2OO 
 
 Aaft 
 
 UC-NRLF 
 
 152 7M1 
 
THE LIBRARY 
 
 OF 
 
 THE UNIVERSITY 
 OF CALIFORNIA 
 
 PRESENTED BY 
 
 PROF. CHARLES A. KOFOID AND 
 MRS. PRUDENCE W. KOFOID 
 
 PUBLIC 
 HEALTH 
 LIBRARY 
 
Dungliaon* 9 American Medical Library. 
 THE 
 
 MODERN TREATMENT 
 
 OP 
 
 SYPHILITIC DISEASES, 
 
 BOTH PRIMARY AND SECONDARY: 
 
 COMPRISING 
 
 AN ACCOUNT OF THE NEW REMEDIES, 
 
 WITH 
 
 NUMEROUS FORMULAE 
 
 FOR THEIR 
 
 PREPARATION, AND MODE OF ADMINISTRATION. 
 
 BY 
 
 LANGSTON ( PARKER, 
 
 M1MBKK OP THE ROYAL COLLEGE OF SURGEONS, FELLOW OF THE ROYAL MEDICAL AND CHIRUR- 
 
 GICAL SOCIETY OF LONDON, AND LECTURER ON ANATOMY AND PHYSIOLOGY 
 
 IN THE BIRMINGHAM ROYAL SCHOOL OF MEDICINE AND 
 
 SURGERY, &C. &C. 
 
 IRRUPTA TENET COPDLA. 
 
 PHILADELPHIA; 
 
 PRINTED BY ADAM WALDIE, 46 CARPENTER STREET. 
 1840. 
 

AZP2 
 
 PUBLIC 
 HEALTH 
 LIBRARY 
 
 TO 
 
 MONS. RICORD, 
 
 SURGEON TO THE VENEREAL HOSPITAL, PARIS, 
 
 AND AUTHOR OP THE 
 
 " Trait* Pratique des Maladies Veneriennes; ou, Rccherchcs critiques et experimental 
 sur rinocalation appliquee & 1'etude de ces Maladies," 
 
 THIS LITTLE WORK 
 
 IS, BY PERMISSION, DEDICATED, 
 
 WITH EVERY SENTIMENT OP ESTEEM AND RESPECT, 
 BY HIS OBLIGED AND FAITHFUL 
 
 FRIEND AND SERVANT, 
 
 THE AUTHOR. 
 
PREFACE. 
 
 The modern researches on syphilis, its complications and conse- 
 quences, and the improved modes of practice which have been the 
 result of such investigations in this country, and on the continent, 
 have, as yet, been made known to the public only in detached 
 portions, and that chiefly, if not altogether, through the medium of 
 the periodical medical literature of the day. 
 
 Much attention to the subject has impressed me with a convic- 
 tion, that a work containing the result of modern experience, 
 would not be unacceptable to the profession ; whilst, to the junior 
 part of it, such a publication might be exceedingly useful. 
 
 Usefulness, and not originality, has been the great object I have 
 consulted in composing the present work. It contains little, and I 
 believe no theoretical matter, except perhaps the account of Mons. 
 Ricord's researches " On Inoculation" in reference to syphilis. I 
 originally intended, and to the best of my ability I have carried out 
 my intention, that it should contain only the result of generally 
 received modern experience on the treatment of syphilitic diseases. 
 
 I have adopted no party in the question ; as will be perceived by 
 a perusal of the work, not agreeing exclusively with the mercu- 
 rialists, on the one hand, or condemning the remedy in toto on the 
 other, in accordance with the principles of the physiologic school, 
 or the partisans of the simple treatment. I have endeavoured to 
 hold out to the confidence of the reader those plans of treatment, 
 and those only, which are calculated to cure his patient the most 
 speedily and with the greatest safety. 
 
 The opinions and practice of Wallace, Desruelles, Cullerier, and 
 more particularly Mons. Ricord, will be found fully described in the 
 following pages whilst, at the same time, the result of my own 
 experience has been added to the weight of theirs. In addition to 
 this the value of many new remedies now much employed in the 
 treatment of syphilis has been discussed, and numerous forms for 
 their administration given. 
 
 142, Snow-Hill, Birmingham ; 
 September 20, 1839. 
 
 22 d 1 park 
 
SYPHILITIC DISEASES. 
 
 SECTION I. 
 
 Of the Simple Treatment of Syphilitic Diseases. 
 
 1. Various plans of treating syphilis without mercury have been 
 practised by surgeons in all parts of the world prior to the time of 
 Broussais, although that treatment, which is denominated at the 
 present day "simple," dates its origin more immediately from the 
 doctrines of that pathologist. Broussais, considering syphilis as a 
 mere irritation without any specific character, promulgated in 1815 
 the following opinions on its nature and treatment: 
 v^2. "That syphilis is an irritation affecting the exterior of the 
 body. That it is at first a local disease, but becomes subsequently 
 constitutional ; that to prevent the latter, the local disease must be 
 treated by antiphlogistics, more particularly by frequent and full 
 local blood-letting." 
 
 3. "That confirmed or constitutional syphilis may be cured by 
 abstinence and an antiphlogistic treatment ; but this method being 
 tedious, mercury and sudorifics are generally preferred. That 
 mercury and sudorifics cure syphilis by producing revulsion upon 
 the exhalant capillaries:" hence, by Desruelles 1 and others, this is 
 termed the "revulsive treatment." 
 
 4. "That the remedies termed anti-syphilitic should be admin- 
 istered internally with caution, otherwise they commonly produce 
 gastro-enteric affections, which exasperate the primitive disease; 
 the revulsive action of the remedies is thus prevented, irritation is 
 set up in the viscera, which terminates ultimately in their disorga- 
 nisation. 
 
 5. "When the remedies termed anti-syphilitic have produced 
 gastro-enteric irritation or inflammation, and the syphilis is not 
 cured, the latter only amends with the affection of the stomach 
 and bowels, and a long perseverance in a strict antiphlogistic regi- 
 men. If the abdominal viscera are disorganised or the patient too 
 much weakened, the cure is impossible. 
 
 6. "Mercurial preparations applied topically to external syphilitic 
 
 1 Traitfc des Maladies veneriennes. Paris, 1836. 
 
8 PARKER ON SYPHILITIC DISEASES. 
 
 irritations or sores exasperate them always when they are intense, 
 irritable, or inflamed. They cure them only when they are in- 
 dolent, by opposing irritation to irritation. This fact is also appli- 
 cable to all visceral inflammations, &c. 
 
 7. "Scrofulous subjects are more difficult to cure of syphilis than 
 others. Those predisposed to visceral irritations should, when suf- 
 fering from venereal affections, be treated on the antiphlogistic plan, 
 both externally and internally. If treated internally by mercurials 
 the viscera are excited, and sometimes the syphilis itself is not 
 cured." 
 
 8. Such are the principles laid down by Broussais, for although 
 the non-mercurial treatment of syphilis had been occasionally 
 resorted to, it was left to Broussais to lay down the simple treatment 
 as a system. In the aphorisms of this pathologist many opinions 
 are promulgated in reference to syphilis, which are contradicted by 
 all ancient and modern experience, and even by the most candid 
 of the followers of the physiologic school. We do not consider 
 syphilis a mere irritation, independent of any specific character, as 
 the researches of Ricord and others amongst the moderns suffi- 
 ciently prove. It is a specific disease, inasmuch as many of its 
 forms may be propagated by inoculation, and thus diseases of a 
 precisely similar character produced. 1 It is a disease of irritation, 
 inasmuch as all venereal sores are accompanied by a greater or less 
 degree of inflammation, the intensity of this inflammation, and 
 consequently the violence of the disease, depending on the consti- 
 tution of the patient, the circumstances in which he is placed, his 
 habits of living, and the local treatment of the syphilitic sore. 
 
 9. The simple treatment is directed towards the removal of all 
 the local and constitutional irritation which accompanies a venereal 
 sore, by which the sore itself in many instances heals and the dis- 
 ease is cured. Where it becomes necessary to employ mercury, it 
 will invariably be found advantageous to administer the remedy in 
 accordance with the principles of the simple treatment. This pro- 
 position is illustrated by the practice of the late Dr. Wallace of 
 Dublin, who states that the most appalling forms of syphilis which 
 he has met with, have resulted from the injudicious application of 
 mercurial preparations to venereal sores in a state of irritation or 
 inflammation. 
 
 Of the Simple Constitutional Treatment of Syphilis. 
 
 10. In all venereal affections, whether primitive or secondary, 
 the diet should be light and unstimulating, and directly propor- 
 tionate to the degree of irritation accompanying the disease, to the 
 age and idiosyncrasy of the patient. It is difficult (says M. 
 Cullerier) to conceive why the regulation of diet so important in all 
 other diseases, whether acute or chronic, should have been totally 
 neglected in the management of syphilis. The patient should be 
 
 1 See Ricord, Traite pratique des Maladies veneriennes. Paris, 1838. 
 
SIMPLE TREATMENT. 
 
 9 
 
 placed upon the lowest possible diet when the local venereal affec- 
 tion is accompanied by much inflammation or irritability, when 
 the affections are numerous in the same individual, if the disease 
 be constitutional, the principal viscera in a state of excitement or 
 irritability, and the subject young and vigorous. This regimen 
 should be still more closely adhered to if the affection occur in 
 spring or autumn, and is yet more strongly indicated if the patient 
 be subjected to a mercurial course. 1 Desruelles recommends a milk 
 diet if the patient be weak and the viscera unsound. 
 
 11. On this point no fixed rules can be laid down ; 2 they must 
 be dictated by the circumstances of the case, and call for the exer- 
 cise of much judgment on the part of the practitioner. It may be 
 easily conceived that the severity of the regimen must vary accord- 
 ing to the constitution of the patient we have to treat. Some sub- 
 jects are soon weakened or rendered irritable by abstinence, or 
 quickly placed in conditions favourable to the action of remedies; 
 others again are not so readily brought into such states; and in 
 some instances it becomes necessary to resort to general blood-letting 
 and the warm bath. 3 
 
 12. In all local and constitutional venereal affections, our first 
 duty should be to examine the general condition of the system of 
 the patient, to ascertain the state of the viscera of the chest and 
 belly, and to place him upon such a regimen as may be most likely 
 to diminish the irritability of the system generally or of any one 
 organ in particular. The bowels should be kept free by the exhi- 
 bition of mild unirritating purgatives, suited to the gastnc constitu- 
 tion of the patient. 
 
 13. General bleeding should be employed as a preparatory 
 measure, when the circulating system of the patient is too active, 
 or the inflammation accompanying the local disease acute. Local 
 bleeding maybe resorted to, with advantage, in almost all instances 
 of primary venereal sores, and in many forms of constitutional 
 syphilis. In these instances the leeches must be applied in the 
 centre of the sore, and not at its edges, with the view of preventing 
 the extension of disease by the inoculation of the leech bites. 
 
 14. The simple treatment attaches much importance to the posi- 
 tion of the patient, in the cure of venereal affections; hence, when- 
 ever it is practicable, the patient should be confined to bed. This 
 has the advantage of keeping the skin warm, and promoting per- 
 spiration, points of great importance, whilst the recumbent position 
 favours the return of blood upwards through the pelvis, and tends 
 to mitigate any inflammatory action or tendency. This position 
 also renders the application of dressings much easier, and places 
 the patient in a more advantageous condition for the action of 
 remedies. In buboes, posthitis, acute or subacute gonorrhea, ulcers 
 
 1 See Desruelles on this subject, op. cit. p. 249. 
 
 1 Plus vous nourrissez les corps impurs, plus vous leur faites de mal. 
 
 * Lucas Championniere, La Therapeutique de la Syphilis, p. 115. 
 
10 PARKER ON SYPHILITIC DISEASES. '. 
 
 on the genitals, vegetations about the anus, affections of the skin, 
 &c., the recumbent position in bed, if not indispensable, most mate- 
 rially facilitates the cure. 
 
 15. The warm bath is a modifying agent of great utility. In a 
 great variety of venereal affections the patient may use it daily 
 with advantage. The hip-bath, in many cases, from the situation 
 of the venereal affection, may supersede the necessity of immersing 
 the whole body. The patient may be directed to remain in the 
 bath an hour, or two, or more, according to circumstances. In the 
 French hospitals, baths medicated with gelatin, starch, bran, or the 
 decoctions of poppy, henbane, or belladonna, are employed. Gene- 
 ral and local bleeding, low diet, aperients, the warm bath, with 
 repose in the recumbent position, constitute the general simple 
 treatment of syphilis; and so efficacious are these means in miti- 
 gating the irritations accompanying primitive or secondary syphilitic 
 affections that, of themselves, they" frequently work a cure. Where 
 a mercurial, or other specific treatment is adopted, the simple 
 general treatment, pursued at the same time, will be found most 
 materially to assist it, whilst by keeping the constitution in a state 
 free from irritability, it prevents the accidents to which a mercurial 
 course frequently gives rise. 
 
 Of the Simple, Local, or Surgical Treatment of Syphilis. 
 
 16. In this section we shall indicate some general rules for the 
 surgical treatment of syphilitic affections, considering the particular 
 treatment with each separate form of disease. The best anti-syphi- 
 litic (says Cullerier) is frequently a dressing methodically made, it 
 being in vain that we attend to the constitutional treatment of our 
 patient alone ; at the same time irritating or neglecting the local 
 disease. 
 
 17. Syphilitic sores should be daily cleansed, by a soft sponge 
 and tepid water, from the discharges which their surfaces secrete; 
 this should be done without creating any irritation or pain, and 
 care should be taken not to disturb any parts undergoing a process 
 of cicatrisation. Syphilitic ulcers, perhaps, more than any other 
 kind, are liable from slight causes to become irritable, and assume 
 a phagedenic character. The dressings to these ulcers should be 
 of the simplest kind; mild astringent and anodyne solutions gene- 
 rally succeed better than the various kinds of ointments, particu- 
 larly those which contain mercury. The testimony of all modern 
 authors is decisive upon this point. Ricord's aromatic wine, with 
 or without tannin, appears to be one of the most generally useful 
 applications to primary syphilitic sores, particularly adapted to those 
 which are bad conditioned, dark, and disposed to become phagede- 
 nic from the want of a reparative power in the tissues where they 
 are seated. 
 
 18. In syphilitic affections attended by much inflammation, local 
 bleeding, so extensively employed in the French venereal hospitals, 
 
SIMPLE, LOCAL, OR SURGICAL TREATMENT. 11 
 
 is of great utility. In the case of simple primary sores, the leeches 
 must be applied in the centre of the ulcerations. and not round or 
 at the edges of the sore; this mode of local bleeding has sometimes 
 the happiest influence over stationary or slowly spreading sores, 
 with callous and red edges, which resist every other mode of treat- 
 ment, even a mercurial course. I have seen these sores in the 
 throat and upon the tongue, of a purely venereal character, remain 
 stationary, and even appear disposed to spread under the full in- 
 fluence of a mercurial course, heal in a few days from the repeated 
 application of one or two leeches in their centre. 
 
 19. Local bleeding may be employed in primary or secondary 
 ulcerations on the genitals, upon the tongue, in the throat, nasal 
 fossae, or other parts of the body. It may be frequently resorted to 
 with advantage in sinuses remaining after the opening of buboes, 
 the sides of which remain hard and assume little disposition to 
 heal; leeches placed in the course of these sinuses are sometimes 
 very beneficial in removing the irritation and hardness, and favour- 
 ing the process of granulation. In these cases, as in those of simple 
 sores, the leeches must be applied in the course of the sinus, not on 
 its outside ; the latter mode is of little efficacy whilst the former fre- 
 quently disposes an old sinus to close, which has resisted all the 
 usual routine of detergent ointments and stimulating injections. If 
 the course of the sinus be hot, tender on pressure, and painful, the 
 existence of inflammatory irritation is clear; and local bleeding, 
 practised in the manner I have described, is sure to be beneficial. 
 Local bleeding is, however, by no means to be indiscriminately 
 employed in venereal ulcers, &c. Ricord generally prefers, in dis- 
 eases of this kind, attended with much inflammation, emollient and 
 narcotic fomentations, poultices of bread and milk or linseed, with 
 the warm bath, either alone or with the addition of mucilage or 
 gelatin. 
 
 20. In inflammations of the testicle and of the glands of the groin, 
 leeches are more efficacious placed directly upon the most painful 
 part of the tumour, than in the course of the spermatic vessels, or 
 around its base. M. Gama, chief surgeon to the military hospital 
 of Val de Grace, observing the comparatively trifling effect of 
 local bleeding on buboes, &c., as it is generally employed, practises 
 with more success what he terms " saignee permanente." Instead of 
 applying a large number of leeches at once, as twelve, fifteen, or 
 more, he uses four or six, and when the bleeding begins to diminish, 
 reapplies the same number, so as to keep up a constant flow of 
 blood from trje part for many hours. 
 
 21. Irritation is frequently kept up by the mere contact of two 
 inflamed surfaces, notwithstanding an appropriate treatment in all 
 other respects may be methodically practised; hence, certain forms 
 of superficial primary syphilis, or of balinitis, and posthitis, are kept 
 up by the contact of the glans penis and prepuce, and some gleets 
 protracted from the contact of the two sides of the urethra. Fricke, 
 of Hamburg, first established this fact, which has been verified in 
 
I 
 
 12 PARKER ON SYPHILITIC DISEASES. 
 
 the practice of Desruelles and Ricord ; the latter has frequently 
 succeeded in curing obstinate gleets by introducing a small portion 
 of lint into the urethra, dry or soaked in a mild astringent solution. 
 The prepuce and glans, when either is the seat of irritation or 
 ulceration, should always be separated by the introduction of fine 
 linen or lint. The continued contact of the glans and prepuce, 
 when inflamed or ulcerated, frequently occasions their total or partial 
 adherence. 
 
 22. Parts affected with syphilis which are deeply seated, or 
 covered by folds of integument or mucous membrane, should be 
 daily cleansed by tepid anodyne or astringent injections, according 
 to the character of the accompanying irritation. These injections 
 should be practised quietly, without force, and without creating pain. 
 
 23. Abscesses should be opened early, more particularly if the 
 presence of matter occasions much pain, or take place under fasciae 
 or tendinous expansions, where the pus cannot readily make its way 
 to the surface. Long and deep sinuses should be laid freely open, 
 or if it be practicable a counter-opening may be made. 
 
 24. All parts in a state of natural or acquired strangulation which 
 offer impediments to the cure of syphilitic diseases should be quickly 
 relieved; this becomes necessary in natural or acquired phymosis 
 or paraphymosis. The circumstances which contra-indicate this 
 practice will be mentioned under the article on the particular 
 diseases themselves. 
 
 Of the Mercurial Treatment of Syphilitic Diseases. 
 
 25. It is not my intention to enter into any of the controversies 
 respecting the mercurial or the simple treatment of syphilis, but 
 merely in this place to point out the circumstances which modern 
 experience has indicated for its employ ; for although mercury 
 cannot be considered in any measure as a specific against syphilis, 
 in any of its forms, still there are numerous cases in which it is the 
 most powerful and certain therapeutic agent we can oppose to them. 
 
 26. Why is mercury to be employed in the treatment of syphi- 
 lis ? When is it to be employed ? In what manner is it to be 
 employed ? What are the states of the constitution, and of the sore 
 which are to guide us in pursuing its use or giving it up? And 
 when is it to be discontinued ? These are the practical questions 
 which suggest themselves to us in reference to the use of mercury 
 in venereal diseases, and to them we shall give the answers that 
 modern experience has sanctioned. 
 
 27. Mercury is employed to facilitate the healing of a venereal sore, 
 and to diminish the chance of secondary symptoms. 1 When (says 
 Cullerier) the local applications before mentioned are insufficient to 
 produce the cicatrisation of a chancre, the patient must be placed 
 
 1 Wallace, on the Venereal Disease and its Varieties, p. 100. London, 
 1838, 
 
MERCURIAL TREAMENT. 
 
 13 
 
 upon a general mercurial treatment. 1 The rapidity of the complete 
 cure of several varieties of venereal sores, is enormously in favour 
 of the mercurial treatment, whilst the number of secondary affections 
 is, by it, much diminished. 
 
 28. Mercury may be used in the treatment of all primary venereal 
 sores, though it is not necessary to their cure, nor is it used in the 
 Parisian venereal hospitals, 2 when the sore heals under the use of 
 topical applications and an antiphlogistic regimen, unless the healing 
 of the sore leave behind it induration of the cicatrix. 
 
 29. Mercury is not to be used during the state of fever or local 
 inflammation which is present during the first days of venereal 
 ulcers, nor till our patient is prepared for it by low diet, aperient 
 medicines, or local or general bleeding. When the fever and local 
 inflammation or irritation which commonly attend primary venereal 
 sores are removed, when the process of ulceration has stopped, 3 and 
 the sore remains indolent under the use of topical applications, 
 above all when its edges are elevated and hard, mercury may be 
 employed with the full expectation of realising its most beneficial 
 results. 
 
 30. When a certain degree of induration accompanies a chancre, 
 or persists after its apparent cure, Ricord has recourse to mercury, 
 and, continues he, " as the mineral is frequently injurious in some 
 other forms of syphilis, so is it of use here." Cullerier employs 
 mercury in the absence of fever and local inflammation, when the 
 sore has become indolent, and puts on no disposition to heal under 
 ordinary local dressings. Dr. Wallace resorted to mercury, in 
 most cases of primary venereal sores, when the process of ulceration 
 had been arrested by the nitrate of silver, or other caustics when 
 the sore had become indolent, or assumed a disposition to heal. This 
 author, recognising the grand principles above detailed, that we are 
 not to employ mercury in the earlier stages of chancre, whilst the 
 constitution and sore are irritable and are still suffering from the 
 more immediate effects of the venereal poison, says " great mischief 
 frequently results from the topical employment of mercury, as well as 
 of other stimulants, during the stage of ulceration or destruction of 
 primary syphilis, by producing morbid excitement, followed some- 
 times by indolent and sometimes by irritable action, with their 
 concomitants and consequences. The most appalling forms of this 
 disease, which ever came under my observation, were caused by the 
 
 1 Recherches pratiques sur la Therapeutique de la Syphilis, ouvrage fonde 
 sur les observations recueilles dans le service, et sous les yeux de M. 
 Cullerier, par Lucas Championnidre. Paris, 1836. 
 
 1 Ricord, Traite des Maladies veneriennes. pp. 578 et suivantes. Paris, 
 1838. 
 
 8 In certain varieties of phagedana, Dr. Wallace thinks that mercury fully 
 and freely employed, so as to bring the constitution as quickly as possible 
 under its influence, is the most certain and efficacious mode of arresting the 
 rapidly extending ulcerating process. See his remarks on this subject, op. 
 cit. p. 136. 
 
14 PARKER ON SYPHILITIC DISEASES. 
 
 injudicious application of the red precipitate, or other powerfully 
 stimulating dressings, and it has therefore long been a principle with 
 me strict! y to avoid all mercurial and stimulating dressings du ring the 
 ulcerating stage of syphilis. It is also in general highly improper to 
 administer mercury internally during this stage, for if used at this 
 period it may, instead of producing a salutary and specific influence, 
 increase the inflammation, or excite a state of irritable or indolent 
 action, after which the system will become quite insensible to ordinary 
 doses of medicine ; and if, under such circumstances larger doses 
 of mercury be employed, a peculiar and complex state will most 
 probably result, determined in its character by the combined 
 influence of the disease, the remedy, and the constitution of the 
 patient, a state in which mercury acts as a poison, or in other words 
 not only aggravates all the symptoms, but perhaps excites a new 
 train of peculiar morbid actions." 1 
 
 31. Mercury is employed either in the form of ointment by friction, 
 or internally in various forms of preparation. Cullerier prefers 
 employing mercury by friction in primary venereal sores ; he orders 
 from a quarter of a dram to a dram and a half of mercurial 
 ointment at each friction, leaving an interval between them of one, 
 two, or three days, with the view of not irritating either the sore or 
 the constitution, by bringing the latter suddenly under the influence 
 of the remedy. These frictions may be made upon the insides 
 of the thighs or legs, in the inguinal region or popliteal space. 
 Ricord frequently orders the frictions to the axillas. and they are 
 thus employed by Cullerier in certain forms of venereal ulcerations 
 of the mouth and fauces. He relates the histories of two cases 
 cured by mercurial frictions in this situation, which had resisted its 
 employment on other parts. As an internal remedy, in the primary 
 venereal ulcer, the proto-ioduret and cyanuret of mercury are pre- 
 ferred in the Parisian venereal hospitals as more certain in their 
 effects, and less irritating than either calomel or the oxy muriate. 
 The dose is from two to six grains a day, combined with opium, to 
 which antimony may be added with advantage. 
 
 32. During the employment of mercury, the states of the sore, of 
 the constitution, of the mouth and breath are to be carefully watched, 
 since each of them may assume certain conditions which would 
 render the further use of mercury injurious. 
 
 33. The state of the sore whilst the patient is taking mercury 
 should be frequently examined, and topical applications suited to 
 its condition employed. At one time it may require anodynes, at 
 another astringents, or again slightly stimulating applications may 
 become necessary. During the mercurial course also, the diet 
 should be mild and unstimulating, and the condition of the stomach 
 and bowels carefully attended to. Dr. Wallace recommends the 
 mastication and deglutition of grains of allspice or pepper during the 
 day, and covering the abdomen with two or three folds of flannel. 
 
 Op. cit. pp. 109-10. ,j 
 
MERCURIAL TREATMENT. 15 
 
 A nightly draught or pill of some preparation of opium with cap- 
 sicum 1 may be employed with advantage, even during the period 
 the patient is using mercurial frictions ; the former not only prevent 
 those attacks of pain, griping, and diarrhoea which sometimes come 
 on during a mercurial course, and materially retard the healing 
 process, but they contribute directly to the therapeutic effect of the 
 mercury. 
 
 34. It is from a want of attention to these circumstances, that 
 persons are so frequently placed upon the mercurial plan without 
 being cured. This arises from their neglecting the modifications of 
 topical applications and not observing the dietetic regimen suited to 
 their state. 
 
 35. The condition of the sore is very frequently an indication of 
 the effect of mercury upon the constitution, and points out clearly 
 whether it is agreeing with the system or not. From this circum- 
 stance we recommend a frequent examination of the local disease 
 during the time the patient is using mercury. "It will be found 
 a most important rule in practice to omit all mercurial treat- 
 ment whenever there appears an increase of inflammation or 
 sensibility to arise in the local disease during the employment of 
 mercury, for a perseverance in its use, under such circumstances, 
 will almost inevitably tend to some form of destructive action, 
 determined in its character by the constitution of the patient. In 
 such cases we must have recourse to emollient and anodyne appli- 
 cations, purgatives, rest, abstinence, and diaphoretics, with or without 
 narcotics, and as soon as the morbid actions which have supervened 
 have been removed, mercury if necessary may be again resumed, 
 to be suspended afresh in case of a return either of inflammation or 
 irritability." 2 
 
 36. The state of the constitution as well as of the sore, demands 
 great watchfulness during the administration of mercury for the 
 cure of primary venereal sores. It is quite certain that venereal 
 sores, which have resisted all other modes of treatment, daily heal 
 under the use of mercury, whilst the remedy produces no sensible 
 eflect upon the economy either by causing salivation or mercurial 
 fever. We therefore insist upon the principle enforced by Dr. 
 Wallace, that the greater the degree of excitement or of deviation 
 from the healthy condition of any of the functions which mercury 
 produces, the greater is the danger of its action being followed by 
 deleterious effects, or of its ceasing to influence in a salutary manner 
 
 1 *. Pulv. Opii, gr. j. 
 Pulv. Capsici, gr. ij. 
 Conf. Aromat. q. s. ft. Pil. 
 Omni nocte sumend. 
 
 or, 
 
 5. Liq. Opii sedativ. M. xx. ad xxx. 
 . Tinct. Capsici, M. xxx. ad. 1. 
 Aquae Cinnaraomi, 3j. M. 
 ft. Haust. h. ss. 
 1 Wallace, op. cit. p. 119. 
 
16 PARKER ON SYPHILITIC DISEASES. 
 
 the symptoms of syphilis. It is from a knowledge of this fact that 
 both Cullerier and Ricord attend so much to the condition of the 
 general health during a course of mercury, by abstracting their 
 patients from all causes of excitement. 
 
 37. It is not necessary that mercury should produce salivation in 
 order that its benefits, in curing primary syphilitic ulcers, or dimin- 
 ishing the chance of secondary symptoms may be realised. What 
 then are the rules to guide us in these circumstances ? How long 
 is our patient to be submitted to the use of mercury, and when is it 
 to be discontinued ? The healing of the sore, without a thickened 
 condition of the cicatrix, is our rule for the discontinuance of 
 mercury. This remedy must be discontinued as soon as the traces 
 of infection are no longer evident. Some patients are not easily 
 affected by mercury, and their sores remain indolent even under 
 its long continued use. In these cases it is well from time to time 
 to lay aside the mercury and again to have recourse to mercurial 
 treatment under some other form, if the disease still continues 
 obstinate. 
 
 38. We must not think of secondary symptoms after a sore has 
 healed under the influence of mercury, nor prolong the treatment 
 with a view of preventing them. Secondary symptoms appear after 
 the fullest courses of mercury, and occasionally do not appear when 
 mercury has been altogether abstained from. 1 
 
 39. The state of the mouth should be carefully examined before 
 resorting to a course of mercury ; sometimes a stomatitis may be 
 present before the administration of this remedy, and we might thus 
 be deceived in its effect, mistaking the inflammation of the mouth, 
 which was previously in existence, for one which is the result of 
 mercury. It is quite certain that many morbid conditions of the 
 mouth and breath so closely resemble those produced by mercury, 
 that, without an examination of the mouth before resorting to a 
 mercurial course, we might be led into great error. 2 
 
 40. When the breath becomes fetid, and the gums tender, the 
 mercury must be discontinued, or very much diminished in quantity. 
 The patients should use slight astringent gargles, with mineral 
 acids, and lozenges of the chloride of lime. 3 
 
 1 These paragraphs, 37 and 38, embody the principles of the French civil 
 and military venereal hospitals, and to me appear the most rational guide 
 that can be given for the discontinuance of a mercurial course. Dr. Colles 
 continues it a few days after all hardness of the cicatrix is removed, and 
 thinks tfie mercurial treatment should be continued to the extent of moderate 
 ptyalistn for a month. Mr. Judd mentions, as the duration of the course, 
 from twenty-five to thirty days. 1 am fully convinced that the patient is as 
 secure as he can be from secondary symptoms, by following the French rule, 
 " to discontinue the mercury when the sore has healed, and all induration of 
 the cicatrix has disappeared." 
 
