' of ihcir di^cxin, 
hav« (elt It to be nti iaip«rfiiU'e duty i« utiliu.', «o fair fu Iny in idt power, the advantagrt wliich 
I httw enjoj-ed (or the proau),tloii of KicilH^Uid. Ihope^ lor the inirtcsUol humaniiy."— /'/vm 
AitltUf's Prt/iKt. 



I 



ON SEA-SICKNESS. By Fordvce Barker, M. D. 

I vol., itioio, 36 pp. Flexible cloth. 75 cent*. 

Reprinted from the " New Vork Mcdicil Journal." By tcaion of tlic fTCftl dcniMMl Ibr the 
nwnbrr uf thai lunrnal containing the paper, it it iww prcicntcH in lt™>k form, with ttich prcKrip* 
tioiu »ild«ti u ih« author hai found uieful in relUving th« sulltnng from s«a-uelu>«M. 

PARALYSIS PROM BRAIN DISEASE IN ITS COM- 
MON FORMS. By M. Charlton Bastiaw, M. A., M. D., Fellow of the 
Royal College of Physiciaos ; Pixjfessor of Pathological Aoatomy in Uni- 
versity College, London. 

With lUoitnuioiu. I vol., tamo, 340 pp. Cloth. il.7J. 

"Theie lectures wer«- delivcrtnl in UnirerHly Coltcf^ IIo»pitlJ iMt year, kl a time when I WM 
Rojni duly for one of the senior phviidanx, and darinj; ihe Mine year— «fler they had been repro- 
'duc«d frotn very full noiet taken bv my friend Mr. Juhn Tn-eedy—tiiey «)peartd in Ihe page* of 
• The Laooct.' They ure now iciHibiiibed at the requfrii of many (riendt, ibovKh only after haTini; 
iindereoiie a very careful revijinn. during which a comklcniMc ouaniity of new nutler ha> beea 
added. It would Hive been euy to have very aiuch incrcucd die tiie of the book I'y the iniro- 
ducHoaof a lar^jer nontberof iltuitralivecatet, and hy trvolinent ofmany of Ihe )ul>j«Cl» al croaler 
lenpb. bat ihii the author hu purptnely abt^tained from doing under ihe lielirf Iba] in iu pifencnt 
(brill it b likelv to prove more acccpuble to ituitenu, and aUu perhapi mote utefol to bu>y prac- 
fitioneti."— A^/nwf//wa J^/act. 

[the MANAGEMENT OF INFANCY, Physiological and 

Moral. Intended chiefly for the Use of Parems. Dy Andrew Combe, M, D. 
Revised and edit«d by Sir James Clark, K. C. B., M. D., F. R. S., Physician- 
in-ordinary to Ihe Queen. 

PirM American from the tenth London edition. 1 vol.. ismo, 303 pp. Oath. $1.50. 
** This csccllcm Ihttc book ibould be In the tund of every oKither of a fanay,"— TJir La»at. 




D. APPLETOK A- CQ:S MEDICAL WOR. 



ADOLPH STRECKERS SHORT TEXT-BOOK OF OR- 
GANIC CHEMISTRY. By Dr. Johanke3 Wislicencs. Tratiilaled tad 
edited) wilh Extensive Additions, by W. H. Hodgktnson, Ph. D., and A. J. 
Gr«naway, F. I. C. 

8to, 7S9 pp. Cloih, f5.oa 

The jfea! paoulnritjr whidi Praretnor WUlit-enoi'* nliEkMi of *'Sif»c!t«'* TMt-Book of (V- 
oanic ChemiMrj' hu enjoyed in (icnnaiiy hu led to tlic belief 1h.11 tx\ tri£lith timlotioQ wtU 
be acceptable. Sinoe ihc publicatinn of the bouV in Gernuay, ihc kaowlcd^c of ori^inic chciD- 
ii^uy K*t inctcuci, sud tba hu iMce»iitalc^ niwy •ddiltcu)* and alleratioBi aa (be pMi of ibc 
tnatiiuore, 

SraciMKH or luvmuTHM. 



ikd in difa •AtMT. 
bodi ' we h*re lo dtd 1 
a priiDM. EwylMnf k 
oompamivc. ana tba Mh 
•itioft' herr ha* tdalta 
lo tin cflaiwMu* <l« » «h ^ 
■wal and i-nnn of ncMU 
einnic cbeiubtrr. TU 
aohel DTd fariipratwBiiTt 

RMai the pKHcU coo* 
Hon of ibt ■dam hi n 
nuts l«cu and Icadint 
principk*, •> JcMMoM 
\ij the tytfMMIlr chtMal 
Hadtni. ^v■ have ksc, 
prcfeabli. iha ba« wuM 
mt-book erf ornabc cfea» 
buv. Not Dob la ft (uK 
and CMOfWBtMMk* aad 
RfikvkaUr cleat aad ■» 
Ibnlicai. bill it ti up to tb* 
vwty latMi fwvBcAi, aad ■ 
hu bees, iBOrecmr, ;fl» 
)m«d in a wajr to amin 
thv FTNtm radlcKM 
Id lucli a tr(BtiiB.''^TAi 
Pv/aiitr Stitim Mti^tf. 



PRINCIPLES OF MENTAL PHYSIOLOGY, with their 

Applications to the Training and Discipline of the Mind nnd the Study of 
its Morbid Conditions. By Wiluam B. Carpent^k, M. D., LL. D.. Reg* 
btrar of the University of London, etc. 

I mL, 8vo. 737 pp. Cloth. 53.00. 




"Amone the numetoiu ontneni lariicfs ihk 
connuy baa praduocd, noiiE arc more dEKntnic of 
piaue for having aUeaptcd to apply the taiikj of 



pkytaotoekaJ meanb 10 l>w eipLuuiUoci o( Mat ■•■ 
lual Rladooa gf the BMnd asd body Umk I1«. Cv 
pcnter. "— Tkt Ltmttt. 



HEALTH. By W. H. Corfield, Professor of Hygiene and 

Public Health at University College, London, 
r vol.. t»mo. Ootli, $i.«s- 



" Fcwpcnons an b«tl>^Tqoalill(<J than Dr. Qax- 
lield (o wnle iDUtlievDi ly niMn 1 he tub jKI of h*a)th. 
aiid it i* Dot a matUr far suiprue. tberpfore. thai he 
has c^wea us a voIuiih T«v»Aable %ttt aMvracy and 
intereat CotncneociiiK with pB^ral aBattMny. the 
txines and miuUcs mi flv^ """"'t"™ ; next, the 



.tsJ 



circutalioo c/ tht blood. Uwa m^taUM, 
the Hv«r, and ihf vsfcntary ofma. th» 
syMeen. onatu oi the wnaa, the li«Ah «( tbe Wt 
ndual. air, I«»d( and dHalo. drlnktar-intCf, (B- 
\\M». housM and idwok. imatKaa. aoid wnwaV 
caUe dlauM."— /'t'9<*'<r>>4iM ///■*. 



n. APPLETON *- CO:S MEDICAL WORKS. 



[THE BRAIN AS AN ORGAN OF MIND. By 11. 

Charlton Bastian, M.A., M. D.. Fellow of the Royal College of Phy- 
sicians; Professor of Palhological Anatomy in University College, Lonilon. 
Wtlh iS^ IHuslrocionB aii<l tkn Indot. I vol., ismo, 70S pp. Clulh, $2.5a 

" Dr. Bjutlui^i n*v book U nan cX gtMi vi.1ti« 
■od Imponanc*. T^a knowlntec it elvcf Is unlvM- 
hI in lu claim*, and <A momcDI U) cvoybod j. It 
■bovld be forthwith li)iKidue«d u a nuMRt iBio all 
ooUcsEi, hieh schnol*. and □omul Ktioob to tlic 
oounur ; Dul to be mode • nmltvi o( oidloarr me- 
ehatiicil rrritatlonc, but thai iu uibjfCi ma* anvu 
•iicniliin i.i\i\ rfiiisc IntrrrU. and be lodenl In Ihc 
(niiub ■>( liiudcitu In fuiiTi»ct»in vilh <>U>crvalIuna 
aniJ rip*r1niciiu tbai will gW» italliy 10 ili# Lniwil- 
cd£« loitilptd,"— /V/*Ai/' SiitHst M«nihtj, 



" Tlib work U the belt book of lu kind. It U 

(ull, and at Ihe nme lime ciintiii? ; cnmprrlienilvr. 

bul coa&oed lo a n«dab1r limit; and, Ihouch U 

^ dull with manv nbtUe uibiecci. It cxpoundt them 

H in a nj-lc whicn is admirable lot lt> dcarncM and 

B »iia^ici(j."— .Vj/«r^. 

*' TbR fullnt idcnilAc ripmltlnn ycl publUlioil 
ol the vini held on (he subject of ucycnoln^ by 
lb* advanord phniolnttkal lOmoL li iwmi wiili 
Dcw and fUnianlTt ld(a&"— £<»u!ihi AiAeMtetm. 



] 



TREATISE ON MATERIA MEDICA AND THERA- 

PEUTICS. Revised and enlarged. Edition of iS83,n-iih Complete Index 
and Tabic of Contents. By Roberts Bartholow, M. A., M. D., I.t,.D,, 
Profes>or of Materia Mcdica and Therapeutics in the JefTerson Medical Col- 
lege; formerly Professor of the Theory and Practice of Medicine, And of 
Clinical Medicine, and Professor of Materia Medica and Therapeutics in 
the Medical College of Ohio, etc. 

