TREATISE ON GONORRHOEA VIRULENTA, AND LUES VENEREA. BY BENJAMIN BELL, MEMBER OP THE ROYAL COLLEGE OF SURGEONS OF IRELAND AND EDINBURGH, ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. WITH NOTES, ADAPTED TO THE PRESENT STATE OF PRACTICE IN THOSE DlfiEASE^.i TWO VOLUMES /JV OAT VOL. I, ALBANY s PUBLISHED BY E. F. BACKUS, NO. 65, STATE-STREET, 3. & E. Hosford—Printers-Al&ffnvs 1814. 4* District of New-York, ss. BE IT REMEMBERED, tliat on the tenth day of October, m the thirty -ninth year of the independence of the United SJates of Ameri- L. S. ca, E. F. Backus, of the said District, has deposited in this office the title of a Book, the right whereof he claims as Proprietor, in the words following-, to wit ; c A Treatise on Gonorrhoea Virulenta, and Lues Venerea. By Benjamin Bell, Member of the Royal College of Surgeons of Ireland and Edinburgh, one of the Surgeons to the Royal Infirmary, and Fellow of the Royal Society of Edin- burgh. With Notes, adapted to the present state of practice in those diseases. Two volumes in ones. In conformity to the Act of the Congress of the United States, entitled " An Act for the encouragement of Learnmg, by securing the copies of Maps, Charts and Books to the authors and proprietors of such copies, during the time therein mentioned." And also to an Act, entitled " an Act. supplementary to an Act, entitled an Act for the encouragement of Learning-, by securing the copies of Maps, Charts, and Books to the authors and proprietors of such eopxes, during the times therein mentioned, and extending the benefits thereof to the arts of designing, engraving and etching historical and other prints." THERON RUDD, Clerk of the Southern District of JVIew-Tork. ERRATA. Volume 1st. Page 89, line 17, for by, read but. Page 207, line 21, for as, read is. Volume 2nd. Page 162, line 42, for oszena, read eczema. Page 193, line 19, for breat read breast. Page 222, line 46, in a few copies for mtermscence read intumescence Page 284, line 9, for balanci, reaci jbalani. ADVERTISEMENT TO THE PRESENT EDITION. The Editors of the present edition of Bell on 1he Venereal, have endeavoured to render that work more valuable, by adding to it the improvements in practice as well as the investigations on the nature of the disease, which have been offered since the period at which the Author wrote. This information they have condensed in as small a space as possible, and adhering strictly to the principle of leaving the original text untouched, have presented it in the form of notes to the several sections. In preparing these, a free use has been made of every late writer within their reach, whose opinions or expe- rience have appeared to deserve attention; and should their additions comprise to the satisfaction of the med- ical reader, an analysis or notice of the above produc- tions, their wishes will be fully gratified. Albany, Oct. 8th, 1814. TO DOCTOR WILLIAM SANDERS, 6ENI0R PHYSICIAN TO GUT'S HOSPITAL, jRELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON, AND OF THE ROYAL SOCIETY OF EDINBURGH, These Volumes are respectfully dedicated, as a small testimony of regard, and public acknowledg- ment, for the advantages which have been derived from his various exertions to promote the extension and general utility of medical science, by His obedient, And very humble Servant, BENJn. bell. EDnsrBTmsH, V ^St Nov. 1792. 5 PREFACE AS many of the symptoms of Gonorrhoea and Lues Venerea become frequent objects of the surgeon's at- tention, I at one time meant to have introduced a trea- tise on these diseases in the System of Surgery pub- lished some years ago, but I was prevented from doing so, by different publications upon the same subject be- ing announced about the same period. As these works have since made their appearance? and, as some of them have been very favourably re- ceived, it may be imagined, that farther writings upon this subject can scarcely at present be required. It must indeed be admitted that many valuable publica- tions have come forth within these few years upon this branch of the profession ; particularly one by Mr. John Hunter of London, intitled, A Treatise on the Venereal Disease ; and another intitled, Practical Observations on Venereal Complaints, by Doctor Swediaur. But although much information may be obtained from both of these works, as well as from some other late publications upon this subject, there is still much left for others to elucidate. Such is the effect of experience and observation, that farther ad- vantages are daily accruing from the labours of indi- viduals in the treatment of this as well as of almost every other disease ; and as this I hope will in some degree appear from the present publication, so I shall still expect to find that the future endeavours of others will prove yet more successful. Among other points which I have more particularly attempted to elucidate, the treatment of Gonorrhoea by injections, and the quantity of mercury to be ex- hibited in Lues Venerea, are, perhaps, the most im- portant ; and I flatter myself that I have given views concerning them, which, in practice will be found to merit attention. The cure of Gonorrhoea by injec- tions is, no doubt very universally practised ; but while in a great proportion of cases it proves successful, in till PREFACE. others it fails entirely : The cause of this, so far as I know, has never hitherto been explained. Whether I may have conveyed an adequate idea of my opinion upon this point I cannot positively say ; but the obser- vations upon which it is founded are such, that all who pay attention to the subject may be enabled readily to ascertain such cases as will yield to injections, as well as those in which no advantage is to be expected from them. The opinion which I have ventured to support, of the difference between the matter of Gonorrhoea, and that of Lues Venerea, will no doubt be censured by many. They ought, however, to recollect, in matters of opinion, which cannot be proved by demonstration, that some unceriainty must always take place ; and be- fore censuring with severity the opinions which others may suggest, they should consider whether their own may not be equally liable to objection. To me it ap- pears that the reasons which! have adduced in support of my opinion are very conclusive, but I shall make full acknowledgement of my error, if sufficient reasons shall ever be given to show that it is ill-founded. In the mean time, it will be perceived, that the theory which I have adopted does not lead to any deviation from the practice which now generally prevails upon this point, while it serves to explain more clearly than the opinion which has commonly prevailed, several of the phenomena of the two diseases, as well as the cause of different remedies being necessary for each of them. I do not expect that practitioners of experience and observation will derive much information from this publication, but I am hopeful that beginners will de- rive some advantage from it ; for it has been equally my desire to exhibit a correct view of the different symptoms of which I treat, and to point out the method of cure in a manner that will be clear and intelligible. Where theory isever admitted, it is chiefly with a view to explain, upon rational principles, such points as the ingenuity of some speculative writers have tended to render intricate. CONTENTS. VOLUME I. CHAP. I. Consideration of the Question, Whether Gonorrhoea and Lues Venerea originate from the same Contagion, - Page 1? CHAP. II. Of Gonorrhoea Virulenta, SECT. I. General Observations on the Symptoms, Causes, and Seat of Gonorrhoea Virulenta, 37 SECT. II. Of the Prognosis in Gonorrhoea Virulenta, 48 SECT. III. General Observations on the Cure of Gonorrhoea, ■> - 50 SECT. IV. Of the First Stage of Gonorrhoea, 57 SECT. V. Of the Second Stage of Gonorrhoea, - - 70 SECT. VI. Of the Third Stage of Gonorrhoea, - - * - 77 SECT. VII. Of the Fourth Stage of Gonorrhoea, 85 SECT. VIIL Of Chordee, - - - - 9} SECT. IX. Of Haemorrhages from the Urethra, 94. SLCT. X. Of Gonorrhoea in Women, - * ' - - - 95 X CONTENTS. SECT. XL Recapitulation, ---„-.. Page 10 1 CHAP. III. Of the Consequences of Gonorrhoea Virulenta. SECT. I. General Remarks on the Consequences of Gonorrhoea, - 104 SECT. II. Of Gleets, - - - - - . - - - 105 SECT. III. Of Impotency from Seminal Weakness, - 136 SECT. IV. Of Obstructions in the Urethra from Gonorrhoea Virulenta 134 § I. Of Tumours in the Urethra and contiguous parts, - 135 § Z. Of Spasmodic Obstructions in the Urethra, - - 137 § 3. Oi Caruncles in the Urethra, - - - 144 § 4. Of Obstructions in the Urethra from Strictures, proper- ly so called ; of Bougies, and Fistmse in Perineo, - - 146 SECT. V. Of Deranged Sensations in the Bladder, Urethra, and contigu- ous parts, --------- igt SECT. VI Of Swellings of the Testicles, 194 SECT. VII. Of Swellings of the Spermatic Cord, <- 208 SECT. VIII. Of Swellings of the Lymphatic Vessels of the Penis, - 210 SECT. IX. Of Swellings of the Glands of the Groin, - - . - 214 SECT. X. Of Excoriations of the Glans and Prepuce, * - 217" CONTENTS. Xi SECT. XI. Of Excoriations in the Parts of Generation in Women, Page 252 SECT. XII. Of Phymosis and Paraphymosis, - - - - 223 SECT. XIII. Of Warts on the Glans and Prepuce, and Labia Pudendi, - 23! SECT. XIV. Of Gonorrhoea Simplex, - 236 VOLUME II. CHAP. IV. On Lues Venerea. SECT. I. General Observations on Lues Venerea, SECT. IL Symptoms of Lues Venerea, - - - - 12 General Observations, ------ ib. Of Chancres, ------- ib. Of Buboes, 20 Of the Venereal Sore Throat, 37 Of Venereal S >res in the Nose and Mouth, 42 Of Venereal Blotches, ------ 50 Of Venereal Ulcers, 55 Of Nodes, and other Swellings of the Periosteum, Bones, and Tendons, 62 Of Venereal Excrescences about the Anus, - - 70 Of the Venereal Swelling of the Testes, - - 72 Of Alopecia, 75 Of Blindness, as a Symptom of Lues Venerea, - 77 ■ Of Deafness, 80 . Of Anomalous Symptoms, 81 SECT. III. Of the § 1. § 2 § 3. § 4. §5. § 6. §7. §8. §9. § 10 § 11 § 12. § 13. § 14 Of the Venereal Virus. 86 Xll CONTENTS; SECT. IV. Of the Remedies used in Lues Venerea, * - - Page 0g § 1. General Observations, ib„ § 2. Of Mercury, - ~- 99 1. Generai Observations upon Mercury, - - - ib. 2 Of the Effects of Mercury upon the Human Body. - 100 3. Of the Operation of Mercury in the Cure of Lues Venerea, 102 4. Of the Preparations of Mercury, - 130 5. Of the different Methods of exhibiting Mercury, - ' 137 6. Of the Duration of a Mercurial Course, and the Quantity of Mercury to be exhibited, ----- 152 7. Of the Regimen to be observed during a Course of Mer- cury, - - - - - - - - -167 8. Of Profuse Salivation und some other Effects of Mercury, 169 9. Does Mercury ever faii in the Cure of Lues Venerea ? 188 § 3. Of Guiacum, - - 192 § 4 Of Sarsaparilla, 196 § 5. QfMezereon, 198 § 6. Of Opium, ....... 