 See Ricord's remarks on this subject, op. cit.pp. 627-8. 
 
 5. Sodae chlorid. solutionis (Beaufoy's). 
 Tinct. myrrhae, aa ss. 
 Aquae gv. M. ft. garg. 
 
MERCURIAL TREATMENT. 
 
 IT 
 
 41. M. Desruelles, surgeon to the military hospital of Val de 
 Grace, having the charge of the venereal department of that 
 establishment, and a partisan of the simple or physiological treat- 
 ment of syphilis without mercury, entertains the following- opinions 
 as to its use, and gives certain rules for its exhibition. Certain 
 chancres, says he, of a phagedoenic or hunterian character with a 
 hard base, or which leave behind them in healing an indurated cic- 
 atrix, are more frequently followed by secondary symptoms, when 
 treated without mercury, than if this remedy had been given. 
 
 42. When venereal sores become stationary, or do not heal under 
 the simple treatment, and the exhibition of mercury is not contra- 
 indicated by the inflammatory or irritable condition of the sore, or 
 certain states of the constitution, mercury may be advantageously 
 used. Mercury may be given when the local inflammation accom- 
 panying a venereal sore has been subdued, and the patient is 
 prepared for its exhibition by diet and aperients, the sore remaining 
 indolent, of a bad aspect, and not healing, or appearing to be influ- 
 enced by the simple treatment. This remedy may be also employed 
 if the sores are complicated with inflammation or enlargement of 
 the glands of the groin, or if any affection of the skin, as papular or 
 other eruptions, make their appearance during the simple treatment, 
 and there is reason to believe the constitution affected. 
 
 44. In many secondary affections, although generally trusting to 
 the simple treatment, Desruelles thinks the employment of mercury, 
 particularly of the proto-ioduret, may be of service. He merely 
 states that if secondary symptoms appear in an individual, who has, 
 for the primary form of the disease, been treated fully by mercury, 
 it is better to employ the simple treatment, sudorifics, and attention 
 to the general health of the patient, than to have recourse again to 
 the employment of mercury. In secondary syphilis, which succeeds 
 to a primary affection which has been treatei without mercury, this 
 remedy is almost always necessary. A mild mercurial course in 
 such instances is generally more efficacious than any other. 1 
 
 &. Aquae distillatse, % vij. 
 
 Aluminus et potassse sulph. 9ij 
 Mellis Rosarum, 3J. M. ft. garg. RICORD. 
 
 Lozenges of Chloride of Lime. *. Calcis chlorid. ^iv. ; sacohar. alb. IS j.- 
 arayli, ^iv. ; P. gum. tragacanthae, 3\j. M. Aqua? aurantii quantum sufficil. 
 The mass is to be made into lozenges of three grains each. Their use 
 principally in removing the mercurial fetor of the breath. 
 
 1 See the remarks of Desruelles on this subject, op. cit. pp. 341 et suivantes. 
 Reflexions pratiques sur 1'emploi des Sudorifics. 
 
 22 Q 2 park 
 
18 PARKER ON SYPHILITIC DISEASES. 
 
 SECTION II. 
 
 Of particular Preparations of Mercury, and their Mode of 
 Employment. 
 
 MERCURIAL FUMIGATIONS. 
 
 45. These forms of the remedy are principally employed in 
 obstinate affections of the skin, the throat, or the nasal fossae ; and 
 though they may be had recourse to in the primary forms of diseases 
 independent of any other mercurial preparation, they are chiefly 
 used when its external exhibition has failed. The method employed 
 by Werneck in Germany appears the simplest and most efficacious. 
 
 46. The patient is prepared for the fumigations by low diet, the 
 warm bath used daily, aperients, and the compound decoction of 
 sarsaparilla. This preparatory treatment is pursued for five or six 
 days prior to the fumigation, and the patient is confined to his room, 
 which should be of the temperature of fourteen degrees (Reaumur), 
 At the end of this period a smart aperient should be exhibited, and 
 the fumigation may be then employed. The patient is placed upon 
 a seat, covered with a mantle of waxed or oiled cloth ; the apparatus, 
 which consists merely of a spirit lamp and a china plate, upon 
 which the cinnabar, or sulphuret of mercury is laid, put under it. 
 The mantle should be fixed closely round the neck to prevent the 
 mercurial vapours from escaping into the room. 
 
 47. The fumigation is continued for a quarter of an hour, in a 
 chamber of the temperature of eighteen degrees (Reaumur), and at 
 its conclusion the patient is directed to go to bed ; it is for this reason 
 that the remedy is most conveniently employed in the evening. The 
 quantity of cinnabar necessary for each fumigation is from twenty- 
 grains to a dram; one application a day is sufficient, and the cure 
 is generally complete in eighteen or twenty days ; in case of saliva- 
 tion occurring, or any circumstances affecting the constitution of 
 the patient, the fumigations must be used less frequently, the quan- 
 tity of the mercury diminished, or the remedy altogether discontinued. 
 When the treatment is terminated, the patient is to change his linen 
 and take a bath. 1 
 
 48. Cullerier remarks that occasionally fumigations with the 
 sulphuret of mercury produce remarkable cures. It is rare, says 
 this author, that papular or even pustular venereal affections of the 
 skin resist their application. Their use is indicated in obstinate 
 chronic ulcerations of the mouth, throat, nose, and other parts, and 
 by a very simple contrivance the vapour of a few grains of cinnabar 
 may be directed easily into the depths of those parts. 
 
 1 See Werneck's memoir in the Review M6dicale, for January, 1831. Also, 
 Rapou, Traitede la Methode Fumigatoire, &c. Paris, 1824,2 vols. 8vo. 
 
MERCURIAL TREATMENT. 19 
 
 The Proto-chloride of Mercury. 
 
 49. The proto-chloride of mercury, or the chloride of mercury of 
 the London Pharmacopoeia, is extensively used in venereal diseases. 
 Desruelles speaks highly of its anti-venereal properties. The fol- 
 lowing is the form in general use at the hospital of Val de Grace : 
 
 9t. Hydrargyri cbloridi, 
 
 Ext. conii, aa gr. j. 
 M. Pulveris glycyrrhizae, q. s. ft. pil. 
 
 The quantity of the extract of conium may be increased, or a small 
 quantity of opium added, if the circumstances of the case require it. 
 These pills are administered at first in the dose of one or two a day, 
 gradually increased ; Desruelles occasionally pushes them to the 
 extent of twenty-five or thirty in the twenty-four hours. 
 
 50. The employment of this combination of the chloride of mer- 
 cury is particularly indicated in chronic inflammations of the testicle, 
 complicated even with ulceration,or incipient disorganisation of these 
 parts. In such cases M. Gama, Desruelles, and Cullerier, placo 
 implicit reliance on this preparation of mercury, and state that it 
 rarely fails even in the worst cases. It is also extensively employed 
 in tubercles of the labia, with or without ulceration, in various 
 forms of creeping ulcers, and also in ulceration of the throat and 
 nasal fossae. We cannot, says M. Desruelles, too much recommend 
 this preparation, which, united to opium, and an antiphlogistio 
 regimen, may produce the most beneficial results. 
 
 Another form : 
 
 *. Ext. conii, gr. iij. 
 Hydrarg. chlorid. gr. j. 
 Antimonii sulphureti praccip. gr. j. M. ft. pil. 
 
 Ricord's form : 
 
 *. Hydrargyri chloridi, 9 j. 
 Pulveris conii, 
 Saponis Hispaniolae, aa 9ij. M. ft. pil. xxiv. 
 
 These pills are employed by M. Ricord in the treatment of 
 enlargements of the testicle, which remain after inflammation of 
 this organ, complicating or succeeding to gonorrhoea (epididymito 
 blennoragique.) 
 
 The Bichloride of Mercury. 
 
 51. The bichloride of mercury is employed chiefly in the French 
 hospitals, in certain forms of primary syphilitic sores with hard base 
 and edges which have resisted the simple mode of treatment, also 
 in secondary syphilis generally, particularly in those varieties of it 
 
20 PARKER ON SYPHILITIC DISEASES. 
 
 which are complicated with ulcerations of the mucous surfaces. 
 According to Dzondi, whose method of treating syphilis is exten- 
 sively followed in Germany, and at the "La Charite" hospital of 
 Berlin, the bichloride of mercury is the chief preparation of this 
 remedy on which reliance should be placed in the treatment of 
 constitutional syphilis. 
 
 Form in use at Val De Grace. 
 
 9t. Hydragyri Bichlorid., gr. . 
 
 Pulv. O'pii, gr. i. M. Pulv. Glycyrrhizae, q. s. ft. Pil. 
 
 One a day for the first ten days, the dose then gradually increased. 
 M. Desruelles does riot exceed half a grain of this salt a day. 
 
 Dupuytrerfs Form. 
 
 3<. Hydrargyri Bichlorid., gr. ij. 
 Pulv. Opii, gr. viij. 
 Gum. Guaiaci, gr. xxxij. m. ft. Pil. xvj. 
 
 M. Dupuytren was of opinion that small doses of the bichloride 
 of mercury were more efficacious than larger ones ; he rarely ex- 
 ceeded the sixth of a grain for a dose. One of the pills of the 
 above form were given three times a day. 
 
 52. Dzondi's pills each contain one twentieth of a grain of the 
 bichloride united with a small proportion of opium. He adminis- 
 tered in the commencement, four a day, half an hour after the 
 dinner meal. Twelve grains of the bichloride of mercury are 
 made with an inert powder, as liqourice, into 238 pills. Four of 
 these are given the first day; the day but one after, six ; increasing 
 the dose two pills every day, and leaving one day's interval between 
 each dose, so that on the thirtieth day from the commencement, the 
 patient takes thirty pills or one grain and a half of the salt. 
 
 53. Dupuytren and Dzondi recommend that the patient should 
 be strict in his regimen during this treatment, avoiding all stimulant 
 and much animal food. The efficacy of the plan is much aug- 
 mented by taking frequent drinks of the warm compound decoction 
 of sarsaparilla throughout the day. 
 
 The Prolo-Ioduret of Mercury. 
 
 54. MM. Cullerier, Biett, and several others, employ the proto- 
 ioduret of mercury in preference to the bichloride, as more certain 
 in its effects and less liable to decomposition. This preparation 
 may be employed in primary syphilitic sores in strumous habits, 
 but is chiefly resorted to in chronic affections and in those varieties 
 of disease which have been described by authors as constitutional 
 syphilis. 
 
'MERCURIAL TREATMENT. 21 
 
 M. Cullerier's Form for the employment of the Proto-Ioduret of 
 
 Mercury. 
 
 jt. Hydrargyri proto-ioduret, gr. xij. 
 
 Ext. v. Pulv. Opii., gr. vj. 
 
 Gummi Guaiaci, 3J. M. ft. Pil. xxir. 
 Capiat 1 nocte raaneque. 
 
 Pommadc of Val De Grace. 
 
 >. Hydrargyri proto-ioduret, 9j. 
 Adipis, 3j. M. 
 
 Employed in friction upon tumours and indolent buboes after all 
 acute inflammatory symptoms have disappeared. 
 
 55. It is principally, says M. Cullerier, in secondary syphilis that 
 the proto-ioduret of mercury is administered with success. Its 
 effects are principally evident in secondary ulceration of the mucous 
 membrane, cutaneous tubercles, exostosis, and chronic affections of 
 the joints, where the other preparations of mercury have had little 
 effect. 
 
 56. The deuto-ioduret of mercury may be employed in friction 
 or in pills, in the same manner as the proto-ioduret; it is stronger 
 and more stimulating, and consequently should be administered in 
 smaller doses. Both these remedies may be advantageously em- 
 ployed in all cases of secondary syphilis, with more certainty and 
 less risk than the deuto-chloride ; also in indolent buboes, in obsti- 
 nate ulcers with hardened base and edges. In all instances they 
 must be guarded by opium, and the patient must be submitted to a 
 strict dietetic and antiphlogistic regimen during their employ. The 
 dose of the deuto-ioduret from ~ of a grain to a grain. 
 
 The Cyanuret of Mercury. 
 
 57. The cyanuret of mercury is now frequently employed in 
 preference to the bichloride, and for the following reasons. It is 
 more soluble and riot so liable to decomposition, acts more quickly, 
 and does not occasion those pains in the stomach and bowels that 
 so frequently accompany the prolonged administration of the 
 bichloride. According to the researches of M. Parent, 1 the cyanuret 
 of mercury is not decomposed by either acids or alkalies, nor by 
 decoctions containing azotised principles or gallic acid. 
 
 58. The cyanuret of mercury may be administered internally in 
 pills, or in solution, and used externally in form of pommade or 
 ointment. M. Cullerier employs the cyanuret in primary syphilis. 
 Externally it is an extremely useful application to various forms of 
 herpes, particularly that form termed by Alibert, "herpes squamo- 
 sus," the violent itching and irritation of which it allays. It may 
 be employed externally also as a dressing to indolent syphilitic ulcers, 
 
 'Revue Medicale, Aout, 1832. 
 
22 PARKER ON SYPHILITIC DISEASES. 
 
 and scirrhous tubercles, or as a gargle in ulcerations of the throal. 
 The dose of the cyanuret is from T ' y of a grain to a grain. 
 
 Gargle of the Cyanuret of Mercury. 
 
 *. Hydrargyri Cyanuret., gr. x. 
 Infus. Lini Comp., Ibj. M. 
 
 Pills of the Cyanuret of Mercury. 
 
 >. Hydrargyii Cyanuret., gr. viij. 
 Pulv. Opii, gr. xvj. 
 Ext. Guaiaci, 3ij. M. ft. Pil. Ixiv. Capt. 1 ter die. 
 
 Ointment of the Cyanuret of Mercury. 
 
 ^. Hydrargyri Cyanuiet. gr. xij. 
 Adipis, 3J. M. ft. Unguentum. 
 
 Solution of the Cyanuret of Mercury. 
 
 &. Hydrarg. Cyanuret. g. vj. ad gr. r. 
 Aquae, fcj. M. 
 
 Half an ounce for a dose, administered in a mucilaginous vehicle 
 or with the addition of sugar in form of syrup. 
 
 M. Parent's Cyanuretted Pills. 
 
 B. Hydrargyri Cyanuret. gr. xxiv. 
 Ammonia Muriatis, giij. 
 Guaiaci Gummi, |jiij. 
 Ext. Aconiti, giij, 
 Ol. Anisi, 1U- xxiv. M. Mucilagini, q. s. ft. Pil. 400. 
 
 One or two twice or three times a day, the dose gradually increased. 
 Each pill contains about T V of a grain of the cyanuret. These 
 pills are a substitute for the bichloride of mercury in many forms 
 of secondary syphilis. 
 
 Another form of M. Parent. 
 
 *. Hydrarg. Cyanuret., gr. vj. 
 Opii. gr. xij. 
 Micse panis, q. s. ft. Pil. xcvj. 
 
 Each pill contains Jg. of a grain of the cyanuret adapted to forms 
 of primary syphilis. The dose of one or two pills twice a day in 
 the commencement, and gradually increased. 
 
 c - - - ' 1 1 l ' . 
 
 The Dento-Phosphate of Mercury. 
 
 59. The deuto-phosphate of mercury is employed in Italy, more 
 particularly at Naples, in the treatment of venereal affections in 
 
INOCULATION. 23 
 
 preference to the other salts of this metal. It may be given inter- 
 nally in pills or in solution in the same doses as the bichloride. 
 Employed by friction upon indolent buboes or exostoses, it is said 
 to be preferable to all other forms of the remedy. It is of use also 
 as a dressing to indolent chancres. 
 
 Ointment of the Deuto- Phosphate of Mercury. 
 
 9>. Hydrargyri deuto-phosphatis, gr. viij. 
 Adipis, 3J. M. ft. Unguent. 
 
 In cases of indolent bnbo, a few grains are rubbed daily upon the 
 tumour, th.} frictions also are to be made upon the groin of the 
 opposite side. Our experience in the use of this remedy is drawn 
 chiefly from the practice of Piore and the Neapolitan surgeons, it 
 is scarcely used in France, although occasionally employed in 
 Germany. 
 
 SECTJON III. 
 
 On Inoculation^ as applied to the Diagnosis and Treatment of 
 Syphilitic Diseases. 
 
 60. Both before and since the time of Hunter, inoculation has 
 been employed for the purpose of testing: the character of syphilitic 
 diseases: and at the present day, M. Ricnrd, Surgeon to the Pari- 
 sian Civil Venereal Hospital, has deduced, from an extended series 
 of experiments, certain conclusions of great value and importance, 
 which he has given to the world in his great work "Traite pratique 
 des Miiludies Veneriennes, ou Recherches critiques et experimentales 
 sur I'lnoculation, applique'e a 1'etude de ces Maladies." 1 
 
 61. M. Ricord establishes, in the first place, that a cbanrre, 
 wherever it may be seated, is produced by a specific matter which 
 is secreted by a chancre only, which matter produces a similar 
 disease whenever placed in circumstances favourable to contagion. 
 
 62. This specific matter is only secreted from the surface of a 
 chancre during its first stage, that is, during the period of ulcera- 
 tiou, or when the sore is indolent or stationary. At these periods 
 only does a chancre secrete a specific matter capable of producing 1 
 a similar disease by inoculation. When the sore begins to heal and 
 a process of reparation has commenced, it is merely a simple ulcer, 
 does not furnish a specific secretion, and is not capable of propaga- 
 tion by inoculation. 8 
 
 'Paris. 1833. 
 
 It would apppear that these views were likewise entertained by Dr. 
 Wallace, who divided chancre into two distinct stages or phases, the first 
 one of ulceralion, the second one of reparation ; he particularly insists upon 
 the impropriety and danger of administering mercury during the first stage, 
 that of ulceration. 
 
24 PARKER ON SYPHILITIC DISEASES. 
 
 63. If matter be taken from a chancre during the period of ulcer- 
 ation, and introduced under the epidermis by means of a lancet, it 
 produces the following effects. During the first four-and-twenty 
 hours the puncture becomes more or less inflamed ; from the second 
 to the third day it is accompanied with slight tumefaction, and pre- 
 sents the appearance of a small papula surrounded with a red 
 areola; from the third to the fourth day the disease assumes a 
 vesicular form, the epidermis being raised by a fluid more or less 
 opaque, presenting at its apex a small dark point ; from the fourth 
 to the fifth day the contents of the vesicle become purulent, the 
 apex of the pustule depressed, resembling very much the pustule 
 of small-pox. At this period the areola, which had progressively 
 increased, begins to diminish or altogether disappears, particularly 
 if the disease does not increase : after the fifth day, however, the 
 subjacent and surrounding tissues, which hitherto had undergone 
 little or no modification or were merely slightly oedematous, become 
 indurated by the extravasation of a plastic lymph, which commu- 
 nicates to the touch the resistance and elasticity of cartilage. After 
 the sixth day the contents of the pustule thicken, the pustule itself 
 shrivels up, and is covered with crusts. These enlarge towards their 
 base, and forming by successive strata, at length assume the form 
 of a truncated cone with a depressed apex. If these crusts are 
 detached, or if they fall off, we find under them an ulcer with the 
 hard base of which we have spoken, extending through the whole 
 thickness of the skin. The surface of this ulcer, of a deep red 
 colour, is foul, covered with a thick adhesive pultaceous matter, 
 almost like a false membrane, which cannot be removed by any 
 attempt to clean the sore. The edijes of the ulceration at this 
 period appear as though it had been dus: out from the surrounding 
 parts by a sharp circular instrument. The immediate vicinity of 
 the sore is surrounded by a red, dark, or livid margin, more elevated 
 than the surrounding parts. 
 
 64. M. Ricord further establishes that chancre in its commence- 
 ment is purely a local disease; that constitutional or secondary 
 affections can only take place after this antecedent; that they do 
 not occur in all cases, and only after the lapse of a certain period 
 of time. 
 
 65. Whatever may be the varieties and complications which 
 subsequently follow or accompany the inoculated chancre, the pro- 
 gress of the latter is in all instances such as we have described it. 
 The pustular form of incipient chancre is only wanting when the 
 parts to which the virus is applied are destitute of epidermis or 
 epithelium, it is only preceded by phlegmonoid inflammation when 
 the matter has been introduced into the subcutaneous cellular tissue, 
 or into the lymphatic system. 
 
 66. The ulcerations completely destroyed or arrested on the 
 third, fourth, or fifth day from the application of poison are not 
 liable to secondary inflammation. It is not before the fifth day 
 that the induration of chancres commonly commences, and it is 
 
INOCULATION. 25 
 
 the indurated chancre that is most frequently followed by secondary 
 symptoms ; this induration seems to indicate that the affection has 
 become in some measure already constitutional; as long as there is 
 no induration we may suppose the disease to be merely local. 
 
 67. The varied appearance which primary venereal sores pre- 
 sents (says M. Ricord) has given rise to arguments against the 
 identity of the venereal vims, and has led to the promulgation of 
 the theory of a plurality of venereal poisons. Inoculation, how- 
 ever, sets this matter at rest, for whatever may be the actual cha- 
 racter of the sore from which we take the pus, provided it be taken 
 during the first stage of the chancre, that of ulceration or indolence, 
 we obtain by inoculation a regular pustule when the matter is in- 
 troduced beneath the epidermis or epithelium; an ulcer when it is 
 applied to a denuded surface ; and an abscess when introduced into 
 the cellular tissue, or into the lymphatic system. 
 
 68. The various characters of chancres or primary venereal ' 
 sores, are due to circumstances which are foreign to the specific 
 cause which produced them ; these are principally the particular 
 constitution of the patient, his mode of living, the influence of any 
 antecedent or present disease with which he may happen to be 
 affected, and not least the local treatment of the sore. It is from 
 one or many of these circumstances that we see phagfdenic ulcers 
 in subjects who have contracted this disease from others affected 
 with ulcers of the simplest character. 
 
 69. The first stage of chancre, i. e. of ulceration or indolence, is 
 the only one during which the disease is susceptible of propagation 
 by inoculation ; the period of this stage is not limited, hence M. 
 Ricord has known primary venereal sores capable of propagation 
 after having continued eighteen months. 
 
 70. The researches of M. Ricord on the nature and differential 
 diagnosis of buboes are of equal interest with those which we have 
 detailed on the subject of primary sores. According to this author, 
 buboes are of two kinds, simply inflammatory, or virulent: in the 
 first instance, succeeding to gonorrhoea, balanitis or any other pri- * 
 mitive affection; and in the second, from the consequences of the 
 direct absorption of specific matter from a chancre. To the patho- 
 logy of bubo we shall return in the section particularly devoted to 
 its consideration ; in this place merely detailing the results obtained 
 by inoculation from buboes in a condition of ulceration. 
 
 71. M. Ricord deduces from his experiments upon buboes in a 
 condition of ulceration, the following conclusions: that a virulent 
 bubo, or one resulting from the absorption of the specific pus from 
 a chancre, is a disease precisely similar to chancre, merely differing 
 from it in its seat, and the anatomical organisation of the parts 
 affected ; that this species of bubo is the only one capable of pro- 
 ducing a pustule by inoculation ; that the symptoms hitherto indi- 
 cated by authors, with a view of establishing the differential, diag- 
 nosis between a true virulent bubo and one merely inflammatory, 
 
*l> PARKER ON SYPHILITIC DISEASES. 
 
 are of little value, inoculation being the only certain and palhog- 
 nornonic sign. 
 
 72. M. Hi co rd admits the existence of buboes which are not pre- 
 ceded by any other syphilitic affection: these make their appear- 
 ance at a certain period after an impure connection without the 
 intervention of chancres, gonorrhoea, balanilis, or other form of 
 prirmry irritation. The existence of these buboes is also admitted 
 by Pallopius, Astruc, Svvediaur, Bertraude, and lately by Dr. Mondret 
 in a memoir inserted in the "Recueil periodique de la Societe de 
 Medecine," for .August 1837. These buboes are termed by the 
 French surgeons " bubons d'emblee," and may be either simply 
 inflimmatory or syphilitic. M. Ricord .insists that when these 
 buboes occur without the intervention of any antecedent form of 
 disease, it is impossible to judge of their true character without the 
 test of inoculation, and consequently impossible to heal them 
 rationally or well. He maintains that those only which furnish 
 the characteristic pustule of chancre by inoculation are those only 
 which are capable of being followed by secondary symptoms. 
 Those from which no pustule can be obtained by inoculation are 
 simply inflammatory, and must be treated on general principles. 
 
 73. With reference to the test of inoculation itself, some degree 
 of difference of opinion exists, although M. Ricord states that the 
 reason of this is, that the experiments have not been made in a 
 proper manner. On this point we consider the author's opinions 
 worthy of attention. Whenever inflammation and suppuration of 
 the cellular tissue, or lymphatic glands of the groin, is owing to 
 any other cause than the occurrence of chancre, the pus secreted 
 furnishes no result from inoculation, at whatever periods and under 
 whatever circumstances the test may be made. Neither does it 
 follow, of necessity, that buboes succeeding to true chancres will 
 furnish a specific pus; and consequently, by inoculation, a charac- 
 teristic pustule. That this may occur it is necessary that the bubo 
 shall not merely be owing to the simple sympathetic inflammation, 
 but that actual absorption of the specific matter of the chancre shall 
 have taken place. When absorption of the matter from a chancre 
 on the genitals takes place, it is generally confined to the superficial 
 glands of the groin ; and most frequently the syphilitic poison is 
 conveyed to one gland only, although many of the glands in the 
 immediate vicinity of the latter, both superficial and deep-seated, 
 are inflamed, and suppurate at the same time, so that the matter 
 taken from one gland shall be purely syphilitic, and give rise, by 
 inoculation, to the characteristic pustule, whilst those in its imme- 
 diate neighbourhod, and the cellular tissue, shall be affected by 
 simple phlegmonoid inflammation, the pus from which shall, when 
 tesu-ij by inoculation, give a negative result. 1 
 
 74. It may be very readily conceived, that the irritation produced 
 
 * See Ricord, op. cit. p. 142 et suivantes. 
 
INOCULATION. 27 
 
 by the passage of the syphilitic poison through a lymphatic 
 vessel and ganglion may excite in the neighbouring organs an in- 
 flammation which is not specific, but merely phlegmonous, and 
 this appears to be the true nature of the case. M. llicord opened 
 a bubo which had succeeded to a chancre, the pus from which pro- 
 duced no result by inoculation. In the centre of the abscess lie 
 discovered an enlarged lymphatic gland, presenting an evident 
 fluctuation; this was punctured and tested by inoculation, the cha- 
 racteristic pustule of chancre was obtained. 
 
 75. Discharges from the urethra are of two kinds, resulting 
 either from the existence of a true syphilitic ulcer in some part of 
 the passage, or owing to gonorrhoea properly so called. Chancres, 
 or syphilitic ulcers of the urethra, to the consideration of which we 
 shall return in a particular article, are in all respects, except situa- 
 tion, of the same character as other primary sores, and give rise to 
 the same results when the matter is tested by inoculation. 
 
 76. The matter of gonorrhoea applied upon a mucous surface 
 produces an inflammation and discharge of the same character. In 
 no instance can it produce a true syphilitic sore; although remain- 
 ing in contact with a mucous surface for a certain period of time, 
 it may occasion a greater or less degree of excoriation, but is not 
 capable of producing a specific ulcer, as the researches of Ricord, 1 
 Hernandez, 2 and others incoritestably prove. 
 
 77. The diseases which are consecutive to gonorrhoBa, as sympa- 
 thetic buboes, ike. do not secrete pus capable of producing a spe- 
 cific ulcer by inoculation, neither do secondary or constitutional 
 symptoms ever succeed to a simple gonorrhoea. M. Ricord thinks 
 that in the rare cases where secondary symptoms have been said to 
 have followed a simple gonorrhoea, that the diagnosis of the primi- 
 tive disease has been inexact, that the diseased surfaces have not 
 been properly examined, and the cases have been concealed chancres 
 of the urethra, and not gonorrhoea. It is also extremely probable 
 that such were the forms of disease which embarrassed Dr. Wal- 
 lace, who says that lie had met with some forms of discharges 
 from the urethra, which were beneficially influenced by mercury, 
 and which he was unable to cure without its exhibition. 
 
 7S. The pus of gonorrhoea, tested by inoculation, gives no result; 
 it may be followed by inflammation, but never produces a specific 
 sore: injected into the urethra it produces a disease like that of 
 which it is the product; applied externally between the glans and 
 prepuce it occasions inflammation and discharge, balanitis, or ex- 
 ternal gonorrhoea : a similar effect follows its application upon 
 other mucous surfaces. One remark may be made here, in conclud- 
 ing the account of the results obtained by Ricord and others from in- 
 
 1 Mrnoires, sur quelques Faits observes a 1'Hopital des Veneriens, par P. 
 Ricord. Memoires de I'Academie Royale de Medecine. Tome 2me. 
 
 *Essai analytique sur la Nonidentite des virus gonorrhoique et syphihtique; 
 par J. F. Hernandez. Toulon, 1S12. Art. iv. 
 
28 PARKER ON SYPHILITIC DISEASES. 
 
 oculation as a means of diagnosis in syphilitic diseases, that when 
 it is resorted to in cases of uncertainty, we are to test the matter 
 frequently, from day to day, during the whole process of disease; 
 for, as in other instances, we may here find that, although we have 
 not succeeded in obtaining a result from the first, second, or even 
 third puncture, we may eventually do so; daily experience in other 
 diseases, vaccination in cow-pox, inoculation in small-pox, &c, 
 showing that from circumstances we cannot appreciate, the first 
 puncture may not succeed, when a second or third will be followed 
 by a characteristic pustule. 
 