Fifth edition, rcnicd and enlarged. 1 vol., 8vo. Cloth, $5>oo; iliMp, $6.oa 

"The appcsrsncf of ihc iixlh decennial rcrliinn of the 'Unilnl States PhatmacoprcU" Iim 
fanpoacdoD mc the nc<«uil]- uf picpariiie a new edition of tliuiicitiic. t have accordiiiKlr ailxpicd 
Ibe work to the uJBusI >taiidar>l, and have abo £iv«ii lo tite •rliole of it a careful rcvii,i<iD, incorpo- 
nin^ ike more leceni imptovtraenti in the tcieneeand art of therapfulin. Many addition* have 
bcMi itiade, uid part* have been rewritten. Theie additiona and chan^^et ha«« added about one 
hundred pages lo the body of the wori, and increa.<eil ipace lui been i«cured in uiine placu by 
the omiuion of the references. In tlie ncu' miicrial. as in the old. pimiiinl atiliiy haj> l«en ihe 
roliiic principle, bul ihc icicntific ft*pcci* of thciapcuiit* haic not liccn mbonli listed to 11 uiiliiai 
rtaii cmpiricitm. In the new mailer, a» in the old, dtefiil mnsidcialion hiiF been given 10 the 
pb>4iulot;tcui action of rcmciliek, wtiich U icgartlcd aii the ti\ic bwit of all real progrcM in thcra- 
ptatioal tciencc ; but, nt the >>ai»c licae, I have not been unmindful of the wniribuiioni mad* by 
pioperly conducted clinical obiier^'aticlnl." — /■«*» Pn/tur lo Fifth EJiti'tn. 

" The author hai adapted the proent edition lo 
Um changes nude in Ihe sixth nliiiiin al ilie * Unit- 
ed Suitr:i Pharmacnpirla.' lie lui alw ctrrn the 
«h(>le wrirk a earclul reviiion, inciirporatinc the 
BUM* rrcpDi Improvuienta and aUdilloni tu tbcra- 
peutici. Ab<:.ui one hundred pacei art thiu added 
to Ibe volume. The valuable practical chata^tet of 
[>T. rin-itholow'i Irralis* haabeen recnenlied brlho 
profeuiun, and^robaUy no one ho* fucceedcd bet- 
let in iiripuladiiBc the phjrdolrfiilcal In dltlinctlon 
Irnm (lie rmpltlcal mode nf itudjine iherapeullca. 
The t>ix-k b vi cMcliciit a one thai we can haidly 
pick out any faults wiihmtt vcnniTinc dancaroualf 
new hjpeniltkbia.''— JT'ii'/fii/ Kttorit. 

" Profeaaor Bartholow basqwcial talrai torcon- 
Jamation. conbincd with a comprchtn^i^ kiii:ti^l. 
(4ee^ hia HtfcJMt, and a po*er of direct eipi«t- 
aioa. That ihu conabiaatfiin U j:nit«(ully apfiro- 
datedbytbecnenroifced AiDcrkanBliklent,aiid tha 
no leM oveiwotlced ^yalcUn. hat been fatly denw>n- 
Mratcd by tbe lemarfcable denund for ihii wuik on 
Ther ap eutfcfc whid) haa now attained iu fifth edi- 
lioa ia leaa Ihan leveii yearv On aocmint vt \n 
COBvenieiice (or raferroaF aud cumpletene^i. ii hai 
bcciddnf>ted a> a leslbook in many of our mrdi- 
eal oOOtf/a,"--P*ilaJtlfJai Mulaal Times. 

"Abooli which haa reached ita fifth tditioD to 



rapidly a* thix hai dtue, and «Tvffi whUb Ihe pro- 
festino lia»pa»ed M) lavutable a fudetnenl. Itardly 
stnndi in need ti( a tciirir. at uf bavinc Iti merlu 
poinltd out. It is ncil >'Ut of place. hu»»er. Id 
niite that it has tnrn lept fullf abreail i-4 the matiy 
and Important changes (tinsl<iitly aiakinic in the 
hnowleJfe of drugi, and Iheir apptiratim to dis- 
ease, to say iKrthine uf bvdri>-. elcctJ<>-, and iiieta11»> 
tbeiapcuii<:s. all of whloi are thorouchly ucaicd lo 
this tdilloa. . . ."—AmertiAit JtutmiUi/ IJte JteJ. 

" >^'e have lately had oceaokn to notJoe a dub- 
her of new works, and new editions n< well-known 
ten-books, cnnuieriainrdlaand thcniiieutin. and 
on a great proponiwn uf iheai we h»i-e bcMow«) 
high comtnendaiicin. To ntme. hfnrerer. it ircater 
praiK 10 be awarded tboa tn this ftfth editlim ot 
PnJeaint Barlkolow'a. Tbe appeaianee H Ihe new 
PhamiaceMia haa teiidend a aumber of chanee* 
in phnaeruoey nicr miij , but. Id addltica to thne, 
the volume bears evidence tbi«4i|;hoiil ti having 
been brnueht well up to tbe nratent slate of our 
Loowledce- In coniooaDce wHh the ccoeral voice 
of the iiiiifiailrin. we nuai My that peaetilioinetB of 
mcdldna can Kancly aJTord to forefio ibe advan- 
loxe* w be dcdTcd from the pMawlos W Ihia 
book."~.VA[> Yofk HtJKal ^Mtrnal. 



\ 





'APPLEtON 5- CO:S MEDICAL WORKS. 



i TREATISE OX THE PRACTICE OF MEDICINE. 

for the Use of Students and Practitioners. By ROBERTS Bartbolow, 
M. A., M. D., LL. I]., Pjsfcssor of MaieriA Medics and General Thcrspeu- 
tics in tbe Jcffcrsoa Medical College of PbiUdelphia; recently ['roreasor of 
the Practice of Acdicinc and of Clinical Medicine in [he Medical College 
of Ohio, in Cincinnati, etc., etc 

FilUi edition, rcvtud ftiui cnUrged. I voLi Svo. Clothi $5-00; (Iiecp ot ItalfrutMi, $4^90. 

Tlw tamt quolicio And dtvacterUlict whlcb have rmdcccil iht auiboi's "TmllM: cm Halera 
^M«Jica KoA Therapcntio " to acceptable sic cquK^ly nwAifm in thtk li it dcv. caiitlcD>(U, onJ 
CKmte. The whole work is brought up en alcvd wiih, uid incorponue^, the Uicsi ncijuiiitiaai 
■edicRl tideiic«. vid may b« depended on to cyminin ibe dmmI recenl tDf>;nuaiian a]> to ibc dtu 
foT fniblkation. 



SntmtR Of lui'i(iATi'4i. 




?- 



'\ 



" iPrwUlW)' ifcc croiwBioi; Iraliav at fhe b«iV \>r~ 
toK US, and thai whieb vilJ nulu il & ravoht« with 
pnictilloncn of mnltdne. la 111 odniinblc Leitcludi; 
n the troaLmcnl of diiouv. Dr. Barlholow ba* no 
j'm|mli]r witli the niodem schrxil u[ tbnSDntkx) 
nihiiUu, but posesoes ■ wbolcsrinM better in the 
valuo Aiid tfHcac; «f reitdjw. H* do«* not fail io 
JnOiutc. liuwpVFr. Ihal (he pom of innedie* is 
limited, that snrcilica are fc-ir indnd. and tlial mii- 
line and r«lJc&9 mcdkjiUoii An dj^nf^erous^ I'ut 

Ibniuchoui ihe cnbm ((nitlte in runticction with 
C*cb nialady aie loM dnim ircll-deAtied mdbods 
and Irae pdndpW «f trcaiincni. Il vaxj be uid 

^With ^IHtlCC IhM (bit |UTT i>( th« «otk RStX uiMin 

'loroucbly tdcntific and |>tactiu] priadplooltiieT- 

— lilies, and incireutcd oi ■ nuLSlaily naBoer. No 

L an the pntcilo' if medlctnc wtih nhlch we ai* 

qvi^iilcd will j::uid< iW pfaaltloiter in all the dc- 

■ of irvatmenl sn well » ihc nnr of which we an 

nj." — .ImrrK^m fritetitiatttr. 

' The walk U concise and (SefiniTe tn Its uale- 

Donta, and eminently practical in il* itachincs. Il 

I ivfilMn with tpecial r*f'r4flce \n the Dcedi of the 

■ludeiM. and wQl ai once lake iu pUccu ■ iext> 

btwk ia Aaaj medical ochod^ It will be (onad o( 

iiMlvatue in the pncttdnp physician." — Jtojrfewrf 

" Tbe mtaaie belor* <» pvm not oaly (uU and 
t deacripdona of dlacoieii boi the lieatttteat b 
DR'KMd under the butrueilon of ■ nev Ibeiapr, 
itbMi mwtoicniiMndilaeir loererf itudpni. Iia 
I bonur alike to autb<>nt and tbe prolestivn of the 



"Tbe w«>rk a* a whole is pceulor,) 
that il b aianped wiili ibe iudntiiu 
iuautlior. The raaderb made ta fed j 
the enpenenw Upoa vhicb thii 
boxd u leol, that tbe aoueenmu of 
wtner arc founicd on firaican*lciioQi, ttA' 
Ulat lhn>«;v*i'>*> tl^ oowdinfciBi .in tw^ 
aetulr aouiid. It U not an rbbotaB tm- 
llse. nntbn U fl « mafiMl, fcut hilHM 
brtwecD ; tl nur beowntdercd a dwiuu- 
br uwful. tnMvonhr. and ptenin] nJile 

