the size of a pea, in the clitoris; then warty growths of more rapid formation from the surrounding parts, the latter only of four months' duration. She has fallen away very much, and complains of constant thirst. She perspires profusely at night. So severe have been the pains in the loins, that she has required pressure to render them tolerable. There is enlargement of the clitoris, preputium clitoridis, nymphæ, and inferior commissure of the vagina, with ulceration of the orifice, which is larger than natural. There are numerous large red vegetations from the clitoris. Enlargement of the absorbent glands in each groin. Only palliative treatment could be adopted. In the male, herpes and excoriations of the glans and prepuce, and simple abrasions, frequently occur from sexual intercourse, without venereal taint. They admit of easy diagnosis, inasmuch as they are usually noticed a few hours after connexion. The only disease affecting the penis with which syphilis is apt to be confounded is cancer; and it must be admitted that mistakes have occurred at the commencement to surgeons of great experience. Cancer of the penis may commence as a wart; or as an indurated knot under the prepuce, which, in a large number of such cases, has been contracted at its orifice (phymosis) from birth. The course of the disease is ulcerative: the glands in the groin become affected, as in cancer affecting the female breast. The following case was under Mr. Lawrence's care about ten years ago : Francis J. aged fifty, married, formerly a publican, afterwards a commercial traveller, accustomed to live freely, states, that two years ago he noticed on the inner surface of the prepuce a small wart, which he picked with his fingers. Upon its recurrence he went to a chemist, who burnt it away with caustic four times, after which he one day dragged it out by the roots. The wart never came again, but the raw surface would not heal; but when touched with bluestone became very tender, and spread. Twelve months ago a small subcutaneous knot, the size of a pea, very hard, but not particularly painful, came behind the preputial sore. He then consulted a hospital surgeon, who put him under a mercurial course for seven weeks, in the belief the disease was syphilitic. The knot had become as large as half a walnut. He then came to St. Bartholomew's Hospital. A hard mass, the size of a small walnut, is situated in the skin and corpus cavernosum penis of the left side, behind the glans. There are two ulcerated surfaces, one as big as a shilling, the other as big as a pea, upon its surface. The penis was removed. October 17.-The case went on favourably till November 25, when a stricture formed three inches down the urethra. This was relieved by the use of catheters, and he left the hospital in a comfortable state. December 10.-He was admitted, suffering from an extravasation of urine. An opening was made in the perineum; but the patient died. Upon examination after death, it was found that the urethra and bladder were healthy; the orifice of the former alone being contracted. There was no return of disease in the penis, but the inguinal glands were slightly infiltrated with cancer. A patient has just left the hospital, from whom I removed the entire scrotum and the testicles, with some of the integuments of the right thigh, for that form of epithelial cancer, termed chimney-sweeps' cancer. The disease commenced in the usual manner, as a soot-wart in the scrotum, and gradually extended until the whole surface was occupied by a vascular wart and ulcerating surface, secreting a most offensive discharge. The inguinal glands were somewhat enlarged, but not very hard. Under the circumstances, it was considered right to give the patient the benefit of an operation, and the morbid parts were removed, including the testicles, which, though not absolutely diseased, adhered firmly to surrounding parts. The case went on favourably, the wound healing completely by granulation, and the glandular swellings subsiding. A very little inquiry will suffice to enable the youngest surgeon to distinguish this affection from syphilis. 91 CHAPTER VI. SECONDARY SYMPTOMS. In the preceding pages I have endeavoured to show that the poison producing any kind of primary syphilitic sore (the varieties or the characteristics of which depend chiefly on the structure of the part occupied), may become the means of infecting the system by its direct conveyance along the absorbent vessels into the venous circulation. Buboes occur far more often than is generally supposed; that is to say, the inguinal glands very commonly swell, and remain tender for a few days, and then subside; this occurrence, after a lapse of years, is often forgotten by patients, or misunderstood, and called a passing stiffness of the hip-joint, attributed to a sprain. I beg, Mr. Acton observes, "that the simple and the phagedænic sores are rarely followed by constitutional syphilis, whereas the indurated chancre rarely if ever fails to be succeeded by the most positive secondary symptoms."(On the Urinary and Generative Organs, p. 475.) with every respect, to dispute both these positions. From my observation of a vast number of cases of primary and secondary syphilis in St. Bartholomew's Hospital, I have come to the conclusion that secondary symptoms, in an immeasurably larger proportion, ensue after every variety of simple and non-indurated chancre. Indeed, the indurated sore is, according to my experience, rather of rare Occurrence. After primary phagedæna, too, secondary the fraction in question. symptoms may me. He had a well-marked indurated chancre, the subcutaneous knot was about the size of the last joint of a man's little finger. Upon its prominent part was a small excoriation: the whole occupied the loose areolar tissue at the root of the prepuce. Of course I directed a course of mercury, to be continued until the hardness had entirely disappeared. He requested my opinion as to the probability of secondary symptoms, and I gave an unfavourable reply, to his evident distress. Thirteen years have now elapsed, and I am in a position to state, from intimate acquaintance with him during the whole time, that he has never had a spot or blemish about him. On the contrary, he has married, and is the father of several healthy children. It appears to me that it would be more correct to say |