 79. We now enter more particularly upon the particular descrip- 
 tion and treatment of syphilitic affections. These diseases present 
 in their primitive forms two varieties, distinct in their nature, treat- 
 ment, and results ; these are gonorrhoea and its varieties, and 
 chancres or primary venereal sores. A third primitive form may 
 be added, which is bubo, the "bubon d'emblee" of the French 
 syphilographers ; but, as this occurs more frequently as a conse- 
 quence of one of the other two varieties, than as a primary symp- 
 tom, we shall not here rank it among the latter. 
 
 SECTION IV. 
 
 Of the First Class of Primary Syphilitic Diseases. 1 
 GONORRHOEA, ITS VARIETIES AND CONSEQUENCES. 
 
 I. OF BALANITIS. 
 
 Inflammation of ike Glans Penis External or False Gonor* 
 
 rhosa. 
 
 80. This disease is characterised by more or less redness, and a 
 muco-purulent discharge from the surface of the glans penis, with 
 or without excoriation. Balanitis rarely occurs alone, but is more 
 frequently complicated with a similar condition of the internal sur- 
 face of the prepuce (posthitis). It is then termed by Desruelles, 
 balano-posthitis. As it is rare to see the affections separate, I shall 
 consider both under the title of balanitis. 
 
 81. This affection may have a purely venereal origin, or may 
 succeed to connection with women labouring under leucorrhrea, or 
 other simple inflammatory affections of the vagina, or when this 
 part is covered with secretions of a more or less irritating character. 
 
 1 Synonyms. Affections non virulentes. Ricord. Maladies primitives 
 a forme erythemateuse. Desruelles. Catarrhal primary syphilis. Wal- 
 lace. 
 
GONORRHCEA. 29 
 
 The menstrual discharge will also frequently occasion balanitis; and 
 I have frequently seen great anxiety arise to married men who 
 have suffered from balanitis, the result of connection with their 
 wives in one or other of the above-mentioned states. Balanitis 
 sometimes owes its origin to a natural conformation of parts, and 
 hence subjects with a natural phymosis, or small preputial opening, 
 may be considered as predisposed to it. 
 
 82. The symptoms which ordinarily denote the existence of 
 balanitis are heat and itching of the glans and prepuce, with a dis- 
 charge of variable character from the orifice of the latter ; these 
 symptoms may be accompanied by phymosis, or paraphymosis. When 
 the prepuce can be drawn back and the glans uncovered, this is 
 found red, swollen, and covered with a muco-purulent fluid of an 
 unpleasant smell. The epithelium of the glans and prepuce is 
 detached in places, excoriated, but not in a state of true ulceration. 
 The testicles and glands of the groin are sometimes more or less 
 swollen and tender; we have seen the former occasionally suppurate, 
 and bubo supervene upon balanitis. 
 
 83. Balanitis may be complicated with gonorrhoea, or with true 
 venereal ulcerations of the glans or prepuce. It is commonly an 
 acute disease, and generally gives way easily to proper remedies ; 
 it may, however, pass to the chronic state, or exist in such a condition 
 from the commencement ; in either case, after relief or cure, it is 
 prone to be easily reproduced by slight exciting causes. The con- 
 tinuance of balanitis, in the chronic state, may occasion enlarge- 
 ment of the sebaceous follicles, vegetations at the base of the glans, 
 thickening and hypertrophy of the mucous membrane, adhesions 
 between the glans and prepuce, or according to Roux, cancer of the 
 penis ; it is also the most common cause of phymosis and paraphy- 
 mosis. 
 
 84. The treatment of uncomplicated balanitis is extremely simple. 
 When the glans can be denuded, and the inflammation is not very 
 acute, M. Ricord passes the solid nitrate of silver slightly over the 
 surface, covers it with a piece of soft linen, and then brings the 
 prepuce forwards over the glans. The penis should be covered 
 with linen compresses soaked in cold water, or the liquor plumbi 
 diacetatis dilutus, and the linen between the prepuce and glans 
 renewed twice in the day: at each renewal of the linen, the parts 
 should be washed with an astringent lotion. 1 It will be occasion- 
 ally found that lotions of all kinds tend to keep up the irritation. 
 When this is the case, the surface of the glans should be thickly 
 dusted with an astringent powder; 2 this tends to allay the irritation, 
 by absorbing the acrid secretions, and preventing any friction be- 
 tween the glans and prepuce. If the inflammatory symptoms 
 
 '*. Plumbi acetatis, jj. 
 
 Aquae distillate, Sviij. M. ft. Lolio.JRicord. 
 
 f !k. Plumbi subcarbonat. 
 Pulvis cinchonas, aa ^j. 
 Pure tannin, gr. v. M. ft. pulvii. 
 
30 PARKER ON SYPHILITIC DISEASES. 
 
 accompanying balariitis run high, and are complicated with phy- 
 mosis, leeches may be applied in the groin or perineum, aperients 
 administered, and the patient should keep quiet and live low. In- 
 jections of the nitrate of silver or an aqueous solution of opium 
 may he thrown up between the glans and prepuce, and one or two 
 leeches applied to the tumefied under portion of the prepuce. In 
 cases where balanitis, thus complicated, terminates in gangrene, or 
 this is threatening", Ricord recommends the free exhibition of opium, 
 either by the mouth, or united with camphor in form of enema. 
 Desruelles speaks highly of continued injections or irrigations in 
 balanilis, or balano posthitis, resorted to when these diseases are 
 complicated with phymosis. To accomplish this, a small canula 
 may be fitted to one of Weiss's self-acting- enema syringes; the 
 canula, which should be made of caoutchouc or elastic gum is to 
 be passed between the glans and prepuce, and thus, without re- 
 moving it, a continued stream of some narcotic or astringent injec- 
 tion 1 may be thrown gently up for some minutes together. 
 
 83. Balanitis may occur without being complicated with other 
 and more marked venereal symptoms, or it may coexist with 
 chancres of the glans or surface of the prepuce. In these instances, 
 where patients present themselves to us, after a suspected intercourse, 
 with phymosis and muco-purulent discharges from the preputial 
 opening, we must remain uncertain whether the disease is compli- 
 cated with chancre or not; but as it frequently is so. Cullerier and 
 Ricord are very guarded in resorting to any operation with the 
 knife for the relief of the phymosis unless the danger of gangrene 
 be imminent. In these forms of disease we must, in the first in- 
 stance, subdue the inflammatory symptoms in the manner recom- 
 mended for the treatment of simple balanitis; injections of nitrate 
 of silver are to be thrown up between the glans and prepuce, 8 or 
 we may endeavour to pass the solid nitrate between these two parts, 
 and thus superficially cauterize the whole surface within reach. 
 Ricord speaks most highly of this practice in balanitis complicated 
 with inflammatory phymosis. The antiphlogistic treatment roust 
 be followed up till the glans can be denuded, and the true nature of 
 the disease and its complications thus made evident. When bala- 
 nitis is complicated with chancres, the general inflammatory symp- 
 
 1 *. Decoct, papaveris, h. ij. 
 
 Alurainis ust. gr. xx. M. ft. injectio. Desruelles. 
 
 Simple tepid water, with alum in the proportion of eight or ten grains to the 
 pint, forms an exceedingly useful injection, particularly where large quan- 
 tities are used. 
 
 Cullerier employs the following preparation: 
 9*. Cerati simplicis. vel mellis, 
 Olei olivae, aa 3j. 
 Hydrargyri chlorid. Jss. 
 Ext. opii, 3j. M. 
 
 Introduced between the glans and prepuce by means of a camel-hair pencil; 
 a remedy of great value. 
 
GONORRHCEA. 31 
 
 toms are to be first removed, and the syphilitic affection then treated 
 specifically. 
 
 II. OF GONORRHCEA. 
 
 Urcthritis, Acute or Chronic, Dcsruelles. Bleu orrh agio, 
 Swediaur. Venereal or Syphilitic Catarrh, Wallace. 
 
 86. Gonorrhoea, a disease of daily occurrence, is perhaps as much 
 or more than any other presented to the surgeon, the daily source 
 of annoyance to him, and anxiety and weariness to his patient. 
 This, we apprehend, arises in a great measure from the want of a 
 correct knowledge of its modifications and varieties, 1 and conse- 
 quently an uncertainty in the treatment more especially adapted 
 to its different forms. Gonorrhoea consists in inflammation more or 
 less acute of the mucous membrane of the urethra or other parts of 
 the genito-urinary passages, accompanied by the secretion of a 
 muco-purulent fluid of a yellow or greenish appearance ; pain, itch- 
 ing, or irritation in voiding the urine, with, in the male, repeated 
 and involuntary erections of the penis. 
 
 87. We believe, with the best pathologists of the day, that gonor- 
 rhoea, though the result of impure cohabitation, and hence termed 
 a venereal disease, is an affection of a totally different character to 
 the primitive syphilitic ulcer. We do not believe the opinions of 
 the late Dr. Wallace to be true, that syphilis and gonorrhoea are 
 varieties of the same disease; 2 modern testimony, drawn from the 
 results of inoculation, universally proving that the pus of chancre 
 has never produced gonorrhoea, and the reverse. 3 Holding these 
 views, we believe, with M. Cullerier, that gonorrhoea, properly so 
 called, is incapable of producing secondary symptoms, and that the 
 instances, which are, however, comparatively rare, in which this is 
 said to have occurred, have been owing to chancres or primary 
 venereal sores of the urethra, which an imperfect diagnosis has, in 
 the first instance, confounded with gonorrhoea. 
 
 88. The causes of gonorrhoea are various ; the most frequent, 
 however, is cohabitation with a female affected with the same dis- 
 ease. It is certain that inflammation, with rnu co-purulent discharge 
 from the urethra, may be the result of connection with women who 
 
 1 Varieties of gonorhoea. Ricord. 
 First species. Gonorrhoea in the female : 
 ( the vulva, i 
 
 Varieties, seated in |jj * j * ""** < ' Usl * 
 
 C the urethra, ) 
 Second species. Gonorrhoea in the male 
 
 " " 
 
 Varieties, seated in j thr, or j T "jlbined' 
 
 ( the glans penis, ) 
 f On the Venereal Disease, &c. p. 284. and elsewhere. 
 8 See Ricord, and the authors quoted by him in his work already referred 
 lo, also Cullerier, in Lucas Championniere's work, p. 384, &c. &c. 
 
32 PARKER ON SYPHILITIC DISEASES. 
 
 labour under various forms of disease, such as inflammation of the 
 vagina; the lochial or menstrual discharges, fluor albus, liberations 
 of various kinds not syphilitic, different morbid conditions of the 
 os uteri, amongst which Cullerier and Ratier specially mention the 
 cancerous ulcer. It appears to me evident that, in the present state 
 of science, it is impossible with certainty to ascertain what may be 
 the true cause of that gonorrhoea which succeeds to cohabitation, 
 unless the female be submitted to examination with the speculum: 
 and hence M. Ricord states that no confidence is to be placed upon 
 any statements of this character, unless the speculum have been 
 employed as a means of confirming our diagnosis; the condition of 
 the constitution also at the time of exposure to infection must be 
 ranked as a predisposing cause. Gonorrhoea is also due to other 
 causes apart from sexual intercourse, as masturbation, habitual 
 costiveness, inflammation of the prostate gland, certain morbid 
 conditions of the bladder or ureters, particularly the presence of 
 calculi in these parts, piles, and the excessive or immoderate use of 
 wine or fermented liquors generally. In children this affection is 
 sometimes dependent upon teething or intestinal worms. It also 
 recognises for its cause a gouty or scorbutic diathesis, or succeeds 
 to the suppression of habitual discharges or the cure of old stand- 
 ing cutaneous eruptions. In addition to all these causes, which 
 are strictly internal, gonorrhoea is produced by external violence 
 or injuries to the penis, and the operation of a second class of causes 
 of various kinds which are external. 
 
 89. Pathology. Gonorrhoea consists in an inflammation more 
 or less diffused of the mucous membrane of the urethra, (fee. Dr. 
 Wallace considers this inflammation, from its diffused or erratic 
 character, to be of the erysipelatous kind; hence Desruelles terms 
 it "inflammation erythemateuse." The inflammation does not 
 commonly affect the whole surface of the urethral mucous surface: 
 when it does so, it assumes the name of "gonorrhoea vimlenta," 
 and is generally accompanied with violent symptomatic fever. The 
 points in which the inflammation remains most commonly fixed, or in 
 which it is manifested with greatest intensity, are the fossa navicu- 
 laris, and the vicinity of the bulb: this arises from the anatomical 
 disposition of the mucous membrane, which, in this situation, is 
 much more intimately adherent to the erectile tissue beneath it. 
 Gonorrhoeal inflammation may be diffused over a wide surface, and 
 " may involve at the same time the whole of the urethra, the bladder, 
 the testicles, the glans and prepuce in the male ; and in the female 
 the nymphae, clitoris, labiee, vagina, &c. ; and thus commencing at 
 the preputial end of the penis, in the fossa navicularis, it not unfre- 
 quently creeps slowly on to the posterior parts of the urethra, to 
 the bladder, or to the testicles 3 while it decreases or ceases entirely 
 in the parts first affected." 1 It may be confined to the mucous 
 membrane itself, or extend to the tissues beneath it ; in the latter 
 
 1 Wallace, pp. 237-8. 
 
GONORRHOEA. 33 
 
 instance the irritation constantly determines a flow of blood into 
 the cells of the erectile tissue of the corpora cavernosa and corpus 
 spongiosum, which occasions a continual tension of the penis. 
 Occasionally the inflammation becomes located in some part of the 
 canal, producing thickening, effusion into the suhmucous cellular 
 tissue, and in some cases ulceration; in these forms the disease 
 assumes more of a local character, and is not so much disposed to 
 spread by continuity of tissue. 
 
 90. Symptoms. The general symptoms of gonorrhoea are too 
 well known to need description, yet those which indicate its locali- 
 sation in particular parts of the urethra may be detailed with 
 advantage. When the disease is confined to the fossa navicularis, 
 it is only in this portion of the passage that uneasiness or pain 
 is felt when the patient voids his urine; the glans is more or less 
 swollen, and its lips tumefied arid red. On pressing and rolling 
 the urethra between the thumb and finger a distinct thickening is 
 felt, as though a portion of a sound had been introduced into the 
 urethra, the pressure is also painful to the patient. The greater 
 and more marked the thickening of the urethra in this situation, the 
 stronger is the presumption that the disease is localised there, and 
 does not extend to other portions of the canal. The discharge 
 under these circumstances, is trifling, though very teasing to the 
 patient ; it is constantly presented at the orifice of the urethra. 
 When the inflammation predominates, or is fixed in the straight 
 portion of the urethra between the glans and the bulb, the patient 
 has no pain in the perineum, .but he experiences severe pain in 
 making water, has frequent erections of short duration, and the dis- 
 charge is more copious than when the disease is confined to the 
 fossa navicularis. 
 
 91. If the disease be located in the bulbous portion of the ure- 
 thra, the patient has pain in the perineum increased by pressure, a 
 constant desire to void his urine, with frequent erections of the penis. 
 The discharge is abundant accompanied with great pain, and the 
 stream of urine is diminished. When the membranous portion of 
 the urethra is chiefly affected, the pain is severe in the perineum 
 and the neighbourhood of the anus; the desire to void the urine isiii 
 many cases constant. The prostate anc* ue isticles are commonly 
 enlarged and painful, the spermatic vesse^congested, as well as the 
 vasa daferentia. Consecutive diseases of .he bladder, prostate, and 
 testicles, are more frequently to be feared when the gonorrhoea 
 occupies principally the two last mentioned seats. 
 
 92. Sympathies. During the course of a gonorrhoea, the patient 
 is not unfrequently tormented with pains in the groins, weight and 
 dragging in the testicles, irritation in the rectum, and tenesmus. 
 These depend chiefly upon the localisation of the primitive disease, 
 and are easily explained by the anatomical relations of the urethra. 
 Fever of an inflammatory or intermittent character is sometimes 
 present, arid affections of the joints, which have been described by 
 some authors under the title of gonorrhceal rheumatism. 
 
 23 a 3 park 
 
34 
 
 PARKER ON SYPHILITIC DISEASED. 
 
 93. Varieties. Gonorrhoea is not always confined to the organs 
 of generation, or their dependencies ; hence varieties in its seat, 
 owing either to the sympathies of other parts during the presence 
 of an urethra! gonorrhoea, or from the direct application, from acci- 
 dent or carelessness, of the matter to a healthy mucous surface. 
 These varieties in the seat of gonorrhoea have chiefly been observed 
 in the eye, the nose, and the rectum. Ricord speaks of having 
 observed the latter, principally in the female. 1 
 
 94. Consequences and terminations. The more acute forms 
 of gonorrhoea may terminate in resolution or chronic discharges 
 simply, a mere supersecretion, without ulceration or breach of sur- 
 face ; to ascertain this, however, when a discharge continues 
 indefinitely, without being materially influenced by remedies, the 
 canal of the urethra in the male, or the vagina in the female, should 
 be examined by bougies, or the speculum. The other more 
 ordinary terminations of gonorrhoea are ulcerations of the urethra, 
 stricture, and diseased conditions of the bladder, prostate, or tes- 
 ticles. 
 
 95. Treatment. It is of immense importance that gonorrhoea 
 should be prevented, or cut short in its. commencement, since its 
 duration, in many instances, is almost indefinite, and its conse- 
 quences so serious. Patients, in a state of alarm after a suspected 
 connection, frequently seek the advice of their surgeon with the fol- 
 lowing symptoms : slight irritation in the urethra, dragging of the 
 penis and testicles, uneasiness in voiding the urine ; with redness 
 and tumefaction of the lips of the meat us, and a slight increase in 
 the natural secretion of the mucous membrane of the urethra itself. 
 These symptoms do not indicate, as M. Ricord justly observes, that 
 a gonorrhoea has been contracted, since an excessive excitement of 
 the organs of generation, without infection, might produce them ; 
 but in the positive absence of any means of a differential diagnosis 
 between this and the commencement of actual gonorrhoea, it behoves 
 the patient to be careful. M. Ricord is of opinion that many 
 gonorrhoeas might be avoided, and the symptoms cut short on the 
 onset, if the patients did not commit errors or excesses in diet at this 
 period, and continue to expose themselves to all kinds of excitement. 
 This opinion is deserv(is r of the more attention, since we commonly 
 see a discharge from thlhejrethra set up and continue for some days 
 after a debauch and theb>of itself subside. 2 When the symptoms 
 we have indicated make their appearance, the patient should strictly 
 adopt and adhere to the lowest possible diet, repose as much as 
 possible in the recumbent position, and take smart aperients with 
 diluent drinks. The warm bath must be avoided; this, of itself, 
 under such circumstances, has frequently produced the disease ; the 
 cold bath, in warm weather, may be used. 
 
 1 Op. cit. pp. 764-5. 
 
 2 The researches of M. Lombard, of Geneva, prove that the excessive use 
 of malt liquors, wines, &c. tends to produce discharges from the urethra, and 
 inflammation of its lining memhrane. 
 
GONORRHCEA. 35 
 
 96. A true gonorrhoea may be either acute in its commencement, 
 or ushered in with symptoms so mild, and apparently so trivial, as 
 to he termed chronic ; the disease also may assume a variety of 
 shades of intensity, varying- between these two extremes. Against 
 the first form a pure antiphlogistic treatment should be adopted. 
 Bleeding from the arm. aperients, low diet, with local bleeding, by 
 means of leeches, from the perineum, from the glans on either side 
 of the prepuce, or from the meatus urinarius itself, with the warm 
 bath, and complete repose of the organs affected, constitute the rem- 
 edies especially applicable to the first stages of acute gonorrhoea. 
 Little medicine is here requisite, beside small doses of the nitrate of 
 potash, administered in a copious draught of barley tea. The 
 gonorrhceal discharge may be ushered in with symptoms less acute 
 than those just described ; and under these circumstances general 
 bleeding may be unnecessary, although, if the patient be plethoric 
 and of full habit, general depletion in the commencement will most 
 materially facilitate our chance of a speedy cure. 1 Again, in that 
 form of gonorrhoea which is chronic from the commencement, it 
 will be well at first to examine carefully the urethra, and if we find 
 a part which is indurated, hot, and painful on pressure, to apply a 
 few leeches over it. 2 It is merely necessary to state that local 
 bleeding, employed for these purposes, is not to be resorted to for 
 the removal of the discharge merely; nor without the symptoms 
 of inflammation on some point of the urelhra are evident. If 
 employed when the membrane is lax, and no inflammation is 
 present, where the disease is merely a gonorrhoea, and not an ure- 
 thritis, we shall prolong the affection instead of cutting it short. 
 
 97. An antiphlogistic treatment, although calculated to facilitate 
 theaction of other remediesin the cure of gonorrhoea, is notcalculated 
 of itself, at least but rarely, to accomplish this object. Hence another 
 plan of treatment has been framed, which is termed by the French 
 syphilographers " revulsive." This consists in the employment of 
 remedies which are supposed, by producing a specific action of their 
 own on the lining membrane of the urethra, to supersede that of gonor- 
 rhoea: these remedies are principally copaiba, cubebs, turpentine, the 
 preparations of iron, iodine, and cantharides, with injections. Every 
 practitioner must daily witness the uncertainty of the revulsive treat- 
 
 de pratiquer la saignee dans ce cas, c'est laisser echapper 1'une 
 des indications les plus pressantes. Desruelles, p. 421. 
 
 2 To illustrate by a case the use of topical bleeding from a point of the 
 urethra, in that form of gonorrhoea which is termed chronic : A gentleman 
 consulted me, who had been the subject of a slight discharge from the ure- 
 thra for five months, he had frequent desire to void his urine, with a constant 
 and troublesome tenesmus ; he had tried remedies of all kinds, and injections 
 during this period with partial benefit, and occasional injury. On examining 
 his urethra, which had not been before done, I discovered tenderness, with 
 thickening of the urethra, in the perineum. Four leeches were applied with 
 great benefit, and by their repetition at intervals three or four times, he lost 
 his pain, his tenesmus, and the discharge. 
 
36 PARKER ON SYPHILITIC DISEASES. 
 
 merit of gonorrhoea employed alone, and the change from remedy to 
 remedy, with but partial benefit to the patient. In this uncertainty 
 Ricord and others have endeavoured to lay down certain rules at 
 what period the revulsive treatment may be resorted to with the 
 most certain hope of realising its full and curative effects. " When," 
 says this author, " the acute stage has ceased, although the patient 
 may yet continue to be troubled with erections, and although the 
 penis may be heavy and uneasy, and the glans and lips of the meat us 
 still red and slightly swollen, I have recourse to those remedies 
 which are termed ' par excellence,' anti-gonorrhoeal, which, however, 
 I abandon, to have recourse again to antiphlogistics, if their em- 
 ployment occasion the least increase of inflammation." 1 
 
 98. "When," says Dr. Wallace, "an impression has been made 
 on the inflammatory symptoms, and that they cease to advance or 
 remain stationary, the urethra should be injected every morning 
 with a solution of the nitrate of silver, made in the proportion of 
 fifteen or twenty grains to the ounce of distilled water, and the 
 patient should be placed under the combined influence of mercury, 
 and the balsam of copaiba and cubebs." 2 
 
 99. We are not to conclude from what has been said, that in all 
 instances general and local bleeding are to be employed in gonor- 
 rhoea before we have recourse to those remedies that are more 
 particularly termed specific. Thus, in scrofulous and weak subjects, 
 those previously troubled with nocturnal emissions the inflamma- 
 tion may be of so passive a character that it will be proper to have 
 recourse at once to the revulsive treatment, with injections. In all 
 cases, however, as I have before said, a careful examination of the 
 state of the urethra and the constitution of the patient, should be 
 instituted. 
 
 100. Of specific, remedies. Copaiba. This remedy, in form 
 of balsam, is the one most commonly used in the revulsive treat- 
 ment of gonorrhcea, and that upon which most dependence is to be 
 placed. It may be employed early in the disease, unless the 
 inflammation of the urethra be very acute; it is then only to be 
 used when the symptoms are in some measure mitigated by general 
 and local bleeding, (fee. If the disease be subacute, it may be 
 administered during the period that local bleeding from the perineum, 
 &c. is practised. In the chronic forms of the complaint, it may at 
 once be employed. Ricord remarks, that it is only against the 
 urethral form of gonorrhcea that copaiba is efficacious; he believes 
 it possesses little or no influence over the vaginal, or uterine varie- 
 
 1 Ricord, pp. 725-6. 
 
 * Wallace, p. 257. In this stage of the disease, Dr. Wallace administers 
 five grains of the blue pill, with a grain of opium every night; we apprehend 
 the benefit said to be derived from the practice is due to the opium and not to 
 the mercury, as we do not recognise the principles on which it is given "to 
 prevent bubo and secondary symptoms." We are likewise of opinion that 
 the nitrate of silver should be employed in the first instance in the proportion 
 of a quarter of a grain of the salt to the ounce only. 
 
GONORRHOEA. 37 
 
 ties, &c. Both this author and Desruelles think it much more 
 effectual given alone, than in a state of combination with other 
 remedies; and recommend it to be given, as the most pleasant way 
 and least likely to disturb the stomach, on the surface of a glass of 
 white wine or lemonade. Dr. Wallace, on the contrary, believes 
 its effects are more marked in a state of combination, at least that 
 the combination is more beneficial than the balsam taken singly. 1 
 This author combines it with cubebs, or alternates one remedy with 
 the other. It may be given by way of enema when the stomach 
 will not bear it, but when so employed the dose must be much larger 
 than when given by the mouth. The copaiba has likewise been 
 administered with succes in large doses al the very onset of gonor- 
 rhoea, however acute, and without any preparatory treatment. 
 Monteggia and Fuller administer from half an ounce to an ounce 
 of the balsam for a dose night and morning, at all periods of the 
 disease. 2 M. Delpech succeeded in curing four hundred cases by 
 administering two drams and upwards for a dose three times a 
 day ; if the inflammation was acute, general bleeding preceded its 
 employ. 3 Rossignol was successful in three hundred cases of 
 gonorrhoeas of all kinds. He employed large doses of the medicine 
 uncombined, and did not submit his patients to any preparatory 
 treatment, or any dietetic regimen. 4 The average duration of treat- 
 ment in these cases was eight days. The method we have just 
 described must be employed with caution, and, in most cases where 
 the patient is plethoric, it would be well to accompany or precede it 
 with a general bleeding. We think it might be then employed with 
 pretty general success, in cutting quickly short a gonorrhoea, when 
 a patient applies immediately after having contracted it. M. Lalle- 
 mand, in repeating the experiments of M. Ribes, 5 concludes, that 
 although the large doses of copaiba succeed sometimes in cutting 
 short an acute gonorrhoea, they sometimes augment the inflamma- 
 tory symptoms and the discharge. 
 
 101. The balsam of copaiba may be administered alone in wine 
 or lemonade, as I have said, and this is the best way when it is 
 used in the commencement of the disease. It may also be given in 
 various forms of combination. 
 
 102. The essential oil of copaiba, the resin of copaiba, and the 
 balsam inclosed in capsules have been employed with the view of 
 
 1 &. Bals. copaibae. 
 
 Pulv. cubebae, aa. j. 
 Liq. Potassae, ^ij. 
 Pulv. acacia:, ^ss. 
 Aquae rosae, ^vj. M. 
 
 Bulletin de la Societe Medicale d'Emulation, 1822. 
 Revue Medicale. T. vii. p. 403. 
 4 Dictionnaire de Merat et Delens. 
 
 6 Memoire sur I'emploi de baume de copahu a haute dose dans la gonorrhee 
 et Penjjorgement consecutif du testicale. Loc. cit. et Revue Medicale. T. ix. 
 M. Ribes gives from two drams to an ounce of the balsam for a dose, to cut 
 short a gonorrhoea in the commencement. 
 
38 PARKER ON SYPHILITIC DISEASES. 
 
 getting rid of its unpleasant smell and taste : these remedies-, 
 however, are none of them entitled to the same confidence as the 
 latter remedy. 
 
 Particular forms for the administration of Copaiba. 
 
 MIXTURES. 
 
 . Balsam, copaibae, 3j. 
 
 Mucilaginis gummi acacise, ij. 
 
 Vini Xerici, giy. M. (Val de Grace.) 
 A fourth part twice a day or more frequently. 
 
 5*. Balsam, copaibae, j. ad^ij. 
 
 Aquae, giv. 
 
 Vitelli ovi, No. 1. 
 
 Liq. opii sedativ. M. x. ad xx. M. Cullerier. 
 The quarter part, or more, night and morning. 
 
 3<. Ralsam. copaibae. 
 
 Syrup, tolutanos. 
 
 Mucilaginis gummi acacias, aalj- 
 
 Aquae rosae, Sjiij. 
 
 Sp. aetheris nitric. i$iij. 
 The quarter to the half, night and morning. 
 
 9<. Aquae menthae pip. 
 
 Sp. vini rect. 
 
 Balsam, copaibse. 
 
 Aquae aurantii, aa ^ij. 
 
 Sp. aetheris nit. sjj. M. Chopart. 
 Two large spoonfuls, three times a day. 
 
 5<. Resinae copaibae. 
 
 Sp. vini rect. 
 
 Syrup, bals. tolutan. 
 
 Aquae menthae pip. 
 
 Aquae aurautii, aa % ij. 
 
 Sp. aetheris nit., gij. M. Chopart. 
 Three or four large spoonfuls, night and morning. 
 
 PILLS. 
 
 &. Sapo. Hispaniolae, ^ij. 
 
 Balsam, copaiba?, ^j. 
 
 Pulv. glycyrrhizse, q. s. ft. pil. 120, 
 Dose. From 15 to 40 a day, at intervals. 
 
 *. Ext. Catechu, gss. 
 Bals. copaibee, 3''j- 
 Terebinthinae chise, ^j. 1 
 Sanguinis draconis, ^ss. M. 
 
 To be made into pills or boluses of ten grains, from ten to thirty 
 of which are to be taken daily at intervals. 
 
 1 1 have substituted the chia turpentine for the colophane, or powdered 
 yellow resin, of the original prescription. L. P. 
 
GONORRHCEA. 39 
 
 >. Ext. catechu. 
 
 Bals. copaibae, aa, Jiij. 
 
 Hyd. chlorid. )j. 
 