\<tt i3m seoenl pcacUlMeer.'— J/rdbce/JTo- 

•• Il may h« Kaid of u> email a teekoi 
to larcc a wbjnl. Ibat il oaii be anir a naf 
uf O'lnpeudiun « vadr muttim. tUil lUi 
nlilCiMn wQl noi be jvn. !■'<«, wblke It* 

-V author is BiaAri in tbr art (d i Ii—lip, 

^ It wiO be found 1 hat ov i iM iitlal poinU he^ 

'] been eniitcd. lltntkiB is natk ai batt H 

tyrtf uneqiiiracal Bjrniptaa in Uie una> 
lion of tbe <>£•• <4 MMifc and cbMiCMl' 
IUk aynuttme aieheU weUonw ikt (bh^ 
Cnnuid ui cvtsy case." — Cimttiman iAMt^ 

" IV Bartbolow b known to W n -nrj clMra>d 
ecpllflt writer, and u tbit ii'iiik. * hid) we tab H 
bchbipedal Ufe-wnrfc. we are -nry aitfebiaOMaf 
friend* aad admiren wUI em b* dwppolalaJ. Ve 
can IKK tav owre than ibK wiiWm aHMBptiaf m 
follow op iM drtalU td ibc pUa, wbiiJi, u( txmm, 

would b» laiJeie in a bnd l>i»L~oo(Jcv. We cu 

only add tbat we feel coDtklent tbe T«r4k> «( tta 
pn>fcs*lon wtB pbcv Dr. Bartbolow'* *Pmcito' 
Afnnnc tha uaMard Mst-beoks ol (be Amf^'—Ct^ 
fimnali OtHtMe GaatlU. 

•• Il h reTt^tinc to dm Cron a wmk m end* 
Bitd inompleta. aaiull of ibc esploded ibnria if 
bt -goDc du«, as thai of Pnilteaar I'alRiM, lo lie 
ririt. Indd paces of Profeeaoe Baithuluw. Pn> 
r«M>r lUnbokiw ban nrca (or liinuiU Ml bkh a pM^ 
lion as an oii|:inal thinker a»d dear an4 ItMeiUa 
wrttei that anv work fioa hb pen aw«U ctmiJ 
attention and icma. Oat peal dum of dN 
writM ta the IMell^enee and ah^aat tboacbi wbkfc 
he belnc* to tbn dlanorinn cd evcey HbJaiC and the 
di f ptiaaa, ckamaw, and lis^f of hi* ■ir'*- ''■ ^^ 
ifMimem ha l> tniKh in adiunee of the bMtac 
writcraof hbacha(il.«ndetn3tnartKd mdiouioaM^ 
prroalinlTeoiMoltbcbcalwftM* 
-.V/K i'trtMi^toa/ TVmtt. 

'• The iMok if narked b^an absence of aldia- 
CTUMOti of the talcn. fiue^imn iheuiia of pcriM* n 
poibolQcr ; bf the daamts* wllb which |hM» to 
Aapuw uc tM»A : br iha (wr f w— and p*' 
■pfealtT of lu mitemxs : b; ibe abaiidaaoe of ibe 

anlhor's tbtnifieiilk rt^ourtxn ; «t.d bjr Iht <icp*"r»- 
DeSB of kl lUuUnlKilB. '— Oku tlt4n4l Kttar^tr. 



tu*inc studied apetT 
of the new •ehonl.''- 



J). APPLETON S* cars MEDICAL WORKS. 



ON THE ANTAGONISM BETWEEN MEDICINES 

AND BETWEEN REMEDIES AND DISEASES. Being the Cart- 
wright Lectures for the Year tSSo. By Roberts Bartholqw, M. A., 
M. D.t LL. D., Professor of Materia Medica and General Tlierapculics In 
the Jcflenon Medical CoUcge of Philadelphia, etc., etc 
I vd., 8vo, Cloih, Ji.aj. 

eu dinibi ihat ihii. hUtaWM contributlAti ta mrdl- 
cal iciaicc, <riU uUl matf ruU)- l(ihK)ircrlnuM)-Jili;)i 
rcjiulAtiua, Mu<h prafit, n<.> lillU iilrjiun, .inj 
CDdirriil iuiiisUuce in Ibe b>lulirn t\ ni:iny iticra- 
peulioil urtiblcDii are lu be nbtoinnl Irtxn «'|)«niui 
of these iMium; The mitior hjti dotic h^wU %xA 
ronJerted a bocia by ptTRiiltine tlivir jxililUwIiin In 
(he prcsmt book-fvnn, and wc an JAtUCccI il will 
be Fkleoidi-Flj uhed ror. and \aA mf nleasinjjr read 
andajiprnutcd."— CAkjj'j ittdaitS anU Surj^ital 

■• It will l« chwrrwl ihal tht »tope 'j( ihc wort 
il txtcnMw, and. in iustkp (u llie auihrir, not «iil)> 
it Uie eilrni of IhU indkalMl. but (lie clioi jcter of 
Il u aiao (umbbtd. No imp ran n-iul iIil- ijn<ipal« 
fpta wMiout beini; unpitned otili ihr: iaijMxUuce 
uid divenitjr of tM HilneEls rnti lidrtrd, Indrol. 
mot «( the tmpaiuuit Icrccs ui UuiapruUcf and 
mjlffia R>»d>cftare herein slated and oJialjtol"— 
Amtwitttn JUidkal Bl'tt'ttVy. 

" Probablr liioM rif our rrjidfre will (rmiililrr 
iluu ire iMivBuanln) t1iJ»uva(lN*hlt:)i iiulvohFti 

wv My that il trrttn In lU Ibr mofi Carrfullj writ- 
ten, M4t ilKiu|;ht-oiii. urd IfoM dneniatii: wmt: 
which ne IkMv ^ (nxt (rora tlie [miii vt lu uutliur. 
It ivindMd avvry pnlarwatthy honk : rint aanricl- 
nal T«MiucIi. iniMM. biit.iua i^mmtii (lip wmla'a 
work upiiii Ibe subjiKi, the brat tbai Iiaa lutlitrtu 
fc«n publiihwl in anjr lanpia^." — fJul^tlfii* 



* Wfi m ri(d lo pmnct, la a fonn ronveoieal 
(or Rrnesor, lAlanuMt ttoent wmmatir nf the phjml- 
oJcftkal ot'liao ol Impatuol renledio. with tni- de- 
ductions of a csivtul and aecompiUhed utsi-tTer. r^ 
Eardbii; ttwappliuti<>ns o( this knowlcdee U> do- 

"Tb«t are few wril»t« who have lakni (he 
trnuble lo cocDplts Ibr ItieubrationH <•( idi^ mu]iiri.idi> 
t>( KiJIiblera wtio find a iptciAc in rrvrry An\£ \\Ky 
happen ta pr^^be fot a Mif-liniited. niio-malii;- 
nanl diaeaw : and fewer who can ildect the tnuh^ 
chaff and earner nnlr the ripe, plump ^rraina. Th)s 
Itartholow hat dnne, and no one is marc ripe, nor 
better (jualikd lur ttiii herv-ulean taiJt : aud. tite 
tx9t r>f alt la, oandeiise It all In hl> anueimlaims. 
No one <an peniM it* precnaat paK** wilbout »o- 
lldnf the painttaklnK reicarch and arge tDlIecUon 
of utborttbH tmm which he hai drawn hb oonclu- 
lAaat. The pfacliliii-nfr who puMhns« these antofr- 
CMbmiwIll AndhiiRuK twltPKiitsliArdiocniMiwItK 
die nultltarlnu* inaLidlei after [u (aicful pcniHl." 
— Jmiiama JtfJicai Rrfoner. 

" The CTilkiunn Btit\f upon th«»e lerton^ have 

iovariablj bei-n mmt f.iTOiaUle. ih« topic iuell i* 
one d( tbe tuinl intcrt^ini; in the entirn ran):* iif 
mcdtcinc, and it (t irralwl nt by ihe aMompliahtd 
autbor l» a hmm Kliolorly mjnnet. t^r. Barlhulow 
wnrtlin)' tonka asi one (ililie bni wHierx. while at 
Iha tame lime one of (he mntt diliftenl workers, in 
.Iba medical field la all Aroetiu, asd Ltwre on be 



B^VINTER AND SPRING ON THE SHORES OF THE 

I MEDITKRRANEAN'; or, the; Gcnotrse Rivieras, Italy, Spain, Corfu, 

^^ Greece, the Archipelago, Consuniinoplc, Cnntica, Sicily, Sardinia, Malta, 

^^^K Algeria, Tunis, Smyrna., Asia Minor, with Biarritz and AKachon, a» Winter 

^^^^Cl imatcs. By James Hf.nrv BBNNtiT, M. D., M«nil>cr of the Royal College 

^f of Physicians, London, etc., etc. 

^r Flfifa edition. With niimerout llliislraiiotifi and Mnpt. t rot., israo. 655 pp. Clotb. $350. 

Tkh work emWhrt the rxpcrlrnce oi ^fteen winter* anil iprin(;» piutol by Dr. Itcnnel na lUe 
aborcx of the Mcdilcrrnnean, and coniain!i much valuable infnnnaiion for pkj^dans in relaitun 10 
the hca]tli-ietlgnii£ cliotile of the regions deiicrilxil. 

*•■ VVr tomnwndihiibooli toaiiTFeader«iuamU once ««ter1ainlitr and trutniaive.'— ^<m Vnrk 
MitieptTseniiiii; Iw capital qualificalli-ina— it It at MrdUiU jNnrnM. 

I ON THE TREATMENT OF PULMONARY CON- 

B^ SUMPTION, by Hygiene, Climate, and Medicine, in its Connection with 

^^Hlrlodem DoctrincB. By Jamks Henry Bexset, M. D., Member of the 

^^^VKoyal College of rh)-sicians, London ; Doctor of Medicine of the (Jni- 

^m versity of Paris, etc . etc. 