201 SECT. V. Of the Cure of Lues Venerea, - 208 § 1. Of the Cure of Chancres, ib. § 2. Of the Cure of Buboes, 223 § 3. Of the Cure of Venereal Ulcers, - 236 § 4. Of the Cure of Venereal Blotches, - - - 243 § 5. Of the Cure of Nodes, Swellings of the Periosteum, he. 244 § 6 Of the Cure of Venereal Excrescences about the Anus, 247 § 7. Of the Cure of the Venereal Swelled Testicle, - 248 § 8. Of the Treatment of Alopecia, Venereal Blindness and Deafness 250 § 9. Of the Cure of some Anomalous Symptoms of Lues Venerea, - 254 SECT. VI. Of Lues Venerea in Infants, ---*-- 257 SECT. VII. Of iome Peculiarities of Form under which Lues Venerea has appeared in Scotland and Canada, - 268 SECT. VIII. Of Prophylactics, -* - - - 282 SECT. IX. Of Lues Venerea as inducing other Diseases, - - - 284 Appendix, - - - - - - - «■ -313 A Treatise ON GONORRHOEA VIRULENTA, AND LUES VENEREA. CHAPTER I. Consideration of the Question, whether Gonorrhea and Lues Venerea originate from the same Contagion. AN opinion has been generally received amongst practitioners, that Gonorrhoea Virulenta and Lues Venerea are of the same nature; that they origi- nate from the same contagion ; and are only distin- guished by the circumstance of Gonorrhoea being a lo- cal disease of the urethra, while the other is a general affection of the system. But, as there is cause to ima- gine that these diseases arise from different specific contagions, and as the establishing of one or other of these opinions must influence the conduct of the cure, it becomes a matter of importance to institute an en- quiry into this part of our subject. Both diseases are contracted in a similar way ; both, in the first instance, affect the genital organs ; and they occasionally appear at the same time in the same patient : hence it has been concluded that they have a common origin, and one method of cure has been supposed applicable to either. The refusal of some patients to submit to the dis- tress and inconveniency, the frequent result of a pro- tracted mercurial course, and who nevertheless reco- vered from the usual symptoms of Gonorrhoea; first 3 18 ON GONORRHOEA VIRULENTA, Ol. I. suggested a doubt of the two diseases being produced by the same contagion. It is well known that Lues Venerea can be certainly cured by mercury only ; and the opinion respecting the existence of a specific contagion of Gonorrhoea, arising from this obvious and marked difference in the method of cure, appears to be fixed and established by the following facts : The symptoms and consequences of Gonorrhoea are perfect- ly different from those which take place in Lues Ve- nerea. Both diseases have appeared, at different pe- riods in the same countries; and, in some instances, they have remained distinct and uncombined for a great length of time. That the symptoms of the two diseases are differ- ent, is universally known. A particular detail of such as are peculiar to each, will be given in the ensuing chapters. At present, it is only necessary to observe, thai Gonorrhoea consists of a discharge of puriform mat- ter from the urethra ; which, even by those who sup- port the contrary opinion, is now admitted to be in almost every instance, a local affection, and that it \e- ry rarely contaminates the general habit of body : while Lues Venerea is a disease of the constitution, ari- sing from the absorption of venereal virus from any part of the surface of the body, but most frequently from the genitals ; by which are produced buboes, ul- cers in various parts, particularly in the nose and throat, pains and swellings in the bones, with a vari- ety of other symptoms which it is not at present ne- cessary to mention. The first appearance of the Lues Venerea is, for the most prat, in the form of a chancre or small ulcer, in some part of the penis. It is universally admitted* that even the slightest affection of this nature is apt to produce the pox, or a general affection of the system - r insomuch, that no practitioner of experience will trust the cure of this symptom to local remedies. If the sore be left to itself, it almost always becomes worse. The matter which it affords is taken up by the absorb- ents ; and buboes, with the other symptoms enume- €h. I. AND LUES VENEREA. 19 rated above, very certainly ensue. These are almost the universal consequences of a sore produced by the venereal virus; but they also occur frequently where the skin remains sound and entire ; that is, absorption of the venereal poison often takes place where no ves- tige of ulceration is perceptible. This, indeed, is de- nied by many ; but I have met with various instances of it, and it will be admitted by every practitioner of experience. Now, this being established, in the ap- plication of the venereal virus to every other part of the body, if the matter of Gonorrhoea were of the same nature, why does it not, in almost every instance, enter the system, and produce pox ? So far as we know, the urethra is as plentifully supplied with ab- sorbents as other parts of the body ; the same kind of matter, when applied to them here, ought therefore to be productive of similar effects : and hence Lues Ven- erea ought frequently, perhaps in every instance, to be the consequence of Gonorrhoea, were the matter by which the two diseases are produced, the same. As this is a strong argument in favour of the two dis- eases proceeding from different kinds of contagion, much ingenuity has been exerted by those who support the* contrary opinion, in endeavouring to account for it. In the first place, it has been said, that Gonorrhoea sometimes terminates in pox, and, therefore, that this of itself is a sufficient proof of the two affections be- ing of the same nature. Were it certain that this ever happened, no farther evidence would be required, as a few well-marked in- stances would be conclusive; but every unprejudiced practitioner will admit, that no sufficient proofs of it have ever occured. In order to support this opinion, data must be re* ceived, which we know to be inadmissible. We must admit, that a person with chancres only, communi- cates to another, not only every symptom of pox, but of Gonorrhoea, and that another with Gonorrhoea on- ly gives to all with whom he may have connection, chancres with their various consequences. This ought, indeed, to be a very common occurrence ; insomuch 20 ON GONORRHOEA VIRULENTA, Cb. I. that every practitioner should be able to decide upon it with certainty, if this opinion was well founded: Instead of which, it will be admitted by all, that the one disease being produced by the other is even, in appearance, a very rare occurrence, I have paid much attention to the point in question ; and, in almost eve- ry instance, a few cases indeed only excepted, and where the most particular enquiries even were made, it has happened, that a person infected with Gonor- rhoea has received it from another evidently labour- ing ^hder that disease, and that chancres have been communicated by such as were distressed with chan- cres only. This, I am convinced, will be very commonly found to be clearly the case ; so that a few instances, bearing some appearances of the contrary, are much more rea- dily explained on the- idea of the two diseases being produced by different kinds of contagion ; and this may also be said of the few solitary cases that may be met with, of chancre being supposed to terminate in Gonorrhoea, and Gonorrhoea in chancre,- and other symptoms of pox. We can more easily eoriceiye that the same person should, in some instances, receive, and therefore be able to communicate, both kinds of con- tagion, than that the incident we are considering should be so seldom met with, were the opinion well founded, of the two diseases being originally of the ^ame nature. However ill founded an established opinion may be, Jf it has received the sanction of being generally a- dopted, we know how difficult it is to overturn it. There are few who enter so minutely into the consi- deration of such points as to be able to decide upon them ; and of those who do, there are very few who will fake the trouble of engaging in such discussions ps are necessary for the conviction of others. This may be considered as the chief cause of the point in question remaining so long in obscurity, as well as of the explanation hitherto usually given, of various cir- cumstances in Gonorrhoea and Lues Venerea having fceen uniformly made to support it f It will also serve to Ch. I. AND LUES VENEREA. 21 account for circumstances being held forth as matter of fact, which, on enquiry, are perceived to be ill founded ; for, when once an opinion is admitted, we are apt to give such an explanation of whatever may seem to relate to it, as can in any way tend to sup- port it. Thus, although few in the present age will assert that Gonorrhoea often terminates in Lues Venerea, yet by many we are told, that it is very apt to do so when it is improperly treated. Whatever puts a sudden stop to a severe or copious discharge from the urethra is by many supposed to do harm. Hence all who con- demn the use of injections in Gonorrhoea affirm, that they often convert a simple clap into a pox, by throw- ing into the blood what otherwise would have been carried off. This, however, is by no means support- ed by experience. A stimulating injection will no doubt excite pain and inflammation in the urethra ; and this, in some instances, will be productive of swel- led testes, and perhaps of sympathetic swellings in the glands of the groin ; but I have not known a single in- stance of pox induced in this manner : and as I have long been in the daily use of injections, many cases of it must have occurred, if the idea I have just stated were well founded. Till of late, indeed, a patient who was so unfortunate as to havea clap suddenly stopped, ;^was so certainly considered as poxed,>that he was im= ^fffe^iately put* under a very complete coiirstTof mer- cW^£?^%McJ3 he was made to undergo a* v^Ty"* (fnne-* cessary ^^disVr^fttJ^confinement. Although this practice, however, is no*w very "com- monly exploded, yet the^are some who still adhere to it. I was called, in April 1784, to visit a gentleman who, in a Gonorrhoea attended with a good deal of in- flammation* had been so foolish as to live freely, and to ride much on horseback. This, with the unguarded use of a very stimulating injection, put a sudden stop to the discharge ; and at the same time it excited a very considerable degree of pain and inflammation along all the posterior part of the urethra, towards the 22 ON GONORRHOEA VIRULENT A, Oil. I. prostrate gland and neck of the bladder, attended with a painful and frequent desire to make water. On the idea of these being symptoms of pox, he was immediately put under a course of mercury ; and, when . I first saw him, he had been using it for the space of six weeks. The surgeon in attendance ac- knowledged that no advantage had been derived from it ; and the patient himself said that his distress was daily increasing. They were both, therefore, easily persuaded to lay the mercury aside ; and, by the re- peated application of leeches to the perineum, of fo- mentations, and opiates, to allay the pain, the inflam- mation soon began to subside ; and, in a short time, he was perfectly well. In December 1738, a young man called upon me, with a painful hard swelling in his groin, of an oblong form, nearly an inch in diameter, and reaching from the ring in the external oblique muscle down to the top of the testis. It appeared suddenly, about four months before, and seemed to be the consequence of a clap being too hastily stopped. He was at first attack- ed with a severe pain at the neck of the bladder, which stretched to the groin, and down to the testis of the same side. This, together with a constant and pain- ful inclination to void urine, rendered his life miser- able. Nor was his distress in any degree abated by a course of mercury which he was immediately put un- der. On the contrary, the swelling, which at first was not thicker than a common quill, was now very con- siderable. My idea of the swelling was, that at first it had been merely an inflammatory affection of the vas deferens, which by degrees had spread to the rest of the spermatic chord ; but, what was unusual, it had never affected either the testis or epididemis. As a considerable quantity of mercury had been taken, and as, instead of proving useful, it had rather appear- ed to do harm, the surgeon whom he employed was easily persuaded to trust the cure to other remedies. Local blood-letting with leeches was frequently re- peated, both in the perineum and groin. The parts were regularly fomented with a solution of saccharum Ch. I. AND LUES VENEREA. 