 Pulv. glycyrrhizae, q. s. ft. pil. 150. 
 Dose. Twelve a day, at intervals. 
 
 When employed as an enema, the dose of the balsam should be 
 from half an ounce to an ounce. 1 
 
 INJECTIONS. 
 
 *. Bals. copaibae. 
 Vitelli ovi, aa.^ss. 
 Infus rosae, ^xv. M. 
 
 5f. Bals. copaibae, ^j. 
 Sacchar. alb., j. 
 Sp. vini, ^vj. 
 Aquae dislillat. h. j. 
 Ext. opii, gr. vj. 
 
 Mix the balsam with the sugar, then add the alcohol and the water 
 gradually; pass the injection through a funnel with a view of 
 extracting those portions of the balsam which may not be dissolved. 
 This injection is employed by Desrueiles at Val de Grace, in chronic 
 gonorrhoea complicated with cystitis. 
 
 Cubebs. The piper cubebae is employed in the revulsive treat- 
 ment of gonorrhoea, after the same manner as the copaiba. It may 
 be administered in moderately large doses on the onset of an acute 
 affection, with a view of at once cutting it short ; when employed, 
 however, under these circumstances the same rules must be observed 
 as those we laid down for the administration of copaiba. The 
 cubebs may also be given in chronic gonorrhoea, and in gleet, sepa- 
 rately combined with copaiba, or as employed by Ricord, united 
 with some preparations of iron. It may also be employed in form 
 of enema. 
 
 Particular Forms for the exhibition of Cubebs. 
 
 MIXTURE OF TFIE CUBEBS AND COPAIBA. 
 
 *. Bals. Copaibae, gij. 
 Pulv. pip. cubebae, 3J. 
 Vini Xerici, ^iij. 
 
 Aquae rosae, aurantii, vel menthae, ^v. 
 Pulv. acaciae, q. s. ft. mist. 
 
 Employed with great success at Val de Grace, in acute or chronic 
 urethritis. 
 
 . ' See Velpeau, Recherches et observations sur PEmploi du Baume de 
 Copahu, et du Poivre Cubebe, adrninistree par 1'anus centre la blennorrhagie. 
 Archives generates de Medecine. T. xiii., p. 45. 
 
40 PARKER ON SYPHILITIC DISEASES. 
 
 ELECTUARY OF CUBEBS. 
 
 5<. Pulv. pip. cubebae. 
 Sanguinis draconis. 
 Pulv. ratanhiae. 
 Ext. catechu, aa. gij. 
 Bals. Copaibse, q. s. ft. Elect. 
 
 Dose. From two to four drams in the twenty-four hours, in 
 chronic gonorhoea, or gleet. 
 
 PILLS OF CUBEBS AND COPAIBA. 
 
 . Pulv. pip. cubebae recentis, 3J. 
 Balsam, copaibse, ss. 
 Vitelli ovi, q. s. 
 
 To be made into pills of five grains each. Dose. From six to sixty 
 a day, at intervals. 
 
 5<. Pulv. pip. cubebae, ^ss. 
 Balsam, copaibae, gij. 
 Ferri sulphatus, gj. 
 Resinae flavae, v. terebinthin. chiae, sjiij. M. 
 
 To be made into boluses of ten grains each. Dose. From fifteen 
 to thirty a day, at intervals. In chronic gonorrhoea, or gleet, in lax 
 constitutions. 
 
 . Pulv. pip. cubebae, gj. ad ^ij. 
 
 Ferri carbonat., gss. ad gj. M. ft. pulv. 
 
 This mode of exhibiting cubebs combined with the carbonate of 
 iron is much and successfully employed by Ricord after the acute 
 symptoms of a gonorrhoea have subsided. One powder should be 
 taken three times a day. 
 
 SYRUP OF CUBEBINE. 
 
 Of the hydro-alcoholic extract of cubebs, gxij. 
 Simple syrup and mucilage, o. j. M. 
 
 One ounce of this syrup contains a little more than two drams of the 
 powdered cubebs. Its dose can be regulated from this knowledge 
 of its strength. 1 
 
 LOZENGES OF CUBEBINE. 
 
 Cubebine, 8 parts. 
 
 Mucilage of gum tragacanth, 1 part. 
 
 Liquorice powder, q. s. 
 
 To be made into lozenges, each containing six grains of cubebine. 
 
 1 The hydro-alcoholic extract of cubebs (Cubebine) is prepared by Labe- 
 loyne, pharmacien, Paris. 
 
GONORRHOEA. 41 
 
 The oleo-resinous extract of Cubebs. 
 
 Obtained by distilling the ctibeb-pepper with water, and separating 
 the volatile oil thus formed ; treating the residue with alcohol ; 
 drawing the latter off by distillation, evaporating to the consistence 
 of syrup and then mixing with the volatile oil obtained by the first 
 process. Tnis remedy is more active and certain than the powder 
 of cubebs, and much pleasanter to take. 
 
 104. Many other remedies may be resorted to in the protracted 
 forms of chronic gonorrhoea, these are chiefly the preparations of 
 iron ; chalybeate waters; iodine, particularly in its combination with 
 iron, so successfully employed by Ricord, Richard, and Henry; 1 
 lead, 2 cantharides, and turpentine. 3 In all instances, however, of 
 chronic discharges from the urethra, this canal should be carefully 
 examined to determine, if possible, the pathological conditions which 
 keep up or are associated with the discharge ; without this we must 
 be at a loss for correct indications, we must prescribe at hazard, 
 and our patient's disease may be prolonged indefinitely. It is often 
 of great service to employ small local bleedings from the vicinity of 
 the urethra at the time we are using astringent or tonic injections, 
 or the remedies alluded to in the present section. 
 
 Of Mercury. 
 
 105. 1 have hitherto said nothing of mercury in gonorrhoea, 
 because I do not believe in the specific effect of mercury over purely 
 gonorrhceal diseases. Dr. Wallace employed it constantly in gonor- 
 rhoea (ill the system was brought slightly under its influence, with 
 the view " of preventing bubo and secondary symptoms." I believe 
 this opinion to have originated, as I have before stated, in a false 
 notion of the pathology and nature of this disease. Whilst, however, 
 
 1 *. Ferri ioduret, gr. ij. ad x. or more. 
 
 Pulv. opii. gr. i. 
 
 Mucilaginis, q. s. ft. Pil. 
 Terdie sumend. 
 
 **. Plumbi acetatis, 9j. 
 Bals copaiba?. 3j. 
 Pulv. glycyrrhizae, q. s. ft. Pil. xxir. 
 
 Dose. One pill to eight. Employed with advantage by Desruelles in 
 chronic gonorrhoea. 
 
 3 5<. Terebinthinae chiae. 
 
 Sanguinis draconis, aa. gij. 
 Olei terebinth, q. s. ft. Pil. xxx. 
 Dose. Prom three lo six or more in the day. 
 
 &. Guiaiaci resinee pulv. 
 
 Terebinthinae chiae, aa gj. M. ft. Pil. xxiv. 
 Capt. iii. v. iv. bis terve die. In gleet or chronic gonorrhoea. 
 
44 PARKER ON SYPHILITIC DISEASES. 
 
 I deprecate the use of mercury as a specific remedy in gonorrhoea, 
 I think it a remedy of great utility in the latter stages of this affec- 
 tion, exhibited with a view of removing those morbid changes in 
 the urethra, which long-continued chronic inflammation has occa- 
 sioned. With this object it may be advantageously employed in 
 the manner laid down by Dr. Wallace. " When," says this author, 
 "gleet or chronic gonorrhoea is connected with an indurated state 
 of the urethra, &c. it will be prudent to submit the patient to a short 
 course of mercury partly because the indurated and narrowed state 
 of the urethra often depends on the specific effects of the venereal 
 poison, and partly because, even when this is not the case, an 
 alternate course of mercury frequently offers the best remedy. 
 Indeed, I have on many occasions experienced much pleasure from 
 observing not only the gleety discharge, but also the contracted and 
 indurated state of the urethra to disappear, as soon as the patient's 
 constitution was brought under the specific influence of mercury." 1 
 Dr. Wallace recommends, as exceedingly efficacious, a combination 
 of calomel with antimony and opium. 2 
 
 Of Injections. 
 
 106. Many surgeons object to the use of injections in gonorrhoea, 
 fearing that they frequently occasion stricture and other morbid 
 conditions of the urethra. I am, however, of opinion, with Dr. 
 Wallace and Ricord, that a long-continued irritation or inflammation 
 of the urethra is much more likely to give rise to these evils, and 
 hence it is of consequence to cure a gonorrhoea by the means which 
 will accomplish this object most quickly, at the same time they do 
 it safely. It is true, that injections require great caution in their 
 use, and their injudicious employment is frequently followed by 
 serious consequences, but in these instances, the blame rests with 
 the surgeon and not with the remedy. Injections should generally 
 be used twice or three times in the day, and the flu id injected should be 
 made to remain in the urethra a minute or two before it is dis- 
 charged. 
 
 107. In the acute forms of gonorrhoea, injections are inadmissable; 
 they should be employed as soon as this stage is passed, and in 
 cases chronic or indolent from the commencement they may at once 
 be used. 
 
 103. To cut short a gonorrhoea at once, when a patient applies 
 before the acute stage has commenced, Ricord prefers injections of 
 
 1 Op. cit. p. 285. 
 *&. Hyd. chlorid., gr. j. ad iij. 
 Pulv. antimon., gr. iij. ad v. 
 Pulv opii, gr. ss. M. 
 Ext. aromat., q. s. ft. Pil. 
 Nocte maneque samend. 
 
 If the disease occur in a gouty or rheumatic constitution, colchicum may 
 be substituted for the antimony in the above prescription. 
 
GONORRHCEA. 43 
 
 the nitrate of silver, which he employs of the strength of two grains 
 to eight ounces of distilled water, 1 gradually increasing the strength 
 so long as no irritation is produced. When the acute stage lias 
 passed this surgeon generally employs the acetate of lead 2 fora few 
 days, but has recourse again to the nitrate of silver in stronger 
 solution, if the lead does not quickly succeed. Dr. Wallace recom- 
 mends the nitrate of silver in the proportion of fifteen grains to the 
 ounce of water, Desruelles, a scruple to the pint, and likewise a 
 pornmade to smear over bougies and then passed into the ure- 
 thra, 3 Dr. Wallace employs the nitrate of silver as long as any 
 morbid sensibility exists in the urethra, when this has censed, and 
 the discharge still continues, he has recourse to solutions of the 
 bichloride of mercury, the acetate of zinc, or the sulphate of copper; 
 the chloride of zinc has also been lately very successfully employed. 4 
 109. A vast variety of injections are employed in the various 
 forms of chronic gonorrhoea, those which I have already indicated 
 are most generally used and successful. When the disease has 
 become perfectly atonic, and all morbid sensibility has disappeand. 
 or when the patient is merely teased with a drop or two of mucous 
 discharge oozing from the urethra once or twice in the day, injections 
 of wine are used extensively both by Ricord and Desruelles, and with 
 
 fr. Argent, nit. gr. ij. 
 
 Aquae distillatae, viij. M. ft. Injectio. Ricord. 
 
 **. Plumbi Acetalis, 9ij. 
 Aquae Rosae, %vj. M. 
 
 This strength is for the male urethra, if used as an injection in the vaginal 
 gonorhoea, &c., the quantity of the acetate of lead may be increased as far 
 as an ounce to the pint of water. 
 
 *Bt. Argent, nitratis, 9j. 
 
 Aquae ferventis, o. j. M. 
 As an injection in chronic urcthritis. 
 
 . Adipis, 3j. 
 
 Argent, nitratis, gr. iv. M. 
 
 Of use in the same affection, smeared upon a bougie and thus passed into 
 the urethra. 
 
 4 &. Hydrarg. bichlorid. gr. iv. 
 Aquae dist., sviij. Wallace. 
 
 jc. Zinci acetatis, gr. xij. 
 Aquae, ^viij. M. 
 
 5<. Cupri sulphatis, gr. xij. 
 Aquae, ^viij. M. 
 
 BI. Zinci chloridi, gr. viij. 
 
 Aquae, ^viij. M. 
 The strength gradually increased. 
 
PARKER ON SYPHILITIC DISEASES. 
 
 much success, alone or combined with tannim. 1 The infusion of 
 galls with alum is also useful, 2 and lately M. Ricord has employed 
 with great success the ioduret of iron. In weak solutions the 
 ioduret of iron has frequently arrested the gonorrhoeal discharge in 
 four or five days, in other instances it has brought on an acute 
 attack of urethritisj but in these instances, when the inflammation 
 has subsided, the patient has been cured of his gonorrhoea. In 
 these instances the average duration of the treatment has not been 
 more than seven or eight days ; in a third series of cases the patients 
 have been unable to bear the irritation which injections of the 
 ioduret of iron occasioned, and consequently its employ was 
 given up. 
 
 110. It will often be found of great service to vary the character 
 of the injection, when one appears from continued use to have lost 
 its effect : we shall also find that some patients bear one kind of 
 injection better than others ; hence I have found persons much 
 benefited by port wine and tannin, who could not bear the weakest 
 solution of the nitrate of silver. 
 
 111. Ricord, Fricke of Hamburg, and Desruelles agree in opinion, 
 that gonorrhaja is kept up commonly from the contact of the two 
 sides of the urethra ; and hence it was proposed by Fricke to intro- 
 duce, by means of an elastic gum catheter or bougie, a fine piece of 
 lint into the urethra, and let it remain there, removing it only at 
 each period of making water ; the lint may be employed dry, or 
 soaked in any astringent injection. The practice has been followed 
 by great success. 3 
 
 112. Sometimes all our remedies are unsuccessful in checking 
 the discharge ; it then becomes necessary to examine carefully the 
 urethra to discover upon what pathologic condition the continuance 
 of this depends. In cases of morbid sensibility of one portion of the 
 
 *. Aquae rosae, ^iv. 
 
 Vini rubri, %\j. M. Ricord. 
 
 The quantity of wine gradually increased, till at length it may be em- 
 ployed pure. Desruelles adds a sixth or an eighth part of brandy. 
 
 . Vini rubri, ^vj. 
 
 Tannin, gr. xviij. M. Ricord. 
 
 For the male urethra; for the vagina, the quantity of tannin may be 
 doubled or still further increased. I have found this injection very valuable. 
 
 &. Gallae, j. ad ^ij. 
 Aluminis sulph., 9ij. 
 Aquae ferventis, ^viij. M. ft. Injectio. 
 
 Z 3<. Ferri ioduret., gr. lij 
 
 Aqua3 dist. ^vj. M. Ricord. 
 
 The quantity of the ioduret may be gradually increased. Its employ 
 requires caution and watchfulness. 
 
 2 See Ricord, op. cit. p. 745, and in the Gazette des H6pitaux ; also 
 Desruelles, op. cit. and Fricke, Lettres au Dr. Desruelles, &c. 
 
GONORRHCEA. 45 
 
 canal only, the solid nitrate of silver should be directly applied to it, 
 by means of the "port caustic" of Lallomand, or any other con- 
 venient instrument. When most other means have failed, and a 
 running still continues, wiih uneasiness, or morbid sensibility in the 
 urethra generally, or in several parts, Ricord considers it advanta- 
 geous to pass the solid nitrate of silver over the whole affected 
 surface of the urethra. 
 
 SECTION v. 
 Of Diseases which succeed to Go?iorrhcea in the Male. 
 
 113. These are more commonly seated in the urethra, or in the 
 testicles. The first comprising the various varieties of strictures, 
 the second those diseases in the testicles and their appendages, which 
 are strictly connected with gonorrhoeal inflammation of the urethra. 
 The consideration of the former does not properly belong to the 
 object of this work ; we therefore refer the reader to the numerous 
 monographs on stricture, particularly the excellent one of the late 
 Theodore Ducamp, 1 merely remarking in this place, that strictures 
 of the urethra, are almost always the consequence of protracted 
 gonorrhoeal inflammation, seated in one or more points of the ure- 
 thra, which ultimately extending to the subjacent tissues occasions 
 thickening, induration, or vegetations. These are the diseases 
 which, in the expression of Desruelles, an imprudent youth 
 bequeaths to adult age, and which in certain instances, at more 
 advanced periods render the patient's life miserable. 
 
 114. The most frequent of all the diseases of the testicle which 
 accompanies or succeeds to gonorrhoea, is inflammation of the 
 epididymis, epididymitis. This occurs so constantly and regularly 
 as a consequence of gonorrhoea, that M. Ricord applies to it the 
 name of "epididymite blenorrhagique." This disease is commonly 
 described under the terms of orchitis, hernia hurnoralis, or swelled 
 testicle ; the dissections of Ricord prove that these names are mis- 
 applied, and the disease is generally confined to the convolutions of 
 the epididymis. 
 
 115. This disease hardly ever occurs during the first, 2 or even 
 the second week of a gonorrhosa, more commonly in the third. 
 Ricord believes the disease may originate in two ways, from sym- 
 pathy, and from the direct propagation of inflammation from the 
 ejaculatory ducts to the vesiculae seminales, through the vas deferens 
 to the epididymis ; his dissections have proved this. Cullerier also 
 
 1 Th. Decamp, Traite des Rtrecissemenls de 1'Uretre, et des moyens a 
 Paide desquels on peut detruire completement les obstructions de ce canal. 
 Paris, 1825. 
 
 *Not once in three hundred times. Ricord. 
 
46 PARKER ON SYPHILITIC DISEASES. 
 
 believes that it is owing 1 to the direct propagation of disease along 
 the seminal passages, and not to metastasis. The longer the con- 
 tinuance of a gonorrhoea, the more likely is it to be thus complicated; 
 the best way to prevent it is to cure the disease as quickly as 
 possible. Amongst other causes are exercise, constipation, the 
 neglect of the suspender, free living, arid the use of stimuli during 
 the course of a gonorrhoea. 
 
 116. If gonorrhoeal epididymitis occur with any degree of intensity, 
 the disease soon involves the neighbouring tissues of the testicle ; and 
 hence we observe speedily succeeding to it, or complicating it, dis- 
 eases of the tunica vaginalis, or testicle itself, and very commonly 
 inflammatory hydrocele, oedema, erysipelas, or phlegmon of the 
 scrotum. 
 
 117. This disease is prevented by the antiphlogistic treatment of 
 gonorrhoea, the use of the suspender, and the early employment 
 of specific anti-gonorrhceal remedies, as copaiba, cubebs, &c. When 
 once setup we must employ general bleeding, if circumstances require 
 it, or local bleeding from the region of the spermatic chord, or peri- 
 neum ; the patient must keep the testicle suspended, and remain in 
 the horizontal position. To relieve the pain which is sometimes 
 very acute, Cullerier employs frictions upon the testicle with oil, 
 opium, or belladonna, &C. 1 When the acute symptoms have in 
 some measure subsided, the most efficacious practice is compression 
 of the testicle, strapping it with plaster of mercury and ammoniacum. 8 
 
 1 s. Olei camphorati, j. 
 
 Tinct. opii, 3J. M.ft. Liniment. Cullerier. 
 
 or, 
 *. Adipis, gj. 
 
 Ext. Opii, sjij. M. 
 
 or, 
 *. Adipis. 
 
 Ext. Belladonnas, aa^j. M. 
 
 2 The Emplastrum " de Vigo," c. Hydrarg. is generally employed for this 
 purpose in the French venereal Hospitals; it resembles much, though is in 
 some points superior to the Em p. Arnmoniaci cum Hydrargyro of the London 
 PharmacopoBia. The form is as follows: 
 
 . Hydrargyri, 95 pts. 
 Styracis liquidse, 48 pts. 
 
 These are to be rubbed together till the globules of mercury disappear; then 
 melt together, in a separate metal pot, 
 
 Emp. Plumbi, 312 parts 
 
 Cerae flavae 16 
 
 Terebintbinse purse, 16 
 
 Picis Burgund., 16 ,$ 
 
 Gum. arnmoniaci, 10 
 
 Olibani, 5 
 
 Myrrhse, 5 
 
 Croci in pulvr. 3 
 
GONORRHCEA. 47 
 
 This practice generally succeeds in curing the sympathetic 
 epididymitis in five or six days, and has the advantage of n 
 
 form of 
 not con- 
 fining the patient. Fricke, of Hamburg, employs it from the com- 
 mencement of the disease, however acute it may be ; Cullerier and 
 Ricord have thus employed it with complete success. 
 
 117. The emplastrum ammoniaci c. hyd. or the emp. Vigo .c. 
 hyd. are to be cut into thin straps, and applied in a circular manner 
 round the testicle, drawing this organ, as far as can be done without 
 pain, to the bottom of the scrotum, and taking care not to pucker 
 the skin in applying the plaster. The first strap is placed circularly 
 round the testicle at the insertion of the cord compressing the organ 
 as much as the patient can bear ; a succession of straps are then 
 applied till the organ is covered: a second series of straps are then 
 placed over the circular ones from below upwards, and over these 
 again a few more circular ones to keep the whole in place. If the 
 pressure of the plaster occasions pain or irritation, the straps are to 
 be removed till the inflammation or sensibility are more diminished ; 
 in many instances the patients experience relief directly, the testicle 
 is supported by the plaster. 
 
 118. During the local treatment of the disease the patient is to 
 persevere in the use of specific anti-gonorrho3al remedies; the 
 copaiba, cubebs, and a mild mercurial course rnay be recommended, 
 to remove any thickening or enlargement which remains after the 
 more acute symptoms of epididymitis and its complications have 
 subsided. 1 
 
 SECTION VI. 
 
 Of Gonorrhoea in the Female. 
 
 119. Gonorrhoea in the female is for the most part a disease of 
 very different character to that in the male ; the anatomical struc- 
 ture and functions of the organs implicated modifying the affection 
 both in its seat, its course, its treatment, and its terminations. 
 
 120. This disease recognises for its pathology acute or chronic 
 inflammation of the vulva, vagina, uterus, or urethra; the inflam- 
 mation itself being of a specific character, the result of impure 
 cohabitation, and capable of producing gonorrhoea in the male. In 
 the female, gonorrhoea is not confined to the urethra; it is more 
 
 These ingredients are to be well mixed, first amongst themselves, and 
 then with the mercury and styrax. The plaster thus made is to be spread 
 upon linen, calico, or thin leather, and then cut into strips of convenient 
 thickness. 
 
 'Ricord employs the following form of pill in these cases: 
 5*. Hydrarg. chlorid. 9j. 
 Pulv. v. ext. conii, $ij. 
 Sapo. dur. 9ij. M. ft. Pil. xxir. 
 
48 PARKER ON SYPHILITIC DISEASES. 
 
 commonly sealed in the vagina, and in the mucous membrane 
 reflected over the neck and mouth of the uterus. 
 
 121. In the more acute forms of the disease, a strictly antiphlo- 
 gistic treatment and regimen must be adopted: general or local 
 bleeding, aperients, the warm bath, emollient fomentations and 
 poultices, and injections or rather continual irrigations of the parts, 
 by means of a self-acting syringe, with sedative, demulcent, or 
 slightly astringent fluids. When local bleeding is thought neces- 
 sary the. leeches should be applied on the inside of the thighs or in 
 the folds of the groin ; these situations are preferable to the peri- 
 neum, or the labia. As it must be uncertain whether the discharge 
 is complicated with ulcers, it is always well to keep the leech-bites 
 free from the contact of the discharge, to avoid the possibility of 
 inoculation, and thus the probable occurrence of venereal sores. 
 
 122. In the earlier and more acute stages of the disease, it is not 
 prudent, and sometimes not always safe, to have recourse to the 
 speculum to ascertain whether the gonorrhoea is complicated with 
 venereal ulcerations or not; our first duty is to subdue the acute 
 inflammatory symptoms, and then if the chronic stage be protracted, 
 or do not yield to treatment, and there is reason to suspect the ex- 
 istence of deep-seated ulcers, the speculum may with propriety be 
 used to clear up our diagnosis. 
 
 123. Adopting the idea of Pricke, the French syphilographers, 
 more particularly M. Ricord, believe the gonorrhoea in the female, 
 as well as in the male, is protracted by the contact of the two sides 
 of the urethra, or vagina, &c. ; and hence, in the case of the 
 female, M. Ricord recommends the introduction of a soft plug of 
 charpie, or lint, which may be changed twice a day, and, during 
 the intervals, kept constantly moist with injections of any kind, 
 suited to the nature of the case, thrown over it with a syringe; the 
 plug may likewise be dipped in these injections before it is intro- 
 duced. This remedy has the double advantage of separating the 
 two sides of the vagina, and thus preventing the irritation their 
 contact occasions, and of applying a direct topical medication to 
 the parts affected a circumstance of vast importance where internal 
 or general treatment is of comparatively little value. 
 
 124. The internal treatment of gonorrhoea in the female is very 
 limited. The remedies which are considered specific in this dis- 
 ease in the male, as copaiba, cubebs, &c. are here almost inert. 
 Their action upon the vaginal forms of the disease is very feeble, 
 a little more energetic over the urethral varieties. Aperients, with 
 diluent and demulcent drinks, constitute nearly the whole of our 
 resources, under the head of internal treatment. Mercury appears 
 useless in the uncomplicated forms of the disease, except with a view 
 of removing any chronic enlargement or thickening which may be 
 the result of long-continued chronic inflammation. The treatment 
 is then to be the same as that we recommended, when speaking of 
 the use of mercury in gonorrhoea in the male. 
 
GONORRHOEA. 49 
 
 125. The local treatment of acute vaginitis or urethritis in the 
 female consists in the topical abstraction of blood, if necessary ; and 
 during the more severe stages the use of emollient and narcotic 
 fomentations and injections, with or without the use of the plug. 
 This treatment, however, should not be long continued if ineffec- 
 tual ; for (says M. Ricord) we frequently find rest, local bleeding, 
 emollient and narcotic applications of little use, the patient still 
 continuing to suffer from severe pain, and an abundant puriform 
 discharge, whilst the mucous surfaces of the vagina, &c. continue 
 red, and turgid with blood. The nitrate of silver may now be 
 employed with the best effects, either by passing the solid nitrate 
 over the diseased surface, or in form of injection ; l keeping the 
 vagina plugged with a dry soft piece of lint in the intervals of the 
 injections. When the acute stage has in some measure given way, 
 M. Ricord has early recourse to astringent injections, with a view 
 of preventing the discharge assuming the chronic form, and thus 
 continuing for an indefinite period. He employs here chiefly the 
 acetate of lead, 2 arid the sulphate of alum. 3 
 
 126. When the more acute stages of disease are passed, and the 
 chronic form continues but little influenced by remedies, it will be 
 well to examine the mucous surfaces of the vagina, &c. by means 
 of the speculum. These may be found in several pathologic con- 
 ditions; simply red, turgid, and hypertrophied, or covered with red 
 isolated patches, apthae, vesicles, pustules, or superficial ulcerations. 
 After the continuance of the disease for some time, the os uteri is 
 always more or less affected; its lips are turgid, red, and everted, 
 and generally covered with small ulcerations, granulations, or other 
 changes, the result of chronic inflammation. 
 
 127. In the chronic forms of the disease unattended by change 
 of structure, Ricord recommends, as local applications or injections, 
 solutions of tannin, 4 kino, 5 the infusion of roses with bark, 6 alum 
 
 1 $r. Argent, nit. gr. x. 
 
 AquaE, 3j. M. ft. Injectio. 
 
 * &. Aquae, o ij. 
 
 Plumbi acet: 3iij. ad ^ij. M. ft. Injectio. 
 
 **. Aquae, o ij. 
 
 Aluminis sulph., iij. ad 3ij. M. ft. Injectio. 
 
 4 *. Tannin, 9ij. ad. 3j. 
 Vini rubri, vj. M. 
 
 6 & Gum. kino, j. ad. 3ij. 
 
 Aluminis sulph. 9j. ad. Jss. 
 
 Aquae ferventis, h. ij. M. Swediaur. 
 
 '?. Infus. rosae comp. o ij. 
 Pulv. cinchonae, ij. M. 
 
 (Hotel Dieu.) 
 
 k 23-b tpark 
 
50 PARKER ON SYPHILITIC DISEASES. 
 
 or myrrh and catechu, 1 &c. &c. The solutions of the chlorides 
 of soda, or lime, are chiefly of use when the discharges are offen- 
 sive, and accompanied by ulceration. 2 When the gonorrhoea! dis- 
 charge is secreted by the mucous surfaces of the vagina, these 
 applications may be thrown up with an ordinary female syringe; 
 when, however, the os uteri or its neighbourhood are the seat of 
 the disease, it becomes absolutely necessary to use the plug of lint, 
 or a piece of sponge, to keep the remedies in contact with the 
 affected surfaces to which they are wished to be applied. 
 
 128. When the chronic state of gonorrhoea in the female is 
 accompanied by any alterations of tissue, these changes demand 
 our first attention, since it is useless to attempt to check the dis- 
 charge as long as these conditions remain upon which it depends. 
 Ulcefations, or papulous granulations (says M. Ricord) should be 
 cauterised with the nitrate of silver, or, what is better, with the 
 nitrated acid of mercury. 3 This caustic is to be applied by means 
 of a camel-hair pencil, or a small roll of lint, to touch the diseased 
 surfaces, these having been previously cleansed by dry lint, or a 
 soft sponge. When ^ulcerations themselves have destroyed the 
 tissues more or less deeply, caustics must be employed with extreme 
 caution. In these cases M. Ricord covers the surface of the ulcers 
 with calomel, upon which he places some dry soft lint, and after- 
 wards passes into the vagina some lint soaked in one of the astrin- 
 gent or tonic injections previously mentioned. 
 
 129. Where the disease has extended more or less into the uterus, 
 and has assumed a form of disease termed uterine gonorrhoea or 
 catarrh, M. Ricord prefers injections of the nitrate of silver, in the 
 proportions of six grains of the salt to the ounce of water. 
 
 130. A true vaginal gonorrhoea may be confounded with acute 
 or chronic vaginitis arising from other causes; and hence arises a 
 question of great delicacy and importance, whether we are in pos- 
 session of any facts which will enable us to establish a correct 
 differential diagnosis between vaginitis as the result of impure 
 sexual intercourse and those forms of disease which are the result 
 
 1 *. Pulv. catechu. 
 P. mynhae, aa 3j. 
 Liquor, calcis, %iv. M. 
 