^H I vol.. thin 8vo, 190 pp, Cloth, f i.jo. 

^V An inteie«ling and initruclive woiL, wiillcn in the Mrnng, c1e*r, nnd lucid manner whUk ap- 
' pean in til the coDtribaiiuni of Dr. Itennei lo modieal or genera] literunre. 

"W« cnrdinllr cnmnKTid ihU fannk to thr at- temperate cHraai««.iiulmon4tycoaHi]npi)oa.*'—£l»- 
Itntian of alU for itf praoinl, coimnion^wnM « lews /nuV Rtvkm «/ MtMam, 
«( llw nature and ireatmeni of the Koiirce td all 



tEDICAL WO, 




8 



GENERAL SURGICAL PATHOLOGY AND THERA- 
PEUTICS, in FiftyHDnc Lectures. A Text-Book for Students and Phy- 
sicians. By Ur. Theodor Biluiotu, Professor of Surgery in Vicwna. 
With Additions by Dr. Alcitander von Winiwarter, Professor of Surgery in 
LUitich. Trjinslatrd from the fourth Gerituin edition wttb the special per- 
mission of the author, and revised from ihc tenth edition, by Charte* E, 
H«cktey, A. M., M. D., Physidaa to the New York and Trinitr HotpiUb; 
Member of the New Vork County Medical Society, etc. 

I vol, SVO, %%% pp. Cloth, $5-00; ill««p, 9&X)0. 




CanKcllBd Smcobu miih Cyan and Oaifyinf P« (ns tW td*« Jaw. — Viniifiml jgs 



" 5tiBCC Uiii Irantlttion vu rcrii«<] (rom iIk tilth Cermaa edition in 1874, two otkei filitlnit 
have l>«cn pabli«hed. The ptctcnl rcvition is made to eotretpond to the ctghLh Gcnnan edition 

■■ Uiiter'c method of antiseptic ireatment U referred to in variant pUcet, and other B«w peisB 
thai have come iip wiitiin a few yean ore dbctmied. 

"A chapter )uu been written on amputation sail rocciiOD. In all, there are MVtmn-JIm* 
adililionol pacct. a-illi a ninabcr of wooiknts." — £jtrartjhtm Tmiultlor't J^/itr t0 ^ jltitud 

" Tlw want of a bnoh In the Cnj^ish lantfuaca, ture to *ay no book cosld son pufKilr annlr 
pnTicnllO); in ■ conciiw (ona Iks view* of (ha C*r- thai Want thaa 1^ pcaMat vohiiaa." — jtr ffi 
nun patttolociiu. haa lone ban (ell. aod wa Tea- c//. 

THE PHYSIOLOGICAL AND THERAPEUTICAL 

ACTION OF EROOr. Being the Joseph Muther Smith Prize Essay for 
1881, By Etienne EvtTZKv, M. U. 

I voL, Sro. limp cloth. $1.00, 



" In ondntaklni; the pretenl work ■ny object wu 10 prewnf in a caii<lctiM«l raanntr all tl ^ 
ihrrapeLilIc pmilliiKtIn of erfioi. In a (asl of itii* oatnre. ompnal meuxb b OBI of ifac qn«s^ 
lloi). No nuu'i evidence a tulGdcni 10 eiiabliab the merits ola d/vs coaMilvrttl in (lie manao 
indicated, nnd do one man'* opp<Htuaiti«* arc »uffia«nt to antp tW entire >uti}ect. C<>nicifoentlr 
it renained ta father frnm the vi>tuinM of pact and carttfnt periodical llleraliire ihc lealimnajr of 
■he mutlHuite of (iliynidins that hnil been led to use ngot bi dlSereai morl'id ronditioni. 1 Mra 
rccoidett cvcryihini: tliii hat come to my notice, I bare gioaped and clattl6ed the immcnte mate- 
rial in our iHMte^sion. In at! cam in which the actkwi of crgM o«aU be capiained, I haic it- 
lemptcit 10 do M, altliou^h tliit uuk ia frequently difficult. If Doi impM^ftJc. . . . The nadci aill 
wc thai er|;AI has hrto u^ei! in 1 la'^r ciuitilwr a! tljicaec* ; MKne c-f ibese ^t**- hart litlle at no 
practical Talun. y«t ti i« very important to know ihcm, at Iher icnre to illutiwe the therapntfk 
pT(^»eitirs^ of the drag. TTicyhavc been brought to the notice of the reader without anrcoa- 
menta. but ihmc that are e»'eniial and of the ercnie^l practical impoftaiux have b«cn dealt wttb 
more fully. Amoaz ibe laiier may be iBcniiuned the uac of crvM In Iiiilam«Mlioa« iovuriaai, car- 
dbc faeasaa, Ibi potl-partwkat state, utcrtoo fibroid laoiora, rtKoaatian^ dc."— /iww / V tfia > . 



I 



J>. AFPLETOIf ** CO:S MEDICAL WORKS. 



OBSTETRIC CLINIC. A Practical Contribution to the Study 

of Obstetrics, and the Diseases of Women and Cbildrea. Bjr George T. 

Elliot, M. M., late Professor of Obstetrics and Diseases of Women and 

Children in the B«Uevue Hospital Medical College ; Physiciaa to Bcllcvuc 

Hospital and to the New York Lying-in Asylum, etc. 

I vol., 8ro, 458 pp. Cl<ith, $4.50^ 

Thii work i«, in n meoxure, a rfttimfoX s«[utTal« papert p levionily ptcpored by ihe late Vn. 
Elliot : and conLiiiii, liuiJc*. a reoani of nearly two hundred imporuni and difficuU cai«t in mid* 
nifery, iclecttil from bit own practice. The caAca iliu« collected rcpicicnc faithfully the dim- 
cultkn, aonclicn, and disappoiatmEou inaepaiablc from the practice of obiuuks. u well s& lonie 
of ibe iwccesvn for whicli the profeniiioti m* enlilled to bone in lhc«e iinluoii» anil rrnuoiiiible 
laaka. Il bit m«t with a horly reception, and liai received the bighcsi cncomiui&i both in thia 
COiuiUy aiid in Kurope. 

THE SOURCE OF MUSCULAR POWER. Arguments 

And Conclusions drawn from Observations upon (he Human Subject under 
conditions of Rest .tnd of Muscular Exercise. By Austix Flint, Jr., M. D., 
Professor of Physiology in the BelletTie Hospital Medical College, New 
York, etc., etc. 

I vol., 8vo, loj ppL Cloib, Si.oo. 

**'nieTe are Tnr qaeations relating lo l^losopby of ffreatei iniereat and hnportiince than the 
oae whidi ii (be nubjeci of Ihit eatay. I have attempled ta pieteni ui Mccuiitt viiirtcenl of my 
own nlMervaLiun* and what neem to me tu be the lopcal conclusion! 10 be dinurn U<om Ibent, as 
vrett as rmm cupcriraciiu itiade bv otheca upon (be buauD lubjtci under cunditioai of icat and of 
nwKuIai eieiuM." — Frant l-^e rrr/act. 

OX THE PHYSIOLOGICAL EFFECTS OF SEVERE 

AND PROTRACTED MUSCULAR EXERCISE. With special ref. 
erence to lis Influence upon the Excretion of Nitrogen. ^By .\ustix Flint, 
Jr., M. D„ Professor of Physiology in the Bellcvue Hospital Medical Col- 
lege, New Vork, etc., etc 

I vol., Svo, 91 pp. Ctoih, fi.cxh 

Thii mono^ph on the relation* of Urea 10 Eierdie E* the reialt of 1 ihorongh anil careful 
iovestigalion made In the cue of Mr. Udward Payson Weiion. Ihe celebrated |>c<icitriaa. The 
dtcanical uiaXy\ti were rriadc uixlet ihc direction of K. U. Uoremuk, M. V., Trofcivor aX Chein* 
latfTUidToiioalngy in ihc Bcllcvuc lloiplinl Medical CoUege. t^' Mr. Okw Locw, hi> asibunt. 
Tlie obiervalioiu were made with the co-i>pcnitiau of J. C. tHIion, At. D., Profeuor of Physiol- 
027 '" ^^ O'llcge of Phviiciani and Surgeoni ; Alcinndn R. M»U, M. I)., Profi.-Kh<vi of Surreal 
Anaiomy: \V. H. Van tluren, M. [>., Professor of Principle ol Surgery; Austin Hint, M- D-. 
Profettur of the I'tindplci and Praclioeof Meiltcinr: W. A. llammoail. M. D., Piofatorof th< 
Obeasct of itic Mind and Nervou* Syatem^li of the BcUcrae Itotpiial Medical t^bllege. 

MANUAL OF CHEMICAL EXAMINATION OF THE 

URINE IN DISEASE. With Brief Directions for the Examination of 

the most Common Varieties of Urinary Calculi. By Acstin Funt, Jr., 

M. D., Professor of Physiology and Microscopy in the Bellcvue Hospital 

Medical College ; Fellow of the New York Academy of Medicine, etc. 

Fifth odiiion, revised and corrected. I vol., lamo, 77pp. Cloth, $!.(». 

The chief aim of thii little work h to enable ihe bmv pmctitinner to make for httntelf. n-?\fi\y 
and caiily, all ordinary ctatninnlioni of Urine; lo give him Ihe benefit of the luihor't ei|>crience 
in elLminiilas liitli^ .litficiillie* in the manipnlfttJona, aiid ta reducing proccisct of analysis to ihc 
vlnuHl limplidty that i< coniitt«ni with itctuiacy. 