23 saturni. His bowels were kept easy with gentle lax- atives, and he was put upon a mild diet of milk and vegetables. In a few days the pain abated, and the tumour gradually lessened, till at last, in the course of five or six weeks, it was entirely gone. In the course of last winter, I attended two different patients, with alarming symptoms about the neck of the bladder, evidently induced by the improper man- agement of Gonorrhoea. The parts in both were not merely pained, but considerably swelled ; and, at the same time, almost a total suppression of urine took place. Although in both, the discharge from the ure- thra had been suddenly stopped, I did not advise mer- cury. The patients being both plethoric, were plen- tifully blooded, first at the arm, and afterwards repeat- edly with leeches in the perineum. This, with fomen- tations, and opiates to allay the violence of the pain, assisted by a cooling regimen and gentle relaxatives, very soon completed the cures. These instances are given out of a great number that might be adduced, merely to shew, that the symp- toms which supervene on the sudden stoppage of a clap, are local, and not connected with any affection of the constitution, which they necessarily would be, if they were of the same nature with Lues Venerea. It will perhaps be said, that although this may have happened in a few cases, yet that in others there has been cause to suspect, that Lues Venerea has been the consequence of a clap disappearing in this manner. In answer to this, it is sufficient for me to shew, that this is at least a rare occurrence, as I think I am intitled to do, from my never having met with an instance of it. It has been supposed, that the sudden check given to the discharge in cases of clap, must necessarily throw the matter into the blood, and that pox must accordingly ensue from it. Were the matter of the two diseases the same, this would happen in every in- stance ; so that, when we can show that it seldom hap- pens even in appearance, we are entitled, from this argument alone, to conclude, that they are produced by two different kinds of contagion ; and, where pox 24 ON GONORRHOEA VIRULENTA, Ch. I. has appeared at the sudden termination of Gonorrhoea, that the two kinds of infection had either been com- municated together; or, what may more frequently perhaps be the case, the patient will be found to have received the pocky contagion by communication with a diseased woman at the very time he laboured under Gonorrhoea. I have already remarked, that Lues Ve- nerea is frequently produced by absorption while the skin remains entire, and where no chancre or excori- ation is perceptible. There is therefore much cause to imagine, that in long continued cases of Gonorrhoea, many may be infected with Lues Venerea by communi- cation with others labouring under it ; and as this may happen without any external mark of it taking place, it is not surprising that some fallacy should arise from this circumstance. The abettors of the opinion, that the matter of the two diseases are the same, admit that Gonorrhoea very seldom terminates in pox.* And they attempt to ac- count for this, that is, for the two diseases not being produced more frequently by the application of the same matter, by saying, that this depends upon the difference of parts to which the matter is applied. They divide the different surfaces of the body chief- ly into two kinds, what they term secreting surfaces and non-secreting surfaces. By the first they mean all the passages for extraneous matter, including also the ducts of glands, such as the mouth, nose, eyes, arms, * This is even granted by one who keenly supports the opposite doctrine in every other point. In speaking of Gonorrhoea and Chancre not terminating so frequently crs might be expected in the production of each other, he says, " Although it does not often happen, yet it sometimes does, at least there is " great reason to believe so. I have seen cases where a Gonorrhoea came on, and " m a few days after in some, in others as many weeks, a chancre has appear- *' ed ; and have also seen cases where a chancre has come first, and in the *' course of its cure a running and pain in making wate3? have succeeded." See a Treatise on the Venereal Disease, by John Hunter, page 16. This is what every practitioner has seen ; but by admitting so clearly that it • is a very rare occurrence, Mr. Hunter tends rather to strengthen the contrary opinion : for, were the two diseases produced by the same kind of matter, the one would clearly and necessarily often terminate in the other. In the few cases which Mr. Hunter, in the course of his extensive practice, has met with, there is more cause to imagine, either that the two diseases were communicated at once, or that the one was given while the patient laboured under the other, than that nature should deviate so much from her ordinary course as to pro- duce in them a few instances so very different from, what obviously happens Ch. I. AND LUES VENEREA. 25 and urethra ; and by non-secreting surfaces, the exter- nal skin in general. To which they add a third kind of surface, leading from the one to the other, as the glans penis, prolabium of the mouth, the inside of the lips, and the female pudendum : which surfaces, par- taking of the properties of each of the others, but in a less degree, are capable of being affected in both ways, sometimes by being excited to secretion, and at other times to ulceration^. Upon this, their theory, or opinion of the point in question, is attempted to be established: When the contagion, either of Gonorrhoea or pox, and w- ich they consider to be the same, is applied to any part of the external skin, particularly to the glans penis where the skin is very thin, chancre or ulceration, they observe, will most readily ensue, as these are non secreting surfaces; while the same kind of matter ap- plied to the urethra must necessarily excite Gonor- rhoea, from this he;n^ a secreting surface, and therefore not so easily atiected with ulceration as with irritation ; by which an increased discharge, attended with some change in the mucus of the pait, must accordingly be produced. This idea, however, is more ingenious than solid. It might answer the purpose of giving a specious ap- pearance to an ill-founded opinion, but it will not stand the test of inquiry. In the first place, on the supposition of the matter of Gonorrhoea and Lues Venerea being the same, the latter ought to be a much more frequent occurrence than the former, from the greater ease with which the matter of infection must, in every instance, be applied to those parts on which it can produce chan- cres than to the urethra, where, instead of chancre or ulceration, it almost always excites Gonorrhoea. It is difficult to conceive how the matter by which the disease is communicated should find access to the urethra; while, on the contrary, all the external * Vide John Hunter on the Venereal Disease. 4 26 ON GONORRHOEA VIRULENTA, Cb. I. parts of the penis, particularly the glans, must be easi- ly and universally exposed to it : and yet Gonorrhoea is a much more frequent disease than pox. Cases of Gonorrhoea are in proportion to those of Chancre and Pox, so far as my observation goes, of about three to one; while it is obvious, that the very reverse should happen, if the two diseases were produced by the same kind of matter*. Again, were this the case, should we not find Go- norrhcea, in almost every instance, terminating in Pox, and Chancre in Gonorrhoea ; for every one knows, that in Gonorrhoea the matter is at all times passing from the urethra over the glans and prepuce, and in Chancre, that it is passing from the glans into the en- trance of the urethra. It happens indeed, in a few instances, (Mr. Hunter, we see, has met with some cases of it) that the one disease supervenes upon the other: but we have also seen that these are rare occur- rences; and where they have not been communicat- ed by subsequent connection with an infected person, that the two diseases have probably been given at one and the same time. It is no argument against this sug- gestion, to say, that instances have been met with of a Gonorrhoea appearing during the continuance of chancres of several weeks duration, and vice versa; for every practitioner must have met with instances of these diseases both appearing at the distance of two or three months from any exposure to infection. I have at this moment a gentleman under cure for a deep, foul chancre, altogether within the urethra. It was of several weeks duration before I saw it, and yet no Gonorrhoea took place. He is now getting well by a complete course of mercury, and repeated appli- cation of caustic. I have met with various cases of this, as every prac- titioner must have done ; and, so lately as the month * Mr.Hunter supposes, that the proportion which the cases of Gonorrh 02a bear to those of Chancre, is as four or five to one. Vide Treatise on the Venereal Dis- ease, p. 217. This is surely a weighty argument against the opinion he endea- vours to support, of Gonorrhoea and Chancre proceeding from the same con- tagion. Ch. I. AND LUES VEffEKEA. 