 *B. Solut. sodae, chlorid. pt. 1. 
 Aquae, pts. 12 ad. 16. M. 
 
 (H6pital des Veneriennes.) 
 
 3 *. Hydrarg. proto-nitratis, pt. 1.' 
 Acid, nitric, pts. 8. 
 
 The above solution may be applied also as an injection, diluted to suit the 
 feelings of the patient and the character of the disease. M. Ricord has 
 employed it diluted with twelve parts of water as an injection in uterine 
 gonorrhoea, &c.; its use sometimes occasions pains and violent hysterical 
 symptoms attended with stupor. Owing to these circumstances M. R. 
 generally prefers a solution of the nitrate of silver of the strength above 
 indicated. 
 
GONORRHOEA. 
 
 61 
 
 of other causes? "The diagnosis of leucorrhcea," says Dr. 
 Churchill, 1 "is, according to all authorities, extremely difficult." 
 Sir C M. Clarke seems to think it impossible. There are some 
 cases, however, in which all doubt may he removed by an exami- 
 nation with the speculum. Whenever the peculiar erosions or 
 superficial ulcers of the mucous membrane covering the cervix 
 uteri, described by Ricord, are discovered, and which occur in 
 nineteen out of twenty acute cases, we can have no hesitation iu 
 pronouncing the disease to t>e gonorrhoea. 
 
 131. In gonorrhoea the discharge is generally more frequent, 
 and the inflammation more acute than in leucorrhoea. In the 
 former disease the glands of the groin are more frequently enlarged, 
 tender, and painful, and in gonorrhoea the affection extends to the 
 urethra in about two thirds of the cases.* 
 
 134. I have stated, in the article " Bnlanitis," that I have seen 
 severe inflammation of the glands and prepuce, with ulcerations, 
 occur after connection with females suffering from leucorrhoea. I 
 shall relate a case of this kind which made a great impression upon 
 me, from the anxiety and distress it occasioned in the family in which 
 it happened. A lady of most exemplary and irreproachable character, 
 the mother of nine children, in the seventh month of her pregnancy of 
 her tenth child, became affected with itchings and swellings of the 
 labia, and a rnuco-purulent discharge from the vagina: her husband 
 consulted me a few weeks afterwards, having certainly had no other 
 connection, with severe inflammation, and excoriation of the surface 
 of the glans and prepuce, from which oozed a rnuco purulent fluid. 
 Some slight astringent washes soon removed the disease, which 
 was thought of no more. The lady, however, became again preg- 
 nant, and about the same period of her pregnancy, her leucorrhoea 
 again returned more severely than before. Her husband again 
 consulted me: the internal surface of the prepuce and glans were 
 swollen, intensely red, and painful, and covered with small apthas; 
 in some places the mucous membrane was denuded, exposing a 
 deep red surface, secreting a thick pus. The general plan of 
 treatment recommended in the article "Balanitis" was followed, but 
 the disease became exceedingly tedious and troublesome; no sooner 
 had one crop of aptha3 been removed, than a second made their 
 appearance; the denuded surfaces spread, and deepened into foul 
 conditioned ulcers, till at length a complete phymosis was estab- 
 lished, and it was not till after many weeks of treatment that the 
 patient was perfectly restored. 
 
 133. This case "certainly proved that ulcerations of a bnd 
 character may follow connection with females labouring under 
 leucorrhoea, but the ulcers themselves are not of a specific character, 
 
 Outlines of the Principal Diseases of Females, &c. Dublin, 1938. 
 pp. 23-4. 
 
 8 See the paper of M. Ricord, Memoires de 1' Academic Roy ale de M4de- 
 cine, 1833. 
 
52 PARKER ON SYPHILITIC DISEASES. 
 
 and yield to a general plan of treatment. I have never seen a true 
 urethral gonorrhea succeed to connection with females suffering 
 from leucorrhoea only. I consider it impossible that constitutional 
 or secondary symptoms should be the consequence of diseases of 
 such a character. 1 
 
 Of the Second Class" of Primary Syphilitic Diseases. 
 
 ULCERS, THEIR VARIETIES AND CONSEQUENCES. 
 
 134. M. Ricord establishes three forms under which the primary 
 venereal sore more commonly makes its appearance: in form of 
 pustule; as a simple ulcer or chancre, then termed by the French 
 syphilographers "chancre d'emblee:" and as an ulcer succeeding to 
 phlegmonous inflammation, which has been seated in a follicle, the 
 cellular tissue, or lymphatic gland, vessel, or ganglion. It is also 
 important here to remark that the primary syphilitic ulcer hus two 
 marked and distinct stages : one of ulceration, the second of repa- 
 ration or granulation; each demanding a separate and distinct 
 treatment, both locally and constitutionally. 
 
 135. The venereal pustule, if presented tons sufficiently early, 
 and conveniently situated, should be removed by the knife or 
 scissors, or should the fears of the patient prevent this, it is to be 
 opened with the point of a lancet, and the whole internal surface 
 well cauterised with a crayon of the nitrate of silver, and afterwards 
 treated in the manner we shall direct for the management of the 
 primary venereal ulcer. 
 
 136. When we are called upon to treat the simple primary vene- 
 real sore during its first stage, or that of ulceration. our first object 
 is to destroy the diseased surface, and reduce it to the condition of 
 a simple sore. This is to be accomplished by means of the nitrate 
 of silver, with which the whole surface of the sore is to be well 
 cauterised, taking care to avoid any parts of the sore, if such there 
 be. where the process of granulation has already commenced. 2 
 
 137. "It is," says Dr. Wallace, "during the ulcerating stage of 
 primary syphilis, or when the process of granulation has only 
 
 'In these remarks, although detailing the results of my own experience, I 
 merely reiterate the opinions of Hunter. Opposite results are said to have 
 taken place. I believe, in these instances, the disease, on the part of the 
 female, to have been imperfectly or incorrectly diagnosticated; holding, 
 with Ricord, the belief that it is utterly impossible lo know the precise 
 nature of the diseases of the female organs of generation, without the use 
 of the speculum. Hence all statements of contagion should be received 
 with caution where this instrument has not, in the first instance, been used. 
 
 *It very frequently happens (says M. Ricord) that the nitrate of silver is 
 not sufficiently powerful to destroy the lardaceous surface of some chancres, 
 and hence he substitutes for ii other caustics, as the potassa fusa, or the 
 potassa cum calce. M. Delpech, of Montpelier, employes ihe nitrated acid 
 of mercury, "acid nitrate de mercure," for the preparation of which I have 
 elsewhere given a form. 
 
ULCERS. 
 
 53 
 
 partially commenced, that our assistance is for the most part sought ; 
 and when the disease is in this stage, there is no doubt on my mind 
 of the propriety or practical utility of immediately applying the 
 nitrate of silver in such a manner as to destroy the diseased surface. 
 I have treated, over and over again, primary syphilitic ulcers with 
 this caustic, and without it, under circumstances as nearly similar 
 as possible in every respect, and the result has uniformly demon- 
 strated the very great advantages of the former over the latter 
 mode of proceeding. The nitrate of silver should be pointed 
 before using, and then rubbed carefully on every part of the ulce- 
 rating surface (previously cleared by poultices or emollient fomen- 
 tations of all incrustations), until the edge of the ulcer be rendered 
 black, and the surface of a deep ash colour. But should any of the 
 ulcerated surface have entered on the stage of granulation, that 
 portion is to be avoided, and the application of the caustic confined, 
 as much as possible, to such parts of the sore as are still in the 
 stage of ulceration." 1 
 
 138. Whilst the chancre continues in the state of ulceration, the 
 application of the nitrate of silver must be repeated, waiting for the 
 separation of the eschar produced by the caustic, to ascertain 
 clearly the condition of the sore before we reapply the caustic. 
 After the application of the nitrate of silver, the ulcer should be 
 covered with a piece of fine soft lint, spread with some simple 
 ointment, 2 over which may be placed a bread poultice, or fine linen 
 moistened in the liquor plumbi diacetatis dilutus, and the whole 
 covered with a piece of oiled silk, or Liston's isinglass plaster. 
 
 139. The local dressings to chancres, employed by M. Ricord at 
 this period, deserve particular notice. They consist in the applica- 
 tion of aromatic wine, 3 medicated either with tannin, 4 with opium, 5 
 or with both. 
 
 1 Wallace, op. cit. pp. 92-3. 
 
 *One of the best applications as anointment at this period is the opiate 
 cerate of the French Codex. 
 
 y. Adipis, ftj. 
 
 Vini opii, j. M. 
 
 A strong aqueous solution of opium may be used where ointments are ob- 
 jected to, more particularly if the patient suffer much pain. Ricord employs 
 the following form : 
 
 *. Decoct, papaveris, v. conii. ^viij. 
 Ext. opii purificati, gr. viij. M. 
 
 s The aromatic wine of the French Codex, employed by M. Ricord in the 
 treatment of chancres, is composed of four ounces of aromatic herbs, (rose- 
 mary, rue, sage, hyssop, lavender, absinthium, origanum, thyme, laurel 
 leaves, the flower of the red rose, camomile, mellilotum, and elder,) digested 
 in two pints of red wine for eight days. 
 
 4 5*. Vini aromatici, 
 Tannin, 9ij. M. 
 6 iy. Vini aromaiici, 3 viij. 
 Tannin, 9ij. 
 Ext. opii pur. ^ss. M. 
 
54 PARKER ON SYPHILITIC DISEASES. 
 
 140. The sores are to be carefully washed with one or other of 
 these preparations, and afterwards covered with soft lint, moistened 
 in them. Care must be taken, in renewing the dressings, to soften 
 the lint well before it is removed, so that no part of the surface or 
 surrounding skin may be torn away with the lint. 
 
 14 K These preparations possess the advantages of modifying 
 the surface of the sore, of thus promoting its rapid cicatrisation, of 
 diminishing the secretion of pns from its surface, and, by their 
 astringent properties acting upon the surrounding tissues, of pre- 
 venting the extension of the disease, or the formation of fresh 
 chancres, a circumstance so common in all other modes of dressing. 
 The use of the aromatic wine with or without tannin is contra- 
 indicated when the surface of the sore is dry, furnishing no secre- 
 tion and remaining indolent, or again where the edges being indu- 
 rated these dressings seem to increase the induration. In all other 
 circumstances these are the local applications most commonly 
 employed by Ricord. 
 
 14'2. The state of the economy at large demands much attention 
 on the first appearance of a venereal ulcer; and we must here bear in 
 mind the golden rule of Ricord, that the varied appearances of pri- 
 mary venereal sores, and the characters they afterwards assume 
 depend very much, if not altogether, upon the natural constitution 
 of the patient, arid upon the particular condition of his health at 
 the time he imbibes the venereal poison. Thus in many instances, 
 a primary venereal sore upon the penis produces the most intense 
 local inflammation and fever. Under these circumstances the 
 patient must be treated upon general principles: he should be bled 
 generally or locally, and the bowels kept freely open; he should 
 be restricted to the simplest diet, and kept quiet in bed, whilst 
 emollient fomentations or poultices are applied to the sore. The 
 local inflammation and fever are first to be removed, in these cases, 
 before we think of resorting to the nitrate of silver, arid should the 
 stave of ulceration be arrested by these means, and the sore assume 
 a disposition to heal, it will not be necessary, or even safe, to use it 
 at all, but the granulating ulcer must be treated in the way we shall 
 presently mention. 
 
 143. Cul'erier, in the treatment of the primary venereal sore, 
 confines his patients to bed, and keeps them upon low diet; if there 
 be any local inflammation or fever, he bleeds them from the arm, 
 and covers the sore with a poultice, the opiate cerate, or a strong 
 
 These three preparations aie extensively employed by M. Ricord in the local 
 treatment of primary venereal sores on the genitals and elsewhere. During 
 the first few days he is satisfied with this local treatment ; the application 
 of the nitrate of silver, and a general antiphlogistic treatment if necessary. 
 Should no benefit result in five or six days, and the edges of the ulcers 
 become thick or hardened, without any disposition to heal, a modified mer- 
 curial course is adopted. I am in the habit of using new port wine, ren- 
 dered aromatic or not, as the vehicle for the application of the tannin or 
 opium. 
 
ULCERS. 56 
 
 aqueous solution of opium. All local inflammation and accom- 
 panying fever are to be subdued before the use of the nitrate of 
 silver; and, during the two or three days which are generally spent 
 in its application, the patient should live low, keep his bed "if pos- 
 sible, and take daily aperients, unless specially contra-indicated. 
 This plan has the two-fold object of preventing or mitigating the 
 inflammation which may be caused by the application of the caustic, 
 and of preparing the patient for any subsequent general or local 
 treatment the nature of the sore may require. 1 
 
 144. During the earlier periods of the local treatment of chancre, 
 M. Ricord particularly insists upon a regimen suited to the consti- 
 tution of the patient. Under this point of view no exact rules are 
 to be laid down. In some cases a purely antiphlogistic treatment 
 becomes necessary, whilst in others tonics and a nourishing diet are 
 required. The state of the general health requires particular 
 attention, for it must be recollected that, from a had constitution, or 
 one enfeebled by previously existing disease, frequently result those 
 complications and severe local affections, so frequently observed 
 during the progress of primary venereal sores. 
 
 145. Having arrested the progress of ulceration in the primary 
 venereal ulcer, and brought it to the condition of a granulating 
 sore, a change in the plan of treatment becomes necessary, both 
 constitutionally and locally. If mercury be used, now is the time 
 to have recourse to its employ with the full hope of realising its 
 most beneficial effects. It is not necessary here to enter into any dis- 
 quisition as to the comparative merits or results of the simple and 
 mercurial plans of treatment. I know the balance is immensely 
 in favour of a modified mercurial course, and, holding such an 
 opinion, should be disposed, unless specially contra-indicated, 
 always to recommend to my patient, at this period of his disease, a 
 mild mercurial treatment. 2 I refer the reader to the section on the 
 
 'During those two or three days which are generally spent in the applica- 
 tion of the caustic, the patient should be prepared by a purgative, and by 
 regularity in his mode of living, for subsequent constitutional treatment ; the 
 lotio plumbi subacetatis may be applied without disturbing the dressing, by 
 immersing the diseased part in it two or three times a day, or by rolling the 
 penis in lint kept wet with this lotion, and covered with oiled silk. Wallace, 
 op. cit. pp. 97-8. 
 
 2 The reader may consult, if he thinks proper, the works of Wallace, 
 Ricord, Desruelles, and Cullerier, on the points here in question. He will 
 find all admitting the superior efficacy of mercury in hastening the cicatrisa- 
 tion of a primary venereal ulcer, and diminishing the risk of secondary 
 symptoms. The last three partisans of the simple treatment recommend 
 mercury, when the sore is indolent, does not cicatrise under the simple plan; 
 when its edges are hard and elevated, or the sore leaves behind it, in healing, 
 an indurated cicatrix. 
 
 Mercury, although not a specific against syphilis, is the most powerful 
 therapeutic agent we can employ, in many cases, in its cure. Ricord. 
 am far from rejecting the internal use of mercury in the treatment of 
 the primary venereal ulcer. I believe that in many cases it is necessary, 
 and even indispensable. See Cullerier, op. cit. p. 186; and the remarks of 
 Desruelles, pp. cit. pp. 313-15. 
 
56 PARKER ON SYPHILITIC DISEASES. 
 
 "Mercurial Treatment of Syphilitic Diseases," for rules to regulate 
 him in the exhibition of mercury; and to the section on u Particular 
 Preparations of Mercury, <fcc." for forms for its employment. 
 
 146. The local treatment of the sore must also be changed when 
 the granulating; process has commenced ; and as the mercurial ap- 
 plications are generally injurious during the ulcerating stage of 
 chancre, so are they beneficial during the stage of reparation. Dr. 
 Wallace employs, as local applications during this stage, calomel 
 and lime-water, mercurial ointment, the ung. hydrargyri nitratis, 
 the bichloride in lime-water or in distilled water: these applications 
 being enumerated in the order of their stimulating properties. Ri- 
 cord's aromatic wine, with or without tannin, will be useful if the 
 sore secrete much pus ; if the surface of the sore be dry and foul, 
 great benefit will be found by alternating the dressings with the 
 wine, and some detergent ointment. 1 
 
 147. The local applications must be varied to suit the actual con- 
 dition and aspect of the sore: hence should it be painful, opium 
 combined with the remedy we apply is useful. 2 Should the irrita- 
 bility of the ulcers be of the inflammatory kind, it will be necessary 
 to leave off all stimulating dressings, and have recourse to emollient 
 fomentations, arid the simple or opiate cerate. Cullerier employs 
 as topical applications, when the inflammatory symptoms have 
 subsided, solutions of the nitrate of silver, sulphate of copper, mer- 
 curial ointment, or pommades of calomel and opium, or mercurial 
 ointment and opium. 3 All these varied preparations maybe found 
 useful in various conditions of the surface of the primary venereal 
 ulcer. The condition of the latter is the only circumstance that 
 can guide us in their proper mode of application. 
 
 148. Dr. Wallace thinks topical mercurial preparations of great 
 value in the treatment of primary venereal sores, and believes that, 
 in some measure, they supersede the necessity of an internal mer- 
 curial treatment. "In dispensary practice, and among the lower 
 ranks of society, the internal administration of mercury, particularly 
 at inclement seasons of the year, can seldom with safety be recom- 
 mended. In such persons, arid under such circumstances, topical 
 applications are of infinite value. In cases of this kind I generally 
 confine my treatment to them, in conjunction with the internal use 
 of nitrous acid, and, by these means, succeed for the most part in 
 
 1 9<. Resina? flavae. 
 Gum. Elemi. 
 Cerse flavae, aa 3j. 
 Ol. olivac, gvj. 
 Olei terebinth., Jij. M. ft. Unguent. 
 
 * &. Cerat. opiat. %j. 
 
 Hyd. chlorid. ij. M. 
 
 * 9<. Cerat. opiat. 
 
 Ung. Hyd. fort., aa gj. M. 
 
CHANCRES OF THE URETHRA. 57 
 
 healing the disease with rapidity. Cases treated in this way are 
 also very rarely followed by secondary symptoms." 1 
 
 149. We have hitherto treated of the regular primary syphilitic 
 sore. We shall now consider some varieties in the seat and cha- 
 racter of chancres. 
 
 SECTION VII. 
 
 Of Chancres of the Urethra. 9 
 
 150. The existence of chancres of the urethia is admitted by 
 Ricord and Cullerier, the latter of whom says, we call the atten- 
 tion of practitioners to this species of nicer, which is not so rare as 
 some have supposed, and may, if mistaken, lead to serious errors in 
 practice. Chancres of the urethra are characterised by the symp- 
 toms of gonorrhoea, (the discharge, however, is much less copious 
 in the former disease than the latter,) induration of the urethra, 
 which may easily be felt externally, arid occasionally by the forma- 
 tion of small abscesses, opposite the indurated portions of the canal. 
 The chancre of the urethra is generally situated at its orifice or in 
 the fossa navicularis ; in these situations it may be generally seen, 
 and our diagnosis is at once certain. In other instances, it is 
 placed lower down, and then the diagnosis becomes difficult and 
 embarrassing. 
 
 151. It is clear, both from the statement of the English and 
 French writers, that discharges from the urethra are due to more 
 causes than one ; and hence is it that we find Dr. Wallace saying-, 
 "that there occur cases of these discharges, in which we find mer- 
 cury to act in the most salutary manner ; and others again, in 
 which the discharge will continue, and be, after a time, followed by 
 induration and bubo, and most probably, by secondary symptoms, 
 unless this medicine be given." 3 When we consider the generally 
 powerless effect of mercury over pure gonorrhoea, we cannot but 
 suppose that these remarks of Dr. Wallace must. rf3fer to chancres 
 or venereal ulcerations of the urethra, which an imperfect diagnosis 
 has confounded with gonorrhoea. 
 
 152. In cases where muco-purulent discharges from the urethra 
 continue to resist the usual methods of treatment, we should resort 
 to the means of differential diagnosis, so extensively practised by 
 Ricord, of testing the character of the disease by inoculation. M. 
 Ricord 4 has established that the inoculation of the skin of the thigh, 
 the prepuce, or elsewhere, with the matter of pure gonorrhoBa, pro- 
 
 1 Wallace, p. 113. 
 
 2 Chancres larves. Ricord. 
 
 3 Op. cit. pp. 248-9. 
 
 4 See the Section on " Inoculation," and the cases of " Chancres larves," 
 in Ricord's work, before referred to. 
 
58 PARKER ON SYPHILITIC DISEASES. 
 
 duces no result, or at best a negative one. The same inoculation 
 with matter from the urethra, secreted by a chancre in that part, 
 gives a characteristic pustule, and subsequently a chancre or sore 
 of venereal aspect. In eighty-five cases of urethral discharges, thus 
 tested by M. Mairion, at the military hospital of Louvain, four were 
 found of true syphilitic character, and produced chancres by inocu- 
 lation, the remaining eighty-one gave no result they were cases 
 of simple gonorrhoea. 
 
 153. The existence of chancre of the urethra being ascertained, 
 the inflammatory symptoms are to be first subdued, by a treatment 
 appropriate to trie earlier stages of gonorrhoea : leeches to the groin 
 or the perineum, diet, rest, diluents, and cathartic medicines, with 
 emollient injections. Afterwards we may resort to injections with 
 aromatic wine, or solutions of the nitrate of silver, or the solid 
 nitrate may oe introduced, and the surfaces of the sores cauterised, 
 if the inflammatory symptoms are not too acute, and the chancre 
 situated within reach. It is useful to introduce a small plug of lint 
 into the urethra, impregnated with the injection we employ, with 
 a view of keeping the surface apart, and preventing any extension 
 of the disease. 
 
 154. Mercury may be employed, in chancres of the urethra, at 
 the period, and in the manner before recommended in the treat- 
 ment of simple primary venereal sores, attending to the local aspect 
 of the sore during its administration. The following case illustrates 
 the practice of Cullerier in these forms of disease. 
 
 155. A man entered the venereal hospital, said to have suffered 
 from gonorrhoea for twelve months, in the treatment of which co- 
 pii-)a, cubebs, and various astringents had been vainly employed 
 by a variety of surgeons. The discharge, from the patient's ac- 
 count, had never been very profuse; on pressing the urethra firmly 
 there hardly issued some drops of pus. The glans was consider- 
 ably swollen, and its summit the seat of an induration the size of a 
 nut, surrounding the meatus. On separating the lips of the orifice 
 a larsje chancre was discovered, which had burrowed itself deeply 
 into the parietes of the canal. This patient had been submitted to 
 several mercurial courses without benefit, because (says M. Culle- 
 rier) the local treatment of the sore had been neglected. AH inter- 
 nal treatment was now suspended ; a strict dietetic regimen and 
 repose wore directed to be observed, arid leeches were applied from 
 time to time on the ulcer itself. In the intervals a piece of lint, 
 covered with opiate cerate, was kept in the urethra, emollient fo- 
 mentations were frequently used, and the penis enveloped in a 
 poultice. Under the influence of these remedies the induration 
 soon disappeared, the sore became clean, and a few applications of 
 the nitrate of silver were sufficient to effect a cure. 
 
 156. It is not necessary to say more on the treatment of chancres 
 of the urethra ; when ascertained, they must be treated on the prin- 
 ciples of primary venereal sores on other parts. The only circum- 
 
PHAGED.KNIC PRIMARY SORES. 59 
 
 stance which leads us to modify the treatment is the situation in 
 which the sore occurs. 
 
 SECTION VIII. 
 
 Of Phagedanic Primary Venereal Sores. 
 
 157. Instead of following the regular course of primary syphilis, 
 venereal ulcers sometimes assume a character of rapid ulceration, 
 sloughing, or inflammation, to which the term phngedajna is ap- 
 plied. In treating the various forms of phagedaenic chancres we 
 must be guided, in the first instance, by the natural constitution of 
 the patient, and the particular conditions of his health at the time 
 of his becoming diseased; the intensity and character of phagedaena. 
 whether inflamed, foul, or irritable, commonly depending upon the 
 general health of the patient, or upon the circumsiances or situation 
 in which he happens for the time to be placed. Hence we must 
 guard against the indiscriminate use of mercury, and of attributing 
 the violence of the disease to any unusual degree of violence in the 
 venereal poison itself. 
 
 The Local Treatment of Phagedanic Primary Syphilis. 
 
 158. The characters of phagedsenic sores may generally be re- 
 ferred to three principal groups, marked either by rapid ulceration 
 and sloughing simply, or by the same processes accompanied by 
 severe local inflammation or irritability. In the first variety of 
 these sores, we may proceed much in the same manner as during 
 the ulcerating stage of regular syphilis. Ricord and Dr. Wallace 
 both recommend ihe use of escharotics. The nitrate of silver may 
 be employed, to destroy the diseased surface, or a solution of the 
 potassa fusa, a mineral acid, the liquor arsenicalis, or the undiluted 
 solution of the chlorides of lime or soda. The utility of alte.n.ate 
 applications of the nitrate of silver, and the aromac'ic wine with 
 tannin, are particularly insisted upon by Ricord. Alternate dress- 
 ings of a strong digestive ointment 1 and the aromatic witie will be 
 found exceedingly useful when the surface of the sore is very foul 
 and disposed to slougli. 
 
 159. In the inflamed variety of disease, local as well as general 
 bleeding, is of great service: the former is carried to a great extent 
 in the French civil and military venereal hospitals. Desruelles and 
 
 1 5. Terebinthinae, 3j 
 Vitelii ovi. gj. 
 Olei hyperici, ss. 
 
 Mix the turpentine with the yolks of eggs carefully in a stone mortar; and 
 add gradually the oil of St. John's wort. 
 
60 
 
 PARKER ON SYPHILITIC DISEASES. 
 
 Cullerier place the leeches in the centre of the sore : Ricord does so 
 occasionally, but prefers, if it can be accomplished, to apply them 
 in its vicinity, so also does Dr. Wallace : the only objection to this 
 practice is the inoculation of the leech-bites, and consequently the 
 formation of fresh phagedsenic sores. The local dressings best 
 suited to inflamed varieties of phagedsena are emollient or anodyne 
 fomentations, poultices, or a strong aqueous solution of opium ;* to 
 these may be added the warm bath, medicated or not with mucilage 
 or gelatin. The opiate cerate may be also employed with benefit. 
 
 160. In the irritable variety of the disease strong aqueous solu- 
 tions of opium are very advantageous ; but here, as in the first 
 form, the use of the nitrate of silver, or some other escharotic, is 
 exceedingly serviceable. Ricord prefers the former preparation : in 
 such cases (says he) the nitrate of silver is the best sedative, as well 
 as the most powerful antiphlogistic. Dr. Wallace touches the sur- 
 face of the irritable phagedasnic chancre with the nitrate of silver, 
 the liquor arsenicalis, or strong nitrous acid. When the ulcer is 
 surrounded by a diffused areola, caustics are occasionally injurious, 
 though not certainly so from such a symptom being present. When 
 they disagree, opiate dressings must be relied upon, 2 or the diges- 
 tive ointment, with aromatic wine or opium. 3 Whatever may be 
 the character of the surface of the irritable phagedaenic ulcer, the 
 application of escharotics is generally beneficial, in those covered 
 with a white or black slough. Dr. Wallace preferred the liquor 
 arsenicalis, or the strong nitrous acid, to the nitrate of silver: he 
 states that the former commonly improve the aspect of the sore, and 
 lessen its irritability, when the nitrate of silver has failed to do so. 
 
 161. When the granulating or reparative process has commenced, 
 the phagedsenic ulcer must be treated in the same way as the re- 
 gular primary venereal sore. 
 
 Of Mercury. 
 
 162. There are many varieties of phagedaena in which mercury 
 is so beneficial as to be almost indispensable. This fact, even ac- 
 cording to the testimony of Ricord, is proved by the practice of 
 those who are partisans of the simple doctrine, and profess the 
 greatest enmity to a mercurial treatment. When, in spite of the 
 local treatment before indicated, the sore continues to spread, Ri- 
 cord has recourse to mercury, first in the form of local applications 
 combined with opium, and secondly, given internally, or by fric- 
 tion. In the present state of science it is impossible to state what 
 
 1 *. Opii, si.]. 
 
 Aquae, ^viij. M. 
 
 * *. Ung. hydrargyri, 3J. 
 
 Ext. opii, j. M. Wallace. 
 
 M. 
 
MERCURY. 61 
 
 are the precise conditions of the phagedaenic ulcer, in which mer- 
 cury is indicated; it appears established only that the sore with in- 
 durated and elevated edges is almost always beneficially influenced 
 by this drug. 1 
 
 163. Mercury is considered as almost indispensable by Dr. Wal- 
 lace in the treatment of the simple phagedaenic primary ulcer: 
 "Whenever we meet with a case of the simple phagedaenic primary 
 ulcer, if it has not been previously complicated by improper treat- 
 ment, it will be necessary to subject our patient to a course of mer- 
 cury (regulated according to the principles already laid down), and 
 we shall always be gratified by the result. But if, on the other 
 hand, the patient has already been dabbling with mercurial reme- 
 dies, and if there be reason to suppose that his constitution has 
 been, in consequence, more or less disordered, we shall act more 
 judiciously by suspending for a time the use of mercury ; and en- 
 deavour by proper measures, but principally by attention to the 
 mode of living of our patient, and by the use of the mineral acids 
 with sarsaparilla, to restore the system to a state of tranquillity 
 before we enter again on a mercurial treatment, which may, how- 
 ever, be then used with success." 
 
 164. Occasionally the form of simple phagedaena occurs with a 
 white slough on the surface of the sore, and considerable induration 
 of its edges. In these instances, both Wallace and Ricord recom- 
 mend the immediate recourse to mercury. Its use must be discon- 
 tinued, if after having in the first instance been beneficial, a degree 
 of febrile irritation is produced by its employ, and the sore, at first 
 disposed to heal, becomes stationary and sensitive, and afterwards 
 painful and spreading. 
 