" We ilo rioi krnw of any work in En^ltth «o tvpulaclon of the sulhor la a (nlBcieiU I 
complete aod handy at the Manual ttnw olTrrrd to the acturacy ai all the dlrectiooa irinii 
llw nofeaaioa bj- Dr. Plltit, and the high aacnUfie t/ Afptiu Cl»*mittrf. 



I 




io 



D. AFPLETON &• CO.'S MEDICAL 




TEXT-BOOK OF HUMAN PHVSTOLOGY. for the Us 

of Statlems and Practiiioncre of Medicine. By Austin Fu.nt, Jr^ \L 
Professor of Phy-<>iolog)rand Physiological Anatomy in the Bclkvuc Ho»pit 
Medical College, >>ev York ; Fellow of Ihc New York AcJidcmy of Medi- 
cine, etc. 
Tlunl aliliaa. Rcvbcd and corrected. In one targeSvo vohtnieof 9}6 pp.. cIcgMilljr fitntedi 

fine paper, aod MofuMly ilioiUatoJ with three l,iUt(^npbie Phlct imd 31$ Enuring* 

WoM. Ooits $6.00 \ sbcep, $7.ool 



tol 

111 



191 



i 



iGj 



j;^ 



1: 



r1 



Scogudi, ?ucnai, tdrgi Imoim, tic 

"TlwmihDrof tbli irnd taVct lanV uDoac the 
VICT foMmott phTviolDCtsU iiF \?\c rln^. and the ouv 
Vhlcb he hM bcMowwl tn brineiiiK lt>l> third cdllinn 
c< III* Mat-book up to the prcMot pcaillrMi ol hfa 
tdonca U eihilMted In •ven^pln'. — ittdioaiamd 

"In Um amaiMit of nult^r tlM It (tintaln*. hi 
Ihc •piDNB and bMutr ol Jti jlluitntioM, in llvt 

*arlMf fi( rxfvninmt* dcvcribcj. in Ihe cnrnplH*- 
B«M with wtiid)il(liW7i«nlhr whole fi«l<l of IniOlan 
pb]ra[oloer. ihU urink aumuan any tut-boolc In 
Ihc Kngliah lanputc*."— /VMMir Lgtttf. 

" "Wi* iludml and Ihe prattttjntirr. who** •obihI 
liraf^crmiixl b« tusnl cm in lnMlit;cnl apprcciilinn 
oftlM'pdncLptantplinioliicy, irllnincinfiadallHib- 
fMt* in which Ihef an Jnlcmled (idl^ diinllT'1 Aiul 

IhoTouehlr cUborated."— GnMxr «atf Cfin. Jtftiv^. 

" \V'« hiiF not (h* dl^htMl IntvnUon o( criiicia- 

he lh« wfirt iMfor* u^, Tbr mrrflcal pmrciaioti 

and college* have taken that pmoKalive out ol the 







LmuiluUlMl S u oiai m tifc* H—M Lan«« 
^htmfeiC (he Vtol Cwda, 



4 



hand* i>f tW >ouitwli>ls bf adofdini; tl m m* al 
their atxadafd Hxt-boolo. 11m woHc haa yry tv 
equal* and oofapnlor tn our lanruec and ct«X' 

bodf Inowa It-" — HahtrmatiitHH J/nUAfy. 

" We nnd onljr »t tbut ia iha third mSOm O* 
work baa h««n CKCtulfr «ad tliomKM]> KifnJ- 1> 
it on* of out itaactutl tut-teok*. «Sil ko phplaaBt 
library iboukt be viihoui It. We Ucaauv b ti|(U)r, 
alMU cine ft a thrfct, wufi. ami p«OPili<«it fg^Uim 
on oui dwif, and detm oc nwl w a rwtunato la pa» 
tern ikto dccwA. ranprcbtnalTC and aMlnrJIM>i>« 
■tirk." — Americmn SfmMiH. 

" Profoaor niM is mw of tl^r inott pradkal 
Iradwn «t pliMMoD' '■> ^i^ ««uMr*. and kli teak 
h emlBinilT Hka Uw man. li la *tt> rull and mm- 
pirtc. oonuiafair praakaBr all th* ».i« M ifced 1«M 
rrUlifiElothctfillmlUnl^Kl*. Thk adKlH cn» 
taina a number of {■pnrlaai aMMom aad if i BM Wk 
batfah* nwineroujoorrwiioBiCf «*[•« lypeffM*" 
SDd OtbM errtit*."— <«i» JMMtf Mftmiirr. 



D. APfLETO^r ** CO:S MEDICAL WORKS. 



II 



[THE PHYSIOLOGY OF MAN. Designed to represent the 

Existing State of Physiological Science as applied to the Functions or the 
Human Body. By Austin FLir^r, Jr., M, D., Professor of Physiology and 
Physiulugical Anatomy m thv B«llevue Hospital Medical College, New 
York ; Fellow of the New York Academy of Medicine, etc, etc. 
\ Krw utd tboToaeUy revitod cdilion. In 5 voJi., Sro. Per ^-oluai^ doth, ^50; ihe«p, $5.50- 

Volume J. The Bloud; Circulation; Respiration. 

Volume n. Alimentation; Digestion; Absorption; Lymph and Chyle. 

Volume 111. Secretion; Excretion; Ductleu Glands; Nutrition; /.oimal 

Fteat; Movements; Voice and Speech. 
Volume IV. The Nervous Systum, 
Volume V. Special Senses ; Generation. 



I 



" Ai a book nf 2*fi"ral Infnmutton It wOl tw 
fvuad lacful to the prjictitloncr. kiid, ta a book of 
ralcMMce. ioiftlitAblc in Ihc baaib ul tha snatutniat 
and v^y^tagnl-'—DiMiM ijturltrij Joanmt «f 
ift^*i S<tmtt. 

•• Dr. Film'* reMUlton b •uffidmc 10 ci»e a 
cbafadci (•> thr book iMoag th« pnlrtaon, wlwre 
i( will chiefly circdUte, and muv o4 the bcu (hen 



hNw bsm nriflrd by the author In hu Ubonuxy 
And ill jiuMIc <lcnu>IiHiuic4i."— Obitf/ii LVMrWr. 

" The sulfior bcsliiws judicioui cue and labor. 
Facta tn wl««:t«l witli d<'<criiiivuid<>o. thcoric* crit- 
iealiy (umincU. and cuncltnimiii vnuncuUd ■itli 
cummciidableclcaiiKsiand prtcuiaa.'—.lMuricoM 



SYPHILIS AND MARRIAGE. Lectures delivered at the 

St. Louis Hospital, Paris. By Ai-fred Foursier, Profcsseuri la Faculty 
de Midecine As Paris; M£decin de I'Hdpital Saint-Loui». Trao&Iatcd by 
P. Albert .Morrow, M. I)., Physician to the Skin and Venereal Department, 
New York Dispensary, etc., etc. 

I val.. Svo. Cloth, $2.00; sheep, $3.00. 



*■ Ths book lapplha a wani Inng neofalttil la 
nitdical blenttire, and a biaod upaa a very Ci- 
Icwled czperiencc in the iwciiJ hopiloU for nyphili* 
at Rtffat. which hiTF (umkhnd th« author wtth a Heft 
•od nne More of dloical cue*, niiliitd by bini with 
great diiRrUDi nation, onpnalily, and clinical Judm- 
nwnt. Ii (ihibiit a prtrfound knanlKlsvotlltfUb- 
)ea undef «U nlatloni. qaltcd with mafkcd ikUl km! 
taM Ib trcathic the dclkals ancial quoiioiu nscM- 
aatHytnviilvedinnehallniior inwaUKatliHi. Tb» 
cuke rolumc U full of lofotmaiiaD, lanimonically 
eondcnacd into azionuiic 'point*.' Ii U a honk v> 
buy, (■> ki)et>. in naA. In pmAt by. and 10 Iprid to 
Otlicrf." — Bvitfft Mr f lit! jvJ Su'ti'iaf yiHirna/. 

•' This work (if ih* able and rfiitinirui»hcd Frmrh 
ayphil0CTA|ihrr. frofcwor Kounii«, ii without doabi 
one of the oi'MI remarkable and imporianl pmdLir- 
tion* of (he day. PoHculne pmfound ktiowltdee 
of typhilLi in all it* proMan fornu, an uninllcd 
eipoieno:, adnnnaticfureeorupiMilon, unilneid, 
how«*tr, by even a suspicion of caanrMtion. and 
■ iv« taMindealiaeviib the mcai delieaw ptnb- 
tami. be hu |ti<m to tha world a mtIm of leourv 
«4dtli, hj ilwir ludnaiion of atyle, comptl* attea- 
Ikm. and b^ th«r prafundlly of witdom arjiea ton- 
»fc»iiw). ■"—,». /jjfui Ctmritr t/ Urditint and Cof- 
UimI Stifitifi. 

"Vr'iilicn with a peifect talmcn. with a mpe' 
rloraNIHy. and in a Ryl« which, wiihaa! aiming at 
afiecl, eOFtfca. ititucsta. peniude*. Ihl« work la mw 
o( thoae wnkh oueht to be immodUiely pboed in 
the haodi of every phyiician wbo duliiM nnt only 
taotn hi* oatienta. out taunderaUDdandluUUl his 
riary ai ao ooiksI man."— Lyon U4tliiiil<. 

" No pbyMdao, who pKteoda to keep hloaaalf 



Informed upon the grave Mdal ^untions 10 whld) 
Ihiadiseaar impajtiaii obnrbinic mienat, can affocd 
U' Imw this raliMbtc work uuread." — St. Lntit 
CUttital Ritord. 

