Primary Forms

First chapter OF VENEREAL PHENOMENA GENERALLY 1. DEFINITIONS OF THE VENEREAL DISEASES. Selection 1.- Various Definitions. EVERY BODY knows that, when speaking of venereal diseases, we mean gonorrhoea, chancre, buboes, figwarts, and other affections occasioned by an impure coit; but if we refer to what authors understand by this term, we shall meet such a great diversity of opinions, or even such a radical confusion of ideas, that it almost becomes impossible to comprehend all the different views in one universal definition of the phenomena that belong to this category. Even if we were to confine the meaning of this term to the simplest limits, and simply understand by it the diseases that had been contracted by an impure coit, or in usu veneris, we should satisfy neither party, inasmuch as such a definition would be too comprehensive for some, and not sufficiently comprehensive for others; according as they regard most of these diseases as depending upon a specific virus which may be transmitted without the act of coition, by simply being brought in contact with susceptible parts of the organism; or according as they hold with the Physiological School that these diseases constitute nothing but simple inflammations, the particular form of which is supposed to be determined by individual or other accidental influences. For, whereas the former exclude from the class of syphilitic products as non-venereal, all those that are incapable, by the transmissions of their secretions, of developing like phenomena in healthy persons, and, on the other hand, comprehend under the term of venereal phenomena even those that had been caused by contact with the infectious virus between the acts of coition, the latter, on the contrary, apply the term venereal even to the most innocent discharges and ulcerations caused, during the act of coit, by a want of cleanliness, acrid menstrual blood, or a corrosive leucorrhoea, and absolutely unable to transmit a like infection; yet, not recognizing idiopathic diseases, they refuse to recognize as venereal a whole category of products which are considered as absolutely venereal by the former, even though it may not be possible to show a direct transmission through an impure coit. A similar confusion of ideas prevails among those who believe in a specific virus as the generator of certain venereal products; some referring the term venereal exclusively to chancre and the phenomena than can be traced to it as their producing cause, thus regarding even infectious gonorrhoea as a non-venereal product; others, on the contrary, who distinguish several varieties of venereal affections, designating the phenomena that owe their development to chancre as syphilitic, the phenomena that constitute the category of figwarts as sycosic, and the phenomena that belong to the class of common gonorrhoea as simply venereal. In addition to this, other again, not content with the already excessive confusion of ideas, apply the term syphilitic, which properly belongs only to a subdivision of this class of diseases, indiscriminately with that of venereal, to all kinds of products of an impure coit, speaking for instance of syphilitic orchitis, phimosis, strictures of the urethra, affections of the prostate, etc., whereas such affections really only accompany or result from a simple venereal gonorrhoea; so that, if we read of non-syphilitic or non-venereal gonorrhoeas or other products, we have first to ask ourselves whether the reporter only meant affections that were not caused by a chancre, or such as cannot be numbered among the products of an infectious coit. The same difficulty prevails in regard to special names of venereal products, such as gonorrhoea, chancre, inguinal swellings, etc., by which some understand exclusively the venereal contagious discharges, ulcers and buboes; whereas other physicians, specially the French adherents of the Physiological School, call every non-contagious ulcer on the genital organs a chancre, every discharge from these organs a gonorrhoea, and every scrofulous or other inguinal swelling a bubo; deducing from these similarly named products whose homogeneousness is only predicated upon their anatomical locality, but which differ essentially in regard to their Pathological character, therapeutic propositions (such as the spontaneous cure of some chancres) that might lead any one who is not acquainted with their mode of expressing themselves, and imagines they mean specific chancres, gonorrhoeas or buboes, into the gravest errors. Secale 2-Precise Definitions. It is easily seen to what misunderstandings and errors in science such a babylonic confusion of terms must and will lead, if the reader, guided by his own customary technical terms, should understand perhaps the opposite of what the author intended to convey by his own language; and it is morally certain that so many endless disputes concerning the nature and treatment of venereal diseases would never have taken place, if the disputants had, in the first place, endeavored to attach the same meaning to the terms which they respectively made use of. In the course of this work we shall touch upon several of these points, and, for the present confine ourselves to the statement, that, for ourselves, we do not by any means understand by the term venereal diseases all those that may have been occasioned by sexual excesses, but only a category of phenomena which, having arisen from this source may, by transmitting the virus to susceptible parts of a healthy organism, reproduce a like series of phenomena, endowed with a like power of reproducing the original malady. In thus stating our general definition we do not yet concern ourselves with the enquiry whether the venereal phenomena spring from a simple or compound virus; our general definition not only comprehends all the products of an infectious coit, hence, likewise, a simple but contagious gonorrhoea, but likewise that further series of products which may result from the former products being brought in contact with susceptible parts in any other manner than by sexual intercourse. In as much as, however, even if all these phenomena should be caused by a single contagium, gonorrhoea, chancre, and figwarts have been described by several authors as so many distinct forms of venereal disease; and inasmuch as we shall be obliged, in discussing their different theories, to adopt particular terms in order to avoid one set of definitions being confounded with another; we shall distinguish, for the purpose of proceeding in a more systematic manner: (a) syphilitic-venereal, or simply syphilitic phenomena, that is to say, those that can be traced to chancre, (b) sycosic venereal, or simply sycosic, that is to say, all the phenomena which belong to the domain of condylomata; and (c) simply venereal phenomena, or all such as do not seem to refer to either of the above mentioned categories. This shows that we do not, like other physicians, regard the terms syphilitic and venereal, as synonymous, but as strictly distinct. If we use the term venereal, we mean to include all the phenomena of this class, even syphilis, sycosis, and simple lues, opposing this whole series to the non-venereal, con-contagious products of sexual intercourse as excluded from it. In order to illustrate we hold that any, ever so simple form of gonorrhoea, which had resulted from an infectious coit, is not, on that account, to be considered of a syphilitic or sycosic nature, unless we are certain that it owes its origin to chancre or sycosis. By non- venereal gonorrhoea we mean a gonorrhoea that has nothing in common with the products of infectious coit, but is the result of irritating scrofulous humors, haemorrhoids or other similar causes. And in order to avoid even in this respect all confusion of ideas, we do not, like others authors, first speak of non- venereal gonorrhoea chancre and bubo, but understand by these terms in every case all such venereal products as have emanated from an impure coit, and are, in their turn, capable of infection. Further on we shall see by what diagnostic signs a venereal transmitting gonorrhoea, chancre or bubo is distinguished from a non-venereal discharge, ulcer or inguinal swelling; previously, however, we will cast a glance at the general forms under which the venereal diseases may appear. II FORMS UNDER WHICH VENEREAL DISEASES MANIFEST THEMSELVES Secale 3-Essential Distinctions. On surveying the totality of the phenomena of venereal origin, which authors have described either as venereal or as syphilitic, we cannot fail to perceive at first sight, that they constitute two essentially distinct classes, namely: (a) Those which, like gonorrhoea and chancre, generally make their appearance soon after an impure coit, or which, even if, like buboes and figwarts, they break out at a somewhat later period, still are so closely connected with the first-mentioned phenomena that their origin from an impure venereal source cannot be doubted; and (b) Those which, like affections of the skin, mucous membranes and bones, frequently do not make their appearance until long, after the first-named symptoms had disappeared, so that their probable derivation from a similar source can only be accounted for by the absence of any other cause, or by the resemblance existing between their course and character and that of the first-named phenomena. The phenomena of this second class, which never appear as the primary symptoms of a direct infection, but always follow such an infection at an earlier or later period, have, on that account, been designated by many authors as secondary symptoms, or, inasmuch as they are principally traceable to a chancre, as secondary syphilis, whereas the phenomena constituting the first class have been comprehended under the general name of lues venerea primaria, or the primary forms of venereal disease. On the other hand, there are physicians who would not even recognize those secondary symptoms as venereal, and even go so far as to deny the existence of secondary syphilis, for the reason that the derivation of this class of phenomena from a venereal source is not only involved in doubt, but that these secondary phenomena do not possess, like the primary symptoms, the capacity of transmitting the original infection. It is indeed true that these secondary phenomena do not clearly possess the characteristic signs which we have pointed out in a previous paragraph as pathognomonic of the venereal disease, we mean their production by an impure coit and their capacity to reproduce themselves in a like form; and even if we should succeed, in the further course of this work, in demonstrating their derivation from one or the other primary form by irrefutable arguments, we cannot accomplish this purpose until we shall have acquired a sufficient knowledge of the symptoms from which the secondary symptoms are derived, to become enabled in this way to form an independent, competent judgment concerning the relation and connection of the two classes of phenomena. Without troubling ourselves just now about the question whether secondary syphilis is a venereal disease, we will for the present confine ourselves to a consideration of the primary products of the lues venerea primaria, in order to ascertain the undoubted signs by which a venereal infection usually manifests itself. Inasmuch, however, as a number of authors, for the want of a fixed diagnostic sign, do not seem to know that symptoms ought to be considered as characteristic of a primary and what of a secondary disease; yea, in as much as not a few authors talk even of tertiary and quaternary forms, and some class the last-mentioned among the primary; we shall not be able to adopt any of the existing classifications of the different venereal products, and guided by the light of own judgment and experience, shall inquire for ourselves which of these products should be regarded as primary symptoms and which not. Secale 4-Essentially Primary Forms. Judging the so-called venereal products which are designated by different authors as primary symptoms, by our criterion of the undoubted derivation of these symptoms from an impure sexual source, we shall find that one of the most positive of these products is the so-called gonorrhoea concerning whose direct origin in an impure coit there can be but one opinion, although there are physicians who are unwilling to class even this affection, among the venereal diseases. But since this opposition as we have seen in No. I and No. II, rests exclusively upon a confusion of the ideas which some physicians attach to the terms gonorrhoea and venereal, and inasmuch as we have explained to satiety our own meaning of the term, venereal, every body will most likely admit with us that gonorrhoea, even if not a chancrous syphilitic, is at least a venereal disease, On the other hand, that chancre is in every case an undoubtedly venereal product, is admitted at the present time by all physicians even those who do not admit the specific virus of chancre, and hence do not believe in the contagiousness of chancre in the strict meaning of the term; as regards the bubo, authors differ very much in opinion, some (among whom Ruckert in his “Klinische Erfahrungen,” vol. II, page 182) regarding it as a symptom of secondary syphilis, others, like Broussais’ Physiological School, denying it every venereal characteristic, and declaring it a purely consensual glandular swelling which terminates in suppuration like any other inflammatory abscess. Now as we stated before, in asmuch as we understand by primary symptoms of venereal disease all those symptoms which still embody both characteristics of the venereal product, namely its evident derivation from impure sexual intercourse and its contagiousness, not obscurely as in secondary syphilis, but with such unmistakable clearness that they cannot be doubted or ignored; we believe ourselves justified, and indeed compelled by logic and science to regard the bubo as a demonstrably primary symptom of the venereal disease, although it may not always occur protopathically, but in most cases as a sequel of chancre. The same remarks apply to the so-called condylomata and to mucous tubercles, with which the former are so frequently confounded, and which often constitute the only sign by which a recent venereal infection is known, yet are nevertheless classed by a number of physicians among the symptoms of secondary syphilis from no better motive than that of simple routine; they had never reflected what constitutes primary and what secondary symptoms of syphilis, and what a vast and deep gap separates these two classes of symptoms even from a pathological point of view. After having sufficiently considered, in the two first divisions of this work, all the primary and secondary forms, we shall in the third division, when reviewing the general course of syphilis (No. 190-198), revert to this point with great fulness and demonstrate by pathological arguments drawn from the essentially distinct nature of the proximate cause of secondary syphilis, why this form of the disease should be considered as something essentially distinct from the primary disease, and why it should be considered strictly scientific to class among the primary symptoms of syphilis many that they have been hitherto considered as secondary. For the present we shall content ourselves with the external diagnostic sign which we have pointed out as showing in all cases the undoubted origin of a given venereal form; this sign leads us to class buboes, condylomata and mucous tubercles, as well as gonorrhoea and chancre among the primary phenomena, not only because they all originate protopathically in the same cause, but likewise because, even if they manifest themselves at ever so remote a period after a gonorrhoea or a chancre, they evince a like origin by the absolute capacity inherent in their secretions of transmitting the infection, and likewise by their specific products; properties that are not possessed in the same manner by any other so-called venereal affection. Secale 5 – Questionable Primary Phenomena. There is another point that will have to be settled before we can enter upon a more circumstantial description of the different primary phenomena; it is this, whether the above mentioned symptoms, such as gonorrhoea, chancre, bubo, mucous tubercles, and figwarts, are the only ones that can manifest themselves as immediate products of venereal infection, or whether there are other symptoms that will have likewise to be considered as primary symptoms of this disease. In this respect it is undoubtedly true that several writers on syphilis, among whom we may mention Dr. Cazenave, of Paris, who has contributed as much towards a correct pathology and treatment of the cutaneous syphilitic diseases, have advanced the opinion that the first manifestations of syphilitic infection may consist in the breaking out of a general cutaneous eruption, though all such eruptions are regarded by those who believe in a secondary syphilis, as characteristic of this form of the disease. In proof of this assertion Cazenave mentions a number of cases where the poison, after having penetrated a more or less perceptible wound, does not develop a chancre, bubo, or mucous tubercle, but a pustulous eruption that had hitherto been regarded as a symptom of secondary infection; so that we may very properly ask the question whether syphiloid eruptions ought not to be classed among the primary syphilitic symptoms. This would undoubtedly have to be done, if such a supposed primary syphiloid eruption were accompanied by symptoms that would render it impossible to connect it with any of the already known form of syphilis and if its syphilitic nature were moreover as self-evident as that of the acknowledged primary symptoms. For, if such a syphiloid has the unmistakable diagnostic signs of one of the primary forms, it is not a new but one of the already known forms which is distinguished from chancre, sycosis condylomata, and figwarts, only by the fact that it does not, as is generally the case, break out only at the place of infection, but spreads at once over a large portion of the surface of the body. If, on the contrary, such a syphiloid is to be classed among the symptoms that do not betray their undoubted venereal origin by positive diagnostic signs, and whose venereal nature is doubted by many even for the simple reason that they never make their appearance after an impure coit, nor ever show the least sign of contagiousness; this syphiloid, in spite of its primary derivation, at some prior period from an undoubted syphilitic source cannot be received in the class of undoubted venereal phenomena, until it has shown a capacity of reproducing its specific form by contagion, or at any rate, one of the known primary symptoms; as is the case with the bubo, for instance, which produces a chancre by infection with its own specific secretion. But even supposing that some observer had described cases where such a syphiloid, unaccompanied by any of the positive primary symptoms, had not only originated in an indubitably venereal source, but had likewise communicated the infection to persons in health, such isolated cases, the real nature of which may be doubted until they are verified by additional observations, would not justify us to class them, without further proof, among the category of phenomena such as chancre, gonorrhoea, buboes, mucous tubercles, or sycosis condylomata, as the only really positive and fixed primary symptoms of lues venerea, and so far, as the only known certain fundamental forms constituting this malady. III. COMMON CHARACTERISTICS OF THE VENEREAL. FUNDAMENTAL OR TYPICAL FORMS. Secale 6-Common Pathological Characteristics. We have seen what are the undoubted and undisputed phenomena and representatives of the lues venerea emanating from impure coit. Since they all originate in one source and hence must be produced by one cause, they must necessarily have certain signs in common, by which, in spite of all other differences, they are distinguished as members of one family from all other families of diseases. However, if we examine these common characteristics for the purpose of establishing a general pathology of the undoubted lues venerea, we meet at the first glance a number of essential differences that may serve to lead to distinctions among those characteristics, but, besides their origin from a common source and their contagiousness, we do not reveal a single sign that is peculiar to all of them. Looking for example, at the different forms under which they appear, we find that each characteristic is distinguished by fixed forms of its own, not possessed by any other characteristic, and that these forms run their whole course without ever infringing upon, or running into other forms. It is indeed true that chancre may, in a given time, assume the form of figwarts; but inasmuch as figwarts never terminate in chancre, it is not at all certain whether this apparent identity of figwarts and chancre is not confined to the external form merely, without justifying the conclusion that they are essentially alike. The cauliflower-shaped excrescences of certain chancerous ulcerations may show a great deal of external resemblance to venereal growths; yet no one has as yet presumed to consider figwarts and chancre as essentially the same. We would be far more justified in inferring a certain pathological identity between chancre and gonorrhoea, since both are equally capable of developing inguinal swellings; but independently of the fact that gonorrhoeal and syphilitic buboes are pathological distinct, if a purely symptomatic similarity were sufficient, we should have to class herpes praeputialis, which may be one of the accidental results of an ardently coit in the same pathological class with chancre and gonorrhoea, so much the more as this herpes, if it should be very, much inflamed, may, like chancre and gonorrhoea, cause inguinal swelling, specially in scrofulous subjects, in whom these frequently terminate in suppuration. This want of a perfect pathological identity becomes still more striking if we consider the course of these different phenomena, some of them, like certain forms of gonorrhoea, running an acutely inflammatory course at the termination of which they become extinct of themselves; others, on the contrary, like chancre, observing in every case a chronic course; added to which we have the additional difficulty that each of these forms seems distinct from any other as regards their specific power of reproducing the contagium; at any rate, the cases where the infection caused by one form, is said to have developed the specific products of another form of phenomena, such as the virus of chancre causing gonorrhoea, are still doubtful, and in need of further confirmation. Be this however as it may, it seems to be admitted that, for the present at least, a general pathology of venereal diseases is an impossible thing, and that we have to content ourselves with describing each of its fundamental form as independent of all others. Secale 7 – General Therapeutics of the Lues Venerea Our remarks concerning the absolute impossibility of building up from the symptoms of the different venereal fundamental forms, a series of characteristics common to all of them, and from which a general pathology or lues primaria could be deduced, applies with equal force to a system of general therapeutic. In this respect we have absolutely nothing that might be regarded as equally applicable to the different fundamental forms of lues venereas, each of this forms having its own rules and laws both as regards its greater or less susceptibility of a spontaneous cure, as well as with reference to the size of the dose and to the remedial agents that are specifically adapted to it; even to the extent that a method of treatment which might be proper for one of these forms, would become a positive falsehood if it were to be applied to venereal diseases generally. If gonorrhoea, for instance, has got well of itself, without the interference of art, we should be greatly mistaken if we were to lay it down as a general rule that lues venerea generally is susceptible of a spontaneous cure. It may indeed be proper to infer the spontaneous curability of gonorrhoea from a few isolated cases of spontaneous cure of this disease; but we would be greatly mistaken if we were to infer from such cases that, because the venereal disease has become spontaneously extinct, this may likewise be expected of chancre or mucus tubercles; for these forms, though they likewise constitute forms of lues venerea, may indeed change to other forms or other localities, but can never spontaneously terminate in a radical cure in the same way as some forms of infectious gonorrhoea. We should commit a grievous mistake if, because cannabis has proved such a signally effective remedy in gonorrhoea, we were to infer from this that cannabis is one of the most efficient anti-venereal remedies generally. It would leave us utterly in the lurch if we would employ this agent against chancre or mucous tubercles, although we cannot deny its antivenereal properties, since infectious gonorrhoea is a venereal disease equally as chancre or sycosis. The same remark applies to mercurial preparations, which, though they constitute one of the most powerful specifics against the different forms of chancre, cannot on that account be regarded as a general anti- syphilitic panacea, since they are far from exhibiting their anti-syphilitic virtues in many cases of gonorrhoea, as well as in a variety of sycosic condylomata. Our remarks likewise apply to the size of the dose. The two general propositions, for instance that venereal primary symptoms can be cured both by low, material doses of the mercurial preparations, and likewise by their highest potencies, are both of them correct and both of them false, according as either of them is adopted as a universal guide for the treatment of all venereal primary symptoms, or is limited only to single forms like chancre, gonorrhoea, sycosis etc.; for, even if chancre requires for its cure the grosser, more material doses of mercury, this is not by any means true as regards the other forms of lues venerea. In no respect, therefore, does it seem possible to lay down, in the domain of venereal diseases, a general therapeutic principle adaptable to all forms of venereal diseases; each form having its own rules of general system of therapeutics of the venereal diseases is just as impossible as a general pathology. Secale 8. Conclusions It is this absolute impossibility of achieving a general system of pathology and therapeutics of lues venerea, which has led several physicians, among whom Carmichael, of England, to assert that there is not idiopathic lues venerea, but only venereal phenomena that have been combined in one general idea by a process of abstraction but have nothing in common but the anatomical locality of their origin, and may, each of them, owe their origin to an entirely different contagium, even as the people united under one imperial sceptre may belong to the most different traces. A similar idea seems to have prevailed in Hahnemann’s mind when he distinguished the common gonorrhoea from the syphilitic chancre as well as from sycosis. Without being intimidated by the tendency that seems to prevail among many of Hahnemann’s adherents to criticise his teachings, we do not hesitate to declare even here that many of this views require further confirmation. At the same time we would not reject all his statements with the disregard with which the Hygea, as the sovereign mistress of out school, sought to put them down thirty years ago, not so much by the scientific superiority of its arguments as by a tone of defiant bravado. Inasmuch as in the course of this work we shall have frequent opportunities, when discussing the views of different old-school practitioners, of reverting to this delicate point, we leave this subject for the present, and content ourselves with stating that, if we have not succeeded in reducing the phenomena of the lues venerea primarla to an unitary generalization, our failure is not to be attributed to out predilection for Hahnemann, but to the absolute impossibility of perfecting such a generalization from a scientific of view. Forms cannot be forced upon Nature, which laughs at the pompous arrogance of modern criticism. However, while in the subsequent chapters we shall treat, (1) of the different forms of gonorrhoea, (2) of chancre, (3) of buboes, (4) of mucous tubercles, (5) of sycosis condylomata, together with the symptomatology, pathology, and therapeutics peculiar to each class, as if these different forms constituted so many distinct diseases having no sort of internal connection with each other; we still to ourselves the privilege of discussing the question of a unitary generalization more specially in a subsequent chapter, but shall allude to it, as often as may be proper, in treating of each particular form of the venereal diseases. We shall not be able to reach a decision on this subject until we shall have considered the general forms in the present division, and canvassed in the second division all the symptoms that have been comprehended under the general designation of secondary syphilis, after which, having acquired a full knowledge of all the elements that constitute the series syphilis, we shall be able to define the essential nature of this disease with an unbiased mind and perfect competency of judgment. This point will be more fully considered in the third division. Until then we shall confine ourselves to a knowledge of the concrete products, and shall proceed as if there existed neither syphilis nor lues venerea, but nothing but isolated venereal symptoms. SECOND CHAPTER THE DIFFERENT FORMS OF GONORRHOEA. 