 165. When mercury is used in the treatment of phagedsenic pri- 
 mary syphilis, it should be discontinued if, in the sloughing variety, 
 the surface assumes a dark or tawny colour in consequence of the 
 intensity of the inflammation, or from any other cause. Its use 
 must also be given up should the local inflammation increase whilst 
 the patient is using the mercury, or should the surface of the sore 
 become clear of slough without any diminution of the inflammation 
 or irritation, or lastly, should the system of the patient become de- 
 ranged, whilst we find any extraordinary difficulty in exciting the 
 mercurial action, the disease at the same time remaining stationary. 
 
 166. Another important variety of phagedacna'is the "phage- 
 
 1 "Si, avec la doctrine physiologique, on fait partir la guerison d'un chan- 
 cre du jour 6u 1' ulceration est cicatrisee, sans inquieter de ce qui reste apres, 
 elle sera quelquefois en apparence plus rapide par le traitement simple, et, 
 dans les h6pitaux, les malades seront moins longtemps en traitement ; mais 
 si, pour dire un maladie gueri, on attend que toute induration ait disparu, on 
 trouvera la difference enorme en faveur du traitement mercuriel : 1'induration, 
 dans le premier cas, restant souvent pendant des temps fort longs, et mieux 
 encore jusqvSd production bien plus frequente d'accidents secondaires. 
 Pour moi done, j'ai recours au traitement mercuriel, toutes les fois qu'un 
 certain degre d'induration accompagne un chancre, Pempeche de se cicatri- 
 ser, ou persiste apres sa guerison superh'cielle." Ricord, op. cit. pp. 578-9. 
 
62 PARKER ON SYPHILITIC DISEASES. 
 
 dsenic primary syphilis with black slough" of Dr. Wallace, which 
 corresponds to the gangrenous phagedaena of Ricord. Here the 
 disease must be treated, in the commencement, on general princi- 
 ples, the inflammation must be subdued by anodyne fomentations, 
 leeches, the local application of opium, and the remedies which 
 have been already mentioned as useful in the inflamed conditions 
 of primary venereal sores. When the process of inflammation and 
 ulceration have been arrested, and the sore assumes a disposition to 
 heal, a mild course of mercury may be adopted to hasten the cica- 
 trisation of the sore, and diminish the risk of secondary symptoms; 
 the use of this remedy to be given up if any of the conditions of the 
 sore* or the constitution above mentii ned occur during ils employ. 
 
 167. The free internal use of the nitrous and nitro-muriatic acids, 
 with or without sarsapanlla, is particularly indicated in most varie- 
 ties of ph.-igedsetiic primary syphilis where the constitution will not 
 bear the exhibition of mercury. 
 
 Of the Simple Treatment of Phagedcena. 
 
 168. The simple treatment of phagedaenic primary syphilis is 
 framed with a view of diminishing all inflammation or irritation 
 which may accompany the local disease, hence leeches and aqueous 
 solutions of opium are the chief topical remedies employed. The 
 following is the result of the experience of Dt?sruelles on the treat- 
 ment of phagedcenic primary syphilis. That generally the treat- 
 ment without mercury has been more successful than a mercurial 
 course; that leeches, sndorifics, and the warm bath have been more 
 successful when combined with a solution of opium as a local ap- 
 plication than when the dressings have been composed of mercury. 
 
 169. The local application of opium has always been useful 
 when combined with the application of leeches, sudorifics, and 
 mercurial inunctions. Most commonly, the simpler the local treat- 
 ment the more successful, whether mercury has or has not been 
 given. 
 
 170. The phagedsenic ulcer is very commonly accompanied by 
 severe inflammatory affections of internal organs: these complica- 
 tions frequently demanding a strict antiphlogistic treatment, during 
 the progress of which the aspect of the sore generally improves. 
 
 Of Bubo} 
 
 171. Bubo may be of two kinds, either simple or syphilitic, and 
 may be either a primary or secondary affection, succeeding either 
 to chancre, gonorrhoea, or balanitis, or making its appearance with- 
 out any one of these diseases having preceded it. The true vene- 
 real bubo is most commonly preceded by one of the affections I 
 have mentioned, but may occur, though rarely, as a primary syphi- 
 
 1 Adenitis. 
 
BUBO. 63 
 
 litic symptom ; it is then termed " buhon d'emble'e." Authors are 
 divided as to the frequency of its occurrence under the latter form; 
 i believe it to be rare. It very commonly happens that ihe n^oet 
 formidable buboes succeed to allections so trivial that they have 
 even escaped the observation of the patient ; and hence we shall 
 frequently, when called to treat buboes which are said to have I r< n 
 preceded by no other syphilitic affection, discover, on drawing bnck 
 the prepuce, a slight balanitis or excoriation, or the fresh cicatrix 
 of some trivial ulcer. The syphilitic bubo may, however, occur 
 as a primary symptom. 
 
 172. Bubo may be, as I have snid, either simple or syphilitic, 
 sympathetic or virulent. Ricord has instituted the test of inocula- 
 tion as a means of differential diagnosis between the two. The 
 virulent bubo that arising from the absorption of pus from a chan- 
 cre, is a disease precisely similar to chancre, differing fiom it only 
 in its seat, and in the anatomical organisation of the parts in which 
 it is seated. The true venereal bubo is the only one which gives 
 a characteristic pustule by inoculation ; and is the only certain 
 means of enabling us to determine whether a bubo is venereal or 
 sympathetic. In cases where bubo occurs as a -primary symptom, 
 this test becomes of the utmost importance, since by its results 
 alone can we be led to frame a rational plan of treatment. 
 
 173. The causes of bubo are various: in addition to their true 
 venereal origin, they frequently arise from excessive indulgence in 
 venereal pleasures with a healthy female; they may also result 
 from fatigue, long journies taken on foot, sudden and violent exer- 
 tion, or from ulcers situated upon any part of the lower extremities. 
 It may generally be assumed that the bubon d'emble'e is not syphili- 
 tic, so rare is its occurrence as a venereal affection in this form. 
 Any stimulus, acting for a longer or shorter period of time upon 
 the parts contained in the inguinal region, is liable to be followed 
 by simple bubo. 1 
 
 174. It is of great importance to the patient that bubo should be 
 dispersed if possible, and not suffered to suppurate, the latter pro- 
 cess involving a long and most troublesome disease, fraught with 
 endless inconvenience, pain, and even danger. In the first stage 
 of bubo, when the inflammatory symptoms are not marked, M. 
 Ricord recommends rest and compression : this author has remarked 
 that, in patients wearing trusses buboes are seldom if ever developed 
 on the side where the pressure of the truss is acting, but on the 
 opposite one; hence in the first stage of bubo, that of mere enlarge- 
 ment, without any acute inflammatory action or pain, a well regu- 
 lated pressure, by means of an appropriate bandage or apparatus, 
 is frequently successful in dispersing the tumour. This plan of 
 treatment is above all useful in the bubon d'emblee. It must be 
 associated with an antiphlogistic regimen, rest, and gentle aperients. 
 
 See the remarks of M. Beaunez, on this subject, Journal de Medecioe et 
 Chirurgie pratique, Art. 427 and 936. 
 
64 PARKER ON SYPHILITIC DISEASES. 
 
 175. The same plan of treatment may be followed in the treatment 
 of true syphilitic bubo, unattended by much pain or inflammation. 
 In this stage, unless specially contra-indicated, mercury may be 
 employed to assist the resolution of the tumour. The primary 
 syphilitic bubo, may (says Dr. Wallace,) in its first stage, be resolved 
 in ninety-nine cases out of a hundred by mercury; if this medicine 
 be used after the plan recommended for primary syphilis, and if 
 its operation be assisted by rest, laxatives, abstinence, and cooling 
 lotions. 1 It is well, in reference to this opinion, to remark, that a 
 vast number of those buboes which succeed to true chancres are 
 sympathetic, that is, when they suppurate, they do not furnish or 
 secrete a specific pus. Hence it must be evident that the general 
 employment of mercury is, to say the least, unnecessary, except so 
 far as it may be used with a view of controlling inflammatory 
 action. Cullerier thinks that at this period, uncertain as we must 
 be as to the true character of the bubo, it should be treated as a 
 pure and simple inflammation. When accompanied by chancre it 
 is of vast importance to our success in the resolution of the bubo, 
 to allay all pain or irritation which may exist in the sores themselves, 
 and for this purpose the aqueous solution of opium before recom- 
 mended will be found of great service. 
 
 176. When the commencement of bubo is accompanied by 
 much pain, tenderness on pressure, or heat of parts, the local 
 abstraction of blood may be necessary, although I have riot a high 
 opinion of this measure in the resolution of bubo generally. It 
 may even be necessary to bleed from the arm if the patient be ple- 
 thoric, and the local disease associated with general excitement, or 
 much symptomatic fever. In local bleedings thus employed, it will 
 be found advantageous to apply a small number of leeches, from 
 four to eight, or more, and wait till the oozing of blood begins to 
 cease, then to apply another relay of leeches so as to keep up a 
 constant draining of blood from the part for twelve or more hours. 
 This form of bleeding, termed "permanent," is found to reduce the 
 inflammation more certainly and speedily than the application of a 
 large number of leeches at once. Two, three, or more relays of 
 leeches may be thus employed, proportionate to the strength of the 
 patient and the intensity of the local disease. 
 
 177. The method originally proposed by M. Malapert, a French 
 army-surgeon, is perhaps, however, of all others the best calculated 
 to disperse the incipient bubo. This method consists in the applica- 
 tion of blisters, and a solution of the bichloride of mercury. 2 
 The bubo is to be covered with a blister about the size of half a 
 crown, larger or smaller, according to the size of the tumour; the 
 following day when the epidermis is detached, a small portion of 
 
 1 Op. cit. p. 356. 
 
 'Archives gen6rales de Medecine, Mars, 1832. Du traitement des mala- 
 dies veneriennes par Papplication directe du deuto-chlorure de mercure en 
 dissolution sur les tissues affectes primilivement ou consecutivement. 
 
BUBO. 65 
 
 lint is to be moistened in a solution of the bichloride of mercury 1 
 and laid upon the denuded surface. This is to be kept in its place 
 for two hours by bandages, or strips of adhesive plaster ; when it is 
 removed a dark brown eschar will be found already formed. The 
 parts are now to be covered with a simple poultice, a cooling lotion, 
 or a solution of opium, and the patient is to keep as quiet as possi- 
 ble till the eschar thus produced has separated ; when this has taken 
 place the tumour is found materially diminished, or altogether gone. 
 If the tumour be of large size, or very indolent, a second or even 
 third repetition of the process may become necessary. 
 
 178. Hundreds of cases of bubo have been, and are daily, thus treat- 
 ed successfully in the French army without the patients being con- 
 fined to bed, or without their taking mercury internally, or using 
 it by friction. M. Malapert's patients have taken during the time 
 of treatment the decoction of sarsaparilla, but this is not considered 
 at all essential to the success of the treatment. M. Malapert 
 employed blisters with cauterisation chiefly against the incipient 
 bubo either indolent or inflamed; since that time a paper has been 
 presented to the academy by M. Reynand, of Toulon, in which the 
 same process has been directed with almost equal success against 
 bubo in its second and third stages, even where the collection of pus 
 has been considerable. The plan or MM. Malapert and Reynaud 
 has now been universally adopted in the French Venereal Hospital 
 by Cullerier and Ricord, with most marked success. The former 
 of these authors says we have tried this practice for three years in 
 this hospital, under circumstances the most varied; it is a method 
 really efficacious, and ought to hold a distinguished rank in the 
 treatment of bubo: in the first stage of this affection, M. Cullerier 
 states that he does not recollect having seen it fail. 
 
 179. This plan of treatment is most certain in its effects when 
 employed in the first stage of bubo, when the inflammatory symp- 
 toms do not run high ; it may be resorted to in all other forms of 
 the affection, but not with so well-grounded a hope of its success. 
 When the tumour has involved to much extent the cellular tissue 
 of the groin, and the accompanying inflammation is great, it will 
 be well, by local or general bleeding, rest, cooling lotions, and mild 
 aperients, to mitigate at least the inflammation before the blister, 
 <fcc. is resorted to. Indeed, in the employment of this method, we 
 are not to lose sight of those other means of known efficacy which 
 the established practice of surgery indicates. Frictions of mercu- 
 rial ointment with or without the iodide of potassium may be 
 rubbed upon the base of the tumour at the same time, or the sore 
 left by the separation of the eschar dressed with an ointment of 
 this character. 
 
 180. Other caustics may be employed to form an eschar on the 
 surface denuded by the blister, such as the sulphate of copper, in 
 
 I 9e. Hydrargyribichlorid.gr.xx. 
 
 Aquae distillate, gj 
 23 c 6 park 
 
66 t PARKER ON SYPHILITIC DISEASES. 
 
 the proportion of two drams to the ounce of water, the nitrate of 
 silver, the chloride of zinc, or tincture of iodine. These, however, 
 are not preferable to the bichloride of mercury. 1 
 
 181. When a bubo has suppurated, this method may be still 
 employed with success if the skin covering the abscess is thick; at 
 this period it very commonly succeeds in dispersing the bubo with- 
 out having recourse to the knife, &c. If the integuments are thin 
 and the collection of pus on the point of discharging itself, it ought 
 not to be used. 
 
 182. The objections to the use of this plan are the pain the ap- 
 plication of the caustic occasions, which, however is of short dura- 
 tion, and the cicatrix which the healing of the sore, after the eschar 
 has separated, leaves behind. Both these evils, however, are trivial 
 when compared with the inconvenience experienced from a bubo 
 which has been allowed to suppurate. 2 
 
 183. M. Ricord thinks that this method, however certain in its oper- 
 ation, should be used only in cases of bubo succeeding to chancre, 
 and which may be presumed of a virulent character. He is of 
 this opinion, because the buboes succeed to excoriations upon the 
 genitals not of a specific character, or to gonorrhoea, or which are 
 d'emblee, have very little tendency to suppurate, and hence the in- 
 convenience and pain of the process may be spared. In these cases 
 M. Ricord prefers pressure with discutient plasters or lotions ; com- 
 presses soaked in solutions of the acetate of lead, or muriate of 
 ammonia, 3 or plasters of belladonna, lead, iodine, or mercury. 4 
 
 1 Dr. Wallace resorts to a similar mode of practice in the treatment of 
 indolent buboes ; this consists in " the vesication of the surface of the tu- 
 mour with the nitrate of silver, if there be not much increase of heat in the 
 part." 
 
 J See the remarks by Cullerier, on the employment of this method, in 
 Lucas Championniere, Therapeutique de la Syphilis, p. 356 et suivantes ; 
 also by M. Ricord, pp. 582-4. 
 
 3 $<. Plumbi acetat., 9 ij. 
 
 Aquae, gxvj. M. Ricord. 
 
 This is the " eau blanche" of the French Hospitals. 
 *e. Arnmon. muriat., ^ij. 
 Acidi acetic. 
 Sp. vini, aa %\j. 
 Ext. belladonna?, 3j. 
 Aquae rosae, ^xiv. M. 
 
 * For this purpose may be employed the " Emp. Ammoniac, c. Hydrargyro" 
 of the London Pharmacopoeia; the Emp. de Vigo of which I have already- 
 given the form, page 46 : 
 
 or, 
 9<. Emp. belladonnae, pts. 8. 
 
 Plumbi ioduret., 1. M. 
 *. Emp. " de Vigo" c. mercuric, pts. 4. 
 
 Extract, belladonnae, pt. 1. M.Dupuytren. 
 *. Emp. belladonnae, iv. 
 
 lodinii, 3j. M. 
 IT. Emp. hydrargyri, iv. 
 lodinii, 3j. M. 
 
 ' 
 
BUBO. 67 
 
 When much pain and tenderness exist, bleeding becomes necessary, 
 with the application of strong aqueous solutions of opium. 
 
 184. In the treatment of indolent bubo, in the commencement 
 M. Ricord has recourse to the discutient plasters with compression 
 in the day time, and friction with the iodide of potassium, or mer- 
 curial ointment, in the evening, covering the part during the night 
 with a poultice. If this has not a marked effect upon the enlarge- 
 ment in a few days, blisters with the bichloride of mercury on 
 Malapert's plan are employed. Frictions with ointments composed 
 of the proto-ioduret of mercury, 1 or compresses soaked in a dilute 
 tincture of iodine, 2 are also very useful in the resolution of the 
 chronic or indolent bubo. 
 
 185. The disease may terminate in two ways: the enlarged 
 glands may pass on slowly to suppuration, or assume a form of in- 
 duration of a scirrhous or scrofulous character. In the latter form, 
 friction with croton oil, the tincture of iodine, or the emp. bella- 
 donnas with the tartar emetic, may be used as local applications. 
 Small issues may also be formed over the induration by means of 
 the caustic potash, or if the disease assume a purely scirrhous cha- 
 racter, extirpation may become necessary. The progress, compli- 
 cation, and termination of bubo will depend very materially upon 
 the constitution of the patient, and the condition of his general 
 health ; hence the latter demands the strictest attention on the part 
 of the practitioner. The organs of digestion, and thje state of the 
 viscera of the chest, and abdomen, should be carefully attended to; 
 we must, to the utmost of our power, take care that no complication 
 on the part of the latter organs interfere with the local disease, and 
 endeavour by appropriate treatment to combat any general cachectic 
 state that may be in existence, and which may not only prevent 
 the resolution of the tumour in the groin, but favour the extension 
 of disease to other parts of the glandular system. For these pur- 
 poses an antiphlogistic treatment may be necessary on the one 
 hand, whilst on the other the internal exhibition of mercury, iodine, 
 or sarsaparilla may be useful, either simply or in any of the forms 
 of combination which have been previously indicated. 
 
 186. When fluctuation is evident, more particularly if the skin 
 covering the tumour be thin, it will generally be useless to lose time 
 in attempting longer the resolution of the tumour. It will, as a 
 general principle, be better to open it freely, and at once, either with 
 the scalpel or the knife. Dr. Wallace believes that buboes in their 
 stage of suppuration may be resolved by mercury if it has not been 
 used earlier in the disease; and M. Reynaud has succeeded in 
 dispersing them by the blister with caustics. These remedies are, 
 however, to say the least, uncertain at this period, and we are more 
 
 1 &. Hydrargvri proto-ioduret, 9j. 
 Abipis, 3j- M. ft. Unguent. 
 
 *iy. Tinct. iodinii, ^j. 
 
 Aquae distillat., gij. M. ft. Lotjo. 
 
68 PARKER OX SYPHILITIC DISEASES. 
 
 likely to save time and our patient's constitution by resorting at 
 once to a free opening. 
 
 187. The bubo may have suppurated freely, and the collection 
 of matter be large, and the surrounding tissue little indurated, or 
 there maybe much surrounding induration, and the collection of 
 matter small and deep-seated. In all cases the best general rule of 
 practice is to open the bubo as soon as fluctuation is evident. 1 
 "When it is deemed prudent to open a bubo before the process of 
 ulceration has ceased, or, in other words, where pus exists only in 
 the centre of the tumour, and whilst this purulent matter is still 
 surroundec^.by a morbid texture passing into the state of liquefac- 
 tion, it will be indispensable to make our incision proportioned, 
 both in its depth and extent, to the size of the tumour; for unless 
 it be made deep, we may not reach the purulent focus; 2 and unless 
 it be made extensive, or through such parts as are in progress to 
 suppuration, we shall not stop this process; and before it is com- 
 pleted, the opening we have made, may close up from tumefaction, 
 and the patient be thus exposed to the necessity of a fresh operation, 
 or else to wait the discharge of the matter by the natural actions of 
 the part. Whereas, if we make an incision sufficiently extensive, 
 we shall not only avoid these evils, but also diminish very consider- 
 ably the extent of the disease. In fact, incision into a bubo, when 
 in the state of incipient suppuration, will in general as effectually 
 put a stop to its progress as it will to that of anthrax when in an 
 analogous state. I would even say further, that we may perhaps 
 uniformly stop the increase of bubo by a sufficiently free incision 
 in its first, second, or third stage i. e. before matter is formed." 3 
 
 188. When the integuments covering a bubo are of a deep blue 
 colour, more or less disorganised, or threatening gangrene, it is 
 better to open the abscess with the potassa fusa, or some other caustic, 
 than by simple incision. Where it is impossible to save the inte- 
 guments, from their thinness and the degree of disorganisation 
 which they have undergone, Desruelles and Wallace prefer open- 
 ing the abscess with caustic; the surface of the skin is to be de- 
 stroyed by the potassa fusa, &c. to the proposed extent, and the 
 next day a puncture made with the lancet in the centre of the 
 slough thus formed. Where, however, it is probable that the in- 
 teguments may be saved, the nitrate of silver is to be rubbed "on 
 the surface of the bubo, and of the surrounding diseased skin, pre- 
 viously moistened with tepid water, until the cuticle is rendered of 
 a bluish colour to the extent of an inch beyond the diseased inte- 
 guments covering the tumour." On the following day a puncture 
 is to be made in the thinnest part of the integuments, and a com- 
 press and roller are to be applied. When the surface of the cuticle 
 
 1 See the priciples inculcated by Ricord, p. 595, and by Dr. Wallace, pp. 
 360-1. 
 
 *Ces bubons veritables puits artesiens. Ricord. 
 9 Wallace, op. cit, p. 361. ? ~ 
 
BUBO. 
 
 69 
 
 has become dry after the first application of the caustic, it may ba 
 reapplied over the integuments as before. This local treatment 
 recommended by Dr. Wallace almost universally succeeds in caus- 
 ing the sides of abscess to agglutinate and the external wound to 
 heal. 1 
 
 189. The open or ulcerated bubo may assume many morbid con- 
 ditions which prevent its cicatrisation. In the first place, the in- 
 flammation which sympathy, or the absorption of the venereal 
 poison, has occasioned in the glands of the groin, and which has 
 terminated in suppuration, may continue to be violent after the pus 
 has been evacuated, and hence one obstacle to the cicatrisation of 
 the ulcer is a degree of inflammation in the part itself. The undue 
 excitement results either from a continuance of the original inflam- 
 mation, kept up by exercise of the diseased part, by too nourish- 
 ing a diet or other causes, or from the imprudent and too early local 
 application of stimulating dressings. In this form of the disease 
 the patient will derive benefit from repose, low diet, gentle aperients, 
 local bleeding, anodyne fomentations, and the application of com- 
 presses soaked in an aqueous solution of opium. The opiate or 
 simple cerates are the most appropriate dressings; and thes'j may 
 be assisted by gentle pressure by means of compresses and a roller 
 methodically applied. 
 
 190. Again, the surface of the open bubo is commonly covered 
 with a thick slough, the ulcer itself is indolent, or disposed to spread, 
 and its edges are red, angry, and elevated. This is the most ordi- 
 nary condition of the true virulent bubo; and all that has been 
 said on the ulcerating stage of chancres is applicable here. It 
 becomes necessary, in these states, to destroy the diseased surface 
 of the sore by means of caustics; and for this purpose the nitrate 
 of silver, the mineral acids, the nitrated acid of mercury, or the 
 powder of cantharides may be employed: the latter remedy is 
 largely employed by Ricord. The dressings best suited to this form 
 of bubo are Ricord's aromatic wine, with or without opium or 
 tannin; this, as in the case of chancre, may be alternated with 
 some digestive ointment, 2 solutions of the sulphate of copper or 
 zinc, or a weak solution of the chlorides of lime or soda. Creosote 
 is also very useful as a local application, more or less diluted. 
 
 191. In chronic open indolent bubo, with a foul surface, where 
 most remedies have failed in modifying the condition of the sore, 
 M. Cullerier employs occasionally, as a caustic, three, four, or five 
 grains of the bichloride of mercury dusted over the surface of the 
 sore, and suffered to remain for some hours. The application of 
 the remedy is followed by severe pain, and inflammation, but gene- 
 
 .,..;,-,. . . 
 
 1 Wallace, pp. 377-8. 
 
 *The reader will find the particular forms for the preparation of these 
 remedies, in the previous pages of this work, under the article Primary 
 Venereal Sores. 
 
70 PARKER ON SYPHILITIC DISEASES. 
 
 rally succeeds in producing a healthy condition of the sore, speedily 
 followed by complete cicatrisation. 1 
 
 192. The alternate application of leeches, and digestive oint- 
 ments are exceeding efficacious in the treatment of ulcerated bubo. 
 Desruelles states that he generally succeeds in healing these ulcers, 
 in thirty or thirty-five days, by applying in their centre from four 
 to six leeches every three or four days, and dressings in the inter- 
 vals with compresses soaked in a solution of opium. The indica- 
 tions, however, of all local applications are to be sought for in the 
 condition of the sore; they require constantly to be changed what 
 is useful to-day may be injurious to-morrow. 
 
 193. A formidable obstacle to the cicatrisation of an open bubo 
 is occasionally presented by the edges of the sore itself. The in- 
 teguments covering- the cavity have lost part of their vitality, they 
 are more or less discoloured, indolent, or indurated, and otfer no 
 disposition to^adhere to the under surface of the sore, or to throw 
 up granulations by which the ulcer might be filled. Jn this condi- 
 tion they offer a permanent obstacle to cicatrisation, and it becomes 
 necessary to adopt means to bring about, their union with the sub- 
 jacent parts, or else to remove them altogether by the knife, scissors, 
 or caustic. To accomplish the first intention, the under surface of 
 the integuments may be rubbed with the sulphate of copper, the 
 nitrate of silver, or some other caustic, the cavity of the ulcer filled 
 with soft lint, covered with some dressing suited to the condition of 
 the sore, and a bandage and compress applied. 
 
 194. When it becomes necessary to remove the floating portions 
 of integument, caustics or the knife maybe used, but this operation 
 must not be performed on a truly venereal bubo in a state of ulce- 
 ration, inflammation, or great irritability. These conditions must 
 be subdued before such an operation is thought of. The late Dr. 
 Wallace thought that the removal of the diseased integuments 
 covering an open bubo might in most instances be prevented "by 
 the vesication of the diseased integuments, and also of the sound 
 skin for a little way beyond them by means of the nitrate of silver." 
 The application of the caustic is to be renewed every four or five 
 days, or as often as the surface of the integuments to which it 
 might have been applied becomes covered by a new cuticle. It 
 will also be useful to apply it occasionally to the whole ulcerating 
 surface, and to the orifices of any fistulous openings that may exist, 
 not with a view of destroying exuberant granulations, but to excite 
 the granulating surface to more healthy actions. 2 
 
 195. Dr. Wallace states that he has known loose portions of in- 
 tegument of several inches in diameter, which were so diseased in 
 
 1 This practice originated with Dr. Ordinaire. He first employed it in the 
 treatment of cancerous or foul sores of the rectum, nose, and other parts. 
 The results of the method were so favourable, that Cullerier tried it at the 
 Hopital des Veneriennes in the treatment of foul indolent buho. It has in 
 many cases exceeded his most sanguine expectations. 
 
 2 See Wallace, op. cit. p. 381. 
 
BUBO. 71 
 
 their structure that they lay on the surface of the ulcer like a dead 
 flap, saved by this process. "I have also," continues this author, 
 "accomplished the cicatrisation of other ulcerations, which pre- 
 sented numerous fistulous openings or detached flaps, and in which 
 all the ordinary means, such as injections, compresses, incisions, 
 <fcc. had all been employed in vain. In short I can most confi- 
 dently recommend this treatment of indolent and atonic ulceration, 
 <fec. as well as that of abscesses of the same class, as a very great 
 improvement in the general practice of surgery. 
 
 196. The internal surface of the open bubo is rarely smooth, 
 uniform, or continuous; it is generally uneven and irregular, fre- 
 quently divided into compartments, or presenting numerous orifices 
 which are the openings to other glands, which have suppurated, 
 and thus open by small orifices into the chief or general cavity, 
 which is very commonly an abscess in the cellular tissue surround- 
 ing the gland or glands, which have been originally the seat of 
 irritation. It is this pathologic condition of open bubo which 
 renders its treatment so difficult and tedious. 
 
 197. Injections may be employed in the treatment of these 
 fistulous openings with a view of modifying the condition of their 
 surfaces, and disposing them to cicatrise. Solutions of the sulphate 
 of copper, the nitrate of silver, the sulphate of zinc, or bichloride of 
 mercury, 1 may be thus employed. 
 
 198. If local bleedings, appropriate dressings, and compression 
 fail in the treatment of these fistulae or sinuses, it may be necessary 
 to lay them open with a knife. Sometimes the enlargement of the 
 orifice is sufficient, or it may be necessary to divide them in their 
 whole length, or if the situation of the sinus permit, a counter-open- 
 ing will generally answer all the purposes of complete incision, a 
 practice attended with much terror and pain to the patient. Culle- 
 rier speaks highly of counter-openings made with the caustic 
 potash ; the caustic as well as the opening may contribute to the 
 cure in these cases. The fistulas may likewise be cauterised inter- 
 nally by means of solid nitrate of silver, or a small portion of the 
 powdered oxymuriate of mercury introduced by means of a grooved 
 director: this practice is painful, but generally successful in its re- 
 sults. Lastly, the whole external skin, corresponding to the sinuses, 
 may be vesicated with the nitrate of silver, in the manner recom- 
 mended for the treatment of loose portions of integument. 
 
 199. The internal use of iodine, alone or combined with potass 
 
 1 *. Cupri sulph., gr. vj. 
 Aquae dist., j. M. 
 
 >. Argent, nit. gr. vj. 
 Aquas, 3j. M. 
 
 l<. Zinci sulph., gr. x. 
 Aquae, j. M. 
 
 *. Hyd. bichlorid., gr. j. 
 
 Aquas, gj. M.Cullerier. 
 
72 PARKER ON SYPHILITIC DISEASES. 
 
 or mercury, is of great service in the treatment of many forms of 
 chronic ulcerated bubo. To the consideration of the employment 
 of this remedy I shall return when treating of the secondary and 
 tertiary symptoms of syphilis, having been most kindly favoured 
 by my friend, M. Ricord, of the " Hopital des Vene>iennes," with 
 the results of his experience in the use of this remedy. 
 
 SECTION IX. 
 
 Of Constitutional or Secondary Syphilis* 
 
 200. I now pass to the consideration of constitutional or second- 
 ary syphilis, a class of morbid actions which make their appearance 
 in the economy at a shorter or later period after a primary venereal 
 sore upon the genitals or elsewhere ; the secondary symptoms not 
 being confined to the organs of generation, but extending to the 
 skin, mucous membranes, or other parts. 
 