27 of April last, I was called to a gentleman with a pain- ful chancre on each side of the urethra. The sore extended about the eighth part of an inch up the pas- sage ; and the parts being much inflamed, I hesitated to apply caustic. This rendered the cure tedious, but still no Gonorrhoea took place. At last, after having taken a considerable quantity of mercury, and when the chancres were looking clean, and in a healing state, he was seized with all the symptoms of a severe clap, with heat in making water, chordee, and a plentiful discharge of a thin green matter. This, however, bore all the appearance of a recent infection. I at once said so to my patient; and he candidly acknowl- edged that he had imprudently exposed himself, by having connection with a girl of the town, three or four days previous to the accession of these symptoms. We may also remark, that the discharge from Go- norrhoea frequently becomes so acrid as to excoriate the glans and preputium, and even to excite a very plentiful formation of matter ; but every one knows that this is materially different from chancre. It is altogether different in appearance, and so materially different in its effects, that scarcely any practitioner of experience will trust the cure of chancre to any thing but mercury, while, in the other, mercury, I imagine, is very seldom employed. However exten- sive the excoriations may be, they are easily removed by local remedies; and I have never known an in- stance of pox succeeding to this kind of treatment. Nay, I have met with various instances of such affec- tions, where mercury had been given in considerable quantities with no advantage whatever, and where a cure was effected by the use of an astringent wash. About eighteen months ago, a gentleman came to town from a considerable distance, with an extensive excoriation over all the glans and preputium, attend- ed with a discharge of a large quantity of thin, offensive matter. The quantity of matter indeed was so con- siderable, that at first sight it appeared to be the dis- charge from a very inveterate recent case of Gonor- rhoea ; but, on farther examination, it was found to 28 ON GONORRHOEA VIRULENTA, Ch. I. proceed entirely from the glans and prepuce, the clap by which it was produced being entirely gone. He lad taken mercury for the space of six weeks ; and the parts had been regularly bathed in milk and vater, but with no advantage. The discharge con- tinued as plentiful as ever, and the preputium was be- girt ing to acquire some degree of thickness, and to be difficult to retract. In the space of a week he wa« completely cured, merely by bathing the parts from time to time with brandy and water, and applying, during the night, a poultice strongly impregnated with saccl arum saturni. This, as well as a variety of similar affections, which, were it necessary, I might enumerate, clearly evince, not only that the matter of Gonorrhoea, when confined to the urethra, does not terminate in pox, but that it proves equally inoffensive to the constitution, where it is even so si arp and acrid as to excoriate the sur- rounding parts, i his points out a very marked dif- ference between the matter of the two diseases. Iri pox, even the slightest sore never fails to throw mat- ter into tie system, while the most extensive affections proceeding from Gonorrhoea are so seldom found to in- jure the constitution, thai I have never met with an instanee of it. By those who wish to support the opposite doctrine, it is said, t! at the matter of Gonorrhoea would more frequently terminate in pox, were it not for the mucus of the urethra with which it is blended, and by which they suppose it to be rendered not only milder in its nature, but not so apt to be taken up by the absorbents. Th;s, however, is n etely ideal ; and no proof can be ( advanced in support of it. Besides, the force of the argument is entirely done away, when we see, from what has been observed above, that event where the matter of Gonorrhoea is more acrimonious than almost ever occurs in cases of Chancre, so as in some instances to produce very extensive excoriations, that still no affection of the constitution ensues from it. Nay, we see, even in such diseases as are found to proceed from what is termed a translation of the matter Cll. I. AND LUES VENEREA. 29 of Gonorrhoea to other parts of the body, and which we suppose to happen through the medium of the cir- culation, that still no affection of the constitution pro- ceeds from them. This is particularly the case in such instances of ophthalmia as sometimes proceed from Go- norrhoea, and in which a considerable discharge takes place, of a puriform matter from the eye-lids, very similar to the matter of a recent c'lap. I have also met with instances, of patients labouring under Gonorrhoea being seized with a similar discharge from the mem- brane of the nose ; but in none of these have I ever known Lues Venerea ensue. A considerable number of examples might be adduced of each of these ; but the three following will be sufficient. In the year 1786, a young man applied to me, with a very troublesome and painful disease in both eyes. The eye-balls were not much inflamed outwardly ; but as lie experienced an intense degree of pain from the ad- mission of light, I concluded that the retina, or other deep-seated parts of the eye, were in a state of inflam- mation ; and the membrane of the eye-lids was not on- ly inflamed, but a constant and copious discharge took place from them, of a greenish yellow matter, bearing much the appearance of the matter of a recent clap. The account I received of his disease was this : That he had for eight or ten days laboured under Gonor- rhoea, the symptoms of which, how 7 ever, were not more severe than usual ; when, after being heated Avith drinking port w r ine, the discharge from the ure- thra, which had previously been copious, disappeared almost entirely. His eyes, almost immediately there- after, became painful; and, in less than twenty-four hours, the discharge of matter had taken place from the eye-lids. The disease was at first treated with blisters, slight evacuations of blood, and the usual applications of oint- ments and collyria. These not proving successful, a course of mercury was prescribed : but, although dif- ferent attempts were made with it, mischief always ensued from it. It did not lessen the discharge, while it obviously increased the inflammation, and rendered 30 ON GONORRHOEA VIRULENTA, Ch. I. the eyes more irritable. I therefore advised this re- medy to be laid aside. A quantity of blood was taken from the temporal artery of one side ; such vessels as were turgid upon the eye-balls were divided ; scarifi- cations were made in the inflamed parts of the eye-lids ; poultices were applied over the eyes, in which opium and saccharum saturni were dissolved; and gentle lax- atives were prescribed. By these means the pain soon abated ; the inflammation and discharge of matter less- ened ; and, in the course of a fortnight, no symptom of the disease remained, but a degree of irritability on exposure to much light, with which both eyes con- tinued to be distressed for fjve or six months thereafter. In the course of the following year, on being attack- ed with Gonorrhoea, but of a more violent nature than the former, he was again seized, after exposure to much cold, and riding on horseback, to a similar af- fection of his eyes. In this instance also, blood-letting, and the other remedies formerly prescribed, proved successful ; and he has not, since that period, had any return of* the disease. About two years ago, I was desired to visit a patient, who, during confinement from a swelled testis induced by a Gonorrhoea, was suddenly seized with a profuse discharge of matter from one of his nostrils, very simi- lar to the running of the clap. The membrane of the nostril appeared tender, and somewhat inflamed ; but little or no pain occurred from it. The discharge from the urethra had diminished considerably previous to the testis becoming inflamed, and, on this taking place from the nose, it disappeared entirely. This suggested the propriety of attempting to excite a return of the dis- charge by the urethra ; but no advantage being derived from this, I advised the affection of the nose to be treat- ed with injections similar to what we use in cases of clap. An astringent solution was thrown up, some- times with a syringe, and at other times by inserting a bit of sponge immersed in it up the nostril ; and in the course of a few days the running ceased entirely. Since that period, the same patient has been twice af- fected in a similar manner, and the same kind of treat- Ql. I. AND LUES VENEREA 31 ment proved equally successful. No mercury was given, and no symptom of pox has ever appeared. In the course of a few weeks after the recovery of this patient from the first attack of the disease, I was desired to see a friend of his, who for several years had been distressed with a similar discharge from both his nostrils. The running had occurred during the c6n- linuance of a clap ; and although it had frequently diminished in quantity, yet at all times it was so con- siderable as to be productive of much uneasiness. No ulceration appeared on the membrane of the nostrils, but it was of a deep red colour, and tender over its whole extent. A variety of remedies had been em- ployed ; and at last, after the disease had gone on for upwards of three years, although no other symptom appeared, he was advised to undergo a course of mer- cury. This was done in the most attentive manner ; but no advantage ensued from it. In this situation, I expected that the same plan of treatment which proved successful in the preceding case, and which had also done so in others, would likewise answer here. In this, however, I was disap- pointed ; for, although every variety of injection was used that I ever employed, yet no material advantage ensued from them. The running was sometimes in- deed lessened by them, but it always returned equally severe as before ; and although it has of late, even when no remedies were employed, become considera- bly less, it still continues in such quantities as to prove highly distressful. No other symptom of the disease, however, has ever occurred. As a farther proof of the difference of the contagions of Syphilis and Gonorrhoea, it may be remarked, that no state of pox has ever been known to induce Go- norrhoea, which surely would occasionally happen, if the two diseases were of the same nature. We may also remark, that, in numberless instances, people have been poxed by the matter of Syphilis being by accident applied to a cut or scratch, as often happens with surgeons in the dressing of chancres and buboes ; but no one ever heard of a pox being got in this man 32 ON GONORRHOEA VIRULENTA, Ch. I. ner from the matter of Gonorrhoea. It has indeed been said, that chancres may be produced by insinuating the matter of Gonorrhoea beneath the skin. But ex- periments upon this subject are productive of such anxiety and distress, that they never have been, nor ever probably will be, repeated so frequently as the na- ture of it would require. Nothing, therefore, can be admitted from this argument ; for, in order to avoid fallacy, and to give support to the opinion, these ex- periments would not only require to be conducted with accuracy, but to be numerous, and to be repeated on a variety of patients under every possible variety of circumstances ; whereas we have heard of only a single experiment or two being made by any individu- al ; and even these seem to have been made under the management of such as were strongly and obviously biassed in favour of one side of the question. In opposition to these, too, I may mention, that, induced by some late publications upon this subject, two young gentlemen of this place have made some experiments upon