1. OF GONORRHOEA GENERALLY Secale 9. Idea of Gonorrhoea FROM what we have said it is evident that we do not understand by the term gonorrhoea, as so many continue to do, every imaginable mucous discharge from the urethra, but only an infectious inflammatory blennorrhoea, and that we regard it as a great calamity in the domain of science that recent practitioners, even medical authors, should ignore the meaning of a term which had been consecrated by the common vernacular, and should designate as gonorrhoea every kind of discharge from the urethra, admitting not only venereal and syphilitic, but likewise arthritic, haemorrhoidal, catarrhal, and Heaven knows what other kinds of gonorrhoea. We cannot wonder, in the presence of such horrible confusion of terms, that some physicians should pretend having cured gonorrhoea with remedies that will never remove a genuine gonorrhoea, and that others should still advance the doctrine that a gonorrhoea may not only be caused by any acrid, though otherwise perfectly innocuous leucorrhoea, but even by the menstrual blood. True, discharges from the urethra may be occasioned by such causes, as well as by irritating bougies or other foreign bodies such as gravel, stone in the bladder, urethral calculi, worms in the rectum, haemorrhoids, medicinal substances, etc. What distinguishes this form of blennorrhoea from a genuine, infectious gonorrhoea is, (1) that the former is not contagious; (2) that it does not pass through a definite inflammatory stage, no matter how violent the inflammatory irritation may have been; and, (3) that after the removal of the irritating matter the blennorrhoea ceases of itself in a few days. Where these three diagnostic marks exist, there is according to our definition of the term elsewhere as well as in the present work, no gonorrhoea, but simply an innocuous discharge. Where these signs do not exist; where the discharge runs through definite stages, from the incipient, scarcely perceptible oozing of a serous fluid to that of a greenish yellow purulent matter, attended with constantly increasing symptoms of inflammation, after which the discharge decreases in quantity while it continues to increase in thickness; in all such cases we do not diagnose a simple discharge, but a genuine contagious gonorrhoea, and it is our positive conviction that, in all such cases, the female who had infected the patient, was not merely afflicted with a corrosive leucorrhoea, or had a too acrid menstrual blood an infectious gonorrhoea, and even other troubles which she was anxious to conceal. Nothing produces nothing; where any infectious disease is contracted, it must have been derived from a an infectious contagium. Hence we cannot call to mind a more foolish illusion than the belief which is not only entertained by many lament, but even by physicians, that a gonorrhoea may be communicated during a heated sexual embrace even by a woman in perfect health; a discharge may indeed be occasioned, which, however, will cease again in a few days provided the women was really sound, but in no case an infectious gonorrhoea like that which constitutes the burden of our remarks. Secale 10. Simple and syphilitic Gonorrhoea Another remarkable confusion of terms prevails in the use of the epithets simple and syphilitic gonorrhoea. Some, specially French authors, designated by that term simple gonorrhoea one that is not infectious, hence a simple blennorrhoea, or what we have described as a simple discharge; whereas they apply the term syphilitic to every from of gonorrhoea capable of transmitting itself to others by contagion, or having been contracted by impure coit, without considering whether the virus that had occasioned the disease was simple gonorrhoeic or syphilitic virus. Further on (No. 15), we shall see whether there exist two different kinds of virus, the simple gonorrhoeic and the chancre virus, by which gonorrhoea may be caused; for the present we will simply observe that, in accordance with the distinction which we have pointed out between the terms venereal and syphilitic, we shall in the present work understand by the term syphilitic gonorrhoea one that is caused by the chancre- poison; whereas we shall apply the term of simple contagious gonorrhoea to a urethral discharge that is occasioned by the simple gonorrhoeal virus; distinguishing both kinds by the term venereal from any other form that is neither non-contagious nor had been communicated by contagion. In this way we expect to prevent misunderstanding at the outset, and by means of these rigorous definitions of terms, elucidate more fully our understanding of the different forms of venereal gonorrhoea, which, though essentially distinct, are yet frequently confounded with each other in consequence of an habitual confusion of terms, showing at the same time that one class can no more be infallibly cured by Cannabis than the other by Mercurius, and that those who designate any discharge from the urethra as gonorrhoea, have a perfect right to declare that they have cured gonorrhoea with Agnus, Mezereum, Natrum muriaticum, Ferrum, even with Nux vomica. Such a discrimination is not only of particular importance in regard to the different forms of gonorrhoea of the female, but even as respects balanorrhoea, which, to this day is regarded by some authors as a harmless secretion caused by a want of cleanliness and scarcely worth naming, whereas others, specially modern French physicians, regard it in all cases as a syphilitic disease. Be this as it may, let us for the present endeavor to obtain. Be this as it may, let us for the present endeavor to obtain a correct knowledge of the exact symptoms, course, accessory phenomena and different forms of the infectious gonorrhoea of the male, and of the most appropriate remedies for this disease; having obtained this knowledge, we shall find it comparatively easy to rectify our opinions concerning balanorrhoea, and to perceive even a ray of light in the obscure domain of gonorrhoea of the female. II. GONORRHOEA OF THE MALE Secale 11. Symptoms So far we have shown with sufficient clearness that we understand by the term gonorrhoea a urethral discharge that have been caused by the action of some specific infectious virus; not any discharge occasioned and contained by the action of some internal or external irritation of the urethra. A gonorrhoeal infection that may not only result form impure coit, but likewise from the use of instruments which the gonorrhoeal virus had remained adhering, generally becomes apparent after the lapse of four to seven days, or even two or three weeks after the infection had taken place. At first it may betray its existence by a slight titillation in the urethra which is not disagreeable and excites erections and a desire for sexual intercourse. This titillation is soon after succeeded, and very frequently accompanied by a scarcely perceptible secretion from the urethra (gonorrhoea incipients), which closes more or less the slightly reddened and, but in a few faces, somewhat swollen orifice of the urethra, and leaves very small, slight stains on the linen. Almost always, as I have noticed in many cases, this appearance is preceded the day previous by a feeling of malaise, which either remains unnoticed or is attributed by the patient to some other cause. This feeling of malaise is in a very few cases attended with slight febrile shiverings, but is almost always accompanied by a feeling of goneness or weakness in the praecordial region, and excites in the patient a desire to take something stimulating. Very frequently we notice already at this period of the precursory symptoms a scattering of the stream, which is probably owing to the partial agglutination of the urethra caused by the as yet imperceptible secretion in this organ. This scattering of the stream disappears, together with the other precursory symptoms, in order to reappear again with much more violence after the lapse of a few days. In a few days, probably two or three, the above-mentioned voluptuous titillation changes to a more or less troublesome sensation of smarting or tension, while the erections become even now somewhat painful. At the same time the orifice of the urethra appears more or less swollen, pouting, and a clear serous discharge sets in; the inflammation at the same time increases and is attended with a frequent urging to urinate; urination itself is likewise beginning to become painful. Generally these phenomena increase within a short time, but sometimes only in the second week. At this stage of the disease (gonorrhoea inflammation) the glans swells up and assumes a dark or yellowish-red color; the discharge keeps increasing in quantity, sometimes to an incredible degree, acquiring a yellow or greenish tint, and in appearance and consistence resembling a thin pus, and leaving yellowish stains on the linen which always have a gray sharply- circumscribed border (of which the stains occasioned by the non- contagious leucorrhoea of females are always destitute). The swelling from the meatus urinarius to the glans communicates itself to the prepuce and body of the penis (with more or less phimosis or paraphimosis); the urging to urinate increase, becomes very troublesome, and is attended with violent erections, which sometimes become so painful, specially at night, that they deprive the patient of all sleep. These inflammatory symptoms, if the disease is left to itself, generally increase to the 15th, 25th or 30th day, after which they gradually decrease, simultaneously with the discharge, which loses its greenish color, becomes yellow and afterwards whitish, more consistent and viscid and finally disappears more or less rapidly, accordingly as the constitution of the patient and the employment of proper hygienic and dietetic rules and more or less suitable remedial agents may influence the course of the disease. Left to itself, a gonorrhoea scarcely ever terminates before the 30th of 40th day, but, if mismanaged by improper treatment, or interfered with by a wrong diet, may continue for months, or even years, in the shape of gleet. Secale 12. Accessory symptoms accompanying Gonorrhoea. The course of venereal gonorrhoea which we have described, and by which it is distinguished from all other discharges from the urethra, usually takes place in all uncomplicated, non-syphilitic forms of the disease. Not in all cases, however, is this course equally simple and regular. Even in cases where the inflammation sets in with more than ordinary intensity, the pain becomes extremely troublesome and is frequently felt along the whole course of the urethra as far as the neck of the bladder; in such cases the discharge is streaked with blood; the swelling of the urethral lining membrane cause a true dysuria, and the urinary discharges, which only take place in drops, are sometimes either preceded or succeeded by the discharge of pure blood. At the same time the erections become more frequent and painful, and, in case the inflammatory involves the corpora spongiosa, are not unfrequently accompanied by a painfully tensive curvature of the penis (chordee). In many cases the prepuce becomes swollen and inflamed to such an extent that it cannot be drawn behind the glans (phimosis); or else the swollen prepuce remains drawn back behind the glans cannot be drawn forward, so that the glans becomes constricted and gangrene may set in (paraphimosis). The inguinal glands may like-wise become swollen (consensual buboes), or small knotty swellings may arise on the dorsum or on the sides of the penis occasioned by a swelling of Cowper’s glands or of the adipose tissue surrounding the bulbous of the urethra. If the inflammation is very violent, these swellings may terminate in suppuration, but generally they disappear of themselves in proportion as the gonorrhoeal inflammation abates. There are cases where the inflammation is so intense that the discharge is almost entirely suppressed in consequence (gonorrhoea sicca); in such cases the pain is very acute, the inguinal glands and even the scrotum may become swollen, and ophthalmia, swelling of joints and a high degree of fever may set in. A so-called dry gonorrhoea may exist as an idiopathic, primary form, without any signs of violent inflammation, or without any inflammation whatever, provided such a designation may be applied to a form of gonorrhoea without any real discharge, or where only few drops of a serous fluid are secreted. In this form the patient, a few days after the infection; experiences a more or less sharp pain at some deep- seated spot in the urethra, from which a very small quantity of infectious matter is secreted, which, though scarcely sufficient to form a drop at the orifice of the urethra, is nevertheless sufficient to transmit the infection during sexual intercourse. Here, too, the pain, dysuria and the troublesome erections may likewise acquire a great degree of violence, and the glans as well as the orifice of the urethra will be found swollen. Secale 13. Metastases of the Gonorrhoeal Disease Metastatic changes may occur not only while the secretion is still existing, but likewise, and indeed much more frequently in consequence of a sudden suppression of the same. The most important metastases are: orchitis, prostatitis, ophthalmic gonorrhoea and articular rheumatism. 1. ORCHITIS, INFLAMMATION OF THE TESTICLES. This form of metastasis occurs more frequently than any other and more frequently invades the left than the right testicle, very seldom both at the same time; in the same patient it is frequently seen to travel from one testicle to the other. A metastasis of this kind may be occasioned by any cause that has power to effect a sudden suppression of the discharge before it has run through all its different stages, or to exert a violent irritation of the testicles. Among such causes we number the abuse of astringent injections, cold baths, exposure to wet and cold, excessive bodily exertions, sexual intercourse, dancing, long marches, long standing, any kind of pressure on the testicles and spermatic cord, and a number of other similar circumstances. Generally, however, a gonorrhoeal inflammation of the testicles takes place when the inflammatory stage of gonorrhoea is on the decline rather than at this commencement. The first perceptible sign of gonorrhoeal orchitis is a slight swelling of the epididymis with a sensation of dull pressure, after which the inflammation specially involves the whole testicle, which sometimes swells up to four, six or eight times its size, with agonizing pain. Even the spermatic cord is sometimes involved in the swelling, and the hardness and painful sensitiveness extend over the loins. 2. INFLAMMATION OF THE PROSTATE. This inflammation may not occur while the running is still going on, but likewise after it has ceased. Very frequently it occurs during the inflammatory period in consequence of the irritation extending to the neighboring parts; very frequently, however, a swelling of the prostate may occur after the running has ceased, even months and after the first occurrence of the disease. In the former case, that is if the affection occurs as a consequence of violent inflammation, the patient experience a weight and heat in front of the anus, attended with a violent urging to urinate, tenesmus of the bladder and intense pain in the region of the neck of the bladder, which increases when an effort is made to urinate or to evacuate the bowels; when introducing a finger in the rectum, the swollen prostate becomes distinctly perceptible, the urinary secretions become difficult, and fever supervenes soon after. If the inflammation should reach the highest degree of intensity, it becomes a difficult matter to prevent suppuration, which is always a very troublesome complication. 3. GONORRHOEAL OPHTHALMIA. The affection, which is generally occasioned by a metastasis of the gonorrhoeal inflammation to the conjunctiva of the eye and lids, occurs very rarely, and almost always in one eye. It runs a rapid course, may attain a fearful height even in twenty-four hours, is attended with agonizing pains in the eye and head, violent photophobia, fever, and discharge of a yellowish-green purulent gonorrhoeal mucus oozing from every point of the conjunctiva. The inflammatory may likewise be occasioned by the eye coming in contact with gonorrhoeal mucus. 4. ARTICULAR RHEUMATISM. This always results from the sudden suppression of gonorrhoea, and generally invades the knee elbow and tarsal joints, which become swollen and inflamed. The affection is generally attended with frightful pains and a violent fever, and may, if left to itself, continue for fifteen or twenty days, unless the discharge from the urethra should be restored before that time. 5. AFFECTIONS OF THE MUCOUS MEMBRANES. In the absence of adequate testimony, we are unable to affirm, with some authors, that a sudden suppression of gonorrhoea may be followed by metastasis to the mucous membrane of the ear, nose, pharynx, larynx, etc., even to the serous membranes of the brain, whereby violent cephalalgia, hemiplegia, and mental disturbances may be caused. Secale 14. Sequelae of Gonorrhoea Lues Venerea Among these sequelae we distinguish more particularly, (a) secondary gonorrhea or gleet, which is often very tedious, and, (b) strictures of the urethra. Gleet is undoubtedly a phenomena deserving of our serious attention; for, although it may be nothing more, in many cases, than a symptom of weakness of the lining membrane, yet it may likewise originate in the presence of some hidden syphilitic taint, and may cause the so-called strictures or callous contractions of the urethra. As regards the lues gonorrhoea of which Ritter has furnished us a description, it would seem that, if the existence of this lues were as positive as the lues syphilitica which owes its origin to chancre, we ought to see much more of this disease than we do, specially in the capitals of Europe, where so many hundreds of thousands of cases of gonorrhoea are mismanaged from year to year. What Ritter cites as phenomena of lues gonorrhoeica, such as, violent itching in the hairy parts without any falling off of the hair; non-contagious warts on the labia and small tubercles on the scrotum; bluish-white spots and ulcerous erosions in the male urethra, at the vulva, and afterwards on the lower lip and cheeks; rhagades, inflammation of the skin, spor and herpes; affections of the periosteum covering the articular extremities of bones and in their neighborhood, attended with slight pains which recur only at long intervals, and a perceptible swelling of the bones without caries; affections of the lungs and eyes; all these phenomena may be observed in syphilis and the mercurial disease, as well as among persons who may indeed have had gonorrhoea once in their lifetime, but where the above-mentioned affections cannot be traced to gonorrhoeal infection with as much positive certainty as the sequelae of syphilis, all of which are distinguished by unmistakable, characteristic, pathognomonic signs, can be traced to their source. As for the other symptoms which Ritter regards as symptoms of the continued progress of the disease, such as, steatomata of a greater or less size on the neck and breast, as well as in and on the viscera of the thorax and abdomen, attended with physconia, deranged digestion, heart-affections, nocturnal headache, depression of spirits, feeling of exhaustion, a pale-yellowish complexion, slow fever, increasing tension of the abdomen, progressive debility and sometimes sudden death; all these symptoms may indeed occur among persons who have been afflicted with gonorrhoea, but likewise among those who never had this disease; whereas, on the other hand, thousands of individual had gonorrhoea not only once, but ten times, and were treated with injections, yet never manifested any of the above mentioned symptoms. All this is different as regards the well established symptoms of secondary syphilis. The only phenomena of secondary or chronic gonorrhoea which, beside the above-mentioned metastases, are so far established as undeniably positive sequelae of the original infection, are strictures of the urethra, chronic swelling of the prostrate, and other local affections, such as gleet, which last mentioned trouble may likewise arise form excessive weakness of the mucous membrane of the urethra. Secale 15. Relation of the Gonorrhoeal to the syphilitic Virus. Although, even at this day, a number of physicians regard, with Girtanner, Hunter, Harison, and most French authors on syphilis both miasmata as identical, yet a more matured judgment and correct observation must lead us to deny the correctness of their opinions. For, although it cannot be denied that the gonorrhoeal virus, when inoculated upon a sound mucous surface, may produce chancre, mucous tubercles and other syphilitic phenomena; yea, though it is perfectly positive that the gonorrhoeal virus has produced all the symptoms of secondary syphilis which are generally attributed to the operations of the chancre-virus; it is, on the other hand, equally certain that there are cases of contagious gonorrhoea where none of these symptoms occur; from which we conclude that there exists a special gonorrhoeic virus which has nothing in common with the virus of syphilis; but that, on the other hand, the syphilitic virus may cause gonorrhoeal discharges which, in such cases take the place of chancre, provided that the two poisons have not coalesced which may and does occur here and there. In addition to all this, we have to state that the cases where, as I myself have had occasion to observe, a so called contagious gonorrhoea is afterwards succeeded by all the symptoms of constitutional syphilis, occur much more frequently among women than among men, probably for the reason that if the internal parts of the female were more frequently examined, we should find that what was supposed to be gonorrhoea, was nothing else than a profuse secretion from syphilitic erosions caused by the chancre-poison, with a liberal admixture of leucorrhoeal matter. It is very likely that similar erosions may occur in the urethra of the male, where they likewise occasion a gonorrhoeal discharge which is mistaken for a common gonorrhoea; this may even be considered as certain, if simultaneously with the gonorrhoea, we perceive such erosions on the glans in company with balanorrhoea (see below), or if, at a later period (see Secale 73), we not only notice figwarts but real chancre. Secale 16.Diagnosis. We consider it, therefore, as an established fact that there are two kinds of contagious or venereal gonorrhoea, both of which result from impure coit and differ greatly in their results, one of which, constituting a more or less local affection and confined to the sexual organs, runs the above-described course without leaving any other than local symptoms after the cessation of the discharge; whereas the other form, which might be designated as chancrous, or, in a more restricted sense, as syphilitic gonorrhoea, may be accompanied by, or cause the appearance of, all the phenomena which a chancre may be capable of occasioning. We have shown above in what way these two kinds of gonorrhoea are distinguished from other innocuous non contagious urethral discharge; but it is much more difficult to show by what signs a simple venereal local gonorrhoea is distinguished from the syphilitic form. In the absence of such signs as chancre or syphilitic erosions. Record knows of no better diagnostic proof than inoculation in order to find out whether it will produce chancre or not. This is undoubtedly correct; for all the other signs are altogether uncertain, and may equally occur in both forms of gonorrhoea. It being, however, impossible, in most cases, to employ Record’s method of ascertaining the syphilitic character of gonorrhoea, we shall be compelled, in many cases, to remain in doubt regarding the true nature of the discharge. From may own observations I have deduced the following points, which, if they do not afford diagnostic certainty in all cases of female gonorrhoea, yet will justify the suspicion that we have not to deal with a simple venereal gonorrhoea, but with a discharge that had been caused by the poison of chancre. 1. The more purely the true; specific gonorrhoeal symptoms, with or without the local consensual affections that are peculiar to them, manifest themselves, and the more uncomplicated their course through their different stages, from the first moment of their increasing inflammation to the gradual decrease and final termination of the discharge, the less need we suspect the presence of a secret chancrous virus. 2. The less distinctly marked the course, and more specially the inflammatory period of gonorrhoea; in other words the more torpid a gonorrhoea, and the longer a copious discharge continues, even after the disappearance of all inflammatory symptoms, the more we have a right to suspect that the existing discharge is owing to the presence of change-virus. 3. The probability becomes positive certainty, if, during the course of the disease not only chancre, but suspicious erosions and even figwarts break out upon the mucous lining. 4. The most suspicious in this respect are the so-called torpid gonorrhoeas, consisting of a very slight painless discharge, with scarcely any inflammation either preceding or still accompanying the discharge; for, as we shall see afterwards, inasmuch as the syphilitic erosions caused by the chancre-poison are almost always painless, the presence of such erosions in the urethra, may very readily lead to such a gonorrhoeal discharge. Secale 17. The Contagiousness of Gonorrhoea. As a matter of course, we do not speak here of discharges that owe their origin to the chancre-poison, but of a local gonorrhoea caused by a specific virus. It is an established fact that this form of gonorrhoea is likewise contagious, and capable of exciting a similar pathological product in a person in perfect health. The question here is not whether venereal discharges are contagious, but in what degree the contagiousness of the non- venereal, inflammatory non-syphilitic gonorrhoea exists, and to what stage it continues. Regarding this point, I can refer to six cases in my own practice, where wives were infected by their husbands at a stage of the disease when there was scarcely any perceptible discharge, and only a little redness of the orifice of the urethra, and a secretion leaving only a-few scarcely observable stains on the linen and slightly closing the urethra by agglutination, on account of which the patients came to consult me, admitting that they had sexual intercourse with their wives all the time in spite of these appearances; of course, the consequences of such conduct did not fail to show themselves in 6, 10 or 14 days. It is difficult to say, however, how long after the disappearance of the inflammatory period gleet may still continue to remain infectious; all I know in this respect, is, that I have been consulted by men who had been for years afflicted with more or less considerable mucous secretions from the urethra consequent upon gonorrhoea contracted at that remote period, who finally got married without communicating to their wives any trace of disease. On the other hand, cases have come to my knowledge where women who had been perfectly sound previous to getting married, and whose husbands had been afflicted with gonorrhoea, which, about the period when the marriage took place, still left a secretion of a few drops of serous liquid behind, experienced various irritations of the orifice and neck of the womb, which, in consequence of the continuance of contagious irritation through the sexual act, became very obstinate. In cases where the secretion that had been regarded as a simple inflammatory gonorrhoea, is really a syphilitic discharge arising from the presence of chancre, it is evident that this question must be involved in great doubt, and it may be regarded as certain that, as long as there is the least remnant of a discharge, the danger of contagion is not entirely passed; hence it is advisable to impress all such patients with the conviction that the infection may be communicated even by the least quantity of secretion remaining after gonorrhoea; and that young men who are afflicted in this manner, had better not get married until all traces of the disease, and the remaining secretion, are effectually removed. Secale 18. Prognosis. From what we have said, it must be evident that the prognosis must not only depend upon the individual constitution of the patient (which, however, is of very little moment in the purely inflammatory form of gonorrhoea), but likewise upon the nature of the discharge. The purely inflammatory non-syphilitic gonorrhoea, if left to itself, and if the patient observes a careful diet, generally gets well in six or seven weeks, without leaving any other difficulty than a disposition to stricture and swelling of the prostate. But if the strictest dietetic rules are not observed; if the patient indulges in beer, coffee, but more specially in spirituous beverages; if he fatigues himself by excessive bodily exertions, long standing, forced marches, etc.; if he exposes himself to catarrhal influences, or indulges in sexual intercourse before the discharge is entirely removed; it may not only pass into the form of a most obstinate gleet, but occasion many additional sufferings. Irritating injections or other influences by which the discharge may become suddenly suppressed, not only occasion the metastases described in No. 13, but, even if these metastases do not result, the discharges, which thy suppress palliatively, may return again, in which case its radical cure becomes more and more difficult, and the most obstinate gleet is the consequence. Another circumstance, which is rarely taken notice of, but is of the utmost importance and exerts a powerful influence upon the prognosis, is this, whether the gonorrhoea was the result of a single accidental contact with the gonorrhoeal virus, or whether the patient had repeatedly had connection with the infected female before he became aware of the contagion. Baffled in all my efforts to cure an apparently simple gonorrhoea with remedies that had always exerted a specific curative influence, I have been finally led to conclude, after the most careful observations, that the obstinacy with which the disease, even when of an apparently simple character, resists the effect of the usual remedial agents, is owing to the fact that intercourse with the infected female had been repeatedly indulged in; in other cases, where the disease had been transmitted by one single act of coition, I have effected a cure of the most violent inflammatory gonorrhoea in from fifteen to at most twenty-one days. My experience had led me to establish a rather unfavorable prognosis in all cases where the act of coition had been exercised with the diseased female in repeated succession. As regards the prognosis in the case of syphilitic gonorrhoea (or such as had been caused by the chancre-poison) it is quite the same as in any other case or syphilitic products; a definite prognosis as regards the duration or the possible consequences resulting from such forms of gonorrhoea cannot well be established, though even such forms, if not mismanaged by improper treatment, can be radically cured after a longer or shorter lapse of time, without leaving any untoward consequences behind. The greatest difficulties in the treatment of gonorrhoea will be met with in cases of gleet resulting from so called desiccating injections; such injections, even if not succeeded by metastases, never cure but only mask the disease for a time, which is evident from the fact that the discharge, If the injections are discontinued for a few days, re-appears, generally at once, until finally the injections likewise cease to be of any effect. Secale 19 Treatment of Gonorrhoea. Every homoeopathic physician who has acquired some experience in the treatment of venereal diseases, must have become aware of the difficulty of selecting the specifically characteristic remedy adapted to every case of gonorrhoea. This difficulty will be found much less, in selecting a remedy for any particular case, we keep in view the remarks we have offered in previous paragraphs, relating to diagnosis, and the essential points to be considered in establishing our prognosis. Starting from this position, I commence the treatment of gonorrhoea in every case by interdicting the use of spirituous beverages, coffee, beer, excessive bodily exertions, long standing, and more particularly all sexual intercourse until the discharge is entirely stopped; I warrant a speedy and rapid cure only on condition that all these rules are strictly complied with. As regards the medical treatment, if the case is non-syphilitic, not occasioned by the chancre-virus, 1. I gave the patient, if he presents himself for treatment before there is any actual running, and he only complains of titillation at the orifice of the urethra, with slight redness and a scarcely perceptible secretion, barely sufficient to close the orifice of the urethra by agglutination (gonorrhoea incipiens), Sepia 30, two pellets morning and evening dry on the tongue, by which treatment I frequently effect a cure without any inflammation supervening or, at most, without any other increase of symptoms than perhaps a more profuse secretion. 2. If, at the time when the patient presents himself for treatment, the secretion is already quite copious, or if the inflammatory period is already more or less advanced, or if sepia has had no effect within six or seven days in diminishing the incipient symptoms, I at once give in all cases Cannabis 3, two pellets morning and night, without paying any attention to consensual symptoms (such as pains in the testicles, phimosis or paraphimosis, swelling of the inguinal glands, difficulty of urinating painful erections, etc.); by persevering in the use of this agent, two, or, in very few cases, three weeks, at most, suffice to radically cure every case of gonorrhoea, together with all the consensual symptoms, provided the patient does not commit any of the above mentioned errors in diet, and the disease is not complicated with syphilitic taint, and does not primarily owe its origin to chancre virus. 3. If the patient presents himself after the inflammatory symptoms have entirely disappeared, and is still affected with a continual, painless, more or less profuse discharge, I commence the treatment with Canabis in every case where the remedy has not yet been used, and from which I have derived excellent results in this form of gleet. In cases where Cannabis had almost effected a cure, but where the disease had again become aggravated in consequence of errors in diet, I again restore the normal condition of things by means of a few doses of Cannabis. If Cannabis should prove of no avail, I give in either or these two cases half a grain of the second trituration of Mercurius vivus, repeating this dose every three of four days, a few doses being in most cases sufficient to remove every trace of the discharge. 4. It is only cases where a few scarcely perceptible drops are still secreted that the quite unmanageable, and seem to resist all treatment. In such cases Sepia, Sulphur, Pulsatilla, and, if the secretion is of a milky whiteness, Capsicum and Ferrum, and in some cases Tussilago and Natrum muriaticum have rendered me excellent service. Regarding such remedies as Agnus, Agaricus, Copaivae Balsamum, Cantharis, Cubebae, Petroselinum, Fluoris acidum, Polygonum, Mezereum, etc., I have no experience to offer; but, if I may judge from what I have seen of Cannabis in thee treatment of gonorrhoea, it is my opinion that those who use all sorts of remedies for one or the other accessory symptom, waste their time and and cure gonorrhea much more slowly on that account. It is only when intense inflammations threaten dangerous results, such as gangrene, where Arsenic would have to be used, that intercurrent remedies become necessary. 5. As a matter of course, where gonorrhoea is evidently complicated with syphilitic symptoms (such as erosions, chancre, figwarts, etc.), the remedies which have to be advised for chancre, figwarts, etc., will have to be resorted to. (Sepia and Cannabis, as recommended by Jahr. are relied upon by many of our most prominent homoeopathic physicians in the treatment of gonorrhoea; but there are vast numbers of cases where other means have to be resorted to, as we shall see by and by. Even in cases where cannabis is the remedy, it may have to be given in massive doses. In a case where chordee was a very prominent and very painful symptom, we effected a perfect cure by means of large doses of the tincture of Cannabis, beginning with five drops of the tincture the first day, and gradually increasing the quantity to thirty drops in the course of a day; a cure was effected in a fortnight; our patient was member of the Legislature, and had to transact a large amount of business every day. Hempel.) Secale 20 Treatment of the Metastases and Sequelae of Gonorrhoea. 1. INFLAMMATION OF THE SCROTUM AND TESTICLES, ORCHITIS This inflammation generally yields to Pulsatilla (a solution in water, teaspoonful every three hours); and if Pulsatilla should not prove sufficient, Mercurius vivus 12, given in the same manner, will do the rest. In former years I used to obtain good results from Aurum, but latterly I have got along with Pulsatilla and Mercurius, for the induration of the testicles, which sometimes remains for years after mismanaged gonorrhoea, the most efficient remedies in my hands have been Aurum Clemetis, though they may leave one in the lurch in some cases. (In phlegmonous inflammation of the testicles, Aconite is an agent of paramount importance. We have cured such cases with Aconite 30. Cases may arise where Belladonna may be necessary. We have employed successfully the lower attenuations and even the tincture internally, at the same time applying compresses soaked with a strong solution of the fluid extract in water, externally. If the inflammation is extensive, involving the spermatic cord, and is moreover attended with cerebral symptoms, torpor, slight delirium, etc., Belladonna will be found indispensable. Hempel.) 