 201. Ricord divides the phases of syphilis into the primary, the 
 secondary, and the tertiary. The primitive symptom or chancre is 
 due to the direct application of the venereal poison by means of 
 sexual intercourse, or inoculation. It is capable of propagation 
 with all its properties from one individual to another, by intercourse 
 or inoculation. It is not capable of being transmitted hereditarily ; 
 a female having a chancre at the period of parturition may produce 
 in this manner the same disease in her infant. The chancre may 
 be followed by a series of symptoms which are successive or con- 
 tinuous, but not constitutional or secondary ; these are new chan- 
 cres, buboes, or abscesses, &c. of various kinds these being in their 
 onset purely local, and not dependent upon any affection of the 
 constitution generally. 
 
 202. Secondary symptoms are those which make their appear- 
 ance after the economy has become generally affected by the vene- 
 real poison, by absorption from the primary sore, during which 
 process the matter has undergone modifications which, in some 
 measure, change its character. Secondary syphilitic diseases gene- 
 rally appear on the skin or mucous membranes in the eyes, or the 
 testicles, &c. Constitutional syphilis rarely makes its appearance 
 before the second week after the primitive affection, more com- 
 monly later, towards the fourth or fifth weeks, or at periods still 
 more remote. These symptoms are not capable of producing their 
 like by inoculation, and thus cannot be mistaken for primary affec- 
 tions. They may be transmitted hereditarily from parent to child. 
 
 203. When syphilis has continued in the economy for an indefi- 
 nite period of time, we observe the symptoms which are termed 
 
 1 Syphilis constitutionelle ; accidents secondaires et terliaires. Ricord, 
 Maladies vineriennes consecutives. Desruelles. 
 
SECONDARY SYPHILIS. 73 
 
 secondary to disappear, or to lose the properties which at first cha- 
 racterised them, whilst others of a different kind succeed, to which 
 Ricord has applied the term of" tertiary" The tertiary symptoms 
 appear at an indefinite, and generally very long period, after the 
 primary diseases, and in the greater number of subjects either after 
 secondary symptoms have disappeared, or whilst these are still 
 manifest in the constitution. The diseases which Ricord terms 
 tertiary are deep-seated diseases of the skin, as lupus, and affections 
 of the bones, as periostosis, exostosis, caries, necrosis. To these 
 may be added various internal affections, as yet neither well known, 
 nor described. M. Ricord has presented to the Royal Academy of 
 Medicine specimens of tubercles of the brain, which he believes to 
 be of syphilitic origin. The tertiary symptoms are not hereditary, 
 under any specific form of venereal affection. M. Ricord, however, 
 thinks that the offspring of persons thus affected are very commonly 
 scrofulous, phthisical, or predisposed to cancerous diseases. Ter- 
 tiary symptoms are not capable of propagation by inoculation. 
 
 204. All the forms of constitutional syphilis must be preceded by 
 a primary affection unless the disease be the result of hereditary 
 taint, which then makes its appearance with those symptoms which 
 are generally termed secondary. 
 
 205. It may be naturally inquired here, whether any treatment of 
 the primary disease can certainly prevent the secondary. This ques- 
 tion has also been agitated by Ricord. This author states that he 
 has not been able to meet with any recorded fact where a primary 
 venereal sore healed in five days, has been followed by secondary 
 symptoms; neither has he ever observed such a circumstance in his 
 own practice. The probability of secondary symptoms is in direct 
 proportion to the duration of the primitive disease, the longer this 
 continues the greater is the chance that the constitution may 
 become affected, hence that treatment is the best prophylactic under 
 which the sore most rapidly heals, without induration of itscicatrix. 
 
 206. All persons are not equally susceptible of a constitutional 
 infection from a primary sore, hence we commonly observe those to 
 escape, in whom the sore has healed spontaneously without treat- 
 ment, or where the treatment has been conducted on general 
 principles only. The risk of secondary symptoms is materially 
 diminished, where the primary sore has been treated by mercury. 
 This fact is admitted by all authors practically conversant with the 
 subject. Those individuals are most likely to suffer from constitu- 
 tional syphilis whose general health is bad when they contract a 
 primary sore; hence chronic affections of the skin, stomach, or 
 digestive organs, scrofula, general cachexy, or other diseases general 
 or particular, under which the patient may labour at the time of 
 infection, are to be considered as predisposing causes. Attention 
 to the general health is of the first importance, and the constitution 
 of our patient must most materially modify our treatment. 
 
 207. Secondary syphilis, like primary, only becomes formidable 
 by neglect and ill-treatment ; it is a principle we should never lose 
 
74 PARKER ON SYPHILITC DISEASES. 
 
 sight of, to commence seriously the treatment of constitutional 
 syphilis the moment it becomes manifest in the economy. There 
 is no contra-indication to the immediate commencement of this 
 treatment ; should the constitution be bad, or the patient diseased, 
 it must be modified to suit these circumstances : even the period of 
 gestation is no bar to the anti-syphilitic treatment. M. Ricord states 
 that he has seen more females miscarry when their disease has been 
 suffered to go on unchecked than when they have been subjected to 
 an anti-syphilitic treatment, framed with judgment to suit the cir- 
 cumstances of the case. The same remarks apply to the period of 
 suckling. 
 
 208. When constitutional syphilis is complicated, these compli- 
 cations should never be neglected ; if they co-exist with acute or 
 subacute affections of internal organs, the latter ought first to be 
 attended to, these should be subdued before we commence the anti- 
 syphilitic treatment. When the chronic affections, as scrofula, 
 affections of the skin, or chronic diseases of internal organs, com- 
 plicate constitutional syphilis, the anti-syphilitic treatment may be 
 at once commenced, but it must be framed and conducted with much 
 care, that the accompanying affection, of whatever character it may 
 be, may not be aggravated by it. An exclusive or empirical treat- 
 ment cannot be too strongly condemned. It is in these cases that 
 the compounds of iodine and mercury, iodine and iron, and iodine 
 and potass are commonly so useful. 1 
 
 209. Whenever any of the forms of constitutional syphilis are 
 accompanied by fever, or much inflammation, a strict antiphlogistic 
 treatment and regimen are absolutely necessary. Without a rigo- 
 rous observance of this rule (observes M. Ricord,) we can have no 
 rational hope of success. Whatever be the character of the con- 
 stitutional symptoms, if they are accompanied by local inflammation, 
 or general excitement, a rigorous antiphlogistic regimen and treat- 
 ment ought to be followed till the vascular excitement is subdued. 
 An antiphlogistic treatment is not to be adopted where these 
 phenomena are absent, and of course its employment as a general 
 measure is to be severely condemned, for in many cachectic or scrof- 
 ulous patients, or those whose constitutions are already undermined 
 by chronic disease, an opposite plan of treatment becomes necessary. 
 In the latter instances a low nutritious diet is essential to the success 
 of the treatment. The practice of the Venereal Hospital has taught 
 M. Ricord that debilitated and scrofulous patients, who have been 
 badly fed, quickly recover their general health and are cured of 
 syphilis, under the full diet of the hospital, whilst those whose cir- 
 cumstances have enabled them to live well, frequently become 
 
 ! See the whole of the excellent remarks of M. Ricord on Complicated 
 Syphilis, op. cit. pp. 615-18. 
 
 " En un mot, 1'accident le plus saillant, 1'epiphenomene, quel qu'il soit, 
 esl celui qu'il faut, d'abord combattre, sans negliger aucun des Clemens qui 
 peuvent fournir aux indications therapeutiques." 
 

 DISEASES OP THE SKIN. 75 
 
 cachectic under the hospital regulations, their syphilitic affections 
 remain stationary, and they only recover their health, and lose their 
 disease in returning to the habits of living to which they have been 
 accustomed. 
 
 210. That the internal treatment adopted against any particular 
 form of constitutional syphilis may have every chance of success, it 
 is also necessary that the stomach and bowels be kept entirely free 
 from all irritation or disease. 
 
 SECTION x. 
 Of Syphilitic Diseases of the Skin. 1 
 
 211. Syphilitic diseases of the skin may be referred to eight prin- 
 cipal groups; 1st, the Exanthemata; 2d, Squamae ; 3d, Vesiculae; 
 4th, Pustule; 5th, Papulae; 6th, Tubercula; 7th, Ulcers; and 8th, 
 Vegetations. In considering these several varieties, I shall notice 
 some remedies applicable to the treatment of the Syphilides gene- 
 rally, and then notice more particularly the treatment suited to each 
 particular form. 
 
 212. Of Mercury. All that has been said in the early part of 
 this work on the principles which are to guide us, both in the 
 internal administration and local application of mercury in syphilitic 
 diseases, finds its reapplication here. It is useless to recapitulate 
 what has been there laid down. 
 
 213. The external employ of mercury is occasionally resorted to 
 by Biett, in the treatment of certain forms of constitutional syphilis. 
 It may be employed in baths, in fumigations, or in the shape of 
 ointment. The baths are hardly employed. Weak solutions of 
 the bichloride of mercury have been occasionally used at St. Louis, 
 in the papulous, tuberculous, or vegetating forms of syphilis ; they 
 have, however, sometimes given rise to serious accidents, and hence 
 are almost abandoned. Fumigations or some other form of local 
 application may be substituted for them. Ointments of the proto 
 and deuto-iodurets of mercury 2 are used by Biett by way of friction, 
 on parts of the skin affected with chronic indolent tubercles (syphi- 
 litic lupus.) 3 
 
 1 To this class of diseases the term " Syphilides," (Syphilis and eidos,) 
 was first applied by Alibert; it has since been adopted by Biett, Rayer, 
 Ricord, and all modern writers upon Syphilitic Eruptions. 
 *9c. Adipis, 3J. 
 
 Hyd. proto-ioduret, gr. xxv. M 
 
 *. Adipis. 3J. 
 
 Hyd. deuto-ioduret., gr. xvj. M. 
 
 These tubercles are grouped amongst the tertiary symptoms by M. Ricord. 
 We shall presently have to speak of the particular treatment of this surgeon 
 in such forms of disease. 
 
76 PARKER ON SYPHILITIC DISEASES. 
 
 214. At the Hospital St. Louis, the preparation of mercury, pre- 
 ferred in the internal treatment of the syphilides, is the bichloride. 
 Small doses of aether are added to the form of administration in 
 common use. this adds much to the efficacy of the remedy ; diseases 
 which have resisted the exhibition of the common solution, give 
 way speedily to this combination. 1 To procure ease to patients 
 suffering from pains in the bones the bichloride of mercury with 
 opium, in the proportion of an eighth of a grain to the former, with a 
 grain of the latter is used by Biett. Dupuytren had recourse to the 
 extract of aconite for the same purpose. The cyanuret of mercury 
 is likewise extremely useful in the internal treatment of the syphi- 
 lides : symptoms commonly disappear under its use, which have 
 resisted the other forms of mercury ; indeed a change of form in the 
 remedy we are using is frequently of great benefit. The cyanuret 
 may be given in solution, containing twenty-four grains of the salt 
 to two pounds of distilled water ; of this solution, from one to two 
 ounces a day are administered in any vehicle. The proto-ioduret 
 of mercury in doses of a grain a day in the commencement, is the 
 remedy preferred by Ricord. In constitutional syphilis, mercurial 
 remedies are almost always more efficacious when given by the 
 mouth, than when employed endermically by way of friction. If 
 one form of the remedy disagrees, or does not soon produce marked 
 effects, it will be advisable to have recourse to another, or even a 
 third, till we have found one suited to the constitution of the patient, 
 and the individual peculiarities of his disease. 
 
 215. Iodine and its preparations. These remedies are employed 
 largely in the treatment of the secondary and tertiary symptoms of 
 constitutional syphilis. Iodine of itself is a powerful antisyphilitic, 
 but, unless in a state of combination with mercury, is inadmissible 
 in the treatment of the simple primary forms of the disease. It may 
 be employed in the cutaneous diseases of constitutional syphilis with 
 great advantage, and, though a remedy not so active as mercury, is 
 particularly indicated in constitutional syphilis, where the primary 
 forms of the disease have been treated by full courses of the former 
 medicine. Cullerier uses the following form for its administration. 
 
 *. lodinii, gr. j. 
 
 Potassse lodid., gr. ij. ad. iv. 
 Aquae, gj. M. 
 
 1 SYRUP OF LARREY. 
 
 *. Syrup, sudorific., ffiij. 1 
 Hydrarg. bichlorid.,jgr. xx.' 
 ^Ether. sulphuric., ^ij. 
 Ext. opii, gr. xx. 
 Ammoniae muriatis, gr. xx. M. 
 
 From one to two ounces of this syrup are administered in the course of the 
 day, in divided doses, in a teacupful or more of the decoction of sarsaparilla, 
 or some other sudorific. 
 
 2 The syrup of sarsaparilla may be used for the sudorific syrup; the only 
 difference in the original prescription ia the addition to the sarsaparilla of an 
 equal quantity of guaiacum. 
 
DISEASES OF THE SKIN. 77 
 
 This may be put into a pint or quart of any vehicle ; as the decoc- 
 tion of sarsaparilla, &c. and given at intervals during the day. The 
 dose of the iodine may be increased to two grains in the day, and 
 that of the iodide of potass to six, or ten. The preparations of 
 iodine are chiefly of use in constitutional syphilis, in scrofulous or 
 delicate patients, and in glandular enlargements of syphilitic cha- 
 racter, which have resisted the action of mercurials. 
 
 216. M. Ricord employs the iodide of potassium chiefly in those 
 forms of constitutional syphilis which he has termed tertiary. 
 These are tubercles of the skin and mucous membranes, which, in 
 the venereal pathology of this surgeon, form the link connecting the 
 secondary with the tertiary forms of disease, nocturnal pains, peri- 
 ostitis. ostitis, caries, and tumours of the bones; in all these forms 
 of disease, the iodide of potassium is considered by Ricord as the 
 remedy " par excellence." He does not rely upon it so much in 
 the secondary affections of the skin, unless used in combination 
 with the iodurets of mercury. The dose of the iodide of potassium, 
 in the commencement, should be ten grains in the day, dissolved in 
 an ounce of distilled water, and administered at intervals in any 
 convenient vehicle; every two or three days the dose may be 
 increased, observing its effects : Ricord increases it ten grains every 
 three days ; he has carried it as far as one hundred and forty grains 
 in the day without any ill effect. The iodide of potassium accele- 
 rates the pulse, and occasions a slight heat in the stomach ; 
 generally, however, if the stomach be free from disease or irritation, 
 it materially improves the digestive powers. If given in an over- 
 dose, the heat in the stomach amounts to pain, and may be followed 
 by inflammation ; it occasions also, when thus employed, pricking 
 or irritation of the skin, followed by a pustular eruption ; sometimes 
 the head is affected, and the quantity of urine enormously increased. 
 Ricord mentions a case in which this took place to the extent of 
 forty or fifty pints in the day, it was not found on analysis, to con- 
 tain sugar. We shall return to the special indication for the 
 employment of this remedy when speaking of the particular forms 
 of constitutional syphilis. 
 
 217. Sudnrifics. These remedies are commonly employed with 
 success in the treatment of constitutional syphilis. In addition to 
 the compound decoction of sarsaparilla, <kc. commonly used in this 
 country, either alone or as a vehicle for the exhibition of other 
 remedies, several forms of these medicines are employed at the 
 Hospital St. Louis, and in the Venereal Hospital, which may be 
 adopted with advantage. The decoction of Zittman is the prepa- 
 ration most universally used, and that with great success. It is 
 thus prepared, 
 
 *. Rad. sarsaparillae, 
 
 Aquae, ftxxiv. 
 Boil for two hours and add 
 
78 PARKER ON SYPHILITIC DISEASES. 
 
 Alumnis sulph. 
 Hydrarg. chlorid., ^. 
 Antimonii sulphuret., j. 
 Boil down to two thirds, and add 
 
 Fol. sennae, ^iij. 
 Rad. glycirrhizae ijjjss. 
 Sera, anisi, ss. 
 Infuse for an hour, and strain. 
 
 This is termed the stronger decoction. The weaker one is to be 
 prepared by taking the residue which remains after straining the 
 stronger, and adding 
 
 Rad. sarsaparillse, ^ij. 
 
 Aquae fontanae, ft xxiv. 
 
 Boil for two hours, and add 
 
 Corticis canellae, 
 Corticis limonum, 
 Semin. cardamomi, 
 Infuse for an hour, and strain. 
 
 The patient is directed to take half a pint of the stronger decoction 
 the first thing in the morning, warm, and to remain in bed some 
 time after taking it. During the day, he should take at intervals a 
 pint of the weaker decoction, and in the evening a second half pint 
 of the stronger. The last two doses are to be taken cold. Every 
 fifth day the decoctions are to be omitted, and an aperient taken. 
 This preparation is chiefly used in venereal affections of the bones, 
 but is not less useful in the syphilides generally; it is employed 
 largely in the practice of Biett and Ricord. 
 
 218. The sudorific syrup 1 may be employed as a vehicle for 
 other remedies. M. Ricord makes use of it for the administration 
 of the cyanuret of mercury. 2 The sulphuret of antimony, or the 
 subcarbonate of ammonia, are also valuable additions to the simple 
 sudorific decoctions. The arseniate of soda administered in a 
 sudorific decoction, or in pills is a remedy of great utility in obsti- 
 nate syphilitic diseases of the skin ; M. Alibert mentions the tuber- 
 culous varieties, or ulcerations where its exhibition is most likely to 
 ba successful. The dose is from one sixteenth to one eighth of a 
 grain. Biett uses it largely with great success. 
 
 219. The vapour or warm bath should be regularly employed 
 
 1 SUDORIFIC SYRUP. 
 
 &. Rad sarsae. 
 
 Guiaci ligni rasi, aa %vj. 
 Aquae, fl>iv. 
 
 Macerate for twenty-four hours ; boil to one half over a slow fire ; strain ; 
 and add from one to two pounds of white sugar. 
 *5<. Syrup. Sudorific., Oj. 
 Hydrarg. cyanuret., gr. iv. 
 Ext. opii, gr. viii. M. 
 A tablespoonful night and morning, increasing the dose gradually. 
 
DISEASES OF THE SKIN. 79 
 
 during the administration of that class of remedies of which we 
 have just been speaking. 
 
 220. The muriate of gold. This remedy is particularly useful 
 in the vegetating forms of the syphilides. It is prescribed in the 
 form of ointment ; from six to sixteen grains of the salt to an ounce 
 of the lard. Biett prefers it to every other remedy, as a local appli- 
 cation to syphilitic vegetations. Internally it may be exhibited 
 under the same forms, and in the same doses as the bichloride of 
 mercury ; its internal use is however uncertain. 
 
 SECTION XI. 
 
 Of the particular forms of Syphilitic Diseases of the Skin. 
 
 OF THE SYPHILITIC EXANTHEMATA. 
 
 221. The exanthematic form of the syphilides generally makes 
 its appearance under the form of irregular patches of a shining 
 coppery or bronze colour, on the onset of the disease ; if there be 
 much accompanying fever they are more inclined to redness, and 
 the bronze or copper colour is not marked till the inflammation and 
 fever have disappeared. These patches, rarely confluent, and of 
 about an inch in diameter, are scattered more or less over the whole 
 surface of the body; they more commonly appear on the face, the 
 neck, the forehead, the mammae, or the genitals. They are some- 
 times accompanied by papulae, and other forms of constitutional 
 syphilis, more particularly "iritis," and are frequently succeeded by 
 squamous or tuberculous forms of disease. These eruptions fre- 
 quently accompany the primary forms of syphilis. 
 
 222. They demand, in the first instance, if there be much symp- 
 tomatic fever, antiphlogistic treatment, and the warm bath ; after- 
 wards, if they are rebellious, the cyanuret or bichloride of mercury 
 with sudorifics may be employed. The syrup of Larrey is used 
 by Biett as one of the most efficacious remedies in this form of 
 the syphilides, alone, or given in some decoction of the woods. 
 Ricord's favourite decoction of Feltz may be here employed. 1 
 
 1 THE DECOCTION OF FELTZ. 
 
 *. Rad. sarsaparillse, ^iij. 
 Gummi acaciae, ss ad ^ij. 
 Antimonii sulphuret., iv. 
 
 The sarsaparilla is to be boiled in six pints of water, over a slow fire, till it 
 is reduced to one half. The sulphuret of antimony is to be wrapped in a 
 piece of linen, and suspended in the middle of the decoction, without touch- 
 ing the sides of the vessel. M. Ricord prefers this to the other decoctions 
 of the woods. 
 
80 PARKER ON SYPHILITIC DISEASES. 
 
 Of the Syphilitic Squama. 
 
 223. The squamae are particles of thickened epidermis, become 
 hard, dull, and opaque, and elevated above the surrounding skin by 
 a morbid condition of the subjacent dermis, or simply of the rete 
 mucosum. This disease is essentially chronic, and does not gene- 
 rally succeed to any febrile condition of the economy. The syphi- 
 litic squamae generally appear in the form of patches more or less 
 diffused, varying from the size of a sixpence to that of a half-crown ; 
 the centre of these patches is frequently depressed, they are of a red 
 copper colour, changing ultimately to a dull brown, or even black, 
 which is a Ions: time in disappearing. 
 
 224. The syphilitic squamae have a tendency to excoriate, or 
 ulcerate slightly in the centre, which then becomes covered by a 
 small, dry, thick crust, occasionally, also, their surface is traversed 
 by fissures, when there does not exist any apparent ulceration. 
 After the cure of the disease, the dermis remains depressed in the 
 parts corresponding to the centre of the squamous patches. The 
 other symptoms of constitutional syphilis, with which the squamse 
 are commonly associated, are inflammations and ulcerations of the 
 fauces and palate, iritis, pains and diseases of the periosteum and 
 bones. 
 
 225. As the syphilitic squamae are not generally accompanied by 
 vascular excitement or fever, an antiphlogistic treatment is rarely 
 indicated. Sudorifics, as the decoction of sarsaparilla, or the prepa- 
 rations of Zittman or Feltz, with the carbonate of ammonia, and 
 the vapour bath are generally successful. Mercurial fumigations, 
 the cyanuret of mercury, or the syrup of Larrey, are the best rem- 
 edies when mercurials are indicated. The preparations of arsenic 
 are useful in these forms of disease, particularly when they succeed 
 to primary diseases which have been fully treated by mercury. 
 Biett relates a case of this character speedily cured by the liquor 
 arsenicalis, and the arseniate of soda, after the failure of other 
 measures. The iodide of potassium may likewise be used, but to 
 this remedy we shall return in a subsequent section. 
 
 Of the Syphilitic Vesicula. 
 
 226. The vesiculae are the most rare of all the syphilides. M. 
 Biett himself has only seen a few examples of it. In one case, well 
 observed, the disease was characterised by vesicles seated upon an 
 inflamed base, of a deep copper-coloured red ; they were indolent, 
 and remained stationary much longer than eruptions of the same 
 character, not having a venereal origin. Some of them shrunk up, 
 and were transformed into gray squamous crusts ; others disappeared, 
 but left behind them on the skin where they were situated, a brown 
 mark. They were accompanied by some degree of fever, inflamma- 
 tion of the fauces, and palate, and an ulcer of suspicious character. 
 
DISEASES OF THE SKIN. 81 
 
 Ultimately, the patient became covered with a well-marked pustular 
 syphilitic eruption. 
 
 227. The treatment best adapted to these forms of disease, is an 
 antiphlogistic one ; the warm bath, and sudorifics. A mercurial 
 course will rarely be required. 
 
 Of the Syphilitic Pustulce. 
 
 228. The pustulae are characterised by an elevation of the epi- 
 dermis, raised by a collection of pus, secreted by a circumscribed 
 portion of inflamed skin. The syphilitic pustulae are frequently 
 complicated with tubercles, and the pustules themselves commonly 
 placed upon a tuberculous base. The pustules are again occa- 
 sionally associated with papulae, but are rarely complicated either 
 with squamous or ex'anthematous affections. The syphilitic pustulae 
 frequently ulcerate, and give place to a sore of characteristic appear- 
 ance, with hard and elevated edges, and a foul surface, secreting a 
 sanious pus. Unlike other pustular diseases of the skin, the 
 syphilitic pustule follows no regular course ; they are developed 
 slowly, and remain stationary for a longer or shorter period, fre- 
 quently for many weeks, or till an appropriate treatment be adopted. 
 They are situated upon a hard raised base, of a deep brown or cop- 
 pery red ; this colour is better marked when they have continued 
 some time than in the commencement of disease. The syphilitic 
 pustulae strictly belong to that class of affections, which are termed 
 secondary, but are sometimes observed to co-exist with a primary 
 venereal sore : they are, under these circumstances, developed upon 
 the skin of the penis, the scrotum, the pubes, or the labia ; they are 
 placed upon a red indurated base, soon burst, and change into 
 ulcerations, having all the character of chancres. 
 
 229. The syphilitic pustnlae form two distinct groups. The 
 first is composed of pustules termed psydracia^ by Willan ; and by 
 Alibert, miliary syphilitic pustules. They are small, numerous, 
 arranged in groups and disposed to become confluent ; each pustule 
 is placed upon a hard base, of deep red, or copper colour, and resem- 
 bles an opake white point, which, when opened, presents a small 
 gray-coloured excavation. These excavations ulcerate slowly, or 
 cicatrise, leaving a depressed cicatrix on the skin, of a coppery, or 
 brown colour, or become covered with a thin incrustation. 
 
 230 To the pustules composing the second group the term phlyza- 
 ciae is applied. Willan hasgrouped them under the genericappellation 
 of syphilitic ecthyma. The phlyzaceous pustules, or the pustules of 
 syphilitic ecthyma are formed separately and distinctly upon the 
 skin ; not in groups as in the former variety; they are placed upon 
 a hard, thickened, conical base, surrounded by a deep red, brown, 
 or copper-coloured areola. They commonly ulcerate, and are 
 succeeded by sores, with thick, elevated edges, dug out as it were 
 from the surrounding parts; these ulcers secrete an offensive pus, 
 or become covered with thick crusts ; they have a tendency to spread, 
 23 d 6 park 
 
82 PARKER ON SYPHILITIC DISEASES. 
 
 or to remain stationary, and not to cicatrise or assume any healing 
 process, unless an appropriate treatment be resorted to. Sometimes 
 these ulcerations give origin to red, fungous, painful vegetations. 
 The crusts with which they are occasionally covered, are hard, 
 brown, or black, and not of a yellow, as those which cover the sur- 
 faces of broken pustules generally. 
 
 231. The rupture of the syphilitic pustule, and the incrustation 
 of the pus upon the sore thus produced, give rise to a peculiar form 
 of disease, which Alibert has described as the " crustaceous pustular 
 syphilide ;" but this, it will be perceived, is not a distinct or separate 
 form of disease, but merely the consequence of the breaking of the 
 pustule, and the drying up of the pus upon the sore, or ulcer, which 
 is thus formed. The affection is now characterised by a very thick, 
 and very hard crust, most frequently of a conical shape, covering 
 an excavated ulcer, possessing all the characters both on its base 
 and edges, of a venereal sore. These ulcers sometimes penetrate 
 very deeply, destroying the periosteum, and ultimately producing 
 disease in the bones, over which they are situated. They now 
 enter into the class of the tertiary symptoms of M. Ricord, Should 
 the ulcer heal under the pustule, it leaves behind it a cicatrix of a 
 copper-colour, deeply depressed in the skin. 
 
 232. The syphilitic pustulae are amongst the most formidable of 
 the forms of constitutional syphilis, the crusts and ulceration which 
 succeed to the pustules frequently being so extensive as to cover the 
 entire face, or the greater portion of the body. The constitutional 
 disturbance is, in these instances, so great, as frequently to termi- 
 nate fatally. The records of St. Louis furnish numerous examples 
 of this kind. 
 
 233. The treatment of the pustular forms of constitutional syph- 
 ilis must be varied to suit the period of the disease, and the par- 
 ticular condition of the eruption, and the state of the constitution 
 which accompanies it. In the former, accompanied by much 
 inflammation or irritation, an antiphlogistic treatment is at first tt 
 be adopted ; low diet, the warm bath, either alone, or medicated 
 with gelatin, or anodynes, as the decoctions of poppy, marsh- 
 mallows, henbane, or opiates. The vapour bath is also useful, and 
 mercurial fumigations, when the affection is perfectly chronic. At 
 this period, also, mercurials may be given internally ; the prepara- 
 tions most useful, are the proto-ioduret, the cyanuret, and the syrup 
 of Baron Larrey. 
 
 234. When the patient's health is more or less undermined by 
 the pain and irritation of an extensive pustular eruption, all specific 
 treatment must be abandoned till the general health is improved ; 
 he must be put upon the use of mild tonics, and a generous diet, 
 and the pain of the eruption must be allayed by opiates given inter- 
 nally or applied locally. Opiates are of great use in all diseases of 
 this kind, particularly, where the general health is impaired, and 
 much irritation present. Many patients in the wards of St. Louis 
 have recovered from diseases of this character by their use alone. 
 
DISEASES OF THE SKIN. 83 
 
 i 
 
 Dupuytren had recourse to the aconite; but opiates are preferable, 
 and more certain. 
 
 235. When mercurials fail, as they occasionally will, the iodide 
 of potassium, or the preparations of arsenic may be employed. If 
 the pustules are large, painful, and ulcerated, they should be dressed 
 with aqueous solutions of opium, the opiate cerate, or a lotion of 
 hydrocianic acid, in the proportions of ten, twelve, or fifteen drops 
 to the ounce of water. When the ulcers are perfectly chronic and 
 indolent, the ointment of the proto-ioduret of mercury is used. 
 
 236. The various local remedies mentioned in the section of 
 primary sores may be used to these ulcerations according to the 
 aspect they assume. They may be washed with weak solutions of 
 chloride of lime, and then dusted with calomel, or with calomel and 
 opium. 
 
 Of the Syphilitic Papula. 
 