themselves, with a view to ascertain the point in dispute ; but the result was materially different from what appears to have happened in the experiments to which I allude. By the introduction of the matter of chancres, as well as of buboes, into the urethra, some pain and irritation were excited, but no Gonorrhoea ensued ; and, by fretting the skin of the prepuce and glans with a lancet, and rubbing the parts with the matter of Gonorrhoea, slight sores were produced ; but they never assumed the appearance of chancres, and they healed easily without the use of mercury. — For the reasons mentioned above, however, we cannot place much dependence upon these or any other experiments that have yet been made upon this subject ; we must trust therefore to experience and ob- servation in the ordinary course of practice for means to ascertain it. The other fact on which the doctrine we attempt to establish rests, is, that Gonorrhoea and Syphilis have appeared at different times in the same countries, and in Cil. I, AND LUES TENEREA. ' 33 some instances have remained distinct and uncombincd for a great length of time. If these two diseases were of the same nature, and proceeded from the same contagion, they ought to have appeared nearly at the same time in every coun- try to which the infection w r as- carried. This does not appear, however, from the history of the disease, to have been the case. Prom the earlier writers up- on this subject, it is evident, that the Lues Venerea "was known in Europe at least forty years before the Gonorrhoea Virulenta. Doctor Astruc, whose accu- racy and minute attention to this subject' has not been equalled by any one, asserts, that in his time Go- norrhoea had not been long known in China, although we know that the Lues Venerea had long prevailed in that country : and it would appear, notwithstand- ing any thing that has been said to the contrary, that the Lues Venerea was imported into the island of Otaheite a considerable time before Gonorrhoea. It seems to have been carried to that and other islands in the South Seas by the very first European naviga- tors who touched there, and to have remained distinct, without being connected with Gonorrhoea, for a very considerable time ; for when Captain Cook visited these islands in his second voyage, we have authority for saying, that Gonorrhoea had not then appeared in them. These historical facts all tend to prove, that w T here only one of these diseases has been imported to any particular district, it has always remained distinct, without producing the other ; and which we cannot, suppose w r ould have happened, if both were formed by the same contagion* And, in addition to these, I may add another, not less remarkable, the truth of which may be ascertained by all who incline to in- quire concerning it, as the scene of it lies in our own country. In various parts of the country of Scotland, parti- cularly in some parts of the Highlands ; in Galloway, and in Dumfries-shire ; the common people have, for 5 \ 34 ON GONORRHOEA VIRULENT A, Ch. I. a great length of time, been afflicted with the Lues Venerea, under the denomination, as they term it, of Sibbens ; and which, from those distressed with it having no communication with those infected with Gonorrhoea, has still, retained its original, unmixed form, without a single instance, so far as I know, of Gonorrhoea, having been ever produced by it*. There is evidence, in some of these districts, of this disease having prevailed among them for upwards of seventy years : Nay, in some of them, it is said, from tradition, to have been left there by the soldiers of Oliver Crom- well, and to have been given, since that period, by one generation to another; and, although 3 have had op- portunities of seeing many hunched people labouring under it, with ulcers in the throat, nodes of the bones, fungous excrescences about the anus, blotches over the body, with almost every other symptom of Syphi- lis, yet not an instance has occurred to me, as I have observed above, nor have I heard of any, where Gon- orrhoea took place in it. Whether it is from those in- fected with it concealing it longer than usually happens in towns, or what may be the cause of it, I shall not at present pretend to determine; but certain it is that the symptoms produced by it are more inveterate than we usually find them to be in the ordinary form of this disease. They appear 'to be more particularly infectious; the slightest communication with those la- bouring under the disease being apt to produce it. The symptoms spread more rapidly, and a greater quantity of mercury is, for the most part, required to remove them; but still Gonorrhoea is never pro- duced in any stage of the disease. A disease very similar to this broke out among the country people of Canada, some years ago, owing, as is imagined, to communication with some of the sol- * This must have happened from the disease in these districts prevailing al- most entn-ely among poor country people, whose manners do not expose them to the hazard of being infected with Gonorrhoea! None, however, can escape the Sibbens who are much in company with those labouring* under it ; and so much are they convinced of its being the same disease with Lues Venerea, that even those who get it in the most innocent manner, are so much ashamed, that they never speak of it as long as it can possibly be kept secret, Ci). h AND LUES VENEREA. 35 diet's quartered among them, who were infected with Lues Venerea. It is attended, a? is tne case with the Sibbens in Scotland, with all the symptoms of Syphilis in the most virulent form of that disease ; audit is so very infectious as to be communicated by eating or drinking out of the same vessel, or drying with the same cloth that has been used by those .labouring under it. It often enters the constitution by absorption from the surface, without any previous ulceration : in which case it afterwards breaks out in buboes, nodes, ulcers, and other symptoms of a confirmed Lues; but not an instance, I am informed, has happened, of Gonorrhoea being produced by it. This, as well as what has occurred in (he progress of Sibbens, is precisely what happened with the Lues Venerea when it first appeared in Europe, as w r ell as at a late period in the South Seas; and there cannot be a doubt of the same circumstances taking place wherever the Syphilis only is communicated. We have seen, in all these instances, that Gonorrhoea has never been produced by it, which surely could not have happened if the I wo diseases were of the same na- ture, and produced by the same contagion. They could never, in that case, have remained for anv length of time so distinct and precisely marked ; for the one must necessarily, in almost every instance, have soon been productive of the other. As a farther support of this opinion, I may add, that if the two diseases were of the same nature, and pro- duced by the same infection, the remedies proving useful in the one, might be expected to prove likevvise so in the other. Insiead of this, we find that those upon which we depend with most certainty in Gonorrhoea, have no effect whatever in the cure of Syphilis, whi*e mercury, which is the only remedy, as we have obser- ved above, upon which any dependence can be placed for the cure of Syphilis, does not, in Gonorrhoea, pro- duce any advantage. Nay, that in some cases, it evi- dently does harm. We also know, that Gonorrhoea will often termi- nate whether any remedy be employed or not, merely 36 ON GONORRHOEA VIRULENTA, &C. Ctl. I. by moderate living, and keeping the parts regularly clean. The disease by this alone will, in most instan- ces, become gradually milder, till at last it will dis- appear entirely. No such thing, however happens in Lues Venerea. In this as we have already remarked, even the mildest symptom becomes daily worse, un- less mercury be employed ; nor will any practitioner of experience trust the cure even of the slightest chan- cre to any other remedy. Upon this evidence alone, of the method of cure of the two diseases being so essentially different, we might I think, conclude that they are different in their na- ture, and that they proceed from different contagions. Were they of the same nature, and proceeding from the same cause, it is not possible to conceive that any medicine would act as a certain cure for one and do barm in the other, and yet every practitioner will ad- mit that mercury, is the only remedy hitherto known, upon which we can depend for the cure of Lues Ve- nerea, while it evidently often does harm, as I have al- ready observed, in Gonorrhoea. If the subject now under discussion was merely of a speculative nature I should not have entered so mi- nutely into it, for in that case it would have been a matter of indifference both to practitioners and patients whether these diseases were of the same nature or not ; but, as the treatment of Gonorrhoea ought to depend much upon this circumstance, I judged it proper be- fore proceeding to treat of it, to make this attempt to have the point in question ascertained. It is perhaps unnecessary to add any further arguments to those of the able and judicious author, as to the specific difference of the dis- eases in question ; we cannot however help observing, that though both diseases affect the same parts, and are induced by the same means, yet that Syphilis appeared at least one hundred years before Gonorrhoea, and that it must be in the knowledge of almost every physician, that the termination of one of the diseases in the other, is so rare an occurrence (if it ever did happen) that we might apply the legal maxim, Excefitio regulam firobat. If any other argu- ment was necessary to prove the position of our author, we would draw it from the almost universal experience of the faculty in eve- ry part of the world, in the different mode of treatment which they SeC. I. GENERAL OBSERVATIONS, &C 37 adopt in the two affections, as we believe that with very few excep- tions, Gonorrhoea is treated as a local, and'Syphilis, as a constitution- al affection. The few cases which occasionally occur, and which we have sometimes met with, where both diseases exist at the same time, in the same patient, constitute no rational objection to our doc- trine, as in some of the cases it could be incontestably traced to two different sources of infection, and in others the person from whom it was derived, laboured under both diseases. For a more detailed discussion of this question, we refer to Prac- tical Observations on the Natural History and Cure of the Venereal Disease, by John Howard, Fellow of the Royal College of Surgeons. London, 1806. Ed. CHAP. II. Of the Gonorrhoea Virulcnki. SECT. I. General Observations on the Symptoms, Causes, and Seat of Gonorrhoea Virulenta. EVERY discharge of matter from the urethra, excited by impure coition, is termed Gonorrhoea Virulenta. As the term implies a discharge of semen, and as this disease is not necessarily attended with any seminal evacuation, it is here obviously misapplied ; but we think it better to retain even a faulty denom- ination when very universally received, than to incur the hazard