*'Ttu* author lunitlea thja crare (odal proLTmi 
without EtlDi. A (naeral peonal of thiawork would 
be of tiDlold benefit Co aodcty. "—LMiitvilit MtUKal 

" The snb}tct b Ircaud \tj Profeaor rouniter in 
■ manner that js above crilicwai. £iliau*(iv« cluu- 
ca] koowledee. dlactiralnatinjc judcmeni. and tbcv- 
ou)^ honesty ol oplninn are united ia the author, 
and hf prcMDli hit subject if> a friip and abnoM 
diKRutlc Uyk, ao that it i> a potltiire pkoaure to 
read the book, apa/t from the absolute loiponanoe 
of the quesboR of which ii WmU."— .fm YoHt 

" Emy p*^ U full of ih» mod practical and 
pUhi adrhx. rouchnl in viforoin, crophatic tia> 

Euagc" — Dtlwsii I-amert. 

"TTic tiibiKt hnw proeetcdlaoneof ihcmort 
Importanl llut an t^fa^f^i Ihe ■tl»nlJi>B of the (MO- 

fmtion. Tile voltitn* ihouhl h» i.'efwrBUjr r«ad. as 
tbc tiib]pa-iaalteriiof cTcal importaaoc loaodtly." 
— SlaryloKd Mfdital JturtiAi. 

" We can cite only a very iaeompku Mta oC 
Ihl* vorfc of M. Koumier. which, by In piwi«lr4l. 
iti clearneH. by the foicJbk manarr la which tlie 
fxcts .-itv crtniped and prNentKl, tUIWa all >iuly*U. 
'SyphiUi and Harriaj^' oupM V" hr r^d tiy all 



^^ taotn 
Brinryai 
^L"N 



Ehyidciaoa. wlio will find in it. (irtt (W all. seirate, 
Dl who will aim (irid in it, dHiin)- tin boure lb«jr 
flevole to its peruol, a clurniine Itaerafy pkasult," 
— itaaato dt D crm^ »i»ct* *l m 



I 




ra 



D. APPLETOff *• CO.'S MEDKAL WORKS. 




CyCLOP.^-DIA OF PRACTICAL RECEIPTS, and Co!- 

lateral Information in tlie Arts, ManufacluTes, Profem'ons. and Tndn, 

including Medicine, Pharmacy, and Domestic Economy. Designed as a 

Compreheoaive Supplement to the Pharmacopoeia, and General Book of 

Kefercnce for the Manufacturer, Tradesman, Amateur, and Heads of Fani. 

ilies. Sixth edition, revised and jinrtly rewritten by Richard V. Tusoy, 

Professor of Chemistry and Toxicolog)' in the Royal Veterinary College 

Camplcic in 2 vols., 1,796 |>p. With lUuatratkias. Godi, $9.00. 

Coolcv't " Cfclopicdia «r rracUcnl Receipt* " tto* for utny yctn enjajrcd aa cstcudcd rqnt^ 

lion for itt ■ocuracf and compt«beniiv«ii«M. llic liilh «dition, now Ju«l coniplctei], it Ur|0 

Ihan tlie lut l>v ivoie liic hundred pages. Muck greater space tlun btthnto it devoird to ll^nta* 

L(tndudini; kniiluiiuii, the coiupiuiiiun !Uid adulieraiimt uf (oodi), a& wril as tu ihr Arti. Ptw* 

liucy, Mjiiul>cliiriii)- C'ltciniitir, unil ullirr lulijccit of iin|»rtaoce to ibone for whom lli( wort it 

'^laiCDdcd- The jiiidci la wliit 12 cvoinaunly icrmud " JlotuchoIJ Mcdioac " have beoi aoffr 

ficd and nuiiiciicnlly iii<ic-.u<i). ' 

The doign nf ifiit wnrk i( briefly but not completely (xpmscd in its litlf -pgc Inrtrpfli 

tiCntlv of a (cliAttlc and coinpirJicn»iv« colIeciioR nf foniiulx and |>i>XT»trt tii nnrl\ all the mdiv 

[trial and ui«rul aru, it conijiiiit a ilc«cripiion of ihe leading proprrucK aixl tfi^caiiooa of lli> 

(lutuloncci icfcrccd ID, tngcihcr vriih ample dircciinnt, binl«. dola, and allied informaiiaa. ait> 

uloted to fdcilitxc ctie devclopmcnl of llac procticul voJec of the tiook in the ihoji, the h li ot M ttfc 

ke factory, ivnd the household. Notices of the substaneei embraced in the Malefia M«lia^ta 

[■ddltion to the whole of their preparattoos, sod munesouc other animnl itvd vej^eiihle *iibaa»tr> 

^■mplajed Id medidne. u well as niMt of thom uted for food, clothing, aod luel. niih then «o- 

loailc applicaiians. luvc been iiiciuded in the work. 1'hc synoaymi and refcccitcci ore oiber odfr 

dona which will prove invaluable 10 the reader. Lasilj, there have Lceii appended to all ibr 

incipal antclet referred lo brief btti clcir directions for dcterniiiuiir ibeii I>unty anc) co ma iorid 

Jne, and far deteeting ihcii presentee acid profiottioiit in compound*. Th« iaifi*crininal« ai«^ 

^tlon of matter, without exsmmation. hni Iieen uniramly avoided, and in n« inilanee lias M17 fan*- 

uhi or pfcx^e<» been admitted into thia work, lude** il re*led im loue well-known fact of KioKi; 

had teci) tanciioBed by usage, or come recommended bjr some reipeetabte authority. 



THE COMPARATIVE ANATOMY OF THE DOMl 

TICATED ANIMALS. By A. Chauveau, Professor at the Lyons 
crinary School. Second edition, revised and enlarged, with the co-operatij 
of S. Arloing, laie Pinncipal of Anatomy at the Lyons Veterinary 
Professor at the Toulouse V(!t«rinary Schtxil. Tratulated and edited by 
George Fleming, F. R. G. S., M. A. I., Veterinary' Surgeon, Royal Eagioecn 
I vol., 8vo, 957 pp. With 450 lllustrutons. Cloih, $£.oe. 



)ME^ 

DOSV^ 

>p«iati^| 

scbojn 




'Toktni: it altogether, the tuok ii a very wel* asusltd by no leia iban 471 eitelbal 

■■MDC jkldUinn (o EnclMtt Ikeraiurc, and et^nx credit a nark which rvkira over so «>** a AaU at 1 

"ItdMloUr. KIcinlnelortheeMdIaiCGOlthetnuw cat detail a*ddcK«Dtion, it ladlAcallta 

bUon, and the iBam addtUonid note* be has ap- one ponkw (or renew. b« o«i mbiIb 

|Msdcd to Cfaauvcdtu^ trcatlsG.'— ZamM i£«Miwr> cnatilca na to mah in birh tcnmaf lucnanl^ 

oelkMC. . . .''— J/A/ff«/ TAMf Ml/ C^ 

"TbedMctiptiOQaof tbeleElareiUintiaMdand atM>. 



D. APPLETOy ^ CO:S MEDICAL WORKS. 



13 



THE HISTOLOGY AND HISTO-CHEMISTRY OF 

MAN. A Practical Treatise on the Elements of Composition and Struc- 
ture of the Human Body. By Heitjrich Frey, Professor of Medicine in 
Zurich. Tranjiated from the fourth German edition, by Arthur E. J. Bar- 
ker, Surgeon to the City of Dublin Hospital; Demonstrator of Anaiomjr, 
Royal College of Surgeons, Ireland; and revised by the Author. With 680 
Engravings. 

I vol., 8vo, 6S3 pp. Cloth, $5 : t)i«cp, $6. 

COyTEXrS,—T\te ElcmcDti - 

of CompMitioD fttid of Structure ''x 



<S tL« aoij: Klcraentt of Com- 
litioB— AilmiBinoui or Protein 
■pouiKk. ilKmoglabulin. \\\%- 
tannic UnivalivM of the Albii- 
atttUHU SuhiixnccH or Atliumi' 
■Mill*, the Kail)' Acid* tnti Fali, 
the Catlv-hidfatcii, Non-Niiro- 

SmoiiD A>-i'U, Nilmgrnon? AcitU. 
inidei. Amiiio-Aciilt, and Or- 
Enic Rii.iL-^ Animiit Coloring 
sltcn, (.'yuiiiEcn Comriounila, 
Uineml Comlituprili; Klcinenli 
of Siruciurv — the Cfli, the Origin 
of ilie KematnlDg l^eiiienis uf 
Tisiuc: the 'Iittiics of the Itody 
— TiMurs conipmtd of Simple 
Cdti, with Fluid I Die [mediate 
S<ilMlancc, Tiatucs conipoicd of 
Sinple CelU, with a tmill nmounl 
of !!U>IM Inlermediale Subttnnce, 
Tiitu« tielon^nir lo the Con- 
itective SulBiancc Group, Tisiitcs 
composed of Tran«ri>nncd oad, 
M ft rule, ColHring C«lli, wiih 



:aiB-ai'*-«^::y/ 



i>w-';" 



TiaBflMfM Stcnea ot > Hunwn Bone. 



Homogcneoiii, Scuiiy, and more or 1mi Solid Inlcrracdiitc Sabtlance: Compoolie Tluueit 
Or^faiu of the Body— OrgiRi of the Vegctntiie Type, Organt of the Animal tiioup. 