2. METASTASIS OF GONORRHOEA TO THE EYES. Here we give at once Aconite every three hours, after which, if the inflammation is less, but the discharge is not restored, we resort to Pulsatilla or Mercurius sublimatus. After the danger is removed, and Mercurius should not have wiped out the disease, we finish up the treatment with Acidum nitricum, Belladonna and Tussilago have likewise done me good service in all such cases. (In the case of a blacksmith, whose right eye had become inflamed by being brought in contact with the gonorrhoeal virus, one pellet of Acidum nitricum 200 in half a tumbler of water, effected a perfect cure. The inflammation set in suddenly during the night. The day previous both eyes were perfectly sound. The affected organ seemed like a disorganized mass of a dirty-looking yellow greenish pus. The pain was agonizing-Hempel.) 3. INFLAMMATION OF THE PROSTATE, PROSTATITIS. The first remedy to be employed against this always extremely painful affection is Pulsatilla, and if this should either totally or partially fail, we may resort to Thuja. Mercurius viv. and Nitric acid have likewise rendered essential service, and, in two cases, I have obtained good results from Tussilago, recommended by Rosenberg. (The Hydriodate of Potash should not be forgotten in this affection. Hempel.) 4. ARTICULAR RHEUMATISM. In one of the most desperate cases of this kind, where the patient was a female, and the sudden suppression of the discharge by astringent injections not only induced inflammation of one knee, as is most frequently the case, but inflammation of the knee, elbow, tarsal, and wrist-joints, Pulsatilla, preceded by few doses of Aconite, had a marvellous effect, and restored the discharge, which was afterwards cured, together with the remaining symptoms of articular inflammation, by means of Mercurius vivus. In a few other badly managed, less acute cases, I have seen good effects from Thuja, and sometimes from Sarsaparilla, but never from Clematis, which has been recommended for this affection. 5. GLEET. If painless, and not very copious, gleet is generally nothing more than a symptom of weakness of the mucous lining, which had been occasioned by this disease; in such a case Ferrum, Phosphoric acidum, and Sulphur, have proven more efficient in my hands than any other remedial agent. 6. STRICTURES. Whatever remedies I may have used these callous never contractions of the urethra, as consequences of the gonorrhoeal disease, I have yet succeeded in superseding, by internal treatment, the use of bougies, by the systematic introduction of which into the urethra, this organ is gradually dilated to its natural dimensions. In a single case, where I had administered Aurum, for a considerable period of time against mercurial symptoms, and where a bougie had to be introduced at least once a week, the stricture, with which this patient was afflicted, improved at the same time so fer that, for the last three years, the patient has been able to urinate without any pain or difficulty, only the stream is a little thinner than usual. NOTES BY DR. HEMPEL. Jahr’s remarks on the treatment of gonorrhoea are undoubtedly judicious, and the remedies he proposes for the treatment of this disease may be sufficient in a large number of cases. Nevertheless, a few additional remarks may not be out of place. If the testicles, one or both, should be much swollen and inflamed, it will be found necessary to wear a suspensory bandage for the purpose of alleviating the pain caused by the dragging weight. At the same time the patient should remain in a state of perfect rest until the inflammation is removed. If a sudden suppression of the discharge, consequent upon exposure to wet, a draught of air, etc., or occasioned by violently astringent injections, should result in violent inflammation of the urethra and neck of the bladder, or the bladder itself- accompanied by excruciating burning pain and an agonizing dysuria or ischuria, violent chills and fever, discharge of blood from the urethra Hit will be found necessary to give Aconite, of which, in all such cases, I mix a few drops of the tincture in half a tumbler of water, giving a desert- spoonful of this solution every five or ten minutes until the pain is relieved. Some practitioners, among others Yeldham, in his “Homoeopathy in Venereal Diseases,” propose to alternate Aconite with Cantharides. I prefer giving each remedy by itself: Aconite as long as it is specifically indicated, and, if necessary, follow it up with Cantharides, if this agent seem to be specifically indicated by such symptoms as violent priapism, agonizing chordee, delirium, etc. I have not the heart to give Copaiva and Cubebs the go by, as Jahr and other Homoeopathic physicians are in the habit of doing. Any one who will consult the second edition of my Materia Medica, will find that both Copaiva and Cubebs produce a discharge from the urethra, which, in addition to the other symptoms accompanying the discharge, would seem to justify the inference that these agents must be possessed of powerful curative virtues in gonorrhoea. But they must not be given in small doses. Copaiva is evidently adapted to the primary or acute, and Cubebs rather to a chronic form of the disease, or to gleetish discharges with simple burning and a slightly increased desire to void bladder. If used in the acute stage, Copaiva need not be given in larger doses than ten or twelve drops three or four time a day; when the inflammatory symptoms have subsided with a whitish discharge remains, with more or less burning, urging to urinate, etc., I give larger doses, adapting their size to the tone of the patient’s stomach. This method frequently leads to a cure, and as frequently, perhaps, leaves us in the lurch. In such cases other remedies have to be chosen. If Ricord’s opinion that Copaiva does not act dynamically, but by virtue of a mechanical contact with the urethral lining membrane, is correct Hit is evident that Copaiva, if given at all, should be given in large doses. A very convenient mode of administering the balsam is the frequent introduction into the urethra of a bougie smeared with Copaiva. In the Report of the Medical Statistics of the United States Army Assistant-Surgeon Hammond, in his report on the diseases of Socorro, New Mexico, mentions a new remedy for gonorrhoea, the Exhedra occidentalis, called by the natives popilote. The taste is terebinthinate and astringent, yet agreeable. It is a stimulant diuretic, and does not constipate the bowels. It is prepared for use by macerating two ounces of the branches, cut into small pieces, in a pint of hot water, in a close vessel, for three hours, and then straining. A pint of the infusion may be drunk during the day. It acts with surprising promptness, and is an efficient and valuable medicine. The shrub is an evergreen, and grows in great profusion throughout the country. In the first volume of the North American Journal of Homoeopathy wed find the Nitrate of potash recommended by Dr. J. S. Henry, of Montgomery, Ala., for gonorrhoea. He prescribes one grain three times a day, with a little sugar of milk; sometimes he give ten grains three time a day. Recent cases yield in a week; old cases in two or three weeks. Professor Hale, in his work entitled “New Remedies,” has added the following to the list of those that homoeopathic physicians have been in the habit of employing in this disease: Alnus rubra, or tag alder, recommended by Lee. Asclepias incarnata, or swamp milkweed. Dr. Hauser recommends it strongly for gonorrhoea and syphilis. He gives a table-spoonful of the tincture three times a day, before breakfast, dinner, and supper. (See Tilden’s Journal of Materia Medica, Vol.1. page 41.) Asclepias syriaca, Silkweed. It has long been in use among the Negroes of the South for gleet, gonorrhoea, scrofula, etc. The most usual mode of administration is in powder or infusion, the latter made with water and whiskey. Old cases of gleet, of many years’ standing, have been reported cured, after other medicines had failed, by taking a wine-glassful of an infusion of the fresh root, three times a day, before meals. Chimaphila, pipsissewa, and Caulophyllum, blue cohosh; our experience in the use of these agents is limited. Erigeron canadense, Canada flea-bane. Recommended by Coe. “It allays the scalding of the urine, and assists materially in cutting short the disease.” Eryngium aquaticum, button snakeroot. “Two ounces of the pulverized root, in doses of two or three grains, have effected cures in obstinate cases of gonorrhoea and gleet.” Gelsemium sempervirens, yellow jessamine. A case of cure is reported at page 448 of Hale’s New Remedies.” Hydrastis canadensis, golden seal. Dr. Brown cured a case of gonorrhoea with five-drop doses of a saturated tincture three times a day. It is also used as an injection. Phosphorus, Dr. Meyer of Leipzic reports a case of secondary gonorrhoea, complicated with hypertrophy of the prostate gland, which was cured by the persistent use of this agent in the space of seventy one days. Both the discharge and the hypertrophy yielded perfectly to the treatment instituted. Aloes. Dr. Gamberine, of Bologna, treats gonorrhoea very successfully with injections of dilated tincture of aloes. His formula is as follows. Aloes, 4 drachms; Water, 4 ounces. He injects the urethra three times a day. In the twenty-third volume of the British Journal two new remedies are recommended for gonorrhoea by Dr. Thomas B. Henderson; one of them is obtained from the wood of the tree, Sirium myrtifolium. Dr. O’Shaughnessy writes: “Sandal wood, in powder, is given by the native physicians in ardent remitting fevers. With milk it is also prescribed in gonorrhoea.” The other remedy is the Gurjun or Gurgina balsam, or wood oil. It is the product of the Dipterocorpus turbinatus, an immense tree growing in different parts of India. Thomas recommends both medicines very highly. (See British Journal.) Regarding injection, it may be said that opinions among homoeopathic practitioners are divided. Some reject the use of injections entirely, others resort to them even to the extent of adopting the French “abortive plan.” I have known this plan to succeed to the perfect satisfaction of both the physician and the patient. Sometimes the Gonorrhoeal inflammation is cured upon the principle of Trousseau’s method of substitution; the nitrate of silver inflammation being substituted in place of the Gonorrhoeal inflammation. The former, running a definite course, carries off the disease, having at most a weakness of the urethral lining membrane, which is afterwards removed by the used of tonic astringents, such as tannin, as solution of quinine, the sulphate of zinc, the sub-acetate of lead, hydrastis canadensis, etc. An excellent agent to inject is the sulphate of Hydrastin, which may, at the same time, be administered internally. In all cases where a gleetish discharge remains, more specially in debilitated and cachectic individuals, mild astringent injections, like those mentioned, may be of great use. Even cold water injections may prove expedient and beneficial. The injection-syringe should be provided with a long nozzle that should be well inserted in the urethra. The liquid injected has to be retained in the urethra for several minutes. For this purpose the penis has to be held in a horizontal position, and, at the same time, compressed between the thumb and index finger of the left hand, while the syringe is drawn out with the right. Injections, if they prove suitable and beneficial, may be repeated three or four times in the twenty-four hours. The muriate of iron is likewise useful in this stage, both in the form of an injection and by the mouth. Internally I give ten to twelve drops in water three times a day, and when used as an injection, mix fifteen to twenty drops to an ounce of water. In the ninth volume of the North American Journal of Homoeopathy, the late Dr. J.C. Peterson, of St. John’s N.B. publishes an interesting article on gonorrhoea, where he recommends the following injections of the chloride of zinc during the initial stage of the disease: Three drops of the liquor chloride-zinc to eight ounces of water. Before the patient uses the injection he is directed to void his urine, after which half a drachm of solution is thrown up the urethra, and retained until it produces a smarting sensation; the liquid is then allowed to escape, and is followed in a few minutes with an injection of cold water. In the third stage, when all inflammatory action has ceased, he uses injection of the nitrate of silver, chloride of zinc, or acid nitrate of mercury. Of in the fourth stage, or that of gleet, he uses injection or rose water and wine, and of the iodide of iron; four ounces of the wine to two ounces of water; and two grains of the iodide of iron to six ounces of distilled water. Peterson’s injection of chloride of zinc was first mentioned by Gaudriot. His formula is: Liquid chloride of zinc, 24 to 36 drops. Distilled water, 4 ounces. Two injections a day, for two or three days, will generally suffice for a radical cure of gonorrhoea; the first injection are almost always followed by more or less swelling of the glans pains, but this does not contra indicate their continue use. For gonorrhoea in females suppositories may be used composed of. Liquid chloride of zinc, 5 drops. Sulphate of morph., 1/2 grain. Mix with 3 drachm of paste made of mucilage of gum-tragacanth, 6 parts, Starch powder, 9 parts, Powdered sugar. 6parts, Make into vaginal suppositories, one suppository every day, or every third day. Four or six in all will effect a cure; the first suppository generally causes a swelling, with more or less heat of the vulva, which soon subsides. Thomas Evans, of London, uses very frequent and every weak injection of the sulphate of zinc, one grain to the ounces, to be still further reduced if pain is felt. They are simple but efficacious. He repeats them every half hour during the day. Slight cases are cured in twenty-four hours, severe cases in three or four days. Velpeau prefers nitrate of silver to sulphate of zinc, one grain to the ounce; in old-standing cases two grains may be used. Carmichael prefers a quarter of a grain to one ounce of water; he seldom increase to one grain. He recommends three or four injections a day. Alum injections are used by Dr. H. Collins exclusively in all stages of gonorrhoea. In the most acute form the patient is directed to pour a small jug of cold water on the organ; and immediately inject a syringeful of alum solution one half of a grain to an ounce of water. The first day the injection is to be repeated every half hour; at night as often as the patient wakes. In old cases the injection may be increased to one drachm of alum in eight ounces of water, three or four times a day. (See British Journal, vol. xxiv. page 183.) Injections of Mercurius corr. and Argentum nitr. are used by some French physicians in quantities equivalent to our first or second centesimal attenuation. Many cases are reported by them as having been cured by these injections without the aid of any other remedial agents. Gonorrhoeal ophthalmia, when resulting from metastasis, may have to be treated like any other severe inflammation of the eyes, with Aconite, Belladonna,Bryonia, Pulsatilla, etc., the specific treatment for gonorrhoea being continued all the while, if the gonorrhoeal discharge is not suppressed. For an interesting cure of such a case I refer the reader to page 275 and further, in tenth volume of the British Journal of Homoeopathy. An interesting cure of gonorrhoeal rheumatism is reported at page 23 of the fifteenth volume of the British Journal. It occurred in consequence of a Gonorrhoeal discharge having been suppressed in three weeks by means of copaiva (? Ed.). Soon afterwards he experienced a tearing pain in the left knee, with swelling and stiffness of the joint. The patient took the Schlangenbad, one of the Teplitz baths. The rheumatism left him entirely after the discharge had reappeared; it gradually ceased entirely. Bedside the sequelae of gonorrhoea, mentioned by Jahr, we have “irritable bladder,” a most annoying symptom. In a case of irritable bladder, of several years standing, which remained after a gonorrhoea treated allopathically with caustic injections, and where the patient was troubled with painful urging to urinate, the urine dribbling off in drops; and where quantities of mucus were discharged with the urine, and the patient complained of debility, loss of appetite, etc., we effected perfect relief by the persistent use of Copaiva and the tincture of Cinchona. Owing to circumstance, the patient mixed both ingredients in one bottle, in the proportion of one ounce of Copaiva to two ounces of Cinchona, of which preparation he took a teaspoonful three times a day. After using it for a week he considered himself cured. III.VENEREAL BALANORRHOEA. Secale 21. Symptomatology. As we have a venereal, contagious blennorrhoea, superinduced by venereal infection, and another form of blennorrhoea which in non contagious, and may have been induced by irritating stimuli, so we have a so-called balanorrhoea or external gonorrhoea. The noncontagious form, which frequently befalls individual who do not keep themselves clean, or where prepuce is very long and narrow and covers the whole glans, is a simple affection, that may occur in young as well as old people, and may even be occasioned by the friction in sexual intercourse. As in gonorrhoea the matter is discharged from the urethra, so in balanorrhoea it is secreted between the prepuce and glans, sometimes attended with swelling of prepuce, increased redness of the glans, and partial excoriations, which, however, are merely superficial, and, in a few days, heal of themselves. Venereal balanorrhoea acts in a similar manner, with this difference, that it never gets well of itself, and that the erosions, which, in simple non-contagious balanorrhoea, scarcely look like redness such as may be produced by simple irritating stimuli, in the syphilitic form, which always results from an infection by the chancre-virus, are more or less ulcerated and characterized by thee diagnostic signs of other syphilitic products. What distinguishes they contagious from the non- contagious balanorrhoea, are the complications that either exist or may occur in the course of the disease, such as chancre, buboes, figwarts, mucous tubercles, etc. Regarding its guarding, it may exist as a secondary disease, consequent upon constitutional syphilis, or as a primary disease induced by an immediate, direct or primary infection by the chancre-virus. In this case it commences exactly like simple balanorrhoea, the patient experiencing at first, under the prepuce, a simple titillation, burning and unusual itching; the increased secretion arises between the prepuce and glans at first of a sero-mucous character, and afterwards, as the inflammation increase, assuming an increased degree of thickness, and finally changing to gonorrhoeal matter. If the inflammation is violent, it may induce a true inflammation of the vein along the dorsum of the penis, and even a severely constricting phimosis, in case the pus, instead of running off, remains behind the glans, and the whole of the integuments of the penis become involved in the inflammation. In such a case, the above mentioned erosions, pustules or chancre arise at a later period, whereas, in secondary form of syphilitic balanorrhoea, these phenomena generally precede that effection for a certain period of time. Secale 22. Diagnosis. In the presence of other symptoms of syphilitic infection it is not difficult to distinguish a syphilitic from a simple non- contagious balanorrhoea; but such a distinction is almost impossible, if the balanorrhoea sets in as primary, acute disease, and the erosions are only slight and superficial. In such cases inoculation affords the only true diagnostic sign; nevertheless, the following points may facilitate the diagnosis. 1. A non-contagious balanorrhoea, whether caused by a want of cleanliness or heated coit, gets well of itself, in a few, or at most, in from eight to ten days, simply by frequent washing of the parts; this result is never obtained in the syphilitic form. 2. The erosions which may take place in simple balanorrhoea, are neither as broad, nor as numerous or red as is in the syphilitic form; at the same time the surrounding-mucous membrane is never as much inflamed, nor does the inflammation extend over as large a surface; nor is the discharge as copious. 3. The preputial herpes, which, located on the inner surface of the prepuce, may likewise occasion a sort of balanorrhoea, and may cause erosion by the bursting of its vesicles, nerve exhibits such a red inflammatory border round the ulcerated spots as the syphilitic erosion, and is moreover accompanied by itching both before and after the appearance of the vesicles, which itching is wanting in the syphilitic products. Secale 23. Treatment. In every form of balanorrhoea, no matter what its pathological nature may be, it is advisable to keep the parts as clean as possible, by washing them quite frequently with tepid water, or by injecting this fluid between the prepuce and glans. It may likewise be an excellent proceeding to insert linen rags moistened with water between the prepuce and glans. In non- contagious balanorrhoea this method will prove sufficient in most cases to remove the trouble in four, five, or, at latest, eight days. If there should be violent inflammation a few doses of Sepia or Mercurius vivus will speedily remove it. Care must be had not to apply externally to such erosions remedial agents that have a specific relation to syphilis, lest the removal of such erosions by external means should lead to the breaking out of syphilitic phenomena on other places. The solutions of lunar caustic which are applied by allopaths between the glans and prepuce, are sometimes the most dangerous things to be used. If the phimosis or paraphimosis should become so violent as to result in gangrene Arsenic will have to be used. If the syphilitic character of balanorrhoea is evidenced by the presence of suspicious erosions, figwarts or chancre, we have to resort to the treatment that will be described hereafter. (The non-contagious form of balanorrhoea does does not always yield to mere washing. In highly scrofulous individuals the disease may not only become troublesome, but even disgusting, in consequence of the enormous secretion of purulent matter, which threatens to result in a partial disorganization of the parts. In such cases, we have succeeded in arresting the disease promptly by the external application of a solution of the Muriate of Ammonia, at the same time administering the medicine internally in the form of a weak solution. Hempel.) IV. GONORRHOEA IN THE FEMALE Secale 24. Symptomatology. Nothing probably is more difficult than to furnish a full and correct symptomatic description of female gonorrhoea and its various forms. For the sake of correctness, not only the different varieties of non contagious leucorrhoea, but likewise both kinds of gonorrhoea the simple contagious or venereal and the syphilitic gonorrhoea which owes its origin to the chancre- virus, should be grouped in accordance with their distinctive phenomena; which is the reason that some authors have classed all these different forms more or less under one head. In addition to this there is no portion of the mucous membrane, from the pudendum to the uterus, that may not become the seat of infectious gonorrhoea just as well as it may be the seat of the most innocuous leucorrhoea. Though some authors contend that the gonorrheal infection starts from the orifice of the female urethra, whereas others are of opinion that its primary seat is the vagina, it seems, on the contrary, to be an established fact that the infection may arise from various points indiscriminately; so that the seat of the inflammation, if the affection should emanate from other parts then the urethra, can shed but a feeble ray of light upon the nature of the affection. What we know to a certainty is, that in every case of contagious venereal, though even not syphilitic gonorrhoea, a few days after the suspected coit a feeling of heat, smarting and tension, together with a sensation of increased dryness, is experienced in the more immediately affected parts. If the vulva is affected alone, or in company with other parts, they are swollen either partially or totally, so that, specially if the vagina is involved in the inflammation, the introduction of the finger becomes either difficult or painful, or even intolerable, and the patient is sometimes unable either to walk or to seat herself. These symptoms are attended with a great deal of itching, and occasionally with such a powerful irritation in the sexual organs that the patient experiences a strong desire for sexual gratification. The parts covered with mucous membrane, are dark-red, dry and tense; the redness being sometimes visible only here and there, with or without slight excoriations, or granulations which arise from the swelling of the mucous glands. During micturition, the last drops are attended with the most intense burning pain, though the urethra may not be involved, if this, however, should be the case, its orifice is red and swollen and, when pressing upon it, a drop of purulent matter escapes from it; urination, in such a case, is painful from beginning to end. Very frequently thee appearance of the local phenomena is preceded by other sympathetic, such as colic, constipation or diarrhoea, etc., which may continue even after symptoms the discharge has commenced. In many cases the color and consistence of the menstrual blood are altered. The discharge, as soon as it makes its appearance, has the color and consistence of purulent mucus, leaving sharply circumscribed stains of a yellow, green or brown color upon the linen, by which it is generally distinguished from the ordinary leucorrhoea with which the patient may have affected hereto-fore; towards the termination of the disease this discharge assumes a milky white appearance. Secale 25. Particular Forms. As has already been stated, gonorrhoea in females may be seated in the vulva, vagina, and at the neck of the uterus as well as in the urethra. If the vulva is the seat of the disease, the inflammation may be confined to single parts such as the papillae, labia, clitoris and its prepuce, etc.; in most cases the whole of the vulva is involved. In such a case we notice very often an erythematous redness without any perceptible alteration of the secretion; such an alteration always takes place if the inflammation becomes more deep seated, in which case it may assume a phlegmonous character. In some cases this affection, which is very much like the balanorrhoea of the male, seems more particularly confined to the mucous and sebaceous follicles. In such a case the itching is generally very violent; oedema or an inflammatory swelling of the affected parts, and even abscesses frequently supervene; in some cases the phlegmonous swelling may become so extensive that it may close up the entrance of the vagina and may render the emission of urine difficult and painful. The inflammation may even extend to the external pudendum and the surrounding integuments, in which case they become oedematous, the epidermis softens, and the parts assume the appearance of a suppurating blister. In all these forms or gonorrhoea of the pudendum the secretions always have a fetid odor. In most cases gonorrhoea remains confined to the pudendum; but frequently it gradually progresses through the vagina as far as the uterus, more particularly if it lasts a long time; after having disappeared in every other part, it may localize itself in the uterus, and, without causing any other ailments, may occasion those uterine catarrhs which are often of such an equivocal nature, and which without betraying their true character by any external signs, are nevertheless capable of transmitting the venereal infection by coit. In the female gonorrhoea, the inflammation may extend to the ovaries, as in the male to the testicles; who knows whether a number of ovarian affections in old prostitutes do not owe their existence to such a cause? Another complication which can only take place in females, is the spreading of the inflammation to the anus and the lower border of the rectum; these organs being so situated that, when the female is lying on her back, the discharge from the vagina most necessarily gravitate towards them, and must corrode them to a greater or less extent. Such an invasion of the back parts by the gonorrhoeal disease frequently develops a true anal gonorrhoea (as I know from personal observation), with extensive soreness of the surrounding parts, profuse secretion, frequent tenesmus, and very frequently such violent pains during an evacuation that they cause the patient to scream and tremble. We hardly need allude to the fact that the metastases of which mention was made when treating of the gonorrhoea of males, such as ophthalmia, articular rheumatism, may likewise occur among females. Among the latter, however, they seem to be less frequent than among the former. Secale 26. Diagnosis. If it is difficult, in the case of males, to have a correct opinion of the nature of the discharge, this difficulty sometimes becomes insurmountable in the case of females, who are troubled with so many different kinds of discharges, the most varied of which are grouped together under the general denomination of leucorrhoea. During the inflammatory period, when the affected parts can still be subjected to close observation, the physician may be enabled, either by the period when the inflammation supposed to have resulted from an infectious coit, took place, or by other circumstances that are communicated to him by the patient, who must necessarily by interested in being cured as speedily and radically as possible, to decide with more or less probability or even certainty whether the existing discharge is, or is not, of a contagious nature. But what is to be done if the inflammatory period is passed (though it may be advisable in all cases not to relinquish our suspicion that the discharge is contagious), and the affection has reached the stage which, in the male, corresponds to the period of painless gleet, and where, even if the affected parts show ever so little redness, a contagious discharge still continues to be secreted, though neither the microscope nor chemical reagents are capable of determining its contagious nature or the difference between it only the most harmless leucorrhoea? It is true that in some cases, specially when the inflammatory period is still running its course, a gonorrhoeal discharge in the female does not leave uniform and diffuse stains on the linen, as is the case with innocuous leucorrhoea; but that these stains, when caused by a gonorrhoeal discharge, exhibit a dark nucleus in the centre, and have a grayish, sharply-circumscribed border. Or, in other cases, where females are not only afflicted with ordinary leucorrhoea but at the same time with contagious gonorrhoea we may discover, in addition to a slight, scarcely perceptible redness of the affected parts, a few yellowish particles in the white mucous secretion, the presence of which as long as it continues, furnishes evidence of the infectious character of the discharge. Nevertheless, although all these phenomena are observed in cases of undoubted gonorrhoea, they, as well as the inflammatory of the affected parts, may result from the action of entirely different, extremely harmless causes, and hence can at most only justify suspicion, but not, by any means, infallible, conclusions. And lastly, supposing the contagious nature of the discharge is fully established, how are we to determine whether the discharge is simply venereal or owes its origin to the virus of chancre? In this latter case, if we do not confine our examination to the pudendum, but likewise investigate the condition of the vagina as far as the uterus, we may perhaps discover suspicious products resulting from the action of the chancre-virus; these products may, however, be wanting, since they sometimes occur at a later period. Adding to this that the true syphilitic gonorrhoea, we mean the gonorrhoea caused by the chancre-poison, not by its own specific virus, is very frequently quite painless and only attended with very little inflammation, we cannot fail to comprehend how the most dangerous forms of gonorrhoea, even those causing chancre in the male, and, in the female developing every symptom of syphilitic disease among their ulterior consequence, have been utterly misapprehended, and have been regarded as insignificant leucorrhoea. From my own practice I have now more than ten cases of constitutional syphilis before me, where the patients were not aware of ever having had a chancre, but attributed their trouble to an entirely painless leucorrhoea, which the physician whom they consulted, had declared harmless, and had treated with injections composed of an infusion of walnut-leaves. In the presence of so much uncertainly, inoculation furnishes in such cases the only certain diagnostic sign, although it sheds no light on the question whether a discharge that is incapable of producing a chancre, is caused by the specific gonorrhoea virus, and therefore, is, or is not contagious; for it is a well-known fact that specific gonorrhoeal virus is incapable of causing syphilitic products, although it has power to transmit its own infection by contact when the sexual organs. Secale 27.