arising from the confusion which might en- sue from the proposal of amendments. The period at which the discharge takes place, after exposure to infection, is always uncertain. I have- known it happen in a few hours; often in the course of a day or two, and in some instances not till several weeks have elapsed. From the third or fourth day, to the seventh and eighth, is tijfe most frequent pe- riod. " v 38 GENERAL OBSERVATIONS ON Ch. II. This does not appear, however, to have any effect on the nature or violence of the symptoms. Some in- deed have imagined, that the disease must be mild or severe according as it appears early or late after the matter of infection has been applied ; but this does not accord with my observation. I have often known the symptoms mild when they appeared early after ex- posure to infection, and severe when much time had elapsed. In one of the most obstinate cases of Gon- orrhoea I have seen, the running did not appear till nearly the ninth week from the time of infection. A gentleman sailed from Jamaica two days after having connection with a woman of suspicious character. No symptoms appeared till several weeks had elapsed ; he concluded that he had escaped ; when, two days before coming into port, being the fifty-eighth of his voyage, a very copious running appeared. In some few cases, the discharge takes place with- out the patient having any warning of its approach ; but, for the most part, it is preceded by symptoms in- dicating some degree of inflammation in the urethra: A sense of fulness and tightness is ie\t over all the un- der part of the penis ; the patient has a more frequent desire than usual to void urine, accompanied with a peculiar kind of itching heat along the urethra, at the same time that the extremity of that canal is observed to be of a more deep red colour than ordinary, and more than usually tender to the touch. In some cases, too, the urethra seems to be contracted, or lessened in its diameter ; the urine coming off in a stream much smaller than natural, while at other times it is forked, and as if the passage was divided in two. On the appearance of the running,it is sometimes white, and nearly of the consistence of purulent matter ; but, for the most part, it is thin, and of a yellow green colour. In some cases it is brown, resembling the dis- charge of old scorbutic sores, and in others it con- sists almost entirely of blood, owing to the erosion or rupture of one or more blood-vessels in the urethra. SeC. I. GONORRHOEA VIRULENTA. 39 In a great proportion of cases, the discharge of mat- ter from the urethra, and scalding heat in making water, are the only symptoms which take place ; but in others, these are accompanied with chordee, or painful involuntary erections ; with much uneasiness in the testes, which frequently become so tender and irritable that the slightest touch excites pain. Severe degrees of pain often stretch from the penis to the groins and thighs; and in some cases ovtr all the ab- dominal viscera, particularly over the under part of the belly. In some cases the chordee, and in others these sym- pathetic pains stretching to the groins, and contiguous parts, are the most distressful symptoms of the disease. I have known ttie latter so severe as to render the patient altogether unable to take any kind of exercise; while the chordee, which is usually worst in bed, is apt to deprive him entirely of sleep. Besides these pains in the parts contiguous to the penis, and which we suppose to be chiefly the effect of nervous irritability, the glands in the groin in some instances swell, and become hard ; but unless the run- ning be accompanied with chancres, these swellings very commonly subside, and do not proceed to sup- purate ; an important fact, which may be considered as an additional proof to what was mentioned in the last chapter, of the difference between Gonorrhoea and Lues Venerea. In the course of the disease the glans penis some- times becomes red and inflamed, and a yellow, foetid matter, oozes from its whole surface. In some cases this is accompanied with evident ulceration : in others the skin remains entire, and the matter is observed, upon pressure, to proceed from an infinite number of small points. In both they are supposed to proceed from the matter passing out of the urethra, and al- lowed, by the negligence of the patient, to rest too long upon the tender cuticle of the glans. In some cases, however, this inflammatory affection of the glans, and discharge with which it is accompa- nied, takes place of itself, and without any discharge 40 GENERAL OBSERVATIONS ON Cll IL from the urethra. In which case, from the resem- blance which the matter bears to that of Gonorrhoea, it has usually been termed Gonorrhoea Spuria. This inflammation, in some cases spreads to the prepuce, in which it very commonly produces some degree of contraction. When the prepuce becomes so much straitened that it cannot be drawn back, a disease is formed, which we term phymosis ; and, when it con- tracts behind the glans, a disease termed paraphimo- sis takes place. Although in Gonorrhoea some degree of uneasiness is usually felt along the whole course of the urethra, yet we know, that in most instances, the seat of the disease lies within an inch, or little more, of the point of the penis. In a few cases, however, whether from maltreatment of the disorder; from the nature of the infection being more than usually virulent, or from peculiarity of constitution of the patient, the disease spreads backward till it extends over the whole length of the urethra, even to the bladder itself. The prostrate gland and internal coat of the bladder become affect- ed, and sympathetic pains stretch from these parts along the ureters to the kidneys. When the bladder becomes in this manner diseased? the state of the patient is, for the most, extremely mis- erable : he feels almost a constant desire to make water, accompanied with severe pressure or bearing down upon the affected parts, proceeding from invol- untary spasmodic contractions of the abdominal mus- cles. The whole region of the loins, particularly a- bout the kidneys, becomes so painful and irritable, that much distress is excited by whatever tends to bring the muscles of these parts into action, and the patient often complains of a constant tenesmus, and of a freo^uent shooting pain about the anus and neck of the bladder. In this stage of the disorder there is seldom any con- siderable discharge from the urethra ; but, for the most part, a large quantity of very viscid, feetid mucus is discovered in the urine, which, in the course of a few SeC. I. GONORRHOEA YIRULENTA. 41 hours, subsides, and adheres so firmly to the sides of the vessel as not to be easily separated. When a Gonorrhoea has either been improperly treated, or when much inflammation takes place from any other cause, the testes are apt U* swell and in- flame, and abscesses often form in Cowper's glands, as well as in other parts of the urethra. When these burst outwardly, or when the urine by any means finds access to them, they are often productive of great dis- tress to the patient and perplexity to the practitioner, as they frequently baffle every attempt that is made for removing them. It will readily be conceived that all the symptoms we have described are seldom or never met with in the same patient, and that these which do take place will be in very different degrees in different cases. This is particularly remarkable with respect to the quantity of discharge, which, in some instances, is so trifling as scarcely to excite anv inconvenience, whilst in others it is so profuse as to prove highly distressful. In some cases too, the heat of urine is so inconsidera- ble as not to deserve notice ; and in such instances also, the desire to pass water is seldom very frequent, while, in others, these symptoms are. both so insup- portable as to render the patient miserable. In most instances of Gonorrhoea any external inflam- mation which occurs is confined to the extremity of the urethra ; but in some cases, it runs so high as to spread over the whole glans, where it might be ex- pected to terminate, as inflammatory affections in other parts of the body most frequently do, in the for- mation of abscesses. This, however, very rarely hap- pens. We have observed, above, that, in a few in- stances, a purulent-like matter oozes from the whole surface of the inflamed glans ; but I have scarcely known an instance of any extensive abscess in the substance of the glans. The inflammation, for the most part, terminates by dispersion. In a few cases it ends in mortification. In women the symptoms of Gonorrhoea are, for the 6 42 GENERAL OBSERVATIONS ON CI). II. most part, much milder than in men. It sometimes happens that a flow of matter is all that occurs ; and, as the discharge is very similar to the matter of flu or albus, the two diseases are often mistaken for one another. This absence cf pain, however, takes place only where the vagina is the seat of the disease. When the urethra becomes affected the symptoms are near- ly the same as in the other sex. A distressful degree of irritation occurs at the extremity of the urethra, accompanied with heat of urine, and a very frequent desire to pass water. In some cases the inflammation spreads to the bladder, and even to the kidneys, ute- rus, and ovaria ; or at least these parts come to be so much affected with pain as to give cause to suspect thai they are in a state of inflammation. Pain, even in a severe degree, will no doubt occur from nervous sympathy, and this I believe to he frequently the case here ; but 1 have met with different instances of a considerable degree of inflammation being excited by Gonorrhoea in all the parts which I have mentioned : that is, they have become swelled, hard, and exces- sively painful, insomuch that the slightest touch would create a great degree of uneasiness ; and blood-letting, with other evacuations, were the only remedies from which relief was obtained. In some cases the matter is so sharp and acrid as to excoriate the clitoris, nym- pha?, and labia pudendi. This excites a great deal of uneasiness; more than ever takes place in men from a mere affection of the external parts; for, as these parts are in women pressed upon in sitting, the slight- est degree of inflammation is, from this cause alone, productive of much distress. They are often obliged to remain constantly in bed; being unable either to walk, stand, or sit. It is impossible, in any case of Gonorrhoea, to de- termine at first, in what manner it will terminate, for we often find the most severe, as well as the most ob- stinate discharge, succeed to symptoms of the mild- est nature, while in some cases it ends quickly and Sec. I. GONORRHOEA VTRULENTA. 