The 



[CONSERVATIVE SURGERY, as exhibited in remedying 

some of the Mechanical Causes that operate injuriously both in Health and 
Disease. With lllustratioTis. By Hr.Nfty G. Davis, M, D., Member of the 
American Medical Association, etc., etc 

I vol., Zta, 315 pp. Cloth, %y 

The miliar haa etijojred rare facilities for the titidjr and Iteatmeol of certain dauex of diwoM. 
■nd (lie cccurd) Iicrc presented tu the profcuion arc the gradual accumulation of ewer ibiitj' jreaTi' 
invcstii^tion. 

" Dr. [lavia. brloelnj: a> he dona to hia apedalt^ drem it wonhr ot a place in evrrr phyatdan*! U> 
* ^ntx aptitude for the mIuiIod of riMchanial prat- biair. The Myli ii un|)ictendlnic, tiui mnchaiii, 
lenia, ukn a h)i;h rank as an orthopedic aur^eon. p^ptiir. and, beat ol all. quUa leUlUjMc."— JfAff- 
tad hit mty (iraclicai contribulinn lo the llteratura (at RnarJ. 
of tba mbjvcl ia bnih vajiub1« uid uj^iurtutie. Wg 




! YELLOW FEVER A NAUTICAL DISEASE. Its 

Origin and Prevention. By John Gamcec 

I vol,. Svo, 307 pp. Ooth, Si. so. 

t aothnt docwnn. with a vast arnijr nf dear " Tlie Iheoty ift ccflaialr ahoirn lo be a |dtuaIU> 

d'u«ti.>d fMti. the nature and pievention one : and every reader, whelber be be emrinoNl or 

nw frvrr. The mitlc ii adminbl; written, tint, can AM bul be tntereued. Iiutxucud. and tel lo 

_ the aaihror's Uiconet ploiuible and well lus- thialang." — Lamtti mmd CliMic, 
lained hr Vt^yaX AtOuayara frem Mtabtiahed fact*." 
—JivmoKpiatka r%mti. 



r4 



APPtETOt 



AfEV/CAL WOR. 




1 



Sracnim ov ItuuirRAiNM. 



CONTRIBUTIONS TO REPARATIVE SURGERY.show. 

ing its AppticalioQ to the Treatment of Deformities, produced by Desiruc 
live DiMr;i:ie or Injury; Congenital Defects from Arrest or Excess of Dtri 
opmeat ; and Cicatricial Contractions following Bums. lUuGinted by Thi 
Cases and fine Engravings. By Gukdon Buck, M. \i. 
t vol.. Sro, tyj pjiL Cloth. %y 

" Th«re it no dqMrtioent of surgery w&CM itte in^autty 
and (kill of (lie sttrgeoo ue nore Mvenly UK«d ihaa ahca 
icqulicd to repair lEeduiuige lutMlncd hj itie kxuof portk. 
or to rtitiovc ihc illsfigumooil wodnctd rqr dcitrurtlre db- 
due ot viulcacv. or lo remedy itic Jcfoiiuitin of coopnitil 
nal format fiui. Tlie rMulls ob(iiii>cii n> *tKli ca»ca tritkia 
ibe ImI tMif-centur<r trc ftmonc the moo^l utiifoclor)- •£}!»*#• 
menu of modern mrgrry. Ilie intn 'Ktptrstiic Surpsy" 
chcacti n the title of Uin volume, tbooch it mav, ra a con- 
prclivoiiTC senic, lie a^ied to ibe tieatmrnt of a pnt 
Ttiiiciy »f Icsiotu to wIikIi the body it li>l>t«, ti, lKn| 
rcoridrd in (his wott cxcluilrclv to wW ti:ti faltc 
the Aiiihor'* on-ii oMervation, anc bat brm Kiilj«ttf 
tnl nf cipcrience in his own proclkv. Il Urgrl* e 
ihe irr.-iimcni it( lcMi>nt of th<- f»re. a ir^ina in kSkIi [ 
surt^cir fin<i» il» iBOfl frequent and iratnitanl ai'jilicadiMI^' 
Anolhcr oni] no let* impottanl cla» of tc^K'iit wtll alwlw 
found to have occupied a lar m Aan of (h< aui lior'a arm- 
lion, viz., ddiridal codiractioac rullowing bBrnt. \\ti\t 
thciic COM* have a ftty airtwg dalni apon our cnmntiicri- 
tioa, and tlumtd aiiutilaic ut. ai sureenm, lo iW greaieit 
cAoit* for their reticf, ilicy have too okcii in ilic paat l>c*a 
tUmiiued *\ IiopclrhUr iiioDralitc. Tlie mi^tacldty rciottt 
obtained in the at-ic* r«paited in Ibtt volume nill encosr- 
age other Eurgeoni, wc IruEI, lu reioit wilta ifrc^Iei hopc- 
fulnnt in Ihc fniurc to ofierative interferentx. Accstiet 
of dcacripiion and clcarncis of siatenefit have tieica alned 
at in the followine pa{;es ; and if, in bi* endeavor to attaui 
thlt Important eoA, ih« aaihorha* iKurred ibe i»|iinaah nf 
ledioacneai, ih« iliAknliy of tbe taak miW b« fail 
^Extrart /r»m Prt/aet. 




aI>olaS^^ 



THE CHEMISTRY OF COMMON LIFE. Illustrated 

with numerou.<: Wood Engravings. By Ihe late Jahes F. W. Johwsok, 
F. R.S-, Professor of Chemistry in tlic University of Durham. A new 
edition, revised and brought down lo tbe Present Time, fiy Arthur Hci- 
bcrt Church, M. A., Oxon. 

Utwilratod with Mspt and nnmcrODs Eneravingt on Wood. In one \iA., Ilmo, 59I p[t %X 

SCVJtf.lffV OF CO.Vr/!.\ri'.— Tbe Air we Breaibe; the Water wc l>iiak ; Ike .Si) wt 
Caliivate: the Plant wc Rear : the Bread we Kat ; iIk Beef wc COolc ; ilic Ikvctarei «e lafiuei 
Ihe Sweela w? Kiltaci ; the linuors vc Ferment : ibc Narootica wc Indut^ iiii ihc I'uiKn* «e 
Select: tte OOota nc Enjov; the Smclla ire f >i>lil(c : the Colon wc AJtntre [ Whai we Ifrradiv 
an<l lircatbc foi; Whal, Kow, and Why we Uigetl; the Dedy we Clienalii ihe GtemUtiM of 
Maltcr. 






THE TONIC TREATMENT OF SYPHILIS. By E, 

Kkves. a. M., M. D., Adjunct Professor of Surgery and Profeuor of D« 

maiology in the Bellevue Hospital Medira] College, etc. 

I vol., Svo. 8j pp. Cloth, ti. 

"My ttndict in lypliilitk blood have yielded mulu aioeiceK) Drailfyiac to me. asd aa cnw- 
vincine as to ihc tonic influciu* of mbutc dmc* uf nicicnry, tliai I led Impelled to lar thU heWf 
trniiiaG before ibc tncdical pu1>l>c in tapporl cf a cuattnuoua ircatment of »Tphlti» by imall (*a*^ 
dimcii of memiry. 1 believe thm a general trial of the Bwthod will, in iha lony »wi, nwfic"" '~ 
eaccllcnee." — Extrwet/rwm Prt/Mt, 



D. APPLETON 4* CO:S MEDICAL WORKS. 



15 



^>l 



,A PRACTICAL TREATISE ON TUMORS OF THE 

MAMMARY GLAND: embracing their Histology, Pathology, Diagnotis, 

jtnd Trt-alment. By Sauuei. W. (inoss, A. M., M. D., Surgeon to, and 

Lecturer on Clinical Surgery in, the Jefferson Medical College Hospit^ 

and the Philadelphia Hospital, etc. 

In one buidsomc 8va xtA, of 246 pp-i witli 39 Illuiiniloni. Ctoili, fi ;r>. 

■*The woc^ nMortitncly (upt^liai a real mnl, 

d it llu MMill of iionirale votIi. and vc heatiil^ 

RcaniawBd Ei w our r«sden •* well v»nhr of uic- 

** We know oF no book in Ihr Kii|;ll>ih luf^aKn 
irtidi lUeBlpIs tu cunr the JTVunil couprvd t^ thi» 
ono iladecd. theautbortrcni&iolMlhc&rMwliahaa 
prrwflil lo b*n^ the whol« subjMt »t nuiinnMty 
iBKum is aii« tysienulic ueaUw. How Ite tui »uo- 
cndedwill best bciecn liraMtudyolilMbcKik itNtf. 
ta tile rxtXj chai>)cn Iht ctuaificatkin flixl rtUtim 

iraquMcy fA ihc i-aiiou* lumun, their rmlutiuTj aiid 
inaifcfTMtlonii. and their etiolincj. jue dealt with ; 
tlMtt «iLCk eUiw it studied in a icpjrale diAplm', In 
trtrich Ihf Miult of itie 4u<liE)rii vorfc ii compucd 
wlik lllM of otiien, ^uid ihi- gtncril (oiiduiion* are 
dnvn vblch jjiivc to (he book its ^kA pociical 
raJue; (injllr. Bi:ttBpt(Tl(dcmie<l tixlii^iBU, one 
to tRaUnriit, Biid 00c It) ihc lumon in the majn- 

n»rf (iMtd of the bmJc." — .^>io >'«r< Midtiai 
yumrftat. 

" We hnrtfly cororarad lUi wofl: to Itw pnirM- 
■laa, inovin^ that lhco« who Hud; It* poRc* will 
be w«11 repaid and ttave a better undenuodlni; i%f 
nhat to the nnrare pnctlliuiicr ti obtcuie and un- 
•ltb^<trjr}'.''— '/Vmu^ -V^Ju-jI and ^ufgicaJ y^itr- 
■jY. 