- Prognosis When the allopaths, among whom we mention more particularly Record of Paris, maintain than gonorrhoea in the female is most easily cured if it only affects the vulva; less easily if it is located in the urethra; still less easily if the vagina is invaded by the disease, and least easily if the cavity of the uterus is involved in it: this radical error is in the first place owing to the fact that French pathologist comprehend by the term gonorrhoea, without regard too specific causes, all such inflammation of the sexual organs as are attended with secretions from the affected parts, distinguishing the inflammation according as this or part is affected, by such special names as vulvitis, vaginitis and urethritis; in the second place the error arises from their faulty system of treatment, which leads them to suppress the symptoms (the inflammation, and the discharge) by external applications. Any one who knows what is meant by a radical homoeopathic cure, not a mere removal of the specific cause of the disease itself, must know that the locality of the disease neither facilities nor impedes its cure, and that howsoever difficult it may be to heal many other uterine catarrhs and vaginal blennorrhoeas occasioned by non-contagious causes, affections of the female organs depending upon the gonorrhoea or upon the chancre-virus, are all of them, easily cure with their specific remedies, as soon as the poison which sustains their existence is annihilated in the organism. Where a cure is delayed, as may be the case with syphilitic uterine or vaginal catarrhs, the cause is not to be sought in the anatomical relations of the affected parts, but in the peculiar nature of the body. In this respect we offer the following distinctions: Simple acute gonorrhoea, whatever the affected parts, is most easily cured; next, we cure most easily gleetish discharges remaining, after the acute form of gonorrhoea has passed away; by far the greatest difficulty is experienced in the treatment of truly syphilitic discharges and products, or such as are traceable to the action of the chancre-virus, specially if they are of a secondary nature, provided, always that there is such a thing as secondary gonorrhoea. This point, however, will be discussed in the third division of this work. Secale28.- Treatment What has been said (sec. 19), of the kind of diet that should be pursued in the treatment of gonorrhoea, is equally applicable, and just as rigorously, to the treatment of gonorrhoea in the female. Taking this point for granted, we depend upon Cannabis as our chief remedy in the treatment of simple acute gonorrhoea; this remedy will effect a cure in most cases, in the space of two or weeks, provided its use is persevered in and the patient abstains from all improper dietetic indulgences. As regards female gleet, with or without non-syphilitic erosions, we have in Sepia a remedy whose curative virtues in this affection are unsurpassed, no matter whether the discharge is localized in the pudendum, the vagina, or the uterus. Mercurius, Nitric acidum and Thuja may likewise have good effect, if there is no suspicion of chancre poisoning. In simple excoriations, however, Mercurius and Nitric acidum sometimes aggravate the disease instead of benefitting it, in which case we have resort again to Sepia. If such a gonorrhoea owes its origin to chancre-virus, the treatment of syphilis that will be indicated in the next chapter comes into play. In such cases, beside Mercurius, Nitri ac., and Thuja, we may have do use, and frequently to use with good effect, Lycopodium and Phosphoric acidum, likewise Zincum. If, towards the end of a cure, the disease seems to remain stationary, as is frequently, the case both with males as well as females, and the discharge seems to resist all further treatment without diminishing either in quantity or consistence, this want of success should not always be laid to the charge of the charge of the remedies used, but will have most frequently to be accounted for by the sexual or dietetic excesses committed by the patients who fancy themselves cured before a cure is really completed. In such cases all that the physician, who has it not on his power to lock his patients up, can do, is to try to influence them by the weight of argument; in spite of all he may say or do, he will never learn all the imprudences that they may commit behind his back. Be this as it may, it is indispensably necessary that the patient should be impressed with the importance of avoiding all dietetic irregularities until the cure is complete; lest he should be afflicted with remnants of this disease for months to come. From a single cup of coffee or from a single coit, I have seen the discharge return worse than ever, even after it was all but stopped. V. VARIOUS REMEDIES FOR GONORRHOEA, PROPOSED BY OTHER PHYSICIANS Secale 29.- General Remarks on the Different Stages Not every thing that is recorded in our books on the homoeopathic treatment of gonorrhoea, is the result of clinical experience; a good deal of it is based upon theoretical hypotheses. Let us try to separate as much as possible the chaff from the wheat. 1. First stage.- At this period, Wahle has used with distinguished success, Bignonia rad. min., provided the discharge had not yet made its appearance, and the patient only complained of titillation burning and itching during micturition. He effected a cure with the 20th to the 30th potency in from there to seven days. Drs. Mueller and Noack (in the Allium hom Zeit., vol, 15), and Stap (in Arch., vol. 18., no.3); confirm the curative power of this agent. Regarding the curative virtues of Cannabis in this stage, most practitioners seem to agree. As for Hartmann’s praise of the curative virtues of Copaiva in this stage, I have never seen them verified in my practice, no matter in what does this agent was used. 2. Inflammatory stage.- Most practitioners recommend Cannabis as the best remedy in this stage., Beside Cannabis, other practitioners have used with more or less good effect: Copaiva, Cantharides, Mercurius, Petroselinum and Polygonum (See No. 32), (a). For painfulness of the neck of the bladder: Cantharis, Capsicum, Petroleum, Pulsatilla; (b) for dysuria; Cannabis, Cantharis, Mercurius, Petroselinum; (c) for suppression of the discharge: Cantharis for painless discharge; Cubebs, Capsicum, Ferrum; for bloody discharge: Cannabis, Cantharis Tussilago; for thin discharge; Cannabis; for thick discharge: Capsicum, Mercurius; greenish discharge: Cannabis, Mercurius, Cubebs, Petroselinum: white: Capsicum, Ferrum.- For phimosis; Cannabis, Mercurius; for violent, painful erections: Cannabis, Cantharis, Mercurius. 3. Syphilitic gonorrhoea, with or without figwarts.- In a case of balanorrhoea: Merc, corr.- for figwarts: Nitri. ac., Thuja. 4. Metastasis.- For orchitis: Agnus, Aurum, Clematis, Mercurius, Pulsatilla, (Tussilago); and for induration, of the testicles and the inguinal glands: Clematis. For affections of the prostate pulsatilla Selenium, Nitri. ac., Sulphur, Thuja.- For gonorrhoea ophthalmia: Aconitum, Pulsatilla, Nitric. ac., Mercurius subl.- For rheumatism: Mercurius, Sarsaparilla. 5. Gleet.- Agnus castus, Cannabis, Capsicum, Cubebae, Ferrum Fluoris, ac., Mercurius, Mezereum, Natrum mur., Nitr. ac., Petroleum, Sepia, Sulphur. This is a general list of the remedies that have been used by homoeopathic physicians in the different stages of gonorrhoea and its sequelae. In the following paragraphs we will furnish more special information concerning their therapeutic value and use. Secale 30.- Remarks concerning the Remedies that have been employed by Homoeopathic Physicians up to the present time. 1. Agave Americana.- Rosenburg has cured with the extract of this plant one of the worst cases of gonorrhoea, accompanied by violent erections, chordee, strangury, and drawing in the testicles. 2. Agnus castus.- Recommended by Attomyr, theoretically or speculatively only for gleet and induration of the testes. 3. Bignonia.- Used, with great success, by Wahle, Haubold, Nuller, Noak and Stapf, for gonorrhoea in the initial and inflammatory stage, and likewise for gleet. 4. Cannabis.- The agent has been employed in the initial and inflammatory stage of gonorrhoea more frequently than any other. Kreussler justly observes that two doses of it administered morning and night, frequently cure gonorrhoea in eight days. It may be said that it will cure any case of gonorrhoea, though not always run so rapidly; we should not however, as Hartmann advises in this Therapeutics, change to Cantharis or some other remedy if the cure is not completed in eight days; nor should we allow ourselves to be deceived by the presence of such accessory phenomena as difficulty, of urinating, phimosis, inguinal swelling, haematuria, inflammation of the glans, painful erections, etc., and to be induced to employ some intercurrent remedy for the removal of these symptoms. All these accessory phenomena yield to the continued use of Cannabis, even more readily than to any other agent. It is only when the discharge has become suppressed, either by accident or by artificial means, that Cannabis seems to be powerless; against gleet it is very often more efficacious than any other remedy. The alternate use of Cannabis and Sulphur, recommended Bernstein, leads to no good results, and retards the cure rather than hastens it. 5. Cantharis.- Hofrichter does not think much of this remedy, Attomyr’s and Hartmann’s remarks on the appropriateness of this agent in gonorrhoea, are based upon theoretical grounds rather than upon experience. It is only when the accidental or violent suppression of the discharge causes trouble about the bladder, difficulty of urinating or even haematuria, that this agent may become of real value; I pity those who can be induced by the symptomatic erections or urinary difficulties which are present in every case of gonorrhoea to substitute Cantharides, which are so uncertain in their action, for Cannabis which is reliable and certain. 6. Capsicum annum.- What Attomyr writes concerning this agent, is likewise hypothetical rather than founded upon fact. C. Hering’s remarks, however, concerning the curative virtues of Capsicum in gleet, if the discharge looks like fat milk, and the patient complains of a burning during urination, and of a stinging and cutting pain between the acts of urination, have been verified by me on numerous occasions. 7. Clematis.- What Stapf relates of the efficacy of this remedy in inflammation and induration of the testicles (Arch. 7, no.3), is confirmed by Attomyr (Arch. 19), and likewise by Rosenberg (Allium hom. Zeit., vol. 35), who not only cure with this remedy inflammation of the testicles and a pain in these organs (without swelling) but likewise old indurations of the inguinal glands. 8. Copaiva.- Beside an incipient gonorrhoea for which Hartmann found this remedy useful in one case, we have no clinical experience to refer to; when Attomyr states that this agent has never been of much use of him in his practice, most practitioners of our School will most likely be found willing to confess to a like experience. 9. Cubeba.- According to Hirsch, Rosenberg and Wurda they are of little or no account in the inflammatory stage of gonorrhoea; in gleet, however, they have derived essential benefit from this agent. This has likewise been my own experience. 10. Ferrum.- Attomyr’s remarks concerning Ferrum (Arch. 18) are simply hypothetical. Hering’s statement, however, that Ferrum is useful in gleet, when the discharge is whitish, like milk, is based upon fact. Rosenberg confirms this statement by a case (Allium h. Zeit., 35). Secale 31.- Continuation of the same subject. 11. Fluoris acidum.- Rosenberg state (Allium h. Zeit., 35) that this remedy effected a speedy cure in a case of gonorrhoea that had been treated with Tussilago, and where the following symptom remained: burning urine, painfulness of the bladder, discharge of a yellow drop from the urethra every morning, and an oily exhalation from the genital organs, having pungent smell. 12. Kali jodatum.- Rosenberg’s case, which he describes as a complication of syphilis and lues venerea, resulting from neglected gonorrhoea, and which he cured with this agent, is not very clear; it seems altogether to have been a discharge traceable to the action of the chancre-virus (see No. 14). 13. Kreosotum.- Rosenberg cites another case where this agent after previous treatment with emulsion of flax-seed, almonds, and hemp, cured the remaining gleet, d together with a debilitating fever, exhausting sweats, increasing emaciation, and excessive secretion of a Colorless, very fetid urine. These symptoms may, however, have resulted from the excessive action of hemp; I have noticed them even after the somewhat liberal use of Cannabis. 14. Mercurius.- Hartmann’s (Therapeutics), and Attomyr’s (Arch. 18) remarks about this about this remedy are purely hypothetical. According to the experience of most practitioners, with which my own experience agrees in all respects, the true sphere of action of Mercurius as a form of gleet over which Cannabis has no influence whatsoever; it is more particularly indicated, if, as Hering observes, the discharge continues of a greenish-yellow color. If administered at the commencement of gonorrhoea, or even during the inflammatory period, its sole effect, specially if the doses are continued too long or too frequently, seems to be to render the cure more protracted and more difficult. It is only in cases where chancre and gonorrhoea are combined that Mercurius should be given from the very commencement, when it is often alone sufficient to effect a cure. Rosenberg’s case of balanorrhoea (related in the Allium h. Zeit), which he cured with corrosive sublimate, was most likely of a syphilitic nature. In cases of metastasis of the gonorrhoeal discharge to the testes the prostate and eyes, Mercurius (or Corr. Subl.) is, next to Pulsatilla, an indispensable remedy. 15. Mezereum.- Rummel (all. h. Zeit., vol. 3) says that this remedy has been of much use to him in some cases of gleet; and Attomyr (Arch. 18) alleges that he has found it useful in Haematuria. What he says of the specific virtue of Mezereum in female gonorrhoea, needs further confirmation. 16. Natrum muriaticum.- Stapf recommends this remedy as useful in gleet; Lingen and Hering have found it useful in simple, non- venereal blennorrhoea, owing its origin to acrid menstrual blood (see No.No. 9 and 10). 17. Nitric acidum.- We have to repeat that Attomyr’s remarks on this agent are purely speculative. Hahnemann’s recommendation of this remedy for sycosic gonorrhoea is essentially founded upon experiences; so are Goullon’s, Stapf’s, and Greter’s remarks about its curative power in painless, simply contagious gleet. 18. Nux vomica.- Although Rosenberg relates a case (Allium h. Zeit, 35) where this remedy has cured a kind of gleet; and although others recommend it for similar kinds of blennorrhoea resulting from piles, yet it is more than probable that this agent has nothing whatsoever to do with the true contagious gonorrhoea, and holds curative relations only to harmless or non-contagious discharges from the urethra. Secale 32.- Continuation. 19. Petroleum.- Although Schroen (Allium h. Zeit, 6), as well as Trinks (Griessel. Skizzen, p. 52), praise this agent, if administered in drop-doses of the original substance, not in an attenuated form, as one of the best remedies for gonorrhoea; my own experience leads me to doubt its efficacy in gonorrhoea; except, perhaps, in gleet, which, after all, does not cure more speedily than any other drug. Attomyr’s remarks (Arch. 18) about the curative relation of this drug to gonorrhoea are purely theoretical, and require further confirmation by practice. 20. Petroselinum.- Those who have used this substance in gonorrhoea, will agree with Vehsemeyer, and others, that its boasted curative virtue in gonorrhoea is, to say the least, very problematical and that it would be very wrong, while speaking of the agent, to lose sight of Cannabis; at any rate, during the inflammatory period. In cases of gleet where Cannabis seemed insufficient, I too have found it useful; more particularly when the patient, as Hahnemann likewise observed, was troubled with frequent urging to urinate. Nevertheless, it would be ill advised to employ this agent before we have becomes perfectly convinced, by a fortnight’s use of Cannabis, that this medicine will neither remove the discharge nor the urinary difficulties. To alternate Cannabis with Petroselinum, might be like jumping from the frying-pan into the fire. This would be mismanagement, as I can testify from personal experience, which might result in delaying the cure of gonorrhoea, which another week’s use of Cannabis would have completed, beyond even the period of six weeks. 21. Polygonum maritimum.- Rosenberg (Allium h. Zeit., 35) cured a case of gonorrhoea in a man who habitually afflicted with urinary difficulties, renal calculi, and the most horrid pains when urinating, with a few drops of the saturated tincture. 22. Phosphori acidum.- Rosenberg furnishes (Allium h. Zeit. 36) several more or less hazardous theoretical speculations, concerning this agent. He recommends it for the gleet of debilitated individuals whose system has lost its tone and reactive energy, and who are afflicted with impotence and affection of the testicle. From personal observation I can admit that this remedy is somewhat useful in gleet of an exceedingly chronic nature, but I do not consider it as one of the most important remedies for gleet, and never employ it as long as I can fall back upon some other remedy that is more intimately related to gleet. Bernstein, in his “Mosaik,” mentions a case where, after the cure of gonorrhoea, a few whitish drops were secreted every morning from the urethra of a man who had become weakened by self-abuse. The discharge was attended with the loss of quantities of prostatic fluid. This disease yielded perfectly to Phosph. ac., which was undoubtedly a specific curative agent in this case. Secale 33.- Continuation 23. Pulsatilla.- This medicine has not been much in favor with homoeopathic practitioners as a remedy for gonorrhoea. We must wonder that Attomyr should think much of the curative virtues of this medicine in gonorrhoea, since he himself reports a case where it only helped to quiet the general vascular excitement, to restore the appetite, and to remove the evening-chills and the increased thirst, but where the discharge remained entirely unaffected by the drug. For a discharge of this kind, Pulsatilla will never be of any use; it is so much more powerful as remedial agent in all cases of suppressed gonorrhoea, specially when resulting in orchitis, gonorrhoea ophthalmia and swelling of the prostate. This fact has been confirmed by the experience of the physicians, as well as by my own. 24. Sarsaparilla.- Rosenberg relates a case (all. h. Zeit., 35), where articular rheumatism consequent upon suppression of gonorrhoea was rapidly cured by this remedy. Similar results have been obtained in my own practice. 25. Selenium.- Attomyr’s suggestions (Arch. 18), concerning the curative virtues of this agent in affections of the prostate, are problematical, and require further confirmation. 26. Sepia.- One of the most important remedies for gleet, specially in the case of females, and likewise for incipient gonorrhoea, although Seidel is as yet the only one who has published a case of cure with this remedy (see Annal. 1.); Lobethal has published an observation concerning this drug (Allium h. Zeit., 13). 27. Sulphur.- From my own practice I am able to confirm Attomyr’s, Bernstein’s and Lobethal’s remark concerning the curative virtues of this agent in chronic gonorrhoea. Nevertheless, I would add that I prefer Sepia to Sulphur in this affection, and that the painless, exceedingly chronic forms of gleet seem to constitute the agent’s chief sphere of action. Attomyr’s observation that Sulphur, if given too soon, increases the burning in the urethra and other symptoms of inflammation, is undoubtedly correct. Personal experience, likewise, leads me to confirm the curative virtues of Sulphur in chronic articular rheumatism, chronic gonorrhoea ophthalmia and inveterate affections of the prostate, where these affections have resulted by metastasis from the suppression of gonorrhoea. In accompanying haemorrhoidal affections, Sulphur is likewise eminently useful. 28. Thuja.- The observations of our practitioners concerning the curative virtues of Thuja in gleet, specially when accompanied by affections of the prostate (Attomyr), by figwarts (Habermann), a thin, greenish discharge, etc. and its particular adaptation to such disease in the dose of female patients, find abundant confirmation in my own practice. Nevertheless, except in sycosic gonorrhoea, and in gonorrhoea attended with disease of the prostate, Sepia seems to me to deserve a preference over Sulphur. 29.- Tussilago pitasites.- Although recommended by Schweikert sen., Wahle and Kuchenmeister, as an excellent remedy for gonorrhoea both in the acute and chronic form; yet, so far, it has only been used by Rosenberg in several cases; by means of a watery infusion this practitioner has cured not only chronic, but likewise acute gonorrhoea; likewise ophthalmic affections and indurations of the testes when resulting from suppression of the discharge. 30. Aurum.- Although this remedy has really no connection with gonorrhoea, properly speaking, yet it deserve mention. More than once I have removed with this agent a swelling of the testes attended with slight inflammation when resulting from a suppression of the discharge, which was re-established at the same time; in another case; the use of Aurum was internally attended with considerable diminution of an old stricture. THIRD CHAPTER THE VARIOUS FORMS OF CHANCRE ———— I. OF CHANCRE GENERALLY. Secale 35.- General Properties. NOTWITHSTANDING that the Hunterian chancre is no longer, as formerly, at Hunter’s and even afterwards at Hahnemann’s time, considered as the only primary syphilitic ulcer; and although several chancres are known at the present time which differ more or less by their anatomical relations; yet all these different forms have so many pathological properties in common that it seems logical to regard them as different varieties of the one and the same species, and to apply the term chancre to all of them, that is, if we understand by this term the characteristic ulcer by which syphilis, which, in the more restricted sense of the term, is so entirely distinct from the gonorrhoeal disease, generally first manifests skits existence. This ulcer, which may likewise show itself as consecutive chancre in the course of the syphilitic disease, breaks out in its primary form, that is, as primary manifestations of the syphilitic infection, in six or seven days, sometimes sooner, and sometimes in two or three weeks, or even at a later period, at the very spot that first came in contact with the poison; whereas consecutive chancres appear more or less remotely from the original place of infection, sometimes only several months after the disappearance of the first, primary ulcer. In their primary form these ulcers most generally break out on the glans or prepuce, or on the labia minora or majora, the clitoris, or at the entrance of the vagina, or even, according to some authors, on the neck of the uterus. By accidental contact, primary chancres may likewise break out on other parts, such as the lips, nose, etc., though most of the chancres which break out in the mouth, throat, eyes, on the scrotum, in its primary form, generally begins in the shape of small, red, more or less inflamed spots, which causes little or no itching. Soon after, we see whitish, transparent vesicles start from the middle of these spots, which burst and discharge a reddish, acrid, serous fluid, after which, in most cases, the ulcer caves in the middle, like a funnel-shaped depression, and is surrounded by a red, hard, callous border, with a whitish-gray and lardaceous base; whereas, in other cases, the base is raised, and, instead of forming a depressed, forms an elevated ulcer, which shows in all cases a well-defined tendency to spread, if not in depth, at least in circumference, in which later case it may cause extensive disorganizations. Secale 35.- Various forms of Chancre. Regarding the anatomical relations of chancre, we discover a great diversity, not-only as regards their development, but likewise with reference to the forms which chancres may adopt in their course. So far from always first breaking out as vesicles or pustules, chancres, if the poison comes in contact with a wound or a spot deprived of its epidermis, may at once assume the form of ulcers; whereas, if the poison touches a lymphatic vessel or a ganglion, they may assume the shape of pustules. Sometimes they commence like slight, superficial excoriations, which soon penetrate to greater depth and assume all the characteristic properties of chancres. In other cases, again, the virus is so violent and active that the ulcer spreads immediately and penetrates to a great depth before the pain caused by this destructive process, leads to a suspicion of its existence. We have already stated that some chancres are depressed and deeply- penetrating, whereas others, on the contrary, are more elevated. Beside these, there are other varieties which render it difficult to bring all their pathognomonic characteristic under one generalization. Even the properties which so far have been considered as common to all chancres, such as the lardaceous, whitish-gray surface; the more or less raised, red, almost perpendicularly circumscribed borders, and their hard base, etc., admit of exceptions. Chancres, for instance, that are located on the glans, do not show a fatty, ash-colored but a claret-colored base; the surrounding parts are neither hard now swollen, and their borders are soft and flat rather than raised and sharply circumscribed. Other chancres are indolent, not much inflamed and almost painless, whereas others again are intensely inflamed and cause intolerable pain, which increases from mine o’ clock in the evening until two in the morning, and deprives the patient of all sleep. Finally, there are chancres which, after having attained and certain size, cease to spread either in circumference or depth, whereas others penetrate to and destroy the subjacent tissues, and others again spread more in circumference, like serpiginous ulcers, and while cicatrizing at one end, continue to spread at the other. These differences have led modern writers on syphilis to adopt several varieties of syphilitic ulcers, such as 1, the regular, simple Hunterian chancre; 2, the soft or raised chancre; 3, the phagedenic or serpiginous chancre, and 4, the syphilitic erosions. Whatever may be alleged, however, in favor of such a classification, it has, after all, only a diagnostic value, since, as I know from my own experience, any of these different forms may cause a character of the other class, and may entail the same constitutional symptoms as any of the other forms. All these different forms should not be regarded as symptoms of essentially distinct venereal diseases, but only as members of one and the same family, distinguished from each other by external diagnostic signs. Since it is of importance, however, in order to acquire a correct knowledge of the various syphilitic produces, that all their forms should be known, we shall, in the subsequent chapters, consider more particularly not only the different pathological forms under which syphilitic products manifest themselves, but likewise the differences resulting from their different anatomical localities. II. DIFFERENCES IN THE FORM OF CHANCRES. Secale 36.- Regular, Simple and Hunterian Chancre. (Ulcers regulare, simplex et induratun) This chancre, which forms the real type of the primary syphilitic ulcers, and which is generally located on the frenulum, corona gland is, or even on the glans itself, consists, if manifesting itself upon the skin or upon a mucous membrane, in a simple, not very extensive ulcer, that usually penetrates every layer of the integuments, until it reaches the subjacent cellular tissue that serves it as a base. Its shape is generally round, except in cases where the ulcer rests upon two tissues of a different kind, for instance, partly on the glands, and partly on the prepuce; although even in these cases its round shape is distinctly recognizable, as much so as where this rounded form seems more or less obscured by the position of the affected parts, such as the anal fissure, the folds of the prepuce, etc. The base of the ulcer is usually lardaceous, whitish-gray, rough and uneven; its abruptly-rising borders, which are somewhat shaggy on their inner surface, we in most cases gapping and everted, which communicates to the ulcer a funnel-shaped appearance; the parts around the ulcer are either red or dark- brown, according as the attending inflammation is more for less intense. The ulcer secretes a thin ichor, which is sometimes mixed with blood, has an alkaline reaction, and sometimes contains small animalcules. If it is secreted in large quantity, for instance, on the glans, the prepuce, the pudendum, the anus, it is very apt to assume a fetid odor; upon mucous membranes that are not accessible to the action of atmospheric air, it preserves its liquid form; upon the external skin it dries up, forming crusts which are sometimes sunk deeply into the integuments. This appearance has led some authors to adopt another peculiar form of chancre, under the name of soft chancre. The ulcer may persevere in the shape for several days without showing a hard base. But if the inflammation continues and increases, the ulcer never fails to become dense and hard, so that this induration, which is always sharply circumscribed, can be felt under the ulcers as if it had the shape of half a pea (Hunterian chancre). If resting upon loose cellular tissue, the induration has always a circular form; but it seated upon denser tissue, where it is more or less compressed, the induration may assume an elongated, or otherwise more or less altered form; in every case, however, it offers to the exploring finger a peculiarly elastic resistance by which it can readily be distinguished from any other kind of swellings. Those who have distinguished this chancre into two kinds, namely, a soft and indurated chancre, assert that the induration is not only perceived at the first breaking out of the ulcer, but even before this takes place. This assertion evidently rests upon erroneous observations. Every indurated, genuine Hunterian chancre, is at first soft; the induration generally only showing itself five or six days afterwards, although it may likewise appear in the first twenty-four hours. What distinguishes both these ulcers in common from all other ulcers, is in the first place, their funnel-shaped, depressed form, with abruptly-rising, everted edges; and, in the second place, the fact that, after a short period, the above-mentioned characteristic induration never fails to show itself. Secale 37.- The Raised Chancre. This chancre may be located upon the integuments of the penis, or upon the inner and outer side of the prepuce, even on the scrotum. When first breaking out, it looks like a small whitish ulcer of the size of a small split pea to that of a dine. In eight or ten days, or even sooner, the edges of this ulcer, together with its base, become raised, forming an elevated, projecting, whitish gray ulcer, of a spongy appearance. There ulcers generally are of an oval shape; they secrete a purulent serum, are not very, or even not a all painful; neither the edges not the base are indurated. If fully present, they do not change, neither penetrating to the subject tissues nor extending perceptibly in circumference. When healing, they lose their whitish-gray color, first in the centre, and afterwards from the centre towards the circumference; at the same time they gradually become fatter, so that, after their cicatrization, a small white elevation remains, which finally disappears without leaving the slightest trace of a scar. In this least respect they likewise differ essentially from the regular, simple, and indurated chancre. In the case of this chancre, the first sign that the healing process has commenced, is the diminution of the red areola surrounding the ulcer; the edges flatten and gradually exhibit a paler appearance, white cicatrization extends in concentric circles from the circumference to the centre, the base becomes cleaner and is covered with healthy granulations, but generally leaves a cicatrix of greater or less depth. In addition to this, the regular, simple, and Hunterian chancre usually forms a single isolated ulcer, whereas the elevated chancre very frequently consists of several-ulcers. In one case I have seen the folds near the border of the inner surface of the prepuce covered by these ulcers like a wreath, so that the prepuce itself seemed divided into several patches. In all the cases that have come under my observation, I have never seen them single, but always two or three together, and always in the case of individuals who had been infected with chancres at some former period and still exhibited their badly healed and distinctly perceptible cicatrices; so that I am to this day in doubt whether this form of chancre is not a product of recent infection, but modified by a pre-existing constitutional syphilitic taint. In other respects this form of chancre which breaks out at the outset such as it shows itself at a later period, should not be confounded with the vegetations which, after the ulcerous stage has run its course, likewise manifest themselves with the Hunterian chancre when the vegetative stage sets in. In their case the base may likewise become raised and form a more or less prominent ulcer; but the bash of such an ulcer has no longer the lardaceous and ash-colored appearance which characterizes the elevated chancre of recent origin; but is rather copper-colored throughout its whole extent. Secale 38.