43 easily, where the symptoms at first were very severe. It is in general believed that the disease will be mild, and of short duration, where the running is white or yellow ; and, on the contrary, that it will necessa- rily prove severe and tedious, where it is at first green, or much tinged with blood. This, however, is by no means universally the case, for instances occur daily, of the running proving tedious, where it was at first of the colour and consistence of purulent mat- ter, while others often happen of its ending quickly, where the matter was at first either deeply tinged with biood, or of as deep a green as this discharge has ever been observed. In the progress of this disease, we always reckon it a favourable circumstance to observe the matter be- come thick and ropy. This cannot indeed be mention- ed as an infallible proof of the discharge being soon to terminate; but it is, undoubtedly, one of the most favourable occurrences in every case of clap. When the running does not soon become ropy, it is apt to terminate in gleet, the most perplexing symptom in this disorder, and of which we shall speak more par- ticularly in an ensuing chapter. _ VV e shall hereafter have occasion to observe that a discharge may be produced from the urethra by dif- ferent causes, very similar to the matter of Gonor- rhaea virulenta. At present it is only necessary to remark, that, in this disease, the discharge is obvi- ously the effect of irritation excited in the membrane of the urethra and contiguous parts, by matter horn an infected person being applied to them. Some difference of opinion has arisen on the manner in which the matter of infection is communicated to the urethra. By some it is supposed to happen in consequence of being first absorbed from the surface of the glans, and afterwards deposited on the mem- brane of the urethra; as they do not think that it can pass directly into the urethra, during coition. No good reason, how ever, can be given for this opinion : it appears more probable that the matter at first finds 44 GENERAL OBSERVATIONS ON Oh. II. access between the lips of the urethra ; that it after- wards spreads, in a gradual manner, along the pas- sage, by mixing with the mucus, with which it meets, and that the progress which it makes will, in a great measure, depend upon the parts to which it is applied being more or less susceptible of inflammation ; upon the general state of health of the patient; upon his manner of living ; and perhaps upon other causes. I do not conceive, however, that t he kind of mat- ter by which the discharge is produced has so much influence on the violence or duration of the symptoms as has been imagined. It is indeed the opinion of some that a severe and obstinate case of clap may always be traced to an infection of some peculiar degree of virulency ; but this will not be found to happen with any kind of uniformity. So far as my observation goes; it is in Gonorrhoea nearly the same as in small pox. The mildness or violence of symptoms does not depend upon the matter by which the disease is produced so much as upon other circumstances. Hence the same woman will, under the same infection, com- municate the most virulent symptoms to one person, and the mildest to another. That much depends upon the habit of body of the patient, and upon his manner of living, will scarcely be doubted; but the following fact renders it obvious. Three gentlemen, who associated much together, and who were accustomed to live freely, returning one night from a drinking club, resolved to visit a girl of the town, and to take a friend along with them who d that night been a visitor in their society, but who 1 ually lived with much sobriety. They all had con- ctipn with the same girl. The three associates had all the most severe claps I ever met with ; while the her, who also received the infection, had the dis- se in the mildest form. This would not, in similar re u instances, always happen, as we sometimes find p >ople who live with much circumspection, liable to :ry severe attacks of Gonorrhoea ; but, for the most irt, the degree of violence of this disease has a con- Sec. 1. GONORRHOEA VIRULENTA. 45 siderable dependence on the manner of living of the pal lent. The matter discharged in Gonorrhoea being very similar to what is daily observed, to flow from sores in other parts, and the quantity being often very con- siderable, it was the prevailing opinion, till of late, that it proceeded from sores or ulcers in the urethra. We now know, however, (hat ulcers very seldom take place here ; and, when they do, that they may be traced to some accidental cause, such as the rupture of a blood-vessel, in no degree necessarily connected with the existence of the disease. On dissection, after death, it is found, almost in every instance, that the membrane of the urethra is entire, and that the matter is produced by inflammation alone. It had long been known, that instances were occa- sionally met with on dissection, where no degree of ulceration in the urethra was discovered. This, how- ever, was considered as a singular occurrence, and that it never happened but where the symptoms were un- commonly mild ; for at that time it was supposed, that ulceration, or a destruction of parts, was requisite for the production of matter. But we now know, that this is by no means the case, and that an inflamed sur- face, even where no abrasion is perceived, will pro- duce all the varieties of matter which sores ever afford, and that different kinds of animal fluids may be con- verted into these, merely by being kept in certain de- grees of heat. By this the difficulty is removed, which otherwise we must have experienced in accounting for the large quantities of matter daily discharged from the urethra in Gonorrhoea ; which, in some cases is so considerable, that nothing less than an affection of the whole extent of that canal could afford it. Now those who ima- gine that the matter proceeds from ulcers, have never gone so far as to say that this ever takes place : nor could it probably occur, but with such consequences as very seldom ensue from Gonorrhoea. What I allude to forms an unanswerable objection to the idea of ul- 46 GENERAL OBSERVATIONS ON CI). II. cers being frequent in this disease, even although no opportunities had occurred of proving it by dissec- tion. Where the membrane of the urethra is in any point ruptured, either by the bursting of an ab- scess into it, or by any other cause, the most distress- ful consequences almost universally ensue ; for the urine passing into the contiguous parts, forms swel- lings, which usually terminate in fistulous openings, that prove always tedious, and of uncertain event. Every practitioner knows, that even the slightest opening into the urethra is apt to terminate in this manner; so that, if the matter of Gonorrhoea, pro- ceeded from ulceration, the consequences of almost ev- ery case of Gonorrhoea, would necessarily prove much more formidable than we ever, in any instance, find ihem to be. In cases of long continued Gonorrhoea, the membrane of the urethra is apt to be so relaxed, that fungous ex- crescences form in different parts of it. These not only impede the passage of the urine, but, becoming soft and tender, they at last ulcerate, and throw out very considerable quantities of matter. This however, is never to be considered as the cause of Gonorrhoea, but merely as the effect of it. It often proceeds from mismanagement, either on the part of the patient or practitioner; and sometimes from some constitutional affection to which the patient at the time may be lia- ble. Instead of ulceration, we find, that in a great pro- portion of cases, there is merely a slight degree of in- flammation, extending from the extremity of the glans to an inch or perhaps an inch and a half up the ure- thra. In more obstinate cases of clap, Cowper's glands, with their ducts, which terminate in the urethra, are found affected. In a third stage of the disease, the prostrate gland, and contiguous parts of the urethra are inflamed ; and in the fourth, and what may be reckoned the most distressful stage of clap, the inter- rial coat of the bladder is found inflamed. For the most part, the inflammation is confined to the neck of the bladder; but I have met with instances of its being SeC. I. GONORRHOEA VIRULENTA. 47 perceptible over the whole of it, and of its even ex- tending along the ureters to the kidneys. This inflammation, however, is chiefly obvious at first. On a long continuance of the disease, the parts affected, instead of being either inflamed, or in a state of ulceration, are of a more pale colour than natural ; the membrane of the urethra is found soft and relax- ed ; and coloured mucus or matter may be pressed out from an infinite number of small points over every part of it that has been diseased. This is precisely what happens with every mem- brane that has remained long under a slight degree of inflammation, particularly with the membrane of the nose and trachea. These parts often afford very con- siderable quantities of matter, or of mucus very much resembling matter, for a great length of time : and yet, upon dissection, they are seldom or never found in a state of ulceration, the membrane being for the most part only slightly inflamed. We may here indeed remark, that the resemblance between the two diseases, Gon- orrhoea and Catarrh, is, in certain stages of each of them, very remarkable. They seem both to origin- ate from inflammation excited upon a membrane. The matter of the one is in many instances very simi- lar to that of the other. They seem both to be local affections only ; and the parts on which they are seat- ed are, after death, found to be affected in a similar manner. But although, in the latter stages of Gonorrhoea, in which, chiefly opportunities occur of examining the state of the parts after death, the inflammation is found to be for the most part inconsiderable, yet, in the com- mencement of the disease the parts are often highly inflamed, particularly when those about the neck of the bladder are affected. This is obvious from the symptoms particularly from the violent pain which al- ways takes place, and from the antiphlogistic reme- dies employed for the cure of the disease. 48 GENERAL OBSERVATIONS Ox\ Ch. II. SECT. II. Of the Prognosis in Gonorrhoea Virulenla. IN every disease, it is of importance for a practition- er to be able to say at what time and in what manner it will terminate. In none is information of this kind more anxiously wished for than in Gonorrhoea. The hopes and fears of patients lead them equally to wish for it ; but, from various causes, and more particularly - from want of attention to the exact site of the disease, the duration of Gonorrhoea has always been a matter of much uncertainty. I have observed above, that, on dissection, four dif- ferent set of parts are found at different times to be the seat of Gonorrhoea. When the running proceeds from the extremity, or from within about an inch and a half of the extremity of the penis, as happens in per- haps nine cases out of ten, there will for the most part, be much cause to hope that a cure will soon be obtain- ed. In such instances, when the patient is otherwise in good health, and when he does not interrupt the % operation of the necessary remedies by improper con- duct, the disease will not commonly endure a fortnight. Nay, a cure in such circumstances is often obtained in two or three days: but whenever the lower parts of the urethra are affected, particularly when the pros- trate gland and other parts about the neck of the blad- der are diseased, the running, in almost every instance, proves obstinate. Even our most powerful remedies in other cases of clap are here doubtful in their effects. Hence no certain opinion can be formed of the event of the disease. When these deep-seated parts are affected, the dis- ease proves always tedious, whatever the habit of body- may be ; but it necessarily proves much mqre so when the constitution labours under any general affection, particularly when scrophula prevails, than when the patient is sound and healthy. Indeed a scrophulous taint existing even with the most simple case of clap. SeC. II. GONORRHOEA VIRULENTA. 