" rir. Gmu Iiaa nrnduMd a wnrli of ifil and 
pemuncM mlui! : it U not ov«fsuiine the tnilh Ui 
BIT tluithhliitk ralunM fi probablr ibe be*t c«n> 
irfiMtiM ta ni*dlcAl (cUtiw which the pnwni jru 
' I brooKtil fonh. Webelitrvcthai ihauihorltM 



t.\ ^^ 



».»5i- 




dmvF wtal h« has Ml out to dnt vli., ctmitnirtnl > 
KXildUftiii; and Ai^y aocunie txekilae an mammary 
tumois, and broucbl to hi* task ill th* llebi aUnrded 
brthvDiMi nceot ioivaiiniloiu lalowctf jiatlial- 
onr-"— i"'- ^-!*" CHnittlRttmi. 

" Thia book b a real cantribnllaa in onr proraa- 
dontd Ikcnttirv ; aad it coibm from a aoum wh Ich 
coiDmandx uut loprct. The plan b rcr^ ajrMcraatic 
and «oniplcle, sn<l the *tudcm or prxiititnw* aliln 
will find eiodlii the informauoo he seek* upon uif 
u( tho diBiu4*« which ate inddcot 10 Ibe numnuii 
eland."— M«rc/rfc'ii/ GiMeUe, 

• ■ Ahocethec, the wiirk ia one ot man than onll 
nary inten«l to the rars^oo, cyti»oolecl>>i ud phj- 
aidan."— A/m/ Latuit, 

•■ The work li at once origlnat. adentilic, and 
pneticil. Ill hiitoki|7 will rervlve ili« ca.nful at- 
unilon of the specialist ; the sutmin wlU find ii « 

Ifulde and help ; while the general prvti I iunir, wbo 
wntild be infutnicd. and detim iv tnuw wbalwUl 
be uui:tii in oui trxi-books and in our ooDeeea, 
roiot iludy it. Ii ii an elTmt Ihol will add new 
Iinnqr to an banondde name, and of trbicli wr. u 
/ mcrtcana, nuij all be proud aa aa esaaitilt ul <irii;>- 
haI work and lii*«aiie««toii."— ifv^iata Uidkal and 
Sur^al y«ttrnal. 

'• Dr. Gran hai ffptn lo the pr otm lMi. to Ua 
' TrraiiE on Tunwra ot the Mamnwrr Gland,* one 
of the n«»t uwful and orifinal Mir(;ica1 wotIei of lb* 
niTirteenth wnlury. ll is but houmi and {uit pfatw 
tour that in ihii ireaiiie the autbor shows hldiaclf 
the intellecWa] peer of hi* pr^at father, A«i<Tle*t 
CTedt sutxeon." — LamsviUt ittdkal Stvt. 

"h inMiw baaed upon ibe irMenalk aoaljHa 
of to lar)^ an anoutit of maKfial un not tail to 
reraninend itMtf u the intelUKent raismn. «pe- 
dallr M it, w far as wc baow. U the titAt rrrmt 
work pubUibed «rtii<l) aflords any tnittworihy in- 
fonaaUoii on thia imputuni subiivi. Tb* .iirlhor 
•boviaii mtimate knowledge of Ibc lil*caticalIon 
of olhcn, and refer* to them fn<|UMiilf ibrad^oul 
the work, a fact which naterfalty adda in lu lalua." 
—PHlo^ifJiU if€Jicjl ami Stir£itai /lifvrter. 

" Ha d««nve4 the ihinki of ibe proreiaioQ for 
bli bold aod dirett opiniona. and dooblkaa In the 
fulur* th» c**>''bl mixiral pndiliooer will altadt 
Ontm tumnn with tant* painct^iut, and wttb mom 
con&fciKs in tbc ranba.'— J^Vr/il drc/AM 
ea/ yeumai. 






D. APPLETON ** CW."J MEDICAL WORKS, 




l6 



EMERGENCIES. AND HOW TO TREAT THEM. 

The Etiology, Pathology, and Trenttneni of Accidents, Diseases snd CaMs 

of Poisoning, which demand Prompt Action. Designed for StudcQia aad 

Practitioners of Medicine. By Joseph W, Howe, M. D., Oioita] ftofat- , 

or of Surgcrj* in the Mcdicni Department of the University of New YoHfl 

etc., etc. ™ 

Fourth edlihH), revlied. i vol., Sro, aCs V9- ^'otlt. %i,ya. 



" To ihf Kcneisl pnctltlontf la towna. vIU^^cs, 
and in iIm eoirnuy. n-hcr* the aid and moral lup- 
pon or A cnniulutlon can not U) aTallsd ol, thii 
volume will be rcn^iabnd •* « valuable help. U'c 
cncancnd u to Ihaprofcislon." — CtHcimiiali LaaeH 

" Tlic aullior wutpt no <rord<i, but dcvoui hini- 
Hlf 10 iIn dcKiiptiuo ot tach diaoise ta if the pA- 
licM w*t« Bndcr hi* hatid*. BtauM it li • {ood 



bock wc recotninaiij it mtvt hnirtiljr to tW \mi4m 
tion,"— Baton ilidual aaJ Surgi.-Ai yitmnM/. 
" niiii work bean endrito^ of a l)ii%fi)B(|| pia^ 

ticil uMluainiaiicv with tlM ilUhrait brMubwofilM 
piofcaiaa. TheaudicirHtnn U> r"" ' ' fi pmittfT 
aplilude for imparlint; inalnictian >* wcjl a* IM 
■ioiplKTinc ledioui dcuib. A careful pcnnal ■!! 
amplv rcpsT tbc »tu<kat aad practkioQcr. "— A«» 



A TREATISE ON THE DISEASES OF THE NERV- 
OUS SYSTEM. By William A. Hammond, M. D„ Surgeon -GcocnU 
U. S. Army (retired list); Professor of Dieenses of the Mind and Nervous 
System, in the New York Post-Graduate Medical St:hool; Prettideni of ihe 
American Neurological Association, etc. 

ScTcnih ci^Uon, tewritten, enlarged uid improrcd. la one Urge Sro vol. of 509 pp., witb 0»- 
pictc Index and 150 llluilruiont. Oath, $j \ tliMp or haU rmtsa, $6. 

SnciMBif or luuiTKAnnn TMs, lll« tmmtk rJitim rf 

Dr. HamnMnd's ««U-k«iiws 
worl, bu bccit tborodgbtf n- 
viftd, and raluccd \tx the ad- 
dition ol new cbapicn, cod of 
a *c«It<>ii oil DiMitca of (b 
Symtnihciir Syiicm. 

hoDot of a French tnnililka 

bv Dr. IjihadJc-Lncnve^ flf 

I'ari*, and "i i-iii-.^ .....v 

lion l)j' I'r' 1 

nrlli. of ilir 

li now ffoing Uu4tU(iii liie mcU 

uNapK*. 

"Dr. Hammandk «nfk hat 
now been before Uie jiinfiwlra 




ftw maof ycar«, am) ila 
iBriitid amm7 mati 11; kiMMk 
Tlw preant «dltkin )■*■ a foad 
Ma«]r mhiabl* ^Jdttii ji>. but hu 

ICNt M9lhM[I1< ill [imkiUI ladt- 

vUuallly a» a tntdical voA. Dr. Hammnncl twfl ihc nuUtlnof a noocatful author, llii (nctml w 
fieriafica h Iju)^, hi> o>nvJciions arc poiitiiv, Jmd h« <an tM tbeiD funk rb^vlr and attnclrattf. H b llM 
turprlnine tlul his book hai bnn a r«rv [wpiiUT ua«. And tha prorni tdtlioa U. ax wadtmif 
the tille-pac*, ■ioiprm-wl.'''— J/rflfir/ JP«*n/. 



"Il emywhcrt ettoos ciMnprebnui** ajmncte- 
HoB of ite ictkpe of the (obitcta ooMid««rt, otel^c 
what 1« knmra and ai Ibe Mnw ihiK Udntai ite 
puhi br vbkfe fuither olMB^atiMiwfll |nd to Man 
frrlMt kfiowMlK*. H fa a rtllahb pMt la ttM 
nudjr and iiMiment of a inoa htcMr inienMlnc 
cLia of dlarwo, Md wlU awqwtiKRaliljr 1 
if not «d4ttd In lu prcMfii lomi lb* aff 
and apprcdaiioa lu M*rK> hate Miboto 
nuUKkd^-AVw Ywi Mt^U^ G*mHU. 

'• Th« BieiliB of tMi book. Ukt iho*« of ha ••• 
ttuv. ti*t« imm bMQ hid undn- a bwhK ft iIbw« 
KTBil facility o< ntprentan, mKMhMKM. widwi* 
MrvMiotiar>di»prTleiKe.lhouEhlhrl.ibQnot olhi-n reading, with aa tmonaiaMa fakh Id ibr nnnr of 
arehyiM mMU Icsond."— JlMltVu/^Mtf Ar/i'r.i' rMwedie* owr d t a w lli coram-ioly fooM tiUaef 



"TI1U I* imt|tjnlini)sblr llir CQOMt complctrtn*- 
tiw on th« diicMW* to which it ia dcrowd tSat kaa 

rappeand In thr F.ncrlith lan|rtiae« : and Uinliw 
nuch Incftaied br the faa that Dr. HaramoBd 
hiui tnainly b^^nl It on hi> own pKprri^rp and pra^ 
Ike, whith. WW n»*<t hanJly reoiiod our reiikra. 
have been ivry MtensiiT."— Jfn/u.1/ TiJWJ amd 
Garltf. 

"The author i» a por