- Phagedaenic Chancre. This form, like the preceding one has no induration; if the edges or the base should appear swollen, such swelling is nothing else than a malignant oedema. The ulcers penetrate less to the subjacent tissues then they spread in circumference; they may preserve their round shape, but in most cases they spread about irregularly assuming a serpiginous character. Their base is generally uneven covered with a sort of whitish-gray false membrane or secreting a pulpy matter which, diffusing itself over the surface, shows here and there new granulations that, however, become decomposed again very speedily. The edges of these ulcers are generally very thin, irregularly indented, and, in places where they are gaping and detached, very frequently perforated by the ulcer. When first breaking out the ulcer begins with a scarcely perceptible swelling and slight excoriation of the surface. This excoriation soon becomes putrid, shows yellowish base and secretes a watery, brownish ichor. Any tissue upon which this ulcer rises, may be destroyed by it; although the cellular tissue is more rapidly destroyed by it than the skin of the prepuce and the body of the penis. For this reason, when concealed under the integuments of the penis, the ulcer may spread onward towards the corpora spongiosa which it detaches from their covering, after which it continues to spread even as far as the pubes, so that it becomes impossible to completely lay bare the base of the ulcer. In such a case the visible portion of the ulcer is sometimes quite clean and even cicatrized, while the hidden portion is yellow and putrid, and secretes a copious, quantity of a thin, brown ichor. This hidden portion is surrounded by the usual swelling, which can be felt externally like a hard ring surrounding the penis, and which in proportion as the disease progresses, approximates more and more to the root of the penis. As long as this thick enlargement can be felt, so long does the hidden ulcer continue to progress; in proportion as the ulcer heals and cicatrizes from its base, the enlargement disappears with corresponding rapidity and certainty. Usually the progress of the ulcer is marked by putrid disorganization; accidental circumstances frequently convert it quite suddenly into a gangrenous sore (ulcus syphiliticum gangrenosum), causing the destruction and detachment of large patches of the prepuce, glans, or the corpora spongiosa. Very frequently a portion of the urethra becomes involved in the destruction. These phagedaenic ulcers always secrete a copious ichor, which, however, does not seem to affect the parts with which it comes in contact, since the glans and prepuce are constantly seen inundated by this secretion without showing any signs of ulceration; or since the ulcer may be exclusively localized on the body of the penis, without the prepuce, which is in perpetual contact with the secreted ichor, being affected by it. The pain is seldom acute, and the inflammation not very violent. Nevertheless there are cases, specially if gangrene supervenes, where the inflammation may become intense, and the pain intolerable. On the other hand, the constitutional symptoms are often very prominent, the pulse accelerated, the skin hot, the appetite diminished, and the sleep uneasy and disturbed. Secale 39.- Syphilitic Erosions. These erosions, which, in most cases, are of a secondary order, occur in their primary form, in the case of meals, most frequently as an accompaniment of syphilitic balanorrhoea, and, in the case of females, supervene as an accompaniment of gonorrhoea of the vulva. They are distinguished from benign erosions by their greater depth, by their sharply circumscribed border, their rounded or oval form, and a border which is either whitish with a red centre, or red with a whitish centre. If continuing for a longer period, such erosions, if primary, very readily change to simple or even Hunterian chancres, from which they are usually distinguished by being less penetrating. They never occur singly, but always several together, and may not only produce an infectious chancre by coit, but, if suppressed by external means, may develop symptoms of constitutional syphilis. As a general rule, these erosions do not secrete a great deal, though, in the case of males, they are frequently attended with balanorrhoea, and, in the case of females, with a suspicious blennorrhoea. In one case, that of a girl, I have seen them mixed with mucous tubercles, and in the case of another girl, where they had almost become quite dry, they were accompanied by funnel-shaped, depressed, chancrous ulcers, the deepest of which, of about two lines in diameter, was seated on the clitoris, but did not secrete scarcely anything, and did not seem to leave the least stain on the. There were, at the same time, perceived, wart-shaped, blotches on the hands, and slight, transparent spots resembling syphilitic roseola, of a yellowish brown color on the neck and around the axillae. A young man who had had connection with her, had been infected by her (or perhaps by some other female?) with balanorrhoea and figwarts; six months previously, the girl had had a hard, elastic swelling on the right labium, which was attended with violent itching and had yielded to a small dose of Mercurius. Of leucorrhoea she had never seen a trace either before or after. The phenomena in the vulva were rapidly cured with Mercurius prec., and the wart-shaped blotches in the palms of hands with Nitric acid. III. DIFFERENCES OF CHANCRES WITH REFERENCE TO THEIR LOCALITY. Secale 40.- General Remark. We have already remarked in previous paragraph that primary chancres generally break out at the spot where the poison has come in contact with the parts; in the case of males more particularly on the glans and prepuce, or on the scrotum and dorsum of the penis; and in the case of females on the pudendum; we have likewise stated that chancres appearing on other parts are generally of a secondary nature. Primary chancres may, however, likewise break out elsewhere in consequence of accidental contact; for instance, on the mouth after being kissed by persons who have venereal ulcers in the mouth or throat; on the breasts of nurses who suckle infants which, born of syphilitic parents, are affected with ulcers in the mouth; at the anus of people who indulge in unnatural criminal intercourse, and so forth. These chancres do not essentially differ from those that are seated on the sexual parts, but precisely on account of their unusual locality, may easily be misapprehended and confounded with innocuous ulcers, on which account it may be advisable to devote a little additional space to their consideration. Secale 41.- Chancres of the Anus. These chancres, of occurring as primary ulcers, always result from direct infection caused either by criminal intercourse, or by transmission of the virus from the sexual organs to the anus, which may easily occur in the case of females while in a recumbent position, when the matter flowing out of the pudendum touches the neighboring parts and his contact continues for a certain time. The longitudinal folds of the skin and mucous membrane of the anus generally impart to these chancres an oblong shape sometimes even the form of rhagades, with which they must not, however, be confounded. In most cases all doubt regarding their true character will be readily removed by their simple appearance, by the their edges and base, in which respect they are altogether like other chancres, likewise by their size, which far exceeds that of simple rhagades, by the lesser pain during stool and by a careful investigation of all prior circumstances. They are seldom indurated, still less frequently phagedaenic, but generally belong to the category of the co-called simple, soft chancre, and seldom leave distinctly perceptible cicatrices but may be complicated with buboes. Such chancres may not only occur at the anus, but likewise in the rectum, in which case they are generally located not far from the sphincter ani. They have generally a rounded, irregular shape with edges that are more or less indented. As a general rule they are superficial; frequently, however, they involve the whole thickness of the mucous membrane and the subjacent cellular tissue. The accompanying pain is not very considerable, and the expulsion of faeces is not interfered with. Secale 42.- Chancres in the Mouth and on the Lips. These chancre, when resulting from a primary infection, are always produced by direct contact with the infectious matter. Such a contact may occur while kissing with a chancrous tongue or lips, or by the insertion of a finger to which some of the chancre-virus is adhering, or by touching the parts which are affected with chancre, with the mouth. If located on the tongue, or at the tip of the tongue, they are generally round and indurated, with an ash-colored, lardaceous base; if seated along the edges of the tongue, they appear more elongated. They generally cause an extremely violent pain, and not unfrequently they impede mastication and speech, or cause a more or less considerable swelling of the tongue. On the lips, they always occupy the free border, more frequently that of the lower than the border of the upper lip; sometimes they are seen on the inside of the lips, but never in the corners of the mouth, where only secondary chancres can break out. They are either round or oblong, generally belong to the class of the simple, soft chancres, and only become indurated or phagedaenic if they are treated with irritating agents. They cannot very well be confounded with ordinary rhagades, for these are always long and narrow, in the direction of the folds of the lips; nor with cancer of the legs, the edges of which are everted, with stinging pains. It is with mercurial ulcers that they might be confounded most readily these, however, scarcely ever, if ever, located on the free border of the lips, and have moreover a whitish base, which is on a level with the vermilion border, in addition to which we have swelling of the gums, and the peculiar mercurial fetor. Secale 43.- Chancres of the Eyes, Ears, Nose and Skin. Nothing can be said regarding the form of chancres in the eyes; for if the chancre-virus penetrates the eye, the destruction which immediately results from its presence is so violent that a practitioner has no time to attend to any thing but on the preservation of the organ. Chancres occurring on the lids, being much less destructive, ought, therefore, to be considered as secondary. Primary chancres have been seen on the ears, or in the inner ear, where they may be caused by inserting a finger to which some of the virus is adhering. Upon the whole such chancres are very scarce; where they do occur, they are very easily misapprehended, and, at most, can only be confounded with secondary syphilitic ulcers. The same remarks apply to primary chancres at the entrance of the nostrils, which differ but slightly from the not unfrequently occurring secondary chancres, except that they are much more virulent. Primary chancres upon the external skin are likewise characterized by all the signs generally characterizing other chancres, from which they differ almost exclusively by the manner in which they had originated. If these chancres are caused by the virus penetrating a denuded surface, or open wound, they generally adopt at once the form of an ulcer; if inoculated, they look like the pustules in variola, with a depression in the centre, and are caused by a protracted contact of the skin with a part affected with chancre; for instance, of the thighs with the diseased penis during sleep, the pustules generally soon breaking and showing a fully-formed chancre. In most cases they belong to the class of regular, simple, or Hunterian chancres, but may likewise assume the form of phagedaenic chancres. Secale 44. Chancres of the Female Organs. As primary ulcers, they are most frequently seen at the loser commissure of the labia majora or in the fossa navicularis; but about as frequently on the clitoris or on the inner wall of the labia majora or minora; somewhat less frequently in the neighborhood or even at the orifice of the urethra, or at the entrance of the vagina; and least frequently, perhaps, on the outer side of the labia majora or minora, high up in the vagina, or at the os tincae. Nevertheless, according to some authors who have paid particular attention to diagnosis by inoculation, chancres appear much less frequently at the os tincae than is generally supposed; and even here they are frequently misapprehended by those who make frequent examinations with the speculum, except where the Hunterian chancre form is exhibited. All these chancres may occur in both sexes as regular, simple or indurated, or as elevated and phagedaenic chancres, and may cause more or less extensive disorganizations. Not unfrequently the labia majora and minora are perforated and corroded by them, but the lower commissure and the fossa navicularis are likewise lacerated by them; they penetrate even through the perineum as far as the anus, where they cause ulcers, inflammations, and purulent discharges. Frequently they are accompanied by oedematous swellings, considerable inflammations, extremely violent pains, and more or less copious discharges from the vulva. urethra, and vagina, which do not by any means always justify the belief in a simultaneously existing gonorrhoeal infection. Chancres located at the os tincae are sometimes quite painless, but may speedily superinduce the nervous disorders which so frequently accompany other affections of this organ. Chancres situated at the entrance of the vagina, in the neighborhood of the small papillae, may readily be confounded by inattentive observes as with lacerations that may have taken place during sexual intercourse, for this additional reason, that in all such cases, it is not very easy to discriminate between the two series of phenomena. Nevertheless, errors of diagnosis may be avoided in most cases by co-existing inguinal swellings, which, it is true, are not always very considerably in the case of females; and, in addition, by a careful investigation of all the circumstances that had preceded the outbreak of the disease. Among women, specially while nursing children at the breast, primary chancres are frequently discovered at the nipples, where they are caused by the contact with the infant’s diseased lips. They are generally seated close around the nipples, or on the areola, and may be confounded by an inattentive observer with the ulcerated fissures and rhagades that so often break out on these parts. IV. DEVELOPMENT, COURSE, AND TERMINATIONS OF CHANCRES. Secale 45.- Development of Chancres. We have already stated in a previous chapter, that chancre generally breaks out in six days to a fortnight after infection. Most physicians had agreed on this point until the inoculators made their appearance, maintaining that a so-called period of incubation, which had heretofore been universally admitted, did not exist, and that the development of the product of infection commenced at the moment of contact, and continued uninterruptedly until the breaking out of the first vesicle. In their opinion, the difference in time intervening between infection and the first appearance of the vesicle, in one case or another, depends entirely upon different degrees susceptibility inherent in differences of organization; and likewise upon the important circumstance that most patients do not head the first changes at the place of infection, nor do they notice the infection until the chancre has already caused extensive destructions, and hence are led to imagine that the period intervening between infection and manifestation seems longer than it really is. It is indeed true that it is very difficult, in practice, to determine the number of days that elapse between the moment of infection and the first breaking out of the disease. I have heard patients affirm that they had been with a woman three days ago, and had been infected by her with a big chancre; an examination, however, showed that this woman was perfectly sound and that the chancre must therefore have been caused at a much earlier period. As a general rule, therefore, the cases where a chancre is said to have broken out immediately after the infection had taken place, do not prove any thing. They could only be looked upon as reliable testimony in case the patient had not seen a women for months after the last coit. As regards the experiments of the inoculators, with which they seek to combat the incubation- theory, we have to remind these gentlemen of the fact that all that their experiments, prove is, that when the virus is introduced into a wound, or placed upon a denuded surface, the local inflammation generally begins in 24 hours, and certainly before the third day, as may be seen in the case of all poisoned wounds resulting from a bite, or in consequence of surgical operations; or in all cases of infectious coit when the virus comes in contact with a denuded surface, without epithelium, either on the prepuce or glans. I have often observed that in such cases, on the second or third day a suspicious irritation is seen on the affected part, which very soon changes to a regular chancre. Where this is not the case, the virus is received by the lymphatics and mixed up with the general circulation, after which the local symptom only shows itself in consequence of a general reaction of the organism that seeks to cast out the poison at the original place of infection. In sensitive individuals, this process is often preceded for one or two days by a general malaise and slight febrile motions, which sometimes remain unheeded, or are attributed to other accidental circumstances. Secale 46.- Possible duration of the period of Incubation Expect the cases where the poison is brought in contact with a wound or a denuded surface, it may be said that chancre, generally, breaks out six or seven days after infection, most frequently a fortnight after, sometimes even at a much later period; I know of cases where it did not break out until or two months after infection had taken place. A ship captain, who could not have been exposed on the voyage from Buenos Aeires, which had lasted two months, consulted me on the third day after his arrival in Paris, on account of a chancre that had broken our six week after his departure from Buenos Aeires. A young Englishman, who had hurt his foot during the passage of France, had been compelled, through allopathic mismanagement, to keep his bed for six weeks. A week after I had taken charge of him, and when he had not yet been able to leave his room, one of the worst phagedaenic chancres I had ever seen broke out on him. One of the most remarkable cases, where I had a chance to observe the whole course of the disease from the first moment of the infection to the breaking out of the ulcer, is the following. One of my patients, an abstemious young man of excellent conduct, being in company with a few friends and several girls of an equivocal character, had been induced to have connection with a strange female, who, as he learned the following day, had already infected several men. Having been concerned about his health for some time past, he came to me the next day, begging me to examine the young woman with whom he had had connection, and whom he promised to send to me the next day. Contrary to my expectation, the woman came, confessing that she had done wrong in a moment-of intoxication, and asking me whether I could cure her. An examination revealed a large Hunterian chancre on the inside of one of the labia majora, a bubo in the right and left groin, and on each thigh a moist excoriation of the size of a dollar, so that I cannot conceive it possible, even now, that this woman should have been willing, even in a moment of intoxication, to give herself up to a man for purposes of debauch. In six weeks she was all but cured, before even a trace of disease could be discovered in the young man, who presented himself every four days for examination, with the most conscientious fidelity. His general health remained unimpaired, except a certain dullness of spirits which I attributed to the anxiety which tormented him not till the end of the seventh week he began to complain, on his regular visiting day, of a general feeling of languor in all his limbs, a peculiar feeling of weakness and emptiness in the stomach, and some chilliness. Next day already he came again, showing me on the prepuce, not far from the fraenulum, a small, roundish, red brown spot that had come out over night and which, without the previous frequently-described vesicle, and after destroying the epithelium, had becomes converted into a simple chancre without any induration. I cured him in ten days. sec. 47.- The Initial forms of Chancre. The above-described cases shows that the original chancre- vesicle neither is, nor need be, in every case, the primary beginning of chancre. I have seen this vesicle once in my practice; in this case the appearance of the vesicle was soon after followed by elevated chancres on the margin of the prepuce. The patient was a Spaniard, who, although he had a Hunterian chancre that was not yet entirely cured had not been able to restrain himself from sexual intercourse, had connection with a diseased female, came to me, ten days after this event, with two new white vesicles on the margin of the prepuce, seated upon a red base. While talking about this thing, and I was on the point of examining them with a glass, he scratched one of them open, so that I was able to discover beneath it a small, lardaceous, somewhat depressed base of equal size, which, however, together with the vesicle that had not been scratched open, changed within forty-eight hours to a distinctly recognizable elevated chancre. If, according to Ricord’s observation, inoculation first develops slight swelling upon which a little papula shows itself, which is succeeded by a vesicle, and that this vesicle in four or five days increases to a pustule, which, after breaking, gives rise to a fully developed chancre: this course of development may take place upon the epidermis, but is not to be accepted as a criterion for the development of chancre upon the epithelium. In the case which I have related above, the vesicle were not seated on the inner, but on the outer surface of the prepuce, near the margin, where the epidermis is still intact; and it is very likely that, where a chancre breaks out on the epidermis, for instance, on the body of the penis, or on the outer surface of the prepuce, its development takes the above-described course, from the vesicle to the pustule. On the other hand, it is equally probable that, when a chancre develops itself on the mucous membranes, vesicles never arise; and that the ulcer, according to Castelnau’s very correct and incontrovertible observations, emerges in most cases from red or brown spots by the gradual destruction of the epithelium. Ricord’s destruction of the formation of chancre from a small abscess, I have seen verified in one case, where the chancre was located upon the dorsum of the penis, at a spot where the skin had become chafed by mere accident; five days after I noticed the little abscess, the chancre broke out. Secale 48.- Course and Termination of Chancres If recent authorities assert that it is wrongs to regard chancre as an ulcer that never heals spontaneously, this probably arises from the circumstances that physicians are not agreed on what they understand by a cure. If we mean by a cure a mere cicatrization of the ulcer, those who maintain that a chancre can heal spontaneously, may perhaps be correct. It is indeed true that some chancres may cicatrize without the interference of art; but no one who has seen these cicatrices, as they remain, for instance, after cauterization, will be tempted to consider them as evidence of a cure. Howsoever great the loss of substance; if the chancre is really cured, there must not remain the least induration, nor any discoloration of the cicatrix; the skin must have a natural, healthy color; where the cicatrix remains hard, copper or violent-colored, a cure is out of the question. If the chancre is left to itself and is not phagedaenic, a period arrives sooner or later when the ulcerative process ceases, when the ulcer loses its syphilitic characteristics, its lardaceous base, everted edges and cup-shaped form, and either changes to brown or violent-colored induration or is transformed into condylomata growths. In such a case we may, if we choose, regard the ulcer as healed, or, in other words, the ulcerative process is stopped; but, that this does not mean a cure, is evident from the fact that almost as the very moment when the induration or the condylomatous growths sets in; that is to say, at the very moment when the chancre loses its syphilitic characteristic, its lardaceous base and everted edges, and there remains nothing of the chance than a copper-colored or violet-red surface; the first symptoms of constitutional syphilis, such as roseola, syphilitic itch or ulcerations in other parts, specially in the throat, make their appearance. In a cure of chancre the ulcer first becomes cleansed at its base, secretes a laudable pus, and forms new, healthy granulations, by which means the hardness and the swollen edges gradually decrease, and the ulcerated surface covers itself with a sound skin from the circumference to the centre in gradually decreasing concentric circles, thus forming at last a somewhat depressed, but otherwise perfectly smooth cicatrix of the same color as the sound skin. Phagedaenic as well as Hunterian chancres may terminate in gangrene, which, however, is very seldom the case. On the other hand, recent chancres frequently become transformed into obstinate, malignant indurations. Such a case has occured in my own practice, where after treating an incipient chancre with Arnica, a violet- colored, stone-hard swelling became perceptible on the prepuce, without any trace of an ulcer, but associated with various symptoms of constitutional syphilis. V. DIAGNOSIS OF CHANCRES. Secale 49.- General Remarks. Although anyone who has seen the different form of chancre once, can scarcely ever fail to recognize them again; on the other hand, nothing is more difficult than to point out the general characteristic signs that will render the diagnosis of chancre certain beyond all doubt. This difficulty arises from the fact that not one of these signs, such as the funnel-shaped appearance, the coppery color, the everted edges, the lardaceous base, the indurated border, etc., is uniformly present in every case; and that one or the other of these signs, according as the form of the chancre varies, is, and indeed must be wanting without the ulcer ceasing to be a chancre. If we ask ourselves what diagnostic sign which no one can gainsay, distinguishes the primary chancre, whatever its form, from a non-syphilitic ulcer, we have but one answer; its inherent faculty to cause constitutional syphilis. As regards its contagious character, chancre shares it not only with the small-pox pustule, but likewise with all diphtheritic and other things; and in its serpiginous or deeply-penetrating character, or in its property never to heal spontaneously and radically without the interference of air, it resembles cancerous ulcers so closely that it might readily be confounded with them. For this reason inoculation does not decide any thing; it only proves that the ulcer from which the matter is taken, is of a contagious nature; whether the ulcer is syphilitic, can be doubted until symptom of constitutional syphilis develop themselves. We might go further, and ask; If those who regard inoculation as the sole diagnostic sign, decline to impart the name of chancre to any ulcer, the matter from which does not produce a like ulcer; by what diagnostic sign do they know, after inoculation more than before, that the new ulcer, resulting from the inoculation, as well as the old, is necessarily a syphilitic chancre and not some other contagious ulcer? In order to remove this uncertainty there must be other diagnostic signs which, if not isolatedly, but taken together, must render the diagnosis certain even without inoculation. The case is similar to that of the itch, where modern pathologists will not recognize any other diagnostic or truely pathognomonic sign than the acarus. Here, too, we have a right to ask; if the acarus is indeed the only sign the presence of which justifies us to impact the name of itch to an eruption where the acarus is found; how do these modern pathologists know that the eruption where the acarus is found is really the very same eruption as that which has hitherto been designated as the itch? Although it may be difficult to establish fixed diagnosis of chance for such as are anxious to carry on an argument on the subject, nevertheless there are, fortunately for the practical physician who means to help his patient and free him from a loathsome disease, other diagnostic signs, which, if they do not convey absolute certainty, yet render the recognition of chancre exceedingly probable, and point out a certain road to a cure. Secale 50.- Diagnosis Signs. To the statement which we have made in the preceding paragraph that the simultaneous presence of several diagnostic signs is required in order to establish a reliable-diagnosis of chancre, we desire to subjoin the remark that a careful examination of the following points will render the diagnosis all but certain: 1. The general aspect of the ulcers, and their comparison with the different forms which chancres may assume (No. 36-39). 2. The seat of these ulcers, and their comparison with other more or less similar phenomena that may manifest themselves on the same parts. 3. The anamnesis, or a consideration of the circumstances that may have preceded the breaking out of the ulcers. Chancres occurring an the sexual organs, cannot well be confounded with other similar appearances, since the only two kinds of eruption with which chancres might possibly be confounded in some one of their different stages, herpes pudendorum and the aphthae pudendorum, only occur in little girls. As regards herpes, it may cause more or less extensive erosions and ulcerated surfaces both on the prepuce and on the labia; but in the case of herpes, these ulcerated surfaces are always very superficial, and never penetrate to the subjacent tissues; moreover, its base has a smooth surface and its edges are not the least indurated; the ulceration is, moreover, from the first, more extended than in the case of chancre. In addition to this, chancre always arises from a single isolated vesicle; even where several vesicles exist, they are nevertheless detached, whereas herpes, at its first origin, forms a surface of several densely- crowded vesicles. In females it is much easier to confound the ulcerated surface of herpes intra-vulvaris with chancres; more particularly since, as I have seen in my own practice, herpes, when very much inflamed, may occasion a slight swelling of the inguinal glands. But even in this case an erroneous diagnosis is impossible, provided we remember that the ulcerations of the herpes intra-vulvaris are always irregular, imperfectly circumscribed, and more extensive than chancre, which, even which phagedaenic, always rests, if not upon an indurated, at least upon a swollen base as upon a bed, and has hard edges. These diagnostic signs enable, us to distinguish herpes from syphilitic erosions, which are likewise sharply circumscribed, surrounded by red and hard borders, and never heal, like herpes, is ten days or a fortnight, by resorting to no other means than washing. As regards the aphthae pudendorum, which, in the case of the vulva; their dirty appearance when in a state of ulceration, may indeed lead us, at first sight, to confound them with small chancres, and if reasonable grounds for suspicion exist, may induce us to believe that the ulcerations were the result of violent abuse by some diseased person; but a closer inspection soon shows that these apparently depressed, whitish-gray ulcers are exceedingly superficial, and that the depression is occasioned by an exceedingly soft border, which is raised up like a wall, consisting, as it were, of a fold of mucous membranes, and exhibiting but slight redness, or none at all. Secale 51.- Mercurial Ulcers. In the case of chancres that break out on other parts than the sexual organs, it seems scarcely possible to confound them-unless we except those the diagnosis characteristic of which we have recited in previous paragraphs (No. No. 40 to 43)-with any other form of ulcer, with the exception of mercurial ulcers. We deem it so much the more incumbent upon us to offer a few remarks on this subject, since it is from this source that the most pernicious consequences frequently arise in a twofold manner. For, while on the one hand there are practitioners who falsely look upon every chancre that proves somewhat obstinate and cannot be influenced by Mercury, as a mercurial ulcer, and owing to this mistake, allow the chancre to cause the most horrid destruction; on the other hand there are practitioners, not only among the allopaths, but likewise among the homoeopaths, who smile contemptuously at the aggravations supposed to result from large doses of Mercury, and, whatever course the ulcer may take, deem it necessary to pile on the Mercury in increased quantities, fancying that the organism had not been sufficiently saturated with this metal; and yet, the phenomena which they desire to combat, are most generally nothing else than the effects of large doses of Mercury, Mercurial ulcers, being, therefore, an established fact, we will offer the following advice, by means of which they may be correctly known and distinguished from chancre. As a general rule, the mercurial ulcer is never as painless as chancre; on the contrary, it is very sensitive and painful to the touch, but is never accompanied by the nightly stinging and boring pains that sometimes attend the Hunterian chancre when very much inflamed. The ulcer spreads very rapidly, almost like a phagedaenic chancre, but never like a serpiginous sore; its base is of a milky-white, gray or livid, very frequently with bluish-white, edges, sometimes superficial like simple excoriations, secreting a purulent serum, or else covered with a cheesy layer; sometimes the ulcer dips to the subjacent textures, with a dirty-looking, even lardaceous base, but always of an irregular indistinctly- circumscribed shape, with unequal circumference, and always healing from one side of its border, whereas a chancre first becomes cleansed on its base and afterwards cicatrizes from its circumference in concentric circles. These ulcers most frequently break out in the mouth, or on the inside of the lips, on the edges of the tongue, or on the sexual organs and in their neighborhood. Very frequently they break out in existing wounds, in cicatrices or on ulcerated surfaces, which, in such a case, spread rapidly and become painful, phagedaenic, ichorous, and bleeding. Sometimes this kind of ulcer shows itself on hairy part (specially on the hairy scalp) under the form of a superficial ulcer, with a rough, uneven surface and lardaceous, fungous growths without any malignant character, and dissolving into a purulent liquid, after which the ulcer disappears, without leaving a scar, but reappears again sooner or later on other parts. VI. PROGNOSIS AND TREATMENT OF CHANCRES. Secale 52.