 237. The papulae are small, solid, hard elevations upon the skin, 
 containing neither lymph nor pus, surrounded by a small inflamed 
 areola, having frequently ulcerations at their apices, which then 
 become covered with small, dry incrustations. The syphilitic 
 papulae are more or less disseminated over the body, arranged in 
 groups, or disposed to be confluent. They are distinguished by 
 their deep red, or copper colour, their tendency to ulcerate, and to 
 form hard incrustations on their surfaces, which, falling off when 
 the ulcer has healed, leave brown, copper-coloured, depressed cica- 
 trices in the skin. The papulae are commonly associated with 
 pustules, tubercles, or squamae ; and almost always accompany 
 syphilitic iritis, ulcers of the mouth and fauces, diseases of the bones, 
 or periosteum, nocturnal pains, and other symptoms of confirmed 
 constitutional syphilis. This affection of the skin sometimes accom- 
 panies primary symptoms; when it does so, it assumes a more or 
 less acute form, and is attended with some fever. 
 
 238. This variety of disease has been termed venereal itch, 
 "scabies venerea," on account of the irritation the papulae occasion: 
 when they are seated on certain parts of the body, as on the arms, 
 the prepuce, or the vulva, &c. it has been described by Lagneau, 1 as 
 "syphilitic prurigo of the pudendum." It then attacks the labia, 
 principally on their external surface, the orifice of the vagina, and 
 the clitoris, which parts, on examination, are found covered with 
 small papulae of a deep red colour, causing an intolerable itching, 
 principally in the night ; the eruption sometimes extends to the arms, 
 and internal parts of the thighs. Mercurial ointment generally 
 allays the irritation. 
 
 239. The practitioner must be careful in his diagnosis of this 
 disease, to distinguish it from the common prurigo, which so fre- 
 quently distresses pregnant females, which is symptomatic of some 
 
 ( Expos* des syrapt6me de la maladie venenenne, <fcc. <fec. Paris, 1812. 
 
84 PARKER ON SYPHILITIC DISEASES. 
 
 uterine affection, or consequent upon suppression of the menstrual 
 discharge. 
 
 240. If the papulae assume an acute or subacute form, they must 
 be treated, at first, on the antiphlogistic plan, and a regulated diet 
 must be observed. Should they succeed to primary symptoms, 
 which have not been treated by mercury, this remedy may be 
 employed : fumigations have a marked effect in allaying the irrita- 
 tion by which they are accompanied ; weak solutions of the bichlo- 
 ride of mercury may likewise be used, to sponge the surface of the 
 skin affected with syphilitic papulae. 
 
 SECTION XII. 
 
 Of the Syphilitic Tubercula. 
 
 241. Tubercles of the skin are deep-seated, solid, circumscribed 
 elevations, containing neither lymph nor pus, they differ from the 
 papulae in their size, being much larger, more prominent, and better 
 defined. Syphilitic tubercles are either isolated or grouped, of a 
 shining red, livid, or brown colour, surrounded by an areola of a 
 dark red or coppery appearance. These tubercles are prone to 
 become ulcerated, and form excavated sores with thick and elevated 
 edges, and a foul surface, secreting an offensive pus, which, drying 
 up, is transformed into gray or dark coloured scabs or crusts. The 
 syphilitic tubercle forms the link of connection between the secondary 
 and tertiary symptoms of M. Ricord ; it is the first of that class of 
 syphilitic diseases, in which the virus appears to have penetrated 
 more deeply into the economy, and to have produced a disorganisa- 
 tion in tissues, which those forms hitherto considered have left un- 
 touched. 
 
 242. The flat tubercle of M. Cullerier, or the tuberculous pustule 
 of Alibert, sometimes occurs as a primitive affection, but more com- 
 monly as a symptom of constitutional syphilis ; in the former instance 
 it is observed in the scrotum, the labia, the vicinity of the arms, or 
 the mammae. The surface of these tubercles is smooth and flat, of 
 a deep red or copper colour, varying from the size of a sixpence to 
 that of a shilling ; they are not so much disposed to ulcerate as the 
 other varieties. 
 
 243. The more common forms of tubercle are conical or round 
 elevations, dispersed here and there over the skin, or assembled in 
 groups or clusters, which are also irregularly distributed. The size 
 of these varies from that of a pea to that of a large hazel nut, or 
 filbert; they are more commonly situated on the anterior surface of 
 the chest, or the abdomen, on the neck, or the internal part of the 
 arms. 
 
 244. Another variety of tubercle is situated, more commonly, on 
 the alae and lobule of the nose, or on the forehead ; frequently, also, 
 
DISEASES OP THE SKIN. 85 
 
 upon the neck of the uterus, or upon the tongue, where they may 
 be mistaken for cancerous affections. These tubercles are com- 
 monly assembled in circular groups of variable size; they are so 
 prone to ulcerate, that this termination appears to be one of their 
 natural characters ; when in this condition they are frequently 
 described under the name of syphilitic lupus. The tubercular 
 syphilides are commonly complicated with a scrofulous, scorbutic, 
 or herpetic tendency, or diathesis ; their progress is slow, and gene- 
 rally without pain ; they gradually increase in size till they terminate 
 in softening or ulceration. They are the most formidable of all the 
 forms of constitutional syphilis, producing great deformity in all the 
 parts invaded by ulceration, and exceedingly difficult to cure. 
 
 245. Whilst the tubercles are in a state of induration, and as yet 
 neither ulcerated nor softened, their resolution may be attempted. 
 For this purpose, M. Ricord employs the ioduret of mercury, with 
 the iodide of potassium ; it must be remembered, however, before 
 any plan of treatment is framed, that due attention be paid to the 
 general health of the patient. 
 
 246. If there be no contra-indication, the treatment is com- 
 menced by administering a pill of the proto-ioduret of mercury 
 daily, containing one grain of the salt, combined with conium, or 
 opium, 1 and the solution of the iodide of potassium, 2 at first admin- 
 istered in doses of ten grains in the day. On the fifth day, two pills 
 are given, and the quantity of the iodide of potassium is increased ; 
 it is generally unnecessary to carry the dose of mercury to any 
 extent, or to continue its use very long ; the treatment is to be 
 completed by the ioduret of potassium. The indurated tubercle is 
 commonly resolved by this treatment, leaving behind it in the skin, 
 merely a depression of a brown or copper colour more or less deep. 
 
 247. The mercurial fumigations, alternated with baths, are also 
 exceedingly useful, whilst the tubercles are yet unsoftened, in pro- 
 curing their resolution ; they may be employed with the iodide of 
 potassium, and sarsaparilla. 
 
 248. As the syphilitic tubercles are accompanied by a process of 
 inflammation, under the increase of which they soften and ulcerate, 
 a local treatment, whilst they are in a state of induration, is of vast 
 service in assisting the internal treatment in their resolution. For 
 this purpose cooling lotions may be employed, or fomentations of 
 poppy, or henWie, or aqueous solutions of opium, poultices, and 
 leeches applied at a little distance from the base of the tubercle. 
 
 249. When the' inflammation is subdued, and the tubercles are 
 indolent, folds of linen soaked in a weak solution of the oxymuriate, 3 
 
 1 *. Hyd. proto-ioduret., gr.j. 
 Ext. conii, gi. v., vel 
 
 Pulv. opii, gr. ss. M. ft. pil. o. n. sumend. 
 
 * See the section on the use of iodine and its preparations, in constitutional 
 syphilis. 
 
 * *. Decocti altheae officinalis, o. j. 
 
 Hydrargyri bichlorid., gr. xviij. M. Biett. 
 
86 PARKER ON SYPHILITIC DISEASES. 
 
 or frictions with mercurial honey, 1 or the ointment of the proto- 
 ioduret should be used. They may also be sponged with a lotion 
 composed of the solution of chloride of lime, and afterwards rubbed 
 with an ointment made of calomel, or calomel and opium. Ricord 
 gives one golden rule here, which, in attempting to resolve the 
 tubercular syphilide, we should bear constantly in mind : that, as 
 long as inflammation exists, a local antiphlogistic treatment should 
 be pursued, whatever, according to the constitution of the patient, 
 the internal treatment may be. The local applications above indicated 
 are only to be employed in a perfectly indolent condition of the 
 disease. 
 
 250. In the ulcerated form of tubercles, all that has been said on 
 the treatment of primary venereal sores may be referred to with 
 advantage, since these secondary ulcerations require nearly the 
 same local treatment, the use of the nitrate of silver, the aromatic 
 wine, with astringents, sedatives, narcotics, or digestive ointments, 
 or a local antiphlogistic treatment according to the aspect of the 
 sore. When caustics are indicated, the surface of the ulcers may 
 be touched with a solution of the deuto-nitrate of mercury in nitric 
 acid: 2 this is the favourite remedy at St. Louis, and the ulcers 
 cicatrise rapidly under its application; the separation of the crusts 
 or eschars may be facilitated by the warm or vapour bath. 
 
 251. The iodide of potassium is the favourite remedy with M. 
 Ricord during the ulcerating stages of tubercle; mercurials also 
 may be used, particularly if the primary disease have not been 
 treated by mercury; the proto-ioduret, the cyanuret, or the syrup 
 of Larrey are the best remedies. The decoctions of Feltz or Zittman, 
 the liquor arisenicalis or the arseniate of soda are also remedies 
 which, in particular cases, may be employed with advantage. If 
 the disease do not appear to amend under the use of one remedy, 
 another should be resorted to, and in this manner it will sometimes 
 be found necessary to try several before one is discovered suited to 
 the constitution of the patient. Sometimes the preparations of 
 arsenic succeed when all the rest have failed, occasionally one form 
 of mercurial when another has been unsuccessful. There are 
 cases, happily rare ones, in which all medicines appear useless: it 
 is better, under these circumstances, to omit them altogether for a 
 time, to remove the patient to a fresh atmosphere, to watch his 
 general health carefully, and then again to fjSswfcp^he treatment, 
 after the lapse of a longer or shorter period. 
 
 V/ 
 
 1 MERCURIAL HONEY. 
 
 *. Hydrargyri chlorid., 3j. 
 
 Mellis opt., j. M. ' , 
 
 *9*. Hydrarg. deuto-nitratis. ^ss. ad 5j. 
 Acid, nitric., 3j. M. 
 
CONSTITUTIONAL ULCERATIONS. 87 
 
 ^s 
 
 SECTION XIII. 
 
 Of Constitutional Syphilitic Ulcerations. 
 
 252. The secondary forms of syphilitic ulceration are compara- 
 tively rare, unless we take into the account those forms which 
 succeed to the pustular or tubercular varieties of the disease; 
 indeed, chancres or primitive ulcers themselves are most commonly 
 if not always preceded by a pustule or vesicle. These ulcers are, 
 however, sometimes met with, being only preceded by a slight 
 itching or redness of the skin, succeeded immediately by ulceration. 
 They have generally a specific character, are excavated with 
 thickened and defined edges, and a foul surface, secreting an offen- 
 sive pus. Their situation is generally about the nose, the edges of 
 the mouth, the eyelids, the ears, or the mastoidean region ; they are 
 also common upon the mammae, near the umbilicus, in the axillae, 
 the groins, or round the edges of the nails. The constitutional 
 syphilitic ulcer often makes its appearance in form of fissures, depend- 
 ing upon the disposition of the skin in the parts where the ulcera- 
 tion then takes place; these varieties are seen upon the skin of the 
 scrotum, in the vicinity of the anus, the umbilicus, or the commis- 
 sures of the fingers and toes, the folds of the skin of the eyelids, 
 the lips, the palms of the hands, or soles of the feet. 
 
 253. The local treatment of these ulcers is to be conducted on 
 the same principles which direct us in the management of the 
 primitive venereal sore, or the ulcer succeeding the pustule or 
 tubercle. Local treatment, however, though essential, is seldom 
 sufficient: it will be most frequently necessary to administer inter- 
 nally sudoritics, or the preparations of mercury, or arsenic, as 
 recommended in the syphilides generally. 
 
 Of Vegetations. 
 
 254. Vegetations, or excrescences, of varied form and appearance, 
 upon the skin or edges of the mucous membranes, constitute the 
 last variety of the syphilides or venereal diseases of the skin. Des- 
 ruelles divides these into three heads, according to their anatomical 
 structure: first, the vegetations formed by the epidermis, and of a 
 horny or ^perfectly inorganic character; second, those termed 
 cellulo-vascular, growing from the surface of the mucous mem- 
 branes, arid composed chiefly of blood-vessels; and, third, those 
 springing from the skin itself, and formed of the elements which 
 enter into the composition of this organ. 
 
 255. Vegetations commonly take place from parts which have 
 been previously the seat of inflammation, or long-continued irrita- 
 tion of any kind. Hence they are frequently formed upon the sur- 
 face of the glands or prepuce after long-continued balanitis or pos-< 
 t hit is, and upon the cicatrices, or the surfaces of old constitutional 
 
88 PARKER ON SYPHILITIC DISEASES. 
 
 ulcers upon the skin. The inorganic forms of vegetation may be 
 removed at once with the ligature or the knife; if voluminous, red, 
 or inflamed, local depletion by means of leeches is of service. In 
 operating upon the latter kind of vegetation, we must take care 
 that all inflammation is subdued before we have recourse to the 
 knife, experience having proved that their removal, when painful 
 or inflamed, frequently gives rise to the extension of the disease, 
 and the vegetations themselves are soon reproduced in greater 
 numbers and of larger size. 
 
 256. The local applications to vegetations are occasionally ser- 
 viceable; when they are painful or inflamed, a strong aqueous solu- 
 tion of opium is highly extolled by Desruelles; 1 when indolent, the 
 mercurial ointment, solutions of the oxymuriate, sponging them 
 with the solution of chloride of lime, and then dusting with calomel 
 are all remedies which are very frequently successful. The nitrate 
 of silver, sulphate of copper, or chloride of zinc, are useful when 
 caustics are indicated. The remedy, however, which is more 
 worthy of attention than any other is the muriate of gold, locally 
 applied either in form of ointment or solution. The internal use 
 of the chloride of gold may be resorted to, but not till it has been 
 tried locally. 3 
 
 257. When vegetations are clearly of venereal origin, or coincide 
 with other constitutional symptoms of this disease, an internal mer- 
 curial treatment may be adopted ; fumigations are, in these instances, 
 most serviceable. 
 
 258. There is a species of excrescence rather than vegetation to 
 which the term condyloma or crista galli is commonly applied, 
 which is most usually situated in the vicinity of the anus, between 
 the glans and prepuce, or on the external parts of generation in the 
 female. Its essential character consists in a developement or hyper- 
 trophy of the skin or mucous membrane, and the subjacent cellular 
 tissue, which then forms a soft, flattened, indolent tumour, more or 
 less elongated. Sometimes these tumours are red, painful, and ex- 
 coriated, secreting an offensive pus, and at others perfectly indolent. 
 They frequently depend upon an ulcer situated in the folds of the 
 integument or mucous membrane. If they are in a state of inflam- 
 mation or irritation, this is to be first subdued ; friction may after- 
 wards be made upon them with any of the mercurial ointments 
 previously recommended, or with the ointment of the muriate of 
 gold. Caustics may also be employed; in some circumstances a 
 general mercurial treatment may be necessary. Ricord says that 
 the treatment of condyloma must be the same as that of indurated 
 chancre. When they resist all these means of treatment, and their 
 
 1 $<. Opii dur., &j. 
 
 Aquae, 3 j. M. ft. Lotio. 
 
 *The dose of the muriate of gold is one fifteenth, one tenth or one fifth of 
 a grain; its internal use requires great caution. In solution, it may be used 
 of the strength of two grains to the ounce of water or more ; in the oint- 
 ment, from four grains upwards to the ounce of lard. 
 
PAINS IN THE BONES. 89 
 
 size or situation present serious inconveniences, or impediments to 
 the performance of certain functions, they must be removed with 
 the scalpel or scissors. 
 
 SECTION xiv. 
 Of the Syphilitic Testicle. 
 
 259. This disease, termed also syphilitic sarcocele, occasionally 
 appears as a secondary symptom of constitutional syphilis; it is 
 clearly to be distinguished from that affection of the testicle, which 
 succeeds to gonorrhosa, as well as from sarcocele, depending upon 
 other causes not syphilitic. It is most frequently associated with 
 other secondary diseases, as the syphilides, iritis, &c. When the 
 testicle is affected, it gradually enlarges, becomes hard and heavy, 
 and generally presents an uneven surface to the touch; the indura- 
 tion may also exist in the spermatic cord or epididymis. 
 
 260. Ricord most prudently observes, that in all the diseases of 
 the testicles, which appear of a doubtful character, we must be ex- 
 tremely cautious in recommending amputation of the part. Dupuy- 
 tren, in cases of this character, submitted his patients to a general 
 mercurial treatment, and by this plan saved an immense number of 
 testicles. 
 
 261. The internal treatment of the venereal testicle consists in a 
 modified mercurial course, or the use of the iodide of potassium. 
 Cullerier highly extols the latter remedy, and was very successful 
 in its employ. The local treatment may be pretty much the same 
 as that recommended for the gonorrhoeal testicle, viz. local bleeding, 
 fomentations, lotions, anodyne and mercurial friction, and when 
 quite indolent, strapping with mercurial and ammoniacum plaster, 
 or the plaster "de Vigo." 
 
 SECTION xv. 
 Of Pains in the Bones. 
 
 262. These pains are among the tertiary symptoms of M. Ricord, 
 and frequently precede the true syphilitic ostitis or periostitis. 
 Full courses of mercury used to be prescribed for the relief of these 
 pains; and such was even the practice of M. Ricord, but he consi- 
 ders they may be most advantageously treated by the iodide of 
 potassium. Much, however, depends upon local treatment: this 
 should consist of leeches over the seat of pain ; if there be any 
 heat of the surface, the repeated application of blisters, which are 
 to be dressed with the opiate cerate, or mercurial ointment and 
 
* PARKER ON SYPHILITIC DISEASES. 
 
 opium. M. Ricord states that he has known nocturnal pains which 
 have resisted all modes of treatment for months, yield almost magic- 
 ally to blisters. Occasionally the pains are so obstinate as not to 
 yield to any of these modes of treatment ; they then sometimes 
 suddenly give way to cutting down upon the part which is the 
 seat of pain. 
 
 SECTION XVI. 
 
 Of Periostitis. 
 
 263. Inflammation of the periosteum is frequently occasioned by 
 a superficial inflammation of the bone beneath, which has caused 
 an effusion between it and the periosteum, and the production of 
 those tumours on the surfaces of the bones termed nodes. These 
 tumours may remain indolent, be resolved, or terminate in abscess ; 
 on opening which the bone beneath is found in a state of denuda- 
 tion, carious, necrosed, or covered with granulations. 
 
 264. The earlier stages of periostitis demand a more or less active 
 antiphlogistic treatment, proportioned to the degree and intensity of 
 the inflammation : this is to be followed by blisters, the application 
 of the tincture of iodine, at first diluted, and gradually used stronger, 
 or Malapert's solution of the bichloride of mercury. When the 
 disease remains perfectly indolent under the latter treatment, 
 pressure by means of the emp. hyd. c. ammoniaco, or the emp. de 
 Vigo is frequently successful. The internal treatment should con- 
 sist of the iodide of potassium. 
 
 Ostitis. 
 
 265. The treatment of the earlier and more acute stages of ostitis 
 should be the same as that of periostitis : local bleedings, blisters, 
 the local application of mercury in any of the forms before recom- 
 mended, compression of the tumours caused by effusion, &c. in the 
 latter stages, and the internal use of the iodide of potassium, the 
 proto-ioduret of mercury, the iodide of iron, and the decoction of 
 sarsaparilla, or that of Feltz. In the treatment of those diseases of 
 the bones which are the result of ostitis, as caries and necrosis, M. 
 Ricord relies almost implicitly upon the internal administration of 
 the iodide of potassium : many forms of these diseases have given 
 way quickly to the use of this remedy, which have resisted or been 
 aggravated by mercurial treatment during an indefinite period of 
 time. I have before stated that mercury which has such a marked 
 influence over many forms of primary syphilis, and most of the 
 secondary forms, has little or no influence over many of those 
 varieties of disease which M. Ricord has termed tertiary ; and it is 
 precisely where the mercury loses its effect, that the iodide of 
 
PHIMOSIS. 91 
 
 potassium is so beneficial. The iodide of potassiu m, however, great 
 as are its virtues in certain forms of disease, cannot with advantage 
 be substituted for mercury in others. 
 
 Of the operation for the relief of Phimosis. 
 
 266. Ricord divides the species of phimosis into the complete and 
 incomplete, the permanent or temporary. The permanent may be 
 congenital or acquired coexisting with a preternaturally long pre- 
 puce, one which in the normal condition of the parts does not com- 
 pletely cover the glans, or an excessive length of the frenum. This 
 variety may also be complicated with adhesions of the prepuce to 
 the glans of various degrees of extent and firmness. The temporary 
 or accidental phimosis is most commonly caused by chancres situated 
 on the glans or prepuce ; if these sores are placed upon the prepuce, 
 this part becomes red, painful and swollen, completely covering the 
 glans, which remains in its natural condition. If, on the contrary, 
 the chancre is situated in the glans, the phimosis is occasioned by 
 its swelling anddistention, which prevents the retraction of the pre- 
 puce, the latter part remaining healthy. In other forms both glans 
 and prepuce are affected, when ulcers are situated on both organs, 
 or when the ulcers exist at the base of the glans, where the mucous 
 membrane is reflexed on the internal surface of the prepuce. 
 
 267. Phimosis is also very frequently occasioned by simple 
 inflammatory affections of the glans and prepuce, 1 without the 
 existence of chancres. It is associated also with various morbid 
 conditions, as erysipelas, gangrene, balanitis, gonorrhoea, chancres, 
 vegetations, herpes preputialis, perforation of the prepuce, or com 
 plete retention of urine. The accidental phimosis is more liable 
 to take place when any congenital malformation of the prepuce or 
 glans has previously existed. 
 
 268. Before resorting to an operation for the relief of phimosis, it 
 is necessary to subdue the inflammatory symptoms upon which it 
 depends, the removal of which frequently enables us to retract the 
 prepuce without performing the operation. If there is reason to 
 suspect the disease is occasioned by chancres, it must be recol- 
 lected that the reduction of the prepuce is not necessary to their 
 cure ; and indeed it is a principle laid down by M. Ricord, that the 
 operation, unless the risk of gangrene, &c. is imminent, should not 
 be performed, whilst a chancre between the glans and prepuce 
 exists. For the particular treatment of these complications I refer 
 the reader to the article " Balanitis." 
 
 269. Permanent phimosis, with excessive length of the prepuce, 
 demands the operation of circumcision, unless (says M. Ricord,) 
 we remedy one deformity by the production of another, in perform- 
 ing the old operation of merely slitting up the prepuce, with the 
 knife. If there exist between the glans and prepuce recent and not 
 
 1 Balanitis, posthitis, or balano-posthitis, bastard, or false gonorrhoea, 
 
92 PARKER ON SYPHITITIC DISEASES. 
 
 very firm adhesions, these should be removed by dissection ; when 
 the adhesions are firm, it will be necessary only to circumcise as 
 much of the prepuce as may leave free the meatus urinarius ; 
 vegetations should be removed with the redundant portion of the 
 prepuce. The old operation, which consists in merely slitting up 
 the prepuce and removing the angles from the divided prepuce on 
 either side, is liable to many objections, the chief of which is the 
 deformity which the operation occasions ; when this plan is deemed 
 advisable, as it may be in persons who have naturally a short pre- 
 puce, M. Ricord removes a portion in the shape of the letter V, the 
 apex of which corresponds to the base of the glans, the base or open 
 part being taken from the body of the prepuce. 
 
 270. In most cases M. Ricord prefers the operation of circumcision, 
 which is to be performed in the following manner. The penis 
 hanging in a relaxed state, a line is to be traced round it with ink, 
 two lines in front of .the base of the glans ; this being done, the pre- 
 puce is to be drawn forwards, and fixed between the blades of a pair 
 of dressing forceps, which are to be placed in front of the glans, 
 and immediately behind the ink lines : the forceps are to be held 
 perpendicularly and not transversely, and fixed in this position by 
 an assistant. The operator then seizes the prepuce with his left 
 hand, and with a scalpel or bistoury held in his right, cuts off that part 
 of the prepuce placed before the forceps, the latter serving as a 
 guide for the direction of his incision. That portion of the mucous 
 membrane, which has not been drawn forwards with the skin of the 
 prepuce, is afterwards to be divided, with a view of preventing a 
 secondary phimosis, or paraphimosis. The latter part of the ope- 
 ration is to be performed by dividing the mucous membrane with 
 the scissors upon the dorsal aspect of the glans, and as far as its 
 base, the two flaps thus made are to be dissected off on either side 
 of the frenum, and removed with the latter by one stroke of the 
 knife or scissors. 
 
 271. Some hemorrhage, from the dorsal artery of the penis, that 
 of the frenum, or other small branches demands occasionally torsion 
 of the arteries, or the use of the ligature. The penis should be 
 covered with compresses soaked in cold water or the lead lotion, 
 with the view of keeping down inflammation, and preventing erec- 
 tions. With the latter view also, opiates with camphor should be 
 administered. 
 
 272. The operation for the relief of paraphimosis is so simple that 
 it hardly needs description. The method of Ricord consists in 
 dividing the whole of the strangulated portion of the skin, to an 
 extent equal to the length of the glans penis, by a straight-bladed 
 bistoury, introduced flatly, and the cutting edge then turned upwards. 
 
 THE END. 
 
CONTENTS. 
 
 SECTION I. 
 
 Of the Simple Treatment of Syphilitic Diseases .... 7 
 Of the Simple Constitutional Treatment of Syphilis .... 8 
 Of the Simple, Local, or Surgical Treatment of Syphilis 
 
 Of the Mercurial Treatment of Syphilitic Diseases . 12 
 
 SECTION II. 
 
 Of Particular Preparations of Mercury, and their Mode of Employment . 18 
 
 Mercurial Fumigations . . . . . ib. 
 
 The Proto-chloride of Mercury . . . . . J9 
 
 The Bichloride of Mercury ...... ib. 
 
 The Proto-ioduret of Mercury . .... 20 
 
 The Cyanuret of Mercury . . . . . .21 
 
 The Deuto-phosphate of Mercury . .. . . . 23 
 
 SECTION III. 
 On Inoculation, as applied to the Diagnosis, and Treatment of Syphilitic Diseases ib. 
 
 SECTION IV. 
 
 Of the First Class of Syphilitic Diseases Gonorrhoea, its Varieties and Con- 
 sequences . -. .28 
 
 Of Balanitis . . . . . . . ib. 
 
 Gonorrhoea ', - .. i . x . . . . 31 
 
 Symptoms . ; ; . . . . 33 
 
 Sympathies , . . . % .. . . . ib. 
 
 Varieties . . . . S . . 34 
 
 Consequences and Terminations . '.'..' . . ib. 
 
 Treatment . . . . ' ' . . ib. 
 
 Of Specific Remedies Copaiba . . 4 . .* . . .36 
 
 Particular Forms for its Exhibition '*.'. . 38 
 
 Cubebs . . M ' . . . . . 39 
 
 Particular Forms for its Exhibition .... 41 
 
 Of Mercury . . .,-. . ....' fc . . .42 
 
 Of Injections . .... . . . ib. 
 
 SECTION V. 
 
 Of Diseases which succeed to Gonorrhoea in the Male . . . . 45 
 
 SECTION VI. 
 
 Of Gonorrhoea in the Female . . ''. . . 47 
 
 Of the Second Class of Primary Syphilitic Diseases . . . .52 
 
 Ulcers their Varieties and Consequences . , . . - . . ib. 
 
94 CONTENTS. 
 
 SECTION VII. 
 
 Of Chancres of the Urethra . . ,' . . . 57 
 
 SECTION VIII. 
 
 -Of Phagedsenic Primary Venereal Sores . . . .59 
 
 The local Treatment of Phagedcena . . r ) t ' + . ib. 
 
 Of Mercury . . . . . . A. ' ^ . . 60 
 
 Of the Simple Treatment of Phagedaena . { . . .';.;'* 62 
 
 Of Bubo . , . . ^ . vy ,. . jj . ib. 
 
 SECTION IX. 
 
 Of Constitutional or Secondary Syphilis . . . wJ$i.'i <^ t n'^ 73 
 
 SECTION X. 
 
 Of Syphilitic Diseases of the Skin . '. ;/ : . -,. ' ^ ^ . 75 
 
 Of Mercury .... UUH.;. < . ib. 
 
 Of the use of Iodine and its Preparations . V . . 76 
 
 Sudorifics . . T V^t i-j' 1-fn;",' mv>f/ '; ' M KU*}^ ' . 77 
 
 The Muriate of Gold . *i . ' i'/ 5 u, ?^ w '3 r*o . 79 
 
 SECTION XI. 
 
 Of the particular forms of Syphilitic Diseases of the Skin . -WiK : f ^' ib. 
 
 Syphilitic Exanthemata -; ^ " HKV-';<' 1 /*^ IJW^PH . ;><jl-* . Jb. 
 Syphilitic Squama- t v <v . . . . . . .80 
 
 Syphilitic Vesiculse ... . , . . . ib. 
 
 Syphilitic Pustute . '. . %'"' * ' k ' 81 
 
 Syphilitic Papula <;<*<> h s , ; . ^. ..f- . .>?twr>- . 83 
 
 , SECTION XII. 
 
 Of the Syphilitic Tuborcula..;^ ,. fl .._ ; t ,^ ( , v>r r , . <v '%. ; ' j/^ S 4 
 
 SECTION XIII. 
 
 Of Constitutional Syphilitic Ulcers , ^.V/, . 87 
 
 Of Vegetations . . . ^ , _.. ib. 
 
 SECTION XIV. 
 
 Of the Syphilitic Testicle . '. . ' \. , \,!i ^ ?..- >; n**li( . 89 
 
 SECTION XV. 
 
 Of Pains in the Bones . . . . \. . . > - ib. 
 
 SECTION XVI. 
 
 Of Periostitis . \ . ^ , .. ' . . . 90 
 
 OfOstitis . . . >?*:-.;.- ,. - .-,.+>* ' :?--.wA>i ^ , ib. 
 Of the Operation for the relief of Phimosis . . . . .91 
 
14 DAY USE 
 
 TO DESK FROM WHICH BORROWED 
 
 JAN1968 
 
 LD 21-50m-8,'57 
 (.08481810)476 
 
 General Library . 
 University of California 
 
 Berkeley 
 
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