-Prognosis. In giving the prognosis of a chancre, we always have to take into consideration of the following two points: 1. The greater or less degree of curability of a given chancre: and 2. The greater or less danger that this chancre may terminate in constitutional syphilis. As regards the first of these two points, it is an undoubted fact that a simple chancre is most curable; so is the Hunterian chancre, provided the treatment is properly conducted; for if mismanaged or neglected even ever to little, it is apt to terminate in chronic incursions or condylomatous growths, the appearance of which is inevitably followed by general syphilis. the simple chancre, if neglected, is very apt, on the other hand, to pass in two or three weeks into the Hunterian chancre, with all the danger accompanying this form of the syphilitic disease. If properly treated at the outset, both can be cured in ten to fifteen days; but if the treatment only commences fifteen days after their first appearance it will taken from twenty to thirty and even more days, to cure them. The ulcus elevatum, likewise heals very rapidly, if properly treated; but, if badly treated, may readily assume the character of a phagedaenic chancre. This is undoubtedly the worst form of the primary syphilitic ulcer, not only on account of the difficulties encountered in its treatment; on account of its ready termination in gangrene, and of the terrible destruction it may cause in the tissues; but likewise on account of the violence of the secondary phenomena by which it may be succeeded. If this chancre cicatrices spontaneously, it always leaves behind it hard, uneven, rough cicatrices of a blue and brown-red color. The assertion that syphilitic erosions are easily healed, and that they often disappear of themselves, is incorrect; it is almost certain that those who offer these statements, have confounded the erosions with the harmless herpes intra-vulvaris, whose resemblance to erosions is exceedingly deceitful. According to may experience there are no more tedious, and hence no more deceitful or more dangerous phenomena, than those every erosions; for if they continue for any length of time they may superinduce secondary syphilis, even while they are still out upon the skin. The danger of a primary chancre termination in constitutional syphilis, not only depends upon the treatment, but likewise upon the age of the chancre. Chancres that are only treated externally, readily induce constitutional syphilis; neglected chancres produce this result in six or eight weeks. Ricord’s statement that an incipient induration is a sure site that constitutional syphilis has already set in may apply to all chancres that commence as simple or elevated chancres and afterwards become indurated; in the Hunterian chancre, however, where the induration exists at the outs, the danger only begins after the ulcer passes from the ulcerated stage in to that of condylomatous growths, which at the earliest period, takes place in from four to five, and, at the latest period in from six to eight weeks. Regarding he promises which a physician can safely make to his patient when first taking charge of his case, it is of the utmost importance that the physician should first inquire of hi patient how long the chancre has been in existence; if the chancre has been out four weeks, if would be rash to promise that secondary symptoms may not supervene inspite of the best treatment; if the ulcer has already lost the characteristic appearance of the primary chancre, or has been treatment by external means exclusively, no promise of any kind can be made. Secale 53.-General remarks on the treatment of Chancres. If Ricord and his disciple maintain that every chancre that has not yet become indurated, hence in the first to four or five days, can be safely treated by cauterization, my own experience justifies me in contradicting this statement most positively. It is indeed true that in these cases of suppression of primary chancre, symptoms of secondary syphilis do not occur as readily as when the chancres have already existed for some time. But these gentlemen never see the consequences of their doings which frequently break out three, six, and even eighteen months after the first destruction of the chancre. From my own practice I might fill volumes with what I have seen of the consequences of such criminal proceeding. Every chancre, no matter what its primary form, is a sort of noli me tangere, whose appearance upon the external skin, even where an appropriate internal treatment is pursued simultaneously, is never disturbed in its course by external means without such criminal encroachments being succeeded by terrible consequences, In every case, and at all times, it should only be treated with internal means, gently unit. such treatment has resulted in the destruction of the contagium, after which it disappears, as it were, of itself, without leaving a single suspicious looking cicatrix. The only thing that can be applied, externally is pure water, for the purpose of keeping the parts clean. Cleanliness must not be neglected by any means; the patent may wash the affected parts as often as he pleases, and may seven apply lint moistened with fresh water. In all other respects the treatment must be conducted by internal means; only it is to be regretted that we are not acquired with any remedy which, like Apis and Phosphorus in diphtheritic, non-syphilitic ulcers of the throat, will extirpate a primary chancre even when administered in the smallest dose. For, although Mercurius, which is as yet our chief remedy in syphilis, is capable of rendering eminent device is secondary syphilis, even when given in the 30th potency; yet, on the other hand, it is an established fact that, in the acute form of this disease, we have to administer repeated doses of the first centesimal trituration at least half a grain morning and evening, if we desire to make sure of a radical and speedy extirpation of the syphilitic virus. this necessity is to be regretted, in so far at any rate, since this agent, which, if used in such cases in accordance with specific indications, does not cause any perceptible inconvenience, yet, on the other hand, if not specifically indicated, may cause considerable aggravations which it may afterwards be found exceedingly difficult to remove. for this reason we advise the physician, in case Mercurius should seem to aggravate the symptoms during the first eight days of the treatment, to stop the exhibition of this agent, and to look for a more specific remedy among those that will be described bin subsequent paragraphs. Secale 54.-Treatment of the regular (Simple and Hunterian) Chancre. In this form of chancre the leading remedy is, and always will be, Mercurius. According to my experience, it is the Mercurius solubilis Hahnemanni, half a grain of the centesimal trituration of which, given morning and evening, will in all cases prove sufficient to effect a cure. If the cure proceeds as it should do, signs of an incipient cure will be speedily perceive, sometimes already in twenty four hours, but scarcely ever at a latter period than four days: the base of the ulcer will become cleaner; at first it may bleed a little, but healthy granulations wills it the same time begin to start up; the edges of the ulcer will flatten down, and the hard foundation upon which the ulcer seems to rest, will become more and more diminished in circumference. If the ulcer takes this course, all we have to do is to continue the Mercurius, and the ulcer, provided the treatment commences still or, at the latest eight days after its first appearance, will heal perfectly in fifteen to twenty days without the use of Nitri acidum or any other agent than Mercurius; the general health will remain unimpaired. Among my own customers, who generally apply for treatment one or two days after the products of infection manifest themselves, I have cured both the simple and the Hunterian chancre, even when the induration of the base was already fully present, in he space of ten days incipient signs of a cure of often showed themselves in twenty four days. It is not in all cases, however, that patients present themselves for treatment at the earliest period; two or three weeks sometimes elapse before they apply to a position. In such case, if the patient has already received large doses of Mercury from the hands of an allopathic physician, and the chancre has already passed from the first or ulcerous stage into the second stage, or that of condylomatous growths, I gave Nitri acidum, one drop of the first attenuation morning and night, and by this means, accomplish my end in most cases. But if, at the time when I take charge of the patient the ulcer has still preserved its primary aspect, I give Mercurius solubilis even if the patient should already have been drugged with it under allopathic treatment; and, if no improvement takes place is seven or eight days, I resort to the red precipitate (Mercurius precipitates rubber) which I employ in the same dose as Mercuriussol., and, by this means, accomplish a cure in most cases without resorting to any other remedy. For neglected chancre I employ. Cinnabaris, which in such cases, I prefer to all other mercurial preparations. Even in cases where the chancre either simple or Hunterian, has already lost its primary, lardaceous aspect, and exhibits a copper colored surface with tendency to adventitious growths, I pursue the same treatment with Merc sol., Mercurius, prec, rub., and Cinnabaris, provided the patient has not yet taken any mercury in almost every cases this course of treatment leads to the most satisfactory results without any other agent, like Nitri ac., for instance, being required. In general, I cannot sufficiently caution the physician against the premature employment of Nitric Acid in primary chancre. If administered before the ulcer is perfectly cleansed by Mercurius, and for the purpose of effecting cicatrization more speedily, I have frequently seen the use of this acid followed by symptoms of secondary syphilis, and a general constitutional taint, on which account I only have resort to the acid in chancres that are not complicated with inflamed buboes, in the following cases: (1) if the patient who is affected with chancres condylomatous growths, has already take much mercury: (2) if, under my treatment, the ulcer assumes the form of condylomatous growths; and (3) if chancrous condylomatous growths, in cases that had not been treated with Mercury allopathically do not improve under my own treatment with Mercuriussol., but, on the contrary, get worse; in all such cases, I have had every reason to be satisfied with the good effects of the acid. Secale 55.-Treatment of the other forms of chancre. In all these forms Mercurius remains the leading remedy, with this difference, that it may be necessary to employ other mercurial preparations. (1) For elevated chancre (ulcus elevatum)-which is not, as some suppose, an accidental elevation of the simple chancre, but constitutes a more or less special variety of chancre, and may not only pass into the Hunterian, but, according to circumstances, into the phagedaenic chance-the principal remedy is not Cinnabaris (as has been improperly, or hypothetically inferred, from this ulcer being confounded with the regular chancre, which likewise assumes an elevated form in the second state), but Mercurius solubilis, an agent that will undoubtedly prove most specifically curative, as long as surpass in curative power any other agent, in cases where the ulcus elevatum has already passed into he Hunterian form of chancre. it is only where, by neglecting the fist of lardaceous period, new condylomatous growths develop themselves that Cinnabaris, which, however, is in all cases inferior to Nirri.ac., may be indicated. If, however the elevated ulcer should terminate in phagedaenic chancre, we have at once to resort to corrosive sublimate, and pursue the treatment that will be found described in the following paragraph. (2) Phagedaenic chancre-Nothing can be more ill-advised than to lose one’s presence of mind in the form of chancre, although it is undoubtedly a most dangerous and destructive ulcer; and to follow Hartmann’s advice, who counsels in the system of Therapeutics that the patient be treated with Mercurius until his system is thoroughly drenched with it. Even allopathic practitioners advise the cautious use of Mercury in this disease, for the reason that it will often aggravate the symptoms. I an able, from my own observation, to confirm the fact that even half-grain doses of Mercury of the first centesimal trituration may aggravate the case. The main object is to employ a mercurial preparation that will of itself arrest the ulcerative stage as rapidly as rapidly as possible. this preparation is Mercurius corrosivus. Even in case when any other preparation of this metal would seem to produce a most rapid and danger threatening progress of the ulcer, Corr sub has. never left me the lurch, although I never give it in larger doses than one-half of a grain of the first centesimal trituration, morning and evening. This agent very speedily arrests the ulcerative progress, but should not be repeated too often after symptoms of improvement have begun to set in, lest cicatrization should take place too rapidly and only superficially. for this reason it may be advisable to follow it up with some other mercurial preparation, such as Merc-prec ruber. (3) For the syphilitic erosions describe din No. 39, Prec. rub has always rendered me most excellent service; they often resist most obstinately any remedy that may be employed against them; on the other hand, in spite of this obstinacy their continuance is less dangerous than that of any other form of syphilitic ulceration. I should regard them, without hesitation, as secondary products, if I had not likewise seen them break out simultaneously with primary chancre. Secale 56.-Treatment of Complications and Sequelae of Chancre. The complications that may occur during the presence of chancre, are either purely local, such as gangrene of the affected parts, phimosis and paraphimosis, or other accidental occurrences, such as inflammation and suppuration of buboes, gonorrhea discharges from the urethra, and mucous condylomata. in most of these cases, I do not suffer myself to be influenced by these accessory phenomena in my general management of chancres; only if gangrene, sets in, I give Arsenic: and if this agent his removed the gangrene, which it always does, I return to the mercurial preparation that is specifically adapted to the case; the phimosis and paraphimosis, which are dependent upon the chancre, improving in the same degree as the chancre itself, all we have to do is to use the remedy that will prove most specifically curative in the case. If the chancre is complicated with gonorrhea I leave this last mentioned symptom unnoticed as if it were not present, only attending to the chancre; in by far the largest number of cases mercurius will be sufficient to cure them both. the same results is obtained. if numerous tubercles or buboes are present with the chancre; it is only when the buboes become intensely inflamed and threaten to break (as to inconsiderable consensual swellings of the inguinal glands, I do not heat them), I substitute red precipitate in the place of Merc. sol., or I give Cinnabaris is which is sometimes or preferable to the precipitate; and I only resort to Nitric acid, or to some remedy indicated or buboes in No. 66, if the chancre has been sufficiently cleansed, treatment be instituted against them. If fig-warts are present, I leave them for further treatment until the chancre is entirely healed. Regarding the sequelae of chancre (which occur very frequently under the allopathic treatment; and under homoeopathic treatment only it it is improperly conducted), we must be permitted do offer a few remarks. These sequelae are, 1. indurations of the prepuce or of the spot where the chancre had been located; 2. new ulcers which are sometimes, very superficial sometimes, however, of considerable depth; or re-opening of old cicatrices. the induration are generally the result of the extirpation chancres by external means, and are of a syphilitic nature; I generally treatment them with red precipitate, or, if the patient had already taken more or less Mercury, use the Cinnabaris; in all cases however, they require a long period for their radical and, in order to prevent an excess of mercurial action, I given dose of Mercurius only every other day. For subsequent ulcers or re opening cicatrices which may likewise occur under violent homoeopathic treatment, I generally, specially if no syphilitic discoloration of the skin is any longer present, give with the best effect Nitric ac., or sulphur sometimes Lachesis or phosphorous; but if symptoms are still present such as permanent indurations, discolored cicatrices, etc., that might lead us to suspect remaining traces of syphilis, I commence the treatment with some mercurial preparation that had not yet been given to the patient, (most generally Cinnabaris or Mercuries vivus), and only resort to Nitric ac. or Sulphur, if the former remain without effect or even induce aggravations. If aphthae, which must not be confounded with chancres should break out on the mucous membrane of the lips or on the edges of the tongue, in consequence of too liberal a use of Mercury, or even while this agent is still being given, we have to treat them with the remedies mentions at the end of this work for mercurial syphilis. Secale 57.- Remarks on the different modes of treating Chancre recommended by others. It must be evident, from a simple review of the lists of case and remedies mentioned in Ruckert’s “Klinischen Erfarungen.” that in both schools, the allopathic as well as the homoeopathic, there is so much theory and hypothesis mixed up with the genuine result of practical experience, that a beginner who reads all these things might easily be misled into a labyrinth of errors, without some reliable guide, for this reason we will add a few remarks to our previous paragraphs concerning the practical treatment of chancre. 1. HAHNEMANN. Hahnemann’s remarks on the efficacy of the smallest doses of Mercury in chancre, are undoubtedly correct if applied to secondary syphilis, or to discolored cicatrices remaining after badly managed or suppressed primary chancre, or to other chronic sequelae. Most probably these secondary phenomena occurred in his practice more frequently than primary chance. In the former, small doses of Mercurius do more good than large ones; but in acute primary chancres, comparatively, large doses will have to be employed, for the present, at any rate. 2. ATTOMYR. (Varieties of chancres, pages 23-27). This author’s remarks on his three varieties of chancre, the first of which comprehends the Hunterian chancre, and the second the ulcus elevatum, are in so far correct as the chief remedy for the first class is indeed merc sol; but we must modify the author’s; proposition employ Nitric ac. for chancres of the second class, by stating that, for recent primary, elevated ulcers, several of which may break out at the same time, the chief remedy is likewise Merc sol taking it of course for granted that his second variety, so far from being a chancre, is not rather a mucous condyloma-(see Secale 72). Only in cases where the improper treatment of a chancre with excessive doses Mercury, results in the breaking out of elevated ulcers, Nitric ac. is in its place; whereas, if Mercurius so. is not sufficient in a case of recent ulcus elevatum, Cinnabar is preferable to Nitric ac. The same remark applies to the author’s so-called third form, the more perfectly developed ulcus elevatum, which neither Thuja nor Nitric ac., nor Staphysagria have yielded me the same good effects that I have derived from Merc sol., or in appropriate cases, from the red precipitate. As regards the authors fifth variety, which breaks out with violent itching on the external surface of the prepuce and covers itself with a scurf that only becomes detached after the complete healing of the ulcer, and for which sulphur is said to be the principal remedy: I have met with such scurfy chancres in my own practice, on the prepuce, the dorsum of the penis and the scrotum, but have never known sulphur to do any good in such cases, but have always found Merc sol. Mercurius Prec. ruber, and in some, perhaps secondary cases Aurum, efficacious. Moreover, since it is an established fact that true syphilitic ulcers do not itch, I am almost inclined to believe that Attomyr’s fifth variety is nothing else than an external preputial herpes so much the more as this eruption, if very much inflamed and far spreading may cause swelling of the inguinal glands, and yields to the internal use of Hepar sulph. Finally, in Hunterian chancre, Thuja, and Causticum should never be used, as Attomyr advises, as intermittent remedies; we should only lose time if we were to allow ourselves, by such a proceeding, to interrupt the highly important employment of mercurius, Regarding this author’s fourth variety, for which he recommends Corallium, we have to remark that it most probably coincides with the syphilitic erosions that have been described, Secale 39. But inasmuch as he admits that Corallium is not always capable to preventing the passage of this variety into Hunterian chancre we infer from such an admission that it would be much better to commence the treatment at once, instead of with Corallium, with Mercurius sol., Mercurius Prec. rib or Cinnabaris. 3. BUCHNER (Hygea. vol. 13), utters golden advice which should be thundered into the ears of every physician, when he says that, although Mercurius will cure a chancre in the reproductive stage, yet we should minister the smallest justifiable doses of this agent, and thus guard against a too rapid cicatrization of the ulcer, lest the disease should be merely suppressed, and continue to spread in the organism, as is often the case after the persistent employment of Merc corr. (See also Secale 59, Vehsemeyer.). Secale 58.-Continuation of the former subject. 4. HARTMANN. (Theory and treatment of chronic disease.) As a general rule, the remedies for the different forms of chancre are very correctly and appropriately indicated in this work; we would simply add that, if Mercurius sol. does not act promptly in a case of Hunterian chancre, the red precipitate or Cinnabaris will almost always prove sufficient, so that we need not resort to the equivocal and unreliable Iodide of Mercury, which, beside, is much more adapted to chronic secondary ulcers. Regarding thuja, which hartmann recommends for the ulcus elevatum, we can only repeat what we have already said on this subject, when commenting and Attomyr’s recommendation of this agent for the Hunterian chancre. In fully-formed chancre, the employment of this agent would involve an irreparable loss of time; how far Nitric ac. may here subserve our purpose, has already been shown on No. 55, Hartmann’s remarks on the persistent employment, of Mercurius corr. in phagedaenic chancres, and upon the danger consequent upon the irrational alternation or change of remedies in this disease, deserves the greatest attention, since all these remarks are founded on experience; but if the same author teaches, in a subsequent paragraph, that, in phagedaenic chancre, this agent should not be exhibited in an attenuated form, but in substance, until the organism is thoroughly saturated with it, we have to oppose this advice most positively. As we have said before, in this form of chancre, nothing so more dangerous than an excess of mercurial action, which sometimes super induces the most horrid aggravations and destructions; and since Mercurius corr., if administered in half grain doses of the first centesimal trituration, morning and evening proves sufficiently powerful to control this disease, and too week to develop material aggravations, it seems proper to administer is also in this form of chancre in the above mentioned dose. 5. CLOTAR MULLER. (Allium hom. Zeit., vols., 34 & 57.) What this excellent practitioner observes regarding the curative powers of Mercurius prec and Cinnabaris, which he considers as far superior to those of Mercurius sol., is likewise founded in experience. For myself, I prefer those remedies to Merc nitros, which is so highly praised by Dr. Trinks, but, on account of it intense action is attended with more or less danger; more particularly since I personally have never yet met with any cases, even of inveterate primary chancres where the red precipitate of cinnabaris has not accompanied every thing that could be desired. nevertheless, I never use these remedies in recent primary chancres, where I have found Merc, sol. sufficient in every case; but for all mismanaged and neglected chancres, I consider them as the best preparations that can be used. More specially they become indispensable (more particularly cinnabaris) when recent chancres, whose appearance will counter- indicates the employment of Nitric ac., at the outset are accompanied by buboes. In this case, cinnabaris frequently becomes an indispensable remedy, which often cures chancre and buboes at the same time. In old chances, complicated with buboes, I likewise prefer using cinnabaris before I resort to Nitric acidum. In recent chancres on the glans and prepuce, Clotar Muller always employs the red precipitate; and cinnabaris in the cure of old chancre on the same parts, specially if they dip down to the deeper textured, are indurated, suppurate a good deal, and the individual has already been infected a number of times; for chancres on the scrotum and dorsum of the penis he employs Aurum) mur. (which I likewise recommended), and for chancres in the throat, Corr. subl. he neglects to mention whether it is for primary or secondary chancres. 6. ROSENBERG(All hom. Zeit., vol. 35) asserts, that, in cases complicated with scurvy, he has been unable to effect any thing with Mercurius; that, after the use of this agent, the ulcers became worse assuming an appearance of increases malignity and disorganization. I have met with such ulcers, where the diagnosis was made difficult and uncertain by a complication of syphilis, mercurial poisoning and scorbutic taint. But if Rosenberg process for this condition Mur ac. China, Camphora, Carbo, Ferrum, Kali nitr., Kreosotum, Mangamun, Sabina, Secale, and Sarsaparilla, without particularizing the indications, the beginning practitioner who can be induced to try all these remedies, one after the other, on good luck, deserves to be pitied; according to my own experience, he had better try nitri ac., if Mercurius should aggravate the symptoms; after which he may use Sulfur; he will be much more satisfied with the result. Secale 59.-Continuation of he same subject. 7. VEHSEMEYER. The best thing that has ever been published in. the literature of our school, is to be found in “vehsemeyer’s Jahrbuchern, ” vol. 3, page 134 and following, by the editor of this publication we fully accept what he says this article: Chancres exhibits in its course two stages, an ulcerative and a reproductive state. The character of the first stage is loss of substance, that of the second adventitious growth. The syphilitic ulcers, if taken charge of by a physician at the very outset, leaves this stage under the persistent use of Mercurius sol. in ten or twelve days, at the latest in a fortnight. (V. gives every day two or three disease, of one to five grains each, of the second or third decimal trituration). On the sixth or eight day, an improvement becomes evident the ulcer is arrested in its course, ceases to spread, and begins to cleanse itself from the circumference to the centre. If this change does not take place within the time indicated, another remedy will have to be chosen.” In such case, if the ulcer spreads rapidly. V. gives Corr. subl., and if the ulcer is indolent, Mercurius phosph., but warns the physician against the too long continued use of the sublimate, lest it should produce a deceitful cure. He says: “Instead of becoming cleansed from the circumference, with cleansing process of the ulcer proceeds from the centre; the edges become raised, grow like condylomata, and in a few days, under the continued use of the sublimate, the chancres cicatrices….if this result should take place inspite of the most cautious treatment, the method recommended for the second stage should at once be pursued, and should be persistently continued until the cicatrix assumes a natural appearance. For the second stage, V. recommends Nitri ac., two 0r three drops of the second watery dilution morning and evening but advices and this cannot be repeated too often) near to use it too soon, but to first await the full setting in of the reproductive process; on the other hand., where adventitious growths have begun to make their appearance, the employment of Nitri ac shouldn’t be delayed for a moment. Except the doses of Mercurius, which are unnecessarily large (for half-grain doses the first centesimal trituration, given morning and night, are entirely sufficient). Vehsemeyer’s advice may be safely followed by by practitioner. If the author afterwards states in a note that although chancre is often treated with Mercurius alone, cicatrization doses not taken place as rapidly as when Nitri ac. is used, he certainly can only means cases where her the condylomatous growths had already shows themselves or where the chancre had not been healed in the first state. For if the chancre is healed in the ulcerative stage, the process of cicatrization and the arrest of loss of substance progress in the same ratio, so that, at the moment when the process of reproduction is completed the cicatrix is likewise perfect; whence it follows that, where Mercuries has healed a chancre in the ulcerative stage without the supervention of adventitious growths, no Nitric ac will be found necessary to complete the work, of cicatrization. 8. RUMMEL. See his very remarkable case in the chapter on “Sycosic condylomata ” No. 78 9. OTHER AUTHORS. We might have quoted a number of other authors, such as Aegidi, Bernstein Buchner, Fielitz, Goullon, Hartlaub, Knorre, Kurtz, Kreussler, rummel, Schelling, Schade, Sommer, Thorer, Trinks, Wahle, Wolf, etc.,: but inasmuch as we deal in the present quotations sufficient, if for no other reason than that they give the most important data. At the same time we refer the reader to the last chapter of his work, “General pharmaco-dynamic observations,” No. 227-236), where he will find the views of other authors, who have only furnished isolated remarks concerning one or the other of the remedies that have been recommended so far. 10. HALE. Apocynum androsemifolium or dog’s bane. The Choctaw Indians regard this drug as a specific for secondary syphilis; they chew the root. Asclepias tuberosa, pleurisy -root. Professor Hale has employed this remedy with uniform success in constitutional syphilis. Iris versicolor, blue-flag,. Recommended very highly for mercurial syphilis. Dose one or two fluid drachms of the tincture, six or eight times daily. Lobelia inflata, Indian tobacco; his remedy is used by the Indians for syphilis. Phytolacca decandra, poke. Recommended by the Eclectics for bone-pains mercurial syphilis, It is likewise said to have been used with good effect in primary chancre. Stillingia sylvatica, queen’s root; is extensively used by Eclectics in primary and secondary syphilis; they regard it most as a specific in this diseases. FOURTH CHAPTER SOME OTHER PRIMARY FORMS OF SYPHILIS ______ I.BUBOES Se.60.-General Definition. In former times, by the terms bubo, physicians always understood a swelling of the inguinal glands; afterwards the term was likewise applied to glandular swellings in. the arm-pits, on the neck, etc.; more recently besides the bubo of the plague, this term has been limited to a syphilitic selling of the inguinal glands, in regard to which we distinguish (a) sympathetic and essential, and (b) primary secondary, and constitutional buboes. Sympathetic buboes are in fact nothing else than only from chancre, but likewise from the every come that intensely inflamed herpes, or other ulcers and likewise from gonorrhoea, and are cause not so much by the transmission of he poison as by an extension of the inflammatory irritation to the neighboring lymphatic vessel. These sympathetic swellings, which are scarcely ever entirely wanting if the chancre is more or less inflamed, and painful, and sometimes, very extensive tumor, compressing several glands in one swelling and showing an extraordinary tendency to suppurate. When first originating, the bubo announces itself by an unpleasant feeling had a slightly painful tension in the groin, resembling the the sensation which is sometimes experienced after long walking, or after excessive bodily exertions. An examination with the hand shows that one or more glands are swollen, sensitive to pressure, and even painful. soon after, the neighboring glands and the cellular tissue become irritated, in consequence of which a hard swelling of considerable size develops itself, whose surface appears red, and which interferes a good deal with walking.Suppuration is preceded by a violent throbbing pain, and the bubo discharges, sooner or later, according as the inflammation was more or less intense. If the swelling of the inguinal glands is not sensitive to pressure, at least not much so; the glands involved in. the swelling remain detached for along time, and the skin retains its natural color, the condition may continue for weeks and months, according as the ulcer from which the irritation precedes continues; a sort of induration may even develop itself as an accompaniment of such sympathetic swellings; and if a general infection of the organism should take place, these sympathetic swellings may even terminate in suppuration, without, however, secreting a contagious virus, as is the case with the genuine bubo when it discharges and suppurates. Usually the bubo shows itself while the chance is still existing, particularly if the ulcer is treated with external irritants; if chancres are made to cicatrize by cauterization, the bubo sometimes shows itself all at once after the cicatrix is fully formed; in some cases it shows itself at once, directly, without any previous chancre, as the first sign of primary syphilis. Secale 61. Primary, Consecutive and constitutional Buboes. Recently a good deal has been as occur without any previous chancre; or truly constitutional buboes, or such as arise in the course of whether every bubo is not either a secondary or consecutive phenomenon, that is, a phenomenon which always occurs after the braking our of the chancre, although as one of its immediate consequences. As regards constitutional buboes, I must confess that I have never seen them occur as symptoms of secondary syphilis, and that, according to what I have read on this subject in different authors, not develop themselves while the chancre is still running its course but after its cicatrization, provided the aforesaid authors did not mean by buboes an induration of purely sympathetic inguinal glandular swellings, that had remained behind after the primary chancre had healed. But, it we inquire in to the he manner in which the primary chancre had disappeared, we shall find that it was through some external agency, such as cauterization, after which the bubo remained, not as a symptom of constitutional infection, but as a vicarious product standing in. the place often primary chancre; that is to say, a swelling where the secreted pus retains all the characteristics of the non-modified and still contagious, secretion If, a after the fashion of some French pathologists, we extend the term bubo toe very painless inguinal swelling, even to a mere kernel, we can indeed find buboes in the secondary form or second stage of syphilis, which after former sympathetic swellings. If, in accordance with the present more rigid interpretation of the term, we understand by bubo a large inflammatory, inguinal tumor, produced by the direct action of the poison, it is perfectly proper to consider such a bubo as one of the characteristic production of the primary period of syphilis, and therefore endowed with faculty of transmitting the infection. Whether a bubo may occur all he once, as the primary protopathic sign of syphilis, without any previous chancre or syphilitic affirmative by those who have not yet witnessed it; and will hereafter be denied as long as its possibility is not theoretically established. All we can say on this point is, that those who deny protopathic buboes, affirm in support of their opinion, that, where such buboes seem to exist there must have been some previous chancre which the patient did not heed, and which had been made to cicatrize through some accidental influence, or by the action of some ointment, before the possible. I have sweet such buboes arise after the breaking out of ulcers on the lands, which the patient regarded as simple excoriations contracted during coit, and which were removed at the outset by the use of lead-water. Cases of this kind may occur; yet by many physicians, that buboes may likewise arise protopathically without any other symptom of syphilis having been present previously. Secale 62.-Various Kinds of Buboes. Modern writes on syphilis have attempted to describe several varieties of the syphilitic bubo. Although they are in reality, nothing else than the same bubo in different stages of development, yet they deserve a more attentive consideration, in so far as they enable us to recognize the true character of these swellings, and to distinguish them from tumors of a different class. Agreeably to their classification, we have two large classes of buboes: (1) phlegmonous or inflammatory: and, (2) Indolent or non-Inflammatory buboes. In accordance with their periods of development, these two classes are again distinguished (a) inflating: (b) suppurating: and (c) chancres buboes. A curiosity review of this classification shows that these supposed varieties are not distinct buboes of essentially different natures, but that these differences are purely accidental, depending merely upon the different stages of development through which such a with the sympathetic inguinal glandular swelling that have been described (No. 60), and likewise mas become indurated, so far as not to deserve more special attention until they assume the form of real buboes, in other wards, became inflamed in which case they come under the head of the inflammatory or phlegmonous buboes, and belong to the first class. For this reason, our business here is with the genuine, essential buboes, of which we have the following varieties, or rather stages, as described by moderation authors. (1) The non-fluctuating inflammatory buboes.-The swollen gland is not movable, as is the case when the swelling is purely sympathetic : the cellular tissue, likewise, becomes swollen, forming a more or less dense layer around the gland, where the inflammation progresses much more rapidly than in the tissue of the gland, and which offers a peculiar elastic resistance to the feel. The swelling assumes a dark or violent-colored redness, that sometimes is confined to the middle region of the swelling, but very frequently spreads as far as the circumference. The pain may be violent, with a moderate degree of inflammation; or it may be slight, while the inflammation is intense. (2) The fluctuating inflammatory swelling-According as the pus collects in the cellular tissue, or in the gland, or in both at the same time, the examining finger discovers either a soft, doughty swelling, or distinct fluctuation. As this change sets in, the inflammation and pain became less : as long as the suppurating process remains confined to a few spots, and the skin retain its violent redness, a cure by resorption still remains with the bounds of possibility. The suppurating glandular swelling-If the bubo is of a syphilitic nature, the margins of the opening, after the bursting of the abscess, will appear unequal, gray, more or less indurated, indented, abrupt, and exerted, gaping; the bottom of the ulcer rests upon the tissue of the gland, shows the same phenomena, and the surrounding cellular tissue is more or less indurated. Altogether, the surface of such an ulcer may exhibit all the phenomena observed in the case of simple, indurated, elevated, or phagedaenic chancres; the same remark applies to the course, cicatrization, and healing of these ulcers whose cicatrices are generally most prominent and depressed when seated in the bend of the groin. If the whole body of the gland has been involved in the inflammation, it may have been entirely destroyed by suppuration; in such a case the cicatrix may rest upon the subjacent cellular tissue. Sac.63.-Diagnosis. Although our previous remarks point out the diagnostic signs of a syphilitic bubo, with so much evident correctness that it seems impossible to commit an error of diagnosis in cases where a chancre has preceded the appearance of a swelling; yet we must not overlook the fact that buboes may, although in rare cases occur protopathically. If they do, it is of the utmost importance to be able to diagnose their true nature before suppuration and fluctuation set in. Syphilitic buboes follow the same general course, like any other inflammatory swelling, even to the period of suppuration so that this fact alone would be sufficient to cast a doubt on their true character wherever no positive signs of a previous syphilitic infection are present. If there sings are wanting; if the patient does not show any other symptoms of primary syphilis; if no ulcer can be discovered and the patient is perhaps unwilling to admit that he has had intercourse with a suspected female, the diagnosis is sometimes very difficult. In such cases, we risk to confound buboes with scrofulous swellings or even, if the inflammation is still in considerable, with aneurisms, of the femoral artery, or even with inguinal hernia, or vice versa. The last mentioned mistake occurred quite recently to a Professor of survey in the Medical Faculty of Paris, who, mistaking an inguinal hernia for a bubo, cut into the swelling, when he found, to his amazement, that instead of laying open a bubo, had and ripped open a portion of bowel. This shows that, whereas on the one hand preceding and accompanying circumstances may shed light on the diagnosis, in case a genuine bubo is before us, we may on the other hand be led into grave errors, if circumstances favor the suspicion that the existing tumor is a syphilitic product. Nevertheless a close examination ought to prevent mistakes like that which happened to the French professor; for a hernia swelling is always indolent, the color of the skin remains unaltered, the integuments over the swelling are immovable; in a recumbent posture, the bowel either reenters the abdominal cavity spontaneously, or is easily replaced by the taxis; all of which does not occur in. the case of bubo. Nor is it generally difficult to distinguish a bubo from aneurism of the femoral artery, although throbbing pains which are experienced in a bubo, during the period of suppuration, may lead to false conclusions in cases where all symptoms of syphilis are wanting and where the patient obstinately asserts that he never had any connection with a diseased female. Yet, even in such a case, we may obtain some certainty from the circumstances that, during its earlier period at least, an aneurismal swelling can be compressed with the finger, the removal of which is succeeded by a return of the pulsations that an aneurismal tumor enlarges and that its pulsations become more distinct if the artery is compressed above the tumor; whereas the swelling caves in and the pulsations cease, if compression is effected between the aneurism and the heart. What is most difficult, is, to distinguish a bubo from a scrofulous swelling; if we may give credence to Ricord’s statement, inoculation affords in all such cases in the absence of any other directing circumstances, the only sure diagnostic evidence of the true character of the tumor. Nevertheless, we will endeavor to show in the next paragraph that there are other means to establish, even in such dubious cases, a tolerably reliable diagnosis. Secale 64. -Differences between Scrofulous and Syphilitic Buboes. One bubo might possibly be confounded with another, if the syphilitic bubo is without a sign of inflammation, and there are no circumstances present that might justify the suspicion of any syphilitic taint; in such a case a scrofulous bubo might easily be mistaken for a non-inflammatory syphilitic bubo, and vice versa; although, even in such a case, the appearance and course of the bubo, and other symptoms, may render the diagnosis comparatively easy to an attentive observer. For, in case of scrofulous as well as of syphilitic bubo, we have to depend in our diagnosis upon a careful examination of the general phenomena characterizing the condition of the patient : the leading circumstances of the patient’s childhood and youth, etc.; the presence of the glandular swelling that may denote the existence of a general scrofulous diathesis; and, on the other hand, upon an examination of the bubo itself, which, if scrofulous, progresses much less rapidly than the syphilitic bubo; scarcely ever invades the surrounding cellular tissue preserves for a long time its mobility, and instead of the elastic hardness of the syphilitic bubo, is soft to the feel, remains unchanged for a long period, and only involves the integuments little by little, which in such a case, change to a violent-red color, without any perceptible signs of inflammation and become thinner, until the tumor bursts and discharges a granulated, serious pus, thus becoming converted into a scrofulous ulcer. Such an ulcer, in regard to its slow course and obstinate character, has all the signs of a scrofulous sore; the surrounding skin is seldom red, generally livid; the subjacent cellular tissue is neither hard nor swollen, as in the syphilitic bubo. It is true that a scrofulous ulcer likewise often sends out fungous growths, and is of a whitish-gray color, on which account they may readily be assimilated to syphilitic ulcers. But, in the case of these last-named ulcers, the grayish yellow, lardy appearance always depends upon the formation of a false membrane lining their surface and which can easily be removed by rubbing; whereas, in the case of scrofulous ulcers the grayish-yellow color adheres to the cellular tissue itself without showing a trace of false membrane. In the case of syphilitic buboes the destructive ulceration progresses very rapidly until it is arrested; whereas scrofulous ulceration remains at the same point with the same characteristic signs so that its course is not marked by two essentially distinctly periods, like that of the syphilitic ulcerative process, namely, a substance destroying and a substance-repairing period, or the period of adventitious growths. Moreover, in a scrofulous bubo, the ulcer is always seated on the surface of a more or less extensive tumor, formed by swollen and very hard ganglia; whereas the ulcer of the syphilitic bubo always rests upon the cellular tissue, and, of itself, neither induces hypertrophy nor induration of the inguinal ganglia. There are cases where the scrofulous and syphilitic miasms are united in one bubo. In such a case we first notice a simple inguinal swelling, without any enlargement of the glands : this thickening or enlargement occurs at a later period,. increases more or less rapidly and imparts to the tumor an irregular shape, while the sore remains fistulous and ulcerated, the vivid redness of the skin with the earlier symptoms of inflammation, disappears, and only the livid color of the evidently scrofulous bubo remains behind. Secale 65.-Prognosis and Terminations. With a correct, homeopathic treatment the prognosis is never unfavorable, although if the swelling has already progressed to a certain size before the physician is applied to, cases may occur under homoeopathic treatment where neither the bursting of the tumor, Nor the supervention of gangrene which, however, is not of itself the most dangerous symptom can be prevented. It is the buboes consequent upon superficial or simple chancres that most readily terminate in suppuration, whereas the mostly deep-seated buboes, or those that succeed the Hunterian chancre, incline to induration. Suppuration rarely takes place without the cellular tissue, which surrounds the glands, becoming previously involved in the destructive process; and, vice-versa, the near approach of suppuration must be apprehended, if the skin on the glandular tumor, that had been free and movable heretofore, and the subjacent tissue, become firmly adhering. Where the prognosis is most dubious, is in the case of buboes consequent upon phagedaenic chancre; for the consecutive ulcers are very apt to assume the same character. If this should happen, the ulcer invades with more or less rapidity a considerable portion of the surrounding tissues. This fungous ulcer, which is lined with a copious exudation of a grayish, papescent matter, may preserve its peculiar appearance and its infectious power for years, preserve its peculiar appearance and its infectious power for years, provided its syphilitic nature, after a shorter or longer period of time, does not undergo an essential alternation, as may readily occur with scrofulous individuals; in consequence of which the destructive ulceration ceases to spread, becomes circumscribed, and even shows some inclination to cicatrize. In the case of scrofulous individuals; this, cicatrization, provided there is no mismanagement, may continue more or less rapidly, until the wound is closed; if the treatment, however, is properly conducted, or if the scrofulous diathesis is more or less manifest, the syphilitic virus may become active again before the process of cicatrization is completed; he wound breaks open again, spreads over the surrounding tissues, and frequently covers a considerable surface of the abdomen and thighs. The ulcer is, moreover, the worst of all, for by dipping down to the subjacent textures, it may pierce through the abdominal integuments to the peritoneum which it may inflame, and thus cause the patients death. Buboes, if not healed from with, but when made to cicatrize by external artificial means, may, like chancre when not radically healed but suppressed by cauterization, super induce a general secondary syphilis, for the reason that buboes constitute, property speaking, a vicarious manifestation of the syphilitic disease in the place of chancre. As regards the assertions of some authors that the supervention of gangrene causes a complete extinction of the syphilitic process by the destruction of all they affected pats, I confess that, for lack of experience, I have no opinion on his subject; moreover, it is my opinion that it is externally difficult to collect valid observations on this point, ulcers were have a chancre of watching the patient for years. Secale 66.-Treatment of Buboes. It must be evident from what we have said, that a bubo should no more than a chancre, be treated with cauterizing or desiccating agents, if we desire to avoid the danger of seeing secondary constitutional syphilis break out in its place. The only external application that can be permitted are warm poultices, in case the pain caused by the inflammation becomes intolerable. Even poultices must only be applied in a case of urgent necessity, after it has become evident that suppuration can no longer be prevented. If applied prematurely, they may hasten the bursting of the tumor, which might perhaps have been prevented by the use of judiciously selected agents. Taking all these points for granted, the following is my mode of treating a bubo: (1) If, during a chancre, glandular swellings in the groin supervene, I leave these unheeded, because I am satisfied that these swellings, if the chancre is healed by truly rational means, always get well of themselves. (2) On the contrary, if, during the treatment of chancre, a real, inflammatory bubo develops itself, or which occurs much more frequently, if I take charge f a patient who is at the same time afflicted with bubo and chancre, I resort to Prec. ruber, unless the patient had had a good deal of Mercury given to him by his allopathic attendant; or, if the precipitate should not be sufficient, I give Cinnabaris, both remedies with the same good result. (3) If these remedies are not sufficient to disperse the tumor if the bubo threatens to suppurate, and the condition of the chancre does not demand any immediate, special treatment (which it seldom does under these circumstances); in such a case, I exhibit Carbo animals, generally with the happiest result. This agent has rendered me more than once excellent service, even in cases where fluctuation had already set in; I prefer Nitri ac. to it only when this agent is likewise indicated by the fungous condition of the chancre. (4) If, when the patients come to me for treatment, the breaking of the buboes can no longer be prevented, or if they are already discharging, I institute the treatment which I have indicated for the different forms of chancre in 54 and 55, being guided in the selection of the remedy by the character of the ulcer. (5) If the buboes develop themselves protopathically, or do not make their appearance until the chancre has become cicatrized, I commence the treatment, in case fluctuation is not yet present, and the patient has not yet been drugged with Mercury, with Mercurius sol., or red precipitate, or Cinnabaris; but if the patient has already had Mercury, I give Arum. Nitric ac., or Hepar sulph. If fluctuation has already had Mercury, I give Aurum. Nitri ac., or Hepar sulph. If fluctuation has already set in when I begin the treatment, I first resort to Carbo animalis, and if this doses not effect a speedy improvement, I change to Nitri ac. (6) Moreover, I prescribed in most cases: (a) for gangrened buboes, Arsenicum; (b) for old indurated buboes, Carbo animalis, Hepar. or perhaps sulphur. (c) for suppurating buboes, if after the exhibition of all syphilitic symptoms, the sore has become converted into a clean ulcer, but the secretion of pus still continues; and the wound does not close; Silica, Sulphur, and sometimes Hepar sulph. At the same time, I avoid, under all circumstances and at all times, the artificial opening of fluctuating buboes; I do not even allow the use of emollient poultices except when urgently required and discontinue them at once as soon as the inflammatory pains have become more tolerable. NOTE BY DR. HEMPEL. (I fully agree with Jahr that buboes should not been opened prematurely, but if the abscess is fully matured, and there is no evidence that it will discharge voluntarily, I do not hesitate to make a free incision in order to secure a full and free escape of the Pus. It has happened that in cases where the abscess was allowed to take its own course, the pus has burrowed downwards, behind the fascia, in consequence of which untoward circumstance, the patient may remain crippled for life. Whatever Jahr may advise to the contrary, I can affirm from abundant experience that the Biniodide of Mercury, first or second decimal trituration, is a fever efficacious remedy for chancre and bubo; a solution of thirty grains of the Iodide of Potassium in eight ounces of water to which half an ounce of the Iodide of Potassium in eight ounces of water, to which half an ounce of the tincture of iodine may be added, will likewise be found very useful; I give a dessert spoonful of this solution three times a day. In obstinate cases, I sometimes paint the bubo with the tincture of Iodine; this will either facilitate resorption, or, if resorption is no longer possible, it will hasten the suppurating process. Secale 67.-observations by other Physicians. These are not very numerous, but perhaps so much more important. (1) HAHNEMANN. Hahnemann likewise, like many other homoeopaths, particularly Gross, Hofrichter, and Rosenberg, believes in the existence of idiopathic buboes, that manifest themselves without any previous chancre, but, beside Mercurius, he does not propose any other remedy for the treatment of these tumors, although, as I know from himself, the likewise employed Aurum, Nitri ac., and Carbo animalis. (2) ATTOMYR (in his essay on the different forms of chancre) is of the same opinion as the above-named physicians; he relates two cases, one of which he guard with Nitric ac. and Sulphur, and the other with and Nitri ac., alone. During the inflammatory stage, he propose Merc-sol and Nitri-ac., and for the suppuration, after the bubo has begun to discharge, Sulphur and Silica. This practitioners likewise confirms the statement that, if buboes break under Homoeopathic treatment, they discharge without any untoward circumstances. (3) BUCHNER (Hygea, vol.13) pleads against the opening of buboes either by the knife or cauterizing agents; he likewise asserts that, if the body is kept in a state of quietude, Acidum nitricum will almost always prevent suppuration, and induce a dispersion of the tumor. (4) GASPARY (Vehsem.Jahrb.vol.4) praises Carbo an, as one of the most efficient means by which the resorption of the bubo can be effected, even after fluctuation has fairly set in, without, however, affecting either the gonorrhea or chancre; a cure is generally accomplished in three to five, or at the latest in eight days. I am able to confirm the correctness of these remarks from my own extensive experience. (5) HOFRICHTER (Allium hom. Zeit., vol.35) had seen buboes arise after the suppression of figwarts by external means. under certain circumstances, this may undoubtedly be the case. He too, next to the red precipitate, regards Nitri ac, as the chief remedy it seems to me however, that Hofrichter confound the fungous, condylomatous chancres with figwarts, since he adds that latterly the chancres show an uncommon tendency to run into condylomata, that is to say, not to dip down in the subjacent textures but to grow upward.” (6) SUMMER (Allium hom. Zeit., vol.38) regards Hepar as one of the chief remedies if, after the healing of the chancre (most likely “with Mercurius”) the bubo has not yet broke, and no fluctuation is perceived; and, if the bubo has begun to discharge, or heals too slowly, he recommends Silica; in my opinion, however, this agent will only help, if all the signs of a syphilitic taint have entirely disappeared. (7) TRINKS and VEHSEMEYER likewise recommended Nitric ac. as the chief remedy for buboes, without, however, stating in what stages or under what circumstances. (8) WAHLE(All hom. Zeit., vol..1`5) is certainly mistaken, as will be admitted by all practitioners who have had any opportunities of treating syphilitic diseases, when he expresses the opinion that buboes are not of a syphilitic but of an herpetic or proceeds nature; that patients of this kind “infect by their breath,” and that not Mercurius, but Sulphur is the specific remedy. it is true that Sulphur may have to be given, if, after the complete cure of syphilis, the buboes still continue to suppurate, and cicatrization too slowly; but, if syphilitic symptoms are still present, Sulphur will never be sufficient. If my memory does not deceive me, I have read somewhere that Gross (the elder) has been in the habit of recommending Aurum and Carbo animalis for buboes at a very early period, both idiopathic and consentive; this recommendation had been known to me for years before I became acquainted with Gaspary’s recommendation in ” Vehsemeyer’s Jahrbuchern.” II. MUCOUS TUBERCLES, OR MUCOUS CONDYLOMATA. Secale 68.- Description. This morbid product, first described by French authors as a sign of primary syphilis, is to be carefully distinguished from so-called pustulous syphilides, but likewise from chancre and figwarts; it is a syphilitic product which generally shows itself from six to eight days or even a fortnight or four weeks after an impure coit. In consists in a few moist, broad, flat, and rounded tubercles which, though not usually very numerous, originate in a morbid development of the skin or mucous membrane of the affected part. They occur most frequently on the inside of the labia majora, on the glans, in the region of the anus, on the breasts of women who nurse syphilitic infants, and sometimes if the infection had been communicated by local contact, on the outer side of he labia majora, on the integument of the penis, scrotum, perineum, and on the inner surface of the thighs. They are generally of a more or less dark-red color, from three to six lines in diameter, of a rounded form, flat on their surface, incline to form groups of two or three, without, however, always becoming confluent, and secrete a glutinous, slimy matter, having a specific odor that reveals their true nature to any one who has experienced this odor once. Most frequently they are seen on females, and on persons who do not keep themselves clean. Sometimes, however, these tubercles unite by their edges, in which case they form rather broad disks, with borders that rise abruptly over the surrounding skin or mucous membrane to a height of one or two lines. Their surface is generally rough, granular, even deeply furrowed, and not infrequently like most other syphilitic products, they are surrounded by a red or more or less copper-colored areola, specially when they are seated on the external skin, in which case the redness in much less distinct, whereas those that are seated on the mucous membrane, exhibit a much more vivid redness. It is only now and then that they are quite dry, without any secretion sometimes their usually smooth surface may become slightly roughened by ulceration, so that they assume the appearance of chancre, and might readily be confounded with the ulcus elevatum, if their base had not an entirely different look from that of chancre. Not unfrequently they break out on women in the course of gonorrhoea, or some other dubious discharge, from men while affected with chancre but in many cases they come all of sudden, without any sign of previous chancre or other syphilitic symptoms, whereas in other cases they only show themselves months after the first primary signs of infection had been discovered. If badly managed or when left to themselves, their disappearance from their original locally, or even while they still remain visible, may, as in the case of chancre, give rise to buboes and to all the symptoms of constitutional syphilis. Secale 69.-Nature of these Tubercles. Writers on syphilis have not yet agreed whether these products are manifestations of primary or secondary syphilis. Ricord, who knows of no higher criterion to verify the syphilitic character of a dubious eruptions than inoculation, contents that these tubercles belong to a domain of secondary syphilis, for the reason that he has never been able to produce by means of them, the least symptoms of infection; hence he denies their contagious nature. Others, on the contrary, like Baumes and Reynaud, have shown by a number of observations that, even if these tubercles cannot be inoculated, yet they can be communicated by sexual connection, with this difference, that a chancre may indeed communicate a mucous tubercle, but a mucous tubercle can never produce a chancre, but only a tubercle of like character this would demonstrate, on the one hand, that they may break out as primary phenomena, and, on the other hand, that their derivation from chancre would be evidence in favor of their character as idiopathic and protopathic products. whether such tubercles are always primary and not as frequently, or perhaps more frequently, secondary products, is another question which it may not always be easy to solve. all existing observations seem to show that they have not only appeared without any previous signs of syphilis, but likewise after a chancre had been healed, and that consequently they may be of a twofold order; provided always that, notwithstanding they break out after the appearance of the chancre, and, for this reason, cannot be regarded as absolutely primary phenomena, they may, like buboes, continue to appertain to the primary period of syphilis; this fact is, indeed, proven by their capacity to transmit the infection. At the same time, the fact that they are of a syphilitic nature, and are not produced by the virus of gonorrhoea but by that of chancre, is not only proven by the circumstance that their violent removal by external means is is often succeeded by an outbreak of all the symptoms of constitutional syphilis, but likewise by this other circumstance, that, if these tubercles appear one women together with discharge, this discharge scarcely ever communicates gonorrhoea to a male, but mucous tubercles, at most associated with balanorrhoea. These discharges which, in females, are so easily confounded with gonorrhoea, but result altogether from the contact with syphilitic secretions, most likely constitute the larger number of the cases whereas supposed so-called simple gonorrhoea has not only produced on males chancre-like products, but likewise, in the case of women, all sorts of phenomena of secondary syphilis after a shorter or longer period. According to some authors, these mucous tubercles are even more contagious than chancre. Reynaud asserts that they occasion exceedingly at chronic blennorrhoeas from the sexual organs of females, which continue even after the tubercles have disappeared, and constitute the larger number of those infectious blennorrhoeas and balanorrhoea where a careful inquiry into the history of a case, and an examination of the sexual organs, does not reveal the least trace of gonorrheal or syphilitic infection (Compare No. 14, 15, 16, 17). It is probably from such like gonorrhoeas that the phenomena, by means of which Ritter has constructed his lues gonorrhoeica, have resulted. Secale 70.-Differences between the tubercles according to their locality. We have already stated above that these tubercles occur more frequently among females than males. Among tubercles which occur on other parts than the sexual organs, there prevail different forms, so that, in order to facilitate a knowledged and recognition thereof, we deem it proper to add a few remarks. According to the observations instituted by Dr. Davasse of Paris, they exhibit the following different shapes: 1. In the Mouth.-In the mouth they are seen most frequently on the inside of he borders of the lips or on the inside of the cheeks. On the borders of the lips they generally assume the shape of projecting, somewhat flattened elevations, are almost always oval, rather small, more or less numerous, always single, grayish or rose-colored, rarely moist, sometimes covered with thin scurfs, and exhibiting trifling, ulcerated cracks. They are not very persistent, frequently disappear as rapidly as they return, and are very often associated with similar symptoms in the throat or on the sexual organs. In the corners of the mouth they generally exhibit the same characteristics; here they are frequently mistaken for ordinary rhagades. On the inside of the cheeks they likewise have the same appearance; but on the tongue, where they break out at one time at the tip, at another at the edges, and then again at the root of this organ, they most frequently resemble the tubercles that break out on the pudendum, are oval or rounded, rather large, of the grayish or dirty red color, frequently ulcerate, and in general exhibit all the symptoms that we have described (No. 68 ). 2. In the throat-here they are most frequently seated on the velum or tonsils, in which case they frequently constitute an affection described under the name o syphilitic angina. In the throat they generally appear in the shape of small, round elevations, which are at times broad, at other times shall, and sometimes very numerous or even confluent, having whitish-gray color. At the same time the tonsils may be somewhat swollen or red, the tubercles may be eaten into, giving rise to deep syphilitic ulcers, whereas in other cases all signs of ulceration may be wanting. At the same time the throat is generally affected in other ways; for instance, there is pain during deglutition, and more particularly a peculiar huskiness or loss of voice, known as syphilitic. These tubercles in the throat are very frequently accompanied by chancres on the sexual organs, more particularly indurated chancres. 3. On the nose.-Here they may be seated on the nose as well as in the interior of this organ, at the entrance of the nostrils, In the former case they generally break out in the outer angle of the aloe nasi, where they exhibit almost the same characteristics as when seated on the lips, except that they are smaller and frequently not much larger than a pins head. Most generally they appear in clusters of two or three, of a granular surface, and frequently forming an excoriation in the angle between the cheek and ala nasi. When located in the nostrils, they generally occupy the entrance where they form an annular crust, which, when falling off, exhibits a grayish-red base that soon after is covered again with new crusts. These nasal tubercles are always accompanied by syphilitic appearances on the sexual organs; very frequently they break out simultaneously with these latter as primary phenomena. 4. On the toes-Here they may show themselves at the commencement of the toes as well as on the nails. Being almost always ulcerated, they resemble most frequently the rhagades at the anus. Their elevated portion is of a violent red color; between the toes they are rounded on the nails oblong, surrounding the root of the nail and forming irregular cracks, whose fungous borders cover the nail more or less, while the livid, grayish red base secretes a profuse quantity of a very fetid, purulent ichor. As a rule these ulcers likewise break out while the sexual organs are still affected by disease. 5. Upon the Skin.-Here they principally seen on the nipple of the mammae, on the ears, cheeks, chin, the inguinal region, and the umbilicus; in the case of infants with congenital syphilis, they are spread over the whole body. Secale 71.-Diagnosis. This is a generally not very difficult, specially if other syphilitic symptoms are present on the sexual organs. The only appearances with which they might possibly be confounded, are the elevated chancre, figwarts, mercurial ulcers, and at the anus, with ulcerated haemorrhoids, or haemorrhoids rhagades. From the elevated chancre, and from figwarts, they will readily be distinguished by any one who has read our description of both these appearances in No. 37, 68, and 73. It is likewise impossible to confound them with mercurial ulcers, even when these are seated in the mouth and fauces; for these ulcers are never raised, but always flat, generally spreading over an extensive surface, and always of a milky-white appearance. As regards haemorrhoidal ulcers or rhagades, they are always of a more or less violent-red color, never flattened, but always globular, elastic, and not resisting to the feel. But it is more difficult to distinguish these tubercles from an old, neglected or mismanaged, ordinary, simple chancre, for the reason that a mucous tubercle, if it occurs singly, very frequently resembles a chancre in the stage of fungous growth. It is true that, in most of these cases, the remnants of the sharply-circumscribed edges of the chancre can be readily distinguished from the less sharply-circumscribed border and base of these tubercles; but chancres which, like syphilitic erosions, have remained superficial and which afterwards become suddenly raised, or exhibit marked granulations, very frequently bear a very close external resemblance to these tubercles. Ricord’s assertion that we may always be sure of having to deal with an old chancre, if a patient who had no previous syphilitic symptoms about him, presents himself for treatment after having become infected with one or two such tubercles that had broken out at the spot where chancres are in the habit of making their appearance, may be perfectly correct in most instance, but not by any means in all. I have seen two such tubercles on a young mechanic-one on the fraenulum, the other on the inner surface of the prepuce-three days after they had broken out all at once, which I certainly should have mistaken for old chancres in the period of fungous reproduction, if I had not been well acquainted with the patient, who was in the habit of consulting me for the smallest trifles, and would not have allowed a chancre to reach this period without coming to me for treatment. No other symptom of either primary or secondary syphilis could be discovered in this case; but the girl who had infected him, and who did not keep herself very clean, had a number of such tubercles on the inside of the labia majora and at the anus. On the other hand, it is undoubtedly correct that these mucous tubercles generally break out on different parts at once, in greater or less quantity; in a case of chancre this never takes place in the same manner. Secale 72. Treatment. If old-school physicians assert that nothing is easier than to cure these tubercles, since they yield very readily to appropriate external applications, their assertion is undoubtedly correct, provided we understand by the term “cure,” a simple removal of these tubercles from the skin by external means. But if we consider that a mere external suppression may superinduce all the symptoms of constitutional syphilis, and that a cure implies not only their suppression, but a complete annihilation of the internal syphilitic disease, we may be willing to admit that the healing of such tubercles is attended with the same greater or less difficulties as that of any other form of primary syphilis. If there ever was a case of syphilis, where it is of the utmost importance to heal the disease with internal means, it is mucous tubercles. These tubercles, like buboes, appertain to a period of development of the syphilitic disease (as we shall show in the second division of this work, (No. 79, etc.) where they still constitute a primary form of syphilis, although the whole organism may already be tainted, and where they may lead to consecutive, but not strictly speaking secondary, phenomena; inasmuch as the contagious virus is not yet, as in the secondary period, chemically combined with the fluids of the body (for this is evident from the fact that its products are still possessed of a capacity to transmit the disease), but still exists in a state of freedom, and hence is much more readily excreted than at a later period. However, inasmuch as the period when tubercles make their appearance already constitutes a transition-period, Mercurius, which is a chief remedy even in this period, particularly Mercurius subl. and Cannabaris, may not always be sufficient, but has frequently to be replaced, or assisted in its action, by other agents, such as Nitri ac. and Thuja, which will always prove curative, as I have seen in a number of cases, as long as no real symptoms of secondary syphilis have yet made their appearance. In these last-mentioned cases, of which, until now, I have only seen one with simultaneous Corona veneris, and where the tubercles were seated on the tonsils, inducing a sort of angina syphilitica, other remedies may have to be resorted to. In the case I have just alluded to neither Mercurius nor Nitri ac., nor Thuja proved of any avail; Lycopodium effected a cure. It is strange that, in our own literature, not a single case of these tubercles should as yet be mentioned. Have they been confounded with chancres; or, as in Hartmann’s Therapeutics, with figwarts; or do they occur less frequently in Germany than in France? Attomyr’s description of his second form of chancre, which he cures with Nitri. ac. (see his “Venerische Krankheiten,” page 23), leads me to suspect the former; for his statements: “Ulcers flat and raised; clean, flesh-colored, almost fungous appearance, and simultaneous breaking out of several ulcers,” may refer to numerous tubercles, rather than to the elevated ulcer. As for the rest, these tubercles occur much less frequently than chancre, buboes, and figwarts, perhaps; only in hospitals, where chancres are generally removed by ointments and cauterization. Indeed, most of those who come to me for treatment, when afflicted with such tubercles, are poor servant-girls, who leave the hospitals with all the symptoms of a badly-healed chancre still upon them. Thorer’s cases (Arch, vol. XIII., part 3, pages 80-86) most likely belong to this same class of mucous tubercles. III. SYCOSIS EXCRESCENCES Secale 73. Description. Almost all recent French authors distinguish, after the fashion of Lagneau, two kinds of sycosic excrescences: (1) The grafted or implanted excrescence of greater density than that of the skin, to which they adhere by their base, a sort of pedicle; most of the sycosic products belong in this class under the name figwarts. (2) Hypertrophic excrescences: these arise by a simple swelling of the cellular tissue of a fold of the skin or mucous membrane, and ulcerate readily, after which they secrete a fetid, slimy pus. The former of these two kinds occurs most frequently, has the most varied forms, and is much more numerous than the humid excrescences. As a general rule they are seen on the mucous membrane of the genital organs, for instance, on the prepuce, glans, behind the corona, or on the side of the frenulum; some- times in the orifice of the urethra; among females, we see them on the inside of the labia majora and minora, on the clitoris, around the orifice of the urethra, at the inferior commissure, on the lesser papillae, and even around the os tincae. They are even not unfrequently seen on the margin of the anus, even in the rectum; in some cases they are even seen on the nipples of women, who have been infected by nursing syphilitic infants, on the perineum, on the outer side of the labia majora, on the mons veneris, the inside of the thighs, in the groin, and on the navel of newborn infants. They may even break out on the tongue, velum palati, and eyelids. Generally they are much smaller than the humid excrescences, but occur very frequently in large quantities on the same spot, forming considerable fungous masses. As regards their forms, they sometimes are shaped like cauliflowers, sometimes like warts, sometimes like long stems (they have been known to shoot up from behind the corona glandis to the height of two inches like goose-quills, becoming erect when the prepuce is drawn back, and, when the prepuce is brought forward again, reclining over the glans like flexible, vegetable stems); and sometimes like raspberies, more specially among women, on the clitoris, or round the orifice of the urethra, etc. Their color likewise varies. The wart-shaped excrescences are generally paler than the surrounding skin; those with long pedicles are generally a little redder; the cauliflower and raspberry-shaped excrescences, having frequently a good deal of blood, have likewise the most redness. In general, all these varieties are very dry, except the cauliflower variety, which generally excrete an exceedingly copious, yellowish, and sometimes bloody moisture. If neither irritated by friction nor by acrid substances, all these varieties are very seldom painful; the cauliflower and raspberry-shaped excrescences are the most sensitive. The excrescences of the second class, which, as has already been stated, arise from a tumefaction of the cellular tissue of a fold of the skin, and among which we number the fig-shaped condylomata, and those that are shaped like the articular head of a bone, occur most frequently in the region of the anus, but often likewise at the entrance of the vagina, on the labia majora or minora on the penis between the prepuce and glans, sometimes even on the perineum, and on the inner surface of the things. These condylomata are generally more or less oblong, flattened tubercles, whose free margin is rounded, except when these excrescences are already seated upon an already round elevation, such as old piles, in which case they are attached: a more or less elongated pedicle. They are very seldom of a large size, although some authors assert that they have seen condylomata of the size of a hand, weighing several pounds. From these condylomata, those that are shaped like a cock’s crest are distinguished by this circumstance, that the latter are elevated on the skin with an indented border, and flat like the blade of a knife. Both forms are generally of a hard, almost cartilaginous consistence, and not very painful; at the same time they are very red, easily excoriated, in which case they excrete a very fetid, slimy, more or less acrid matter of a yellowish color. Secale 74. Nature of these Excrescences. Among all venereal phenomena there is scarcely any whose nosological nature has given rise to so many arguments, and has, nevertheless, been explained with so little satisfaction, as these excrescences. For, while Hahnemann and several authors of the old School contend that these excrescences arise from a miasm that is neither the miasm of gonorrhoea nor that of chancre, other authors, on the contrary, regard them either as products of the virus of gonorrhoea or that of chancre, without, however, agreeing whether they ought to be attributed to the former or to the latter, or whether they constitute primary or secondary symptoms of a syphilis. In view of these differences of opinion, our reasonable readers will not expect at our hands an authoritative settlement of the dispute. All we can do is to exhibit in the clearest light all the facts that have been well substantiated so far, namely:- (1) Whatever may be said concerning the syphilitic or idiopathically sycosic nature of these excrescences, they are at all events venereal, that is, products arising sooner or latter from venereal infection, either as protopathic or consecutive phenomena, and capable of transmitting a similar disease during the act of coit. (2) They may occur during, or at the termination of a gonorrhoea, or they may break out before any symptoms of gonorrhoea have set in; in the same way as we see them appear during or after a chancre, even a long time after the chancre has disappeared, in company with a variety of other consecutive affections. The form of these growths is immaterial, although those which occur during the fungous period of a chancre, generally belong to the second variety, the hypertrophic. This might lead us to regard this form as a positively syphilitic product, resulting from the action of chancre-virus, so much more as in more than one respect they resemble mucous tubercles, from which they are often distinguished only, specially when in a state of ulceration, by their greater, characteristic, cartilaginous hardness, which reminds one of the Hunterian chancre. Be this as it may, these excrescences occur after chancres as well as after gonorrhoeas; if they communicate the infection, this never develops chancre but either similar excrescences or gonorrhoea, in which case the only question is whether this gonorrhoea is to be considered as an idiopathic, sycosic discharge, or whether this discharge is identical with one of the two classes of gonorrhoea that have been mentioned, No. 15 to 17, the common clap or the syphilitic gonorrhoea. If we consider that both the chancre-virus as well as the gonorrhoeal poison can produce excrescences, and that, where gonorrhoea is followed by this phenomenon, it, as frequently as chancre, is followed by all the symptoms of secondary syphilis, we are inclined to believe that a gonorrhoea resulting from such a cause is nothing else than the syphilitic gonorrhoea, described in No. 15 to 17, differing greatly from the common clap, and where the chancre-virus appears indeed modified, but ought nevertheless to be regarded as the source of these phenomena. Secale 75. Diagnosis. Upon the whole this is not very difficult, particularly as regards a differential diagnosis of the two kinds of excrescences mentioned in sec. 73. They are likewise readily distinguished from other syphilitic products, inasmuch as the only phenomena with which they might be confounded, and indeed have been confounded by some (by Hartmann in his Therapeutic), or have been ranged in the same class, are mucous tubercles, whose want of cartilaginous hardness, however, distinguishes this product as one that does not belong to the class of which we are speaking. There might perhaps be some difficulty in distinguishing these from non-syphilitic, so to say, purely mechanical formations. Lagneau is perfectly correct in observing that on the same spots which are generally the seat of these excrescences, similar growths may make their appearance that cannot be attributed to venereal infection. This may happen in the case of pregnant females, for instances, upon whose sexual organs small wart- shaped elevations are sometimes noticed, that arise from no other cause than from the pressure of the child upon the rim of the pelvis, and from the varices which this pressure gives rise to in the capillary system; or which varices may likewise arise after forced marches, frequent frictions during sexual intercourse, or any other more or less continued pressure upon the sexual organs. These last-mentioned appearance, however, occur very rarely, but head to be mentioned, in order not to omit anything that might possibly resemble, and be mistaken for, sycosic growths; on which account the physician will do well, if other syphilitic symptoms should be present, or venereal affections have evited some time previous, or in all cases where venereal taint may by suspected, not to allow himself to be led into error by the supposition that the suspected products may probably have been occasioned by some harmless cause, and not to entertain any doubt, except in cases where the previous history of the cases, and the present circumstances surrounding it, do not reveal the least signs of a syphilitic taint, and where the whole aspect of these growths is entirely different from what it would be, if they had originated in venereal poisoning. Another circumstance which cannot be sufficiently impressed upon the attention of the physician, is the shape that these growths assume when they are neglected and continue to spread. In such a case they sometimes cover the whole glans; if at the same time, they should become ulcerated, the whole mass contracts such a horridly-repulsive appearance that one might be tempted to regard them as carcinoma of the glans or prepuce. Nevertheless all doubt regarding the sycosic nature of the excrescence may be removed in a case of this kind, not only by an inquiry in to the history of the case and by the accompanying circumstances, but likewise by a consideration of the fact that carcinoma of the glans and prepuce are very rare occurrences that generally befall on old people. Of course, our conclusions will undoubtedly be corroborated by a more particular examination of the phenomena exhibited to our view. Secale 76. Prognosis. If these excrescences are considered by themselves, independently of their primary cause, we shall very readily be led to the conclusion that their cure is comparatively easy; for in many cases they are even removed by the scissors, and yet do not break out again so very readily. On the other hand, there are many cases of such excrescences, where, if left to themselves, they remain unchanged for years, or, if removed by artificial means, break out again, except that they increase in volume, specially on the penis and at the anus, where they often attain a considerable size, and sometimes from the most hideous ulcers; in addition to which, by virtue of their inherent faculty of growth, they repair the waste of substance consequent upon the ulcerative process, and by this means frequently occasion the destruction of the considerable portion of the penis. Even with regard to the accessory affections which these excrescences may engender, their prognosis is not very dubious, inasmuch as they may sometimes, when no other syphilitic ulcers are present, and they are otherwise accompanied by violent inflammation, occasion a slight sympathetic swelling of the inguinal glands, but never true buboes in the more rigorous meaning of the term, neither phimosis nor paraphimosis. It is only when the figwarts are very large and numerous, suppurate profusely, and the patient’s mind is very much depressed, the vital functions may become disturbed, and the patient may lapse into a sort of marasmus, such as takes place in consequences of cancerous ulcers, and which, unless the excrescences are healed, must render the prognosis more dubious. At the same time, we should never forget that these excrescences, no matter whether they occur primarily or secondarily, never constitute the disease itself, but that they are always symptoms of a more general constitutional diathesis, super-induced by the action of some infectious virus (gonorrhoea, chancre, or sycosis), and which has to be extirpated. With reference to this task, we have a right to declare that there is probably no form of syphilis which is more difficult to reach by internal treatment than these excrescences, which sometimes remain, even after all other syphilitic symptoms have been removed, with all the obstinacy of indolent cicatrices of chancres that had been healed long ago. In such cases, these remaining figwarts may be nothing more than remnants of the disorganizations caused by the action of the syphilitic virus, which no internal remedy can heal, any more than the cicatrices of old wounds can be wiped away by internal treatment. Admitting, however, that these remnants can be healed, it can only be done where, after the extinction of every syphilitic symptom, the figwarts themselves are deprived of every sign of morbid activity. Secale 77. Treatment. It must be evident from what has been said, that where figwarts are to be radically cured, a mere external treatment will prove insufficient, as long as other symptoms of the syphilitic disease are still present, or the excrescences are still painful, continue to grow, spread, and suppurate, in one word, still continue to manifest symptoms of morbid activity. When Hahnemann advised, even in the most inveterate and long-standing cases, to touch the figwarts with the extract of Thuja, he undoubtedly meant no other cases than those which we have described; with the exception of these obdurate cases, the cure of figwarts, by homoeopathic remedies, is not by any means as difficult as those, who do not keep in view the difference between active figwarts and the remnants of a defunct syphilis, imagine. In my own practice, I have derived the greatest advantage, in cases where the figwarts were complicated with chancre, from the use of Cinnabaris and Nitri ac., and sometimes from the use of Phosph ac., or Staphysagria; whereas, when these excrescences were complicated with gonorrhoea, I have derived the most benefit from Thuja, sometimes from Mercurius cor., likewise from Cinnabaris and Nitri ac., even from Sulphur and Lycopodium. In a case of humid condylomata, I prefer commencing the treatment with Nitri ac., after which, if this remedy should not prove sufficient, I resort to Thuja. For dry excrescences, specially when of the cauli- flower, mulberry-shaped variety, I at once administer Thuja or Staphysagria; for pedunculate condylomata, I first employ Lycopodium. In my experience, the locality of the ulcers has never seemed to have much to do with the selection of a remedy. Other practitioners have employed the following remedies: (a) According to their forms: for broad, flat, bean-shaped condylomata: Thuja, Nitri. ac. for elevated, cauliflower, raspberry, mulberry-shaped: Thuja. for fan shaped: Cinnabaris. for pedunculate: Lycop., Nitri.ac.; for cone-shaped: Mercurius sol.; for dry: Thuja, Mercurius sol.; Corr. subl., Nitri ac., Lycop.; for moist, suppurating: Nitri.ac., Thuja, Sulphur, Euphrasia. for soft, spongy: Sulphur. (b) According to their locality, when first manifesting themselves. on the glans, or corona glandis: Nitri. ac., Thuja, Cinnab., Lycopodium, Sulphur; on the prepuce: Thuja, Nitri. ac., Lycopodium, Corr. subl. on the scrotum: Thuja. at the anus: Thuja, Euphrasia, Corr. subl. (c) According to their origin, when first appearing: after chancres: Thuja, Mercurius sol., Staphys.; after gonorrhoea: Thuja, Lycop., Cinnabaris. Secale 78. Practical Observations by other Practitioners. These are mixed up with a good many hypothetical speculations to which we shall add our own observations. 1. HAHNEMANN- If Hahnemann states in his “Chronic Diseases,” that the suppression of the local symptoms, the original figwart, is followed by other similar excrescences in other parts of the body for instance, by “whitish, spongy, sensitive, flat elevations in the buccal cavity, on the tongue, palate, lips,” etc. he evidently means the mucous tubercles, which have been recently observed after chancre (see No. 70); it would be interesting to know whether he had seen these tubercles, that are at the present time so frequently seen after chancres, breakout in consequence of a sycosic gonorrhoea; if so, this would demonstrate the original identity of syphilis and sycosis in an almost irrefutable manner. 2. ATTOMYR (in his “Venereal Diseases”) recommends Thuja for cauliflower-excrescences which at first are dry, and afterwards become humid. This distinction, between “at first and afterwards,” affords, however, no indication for the selection of a remedy, inasmuch as Thuja cures both dry and moist figwarts. 3. HARTMANN (Therapeutics) is of opinion, and very correctly, that sycosis, although presenting peculiar characteristics, yet has its root in the syphilitic disease (see No. 74). But if, in vol. II., page 167, he recommends Nitri ac. for a fungous crusty “ulcer, with a dark-blue, greasy base, and having the appearance as if it had sprung from a boil,” such an ulcer is more likely a chancre in the period of fungous reproduction, than a purely sycosic growth. As regards his statement concerning the curative power of Sabina for condylomata with intolerable burning and itching, or with abnormal granulations; concerning Cinnabaris and Thuja for condylomata that had grown up from chancre; and concerning, or Nitri ac. for pin’s head-shaped condylomata (which are most likely the mucous tubercles described in No. 70), I am prepared to confirm all such statements from personal experience. 4. HOFRICHTER (Allium hom. Zeit., vol. 35) is of opinion that chancre and figwarts spring from the same root, and in so far are identical; but if he infers this identity from the circumstance that “chancres at the present period tend more to fungous growth than to dip down to the subjacent textures,” he evidently commits an error in classing fungous chancres and sycosic excrescences, with which the former are not absolutely identical, in one and the same category; considering their structural differences, however, this is not admissible. 5. RUMMEL (Allium hom. Zeit., vol. 18) very justly observers that Thuja heals most reliably the thick, red, humid, raspberry- shaped, but never the thread-like excrescences; he relates an important case, where, after a chancre had been treated by a homoeopath for several weeks with large dose of Mercury, large figwarts made their appearance with suspicious-looking suppurating surfaces at the anus, for which Staphysagria proved speedily curative; at the same time it removed the burning, twitching, stinging pains that became intolerable during an alvine evacuation. On this occasion he warns against the obstinate use of mercurial preparations, specially in increased doses, if it has become evident, after using them for ten days or a fortnight, that they will not improve the case; for the aggravations resulting from such abuse he advises Nitri ac., and sometimes Sulphur, as appropriate, remedies. 6. LOBETHAL (Allium hom. Zeit., vol. 13) considers sycosis and syphilis as identical; but he is mistaken in his assertion that figwarts can never break out without a previous chancre; this statement is refuted most positively by the observations of a number of writers on syphilis. 7. THORER (Arch. 19) does not think that sycosis is identical with syphilis, for the reason that he has seen figwarts break out after chancres that had been cured with Mercurius. I have met with similar cases, but in all of them, as in the cases related by Thorer, the chancre had already continued for several weeks, and the breaking out of the sycosic excrescence, which had been preparing all this time, could no longer be prevented in spite of the Mercurius, that does not heal every kind of chancre any more than it cures every form of figwarts. Moreover, according to what we have said before (No. 68-71), it is not by any means sure whether the numerous ulcers on the female organs, of which the author makes mention in those cases, were not ulcerated tubercles rather than chancres, in which case it seems quite natural that Mercurius alone was not sufficient to remove products that had already the character of consecutive symptoms; but that other remedies were required to extirpate the syphilitic disease at this stage, as we have shown in No. 72. 8. WAHLE (Allium hom. Zeit., 15) admits that figwarts may partake of the nature of syphilis; but if he imagines that all chancres, which, after having been unsuccessfully treated with Mercurius, pass into the period of fungous growth are no longer syphilitic, but of an herpetic, or scrofulous character this theory has been refuted in thousands of cases by the fact that such chancres may be succeeded by the most loathsome and terrible destructions of the organic tissues. NOTE BY DR. HEMPEL. (One of the most important remedies in the treatment of sycosic excrescences is Tartar emetic. The following case affords a remarkable illustration of the curative virtues of this agent in sycosis. The patient was a fine-looking young man, 25 years old. The first two-thirds of the penis, including the glans, were covered with an almost countless number of figwarts, of various shapes and sizes. After trying in vain all the usual remedies for figwarts, I prepared a solution of ten grains of Tartar emetic in four ounces of water, and directed him to bathe the figwarts with it, and to keep a compress, moistened with the solution, applied to the penis. At the same time I gave him the one-hundredth part of a grain of Tartar emetic, dissolved in eight ounces of water, to take internally, in tablespoonful doses every four hours. In two days the young man returned, and to my amazement this whole mass of figwarts, which had been treated by several allopathic physicians for over six months, had been completely melted, as it were. There was nothing left but a small quantity of moisture where each condyloma had stood, to which lint was applied for a few days, when the skin looked dry and healthy. Only one of these warts did not yield to Tartar emetic. It was removed without difficulty by means of Sabina, used externally and internally. I saw this patient about nine months after, when he still enjoyed the most perfect health. In the case of female patients, the greatest care must be had when applying Tartar emetic to the sexual organs externally. Otherwise we may see the labia studded with vesicles, even after one application. What would a one-hundred-thousandth potentialist have done in the case of my young gentlemen? Most likely he would have driven him to suicide. When this young man came to me, his spirits were profoundly depressed, and he told me that he could not bear life any longer. A year ago I treated one of our young merchants for chancre, Hunterian variety. The cure seemed perfect. Six months after this event, he married a very excellent and refined young lady. About four months after his marriage, he came to me with his wife, informing me that she was diseased. An examination revealed three condylomata; two of them, mucous tubercles, seated on the edge of one of the labia majora, near the inferior commissure; and one, of the pedunculate variety, situated within the vulva. He pledged his word to me that, since his last mishap, he had kept clear of women, and that, when he married his wife, she was as pure as an angel in heaven. I examined him, and discovered a small condylomata under the head of the penis. He bruised it away with his fingers, after which it bled furiously. He could not tell me how long it had been there. Feeling confident that Thuja and Nitri. ac. would cure the lady, I gave her these remedies in small doses, but without any effect whatsoever. I tried other remedies, without results. I then gave her ten drops of the extract, three times a day, and a cure was speedily accomplished).

George Heinrich Gottlieb Jahr

Dr. George Heinrich Gottlieb Jahr 1800-1875. Protégé of Hahnemann. His chief work, " The Symptomen Codex" and its abridgments, has been translated into every European language. He also published several smaller works for daily use, ''Clinical Advice" "Clinical Guide," and "Pharmacopoeia", as well as his "Forty Years' Practice”. Also "Manual of the Chief Indications for the Use of all known Homoeopathic Remedies in their General and Special Effect, according to Clinical Experience, with a systematic and Alphabetic Repertory."