49 is apt to render it obstinate ; I am so much convinced of this being the case, that in every instance of clap occurring in scrophulous patients I always give a guarded prognosis of the event. Cures are sometimes indeed obtained easily, even in patients of this de- scription ; but, for the most part, the discharge goes on for a great length of time, and resists the effect of eve- ry remedy we employ to remove it. This uncertainty which takes place in ihe treatment of Gonorrhoea, and the great length of time to which the discharge, in some instances goes on, together with the many untoward and unexpected occurrences which often happen during the cure, tend altogether to render this branch of practice the most distressful of any in the province of medicine. In a great pro- portion of cases, a cure wilh proper treatment is easi- ly and speedily obtained ; but every candid practition- er will admit that cases often occur in which the dis- charge continues obstinate for a great length of time, even under the use of the most powerful remedies with which we are acquainted. But, by distinguishing be- tween one stage of the disease and another, and thus giving an opinion to patients of the probable event of it, practitioners w ? ou!d avoid a good deal of embarrass- Ynent w r hich they often experience, from giving so in- discriminately as they commonly do, a favourable prog- nosis at the commencement of every case of clap. In forming a prognosis, it ought always to be kept in view, that however mild the symptoms may be at first, they may very quickly and unexpectedly become se- vere, by the disease proceeding from one part of the urethra to another, or even by the inflammation in the part which was at first affected becoming more severe. This arises from various causes, and often from cir- cumstances which it is not in the power of practitioners to prevent. It sometimes occurs, indeed, from the use of improper remedies ; particularly from acrid injec- tions being used with too much freedom ; but it hap- pens much more frequently from other causes, partic- ularly from the tendency which inflammation in one 50 GENERAL OBSERVATIONS ON THE Cb. II. part of a membrane basto spread itself over tbe wbole of it, and to tie misconduct of patients, who, instead of living as they ought to do, very commonly proceed, during the cure, in the same course of riot and de- bauchery by which they were at first exposed to in- fection. Some patients, even under such circumstan- ces, will no doubt get well ; but there is not a more undoubted fact than this, that the cure of the disease is for the most part both difficult and uncertain where the patient lives in a riotous and intemperate manner. No situation is more delicate, or more exposed to censure than the one in which the pnysician is placed when called upon to give an opinion on the probable continuance of a disease. This is particu- larly the case in Gonorrhoea. The impatience, as well as imprudence of the description of persons who are most liable to this complaint, render a prognosis extremely uncertain. Much depends on the habits and mode of life of the patient, his constitutional tempera- ment, and the diseases (if any ^ to which he has been subjected, or is predisposed. As a general rule, it may be observed, that in persons of a sanguine temperament, and accustomed to live freely, the in- flammation will be more violent in its progress, but with proper cau- tion may be removed in a shorter period, than in individuals of a dif- ferent constitution. It ought to be impressed on every patient that temperance and rest are indispensible in order to effect a speedy- cure. The difference of climate and seasons have considerable in- fluence on the degree of inflammation excited. Hot weather tends to render the discharge considerable and acrimonious, and in the spring or beginning of summer the tendency to inflammation is greater, and the symptoms are generally more aggravated than at other seasons of the year. Ed. SECT. III. General Ohservations on the Cure of Gonorrhoea Virulenia. GONORREKEA, as I have observed above, has s till of late, been very generally considered as depend- ing upon an affection of the constitution ; or at least the discharge has been supposed to be of such a nature Sect. III. CURE OF GONORRHOEA VIRULENTA. 51 as at all times to affect the constitution, and therefore that a cure could not he obtained bnt by the use of remedies which operate upon the system at large, For a considerable time mercury was chiefly relied upon. It was employed on the supposition of Gonorr- hoea being a symptom of Lues Venerea ; but experience having shewn that no advantage was derived from mer- cury by itself, other remedies were employed along with it. These consisted chiefly of demulcents, evae- uants, and astringents. By a plentiful use of mucilaginous drinks, and oth- er demulcents, it was meant to sheath the bladder and urethra more effectually from the acrimony of the u- rine, and at the same time to render the urine itself less acrid. Purgatives were employed for the purpose of carrying off the morbid matter of the disease, and nitre and other remedies were given with a similar intention ; and lastly, as the running was seldom lessened by the use of any of these, but, on the contrary, being fre- quently increased, bark, astringent balsams, and other corroborants, were prescribed for putting a stop to it. In some cases mercury was continued during the whole course ; in- others it was left off at the time of entering upon the use of astringents. The practice of physic when this prevailed being in most points highly improved, we are astonished to find such deficiency as this evinces, in the treatment of a disease which necessarily fell under daily observation. If patients had been left to themselves, without any in- terference on the part of practitioners, the disease would often, in the course of time, have disappeared without any injury being done to the constitution ; for Ave know that a simple clap will, in most instances, dry up whether any remedies be employed or not ; but, by the liberal use of strong purgatives, and especially when this was conjoined with a low diet and a course of mer- cury, the constitution was so much debilitated that this alone rendered almost every case that occurred exceedingly obstinate : hence Gonorrhoea was consid- ered as the most distressful as well as one of the most 52 GENERAL OBSERVATIONS ON THE Ch. II. dangerous diseases to which the human species was lia- ble. Lues Venerea was, for the most part, easily cu- red by mercury ; but no advantage was derived from this remedy in Gonorrhoea : the disease usually proved exceedingly obstinate, and was very apt to terminate either in gleet or in obstructions of the urethra. It soon appeared to practitioners of observation, that the medicines employed in Gonorrhoea, instead of pro- ving useful, rather did harm ; but the period was not yet arrived in which a more effectual remedy was to be proposed. Some, however, went so far as to say that medicines of every kind might be avoided, as they bad found, from experience, that the disease went off both more easily and more quickly when left to itself than it ever did with the remedies at that time in gen- eral use. A low diet, mercury, and evacuants, of dif- ferent kinds, did much harm, as we have already obser- ved, by inducing such a degree of debility and relax- ation as materially affected the constitution ; and the drastic purgatives, of which large doses were given daily, proved highly prejudicial, by the irritation which they excited. In certain stages of clap a strong purgative never fails to increase the pain ; .to excite a more frequent desire to make water, and to increase the discharge : nay, I have known various instances of a return of all the symptoms of Gonorrhoea being in- duced by the operation of a brisk purgative, long after the patient considered his cure as complete. We need not therefore be surprised at the proposal of laying all such remedies as these aside ;and it must be admitted that a cure will often take place, that is, the running would disappear, together with all the symptoms which attend it, without the aid of medi- cine. This would frequently happen where the dis- ease was mild; where the patient was possessed of a healthy constitution ; and where the running was not kept up by any impropriety on the part of the pa- tient. The running would disappear here, as happens in coryza and other instances of matter proceeding from inflamed surfaces, whether any remedies should SeC. III. CURE OF GONORRHOEA VIRULENTA. 53 be employed or not : but this would seldom or never happen where the symptoms were severe, nor where the patient did not live in every respect as he ought to do. In all such cases the cure would prove tedious and uncertain, and the constitution would frequently be ruined, in the attempt. When the mode of cure we have mentioned was proposed, an opinion prevailed that the discharge was kept up by some general affection of the constitution, and that nothing therefore could be so safe or so pro- per as to allow it to run as long as any part of the mor- bific matter by which it was produced, continued. It was at that time admitted by all, that Gonorrhoea was of the same nature with Lues Venerea. Chancres, as well as all other venereal sores, were kept open till cures were obtained by the internal use of mercury. An erroneous idea prevailed of some advantage being derived from the discharge which they produced ; and hence even by those who saw clearly that no benefit was obtained from mercury in Gonorrhoea, it was still considered as the best practice to allow the disease as they said, to discharge itself in this manner. Even granting that the matter of Gonorrhoea was the same with that of Lues Venerea, there is no cause to imagine that any advantage would ensue from this practice ; but we now have no reason to doubt of the two diseases being perfectly different. A practice, therefore, which at one period might have been judg- ed proper in one disease, would now be inapplicable in the other ; and hence it has, veiy generally, been laid aside, although not yet given up by some individ- uals. From the observations we had occasion to make in the last chapter, as well as from other circumstances, few will now doubt that the matter in Gonorrhoea pro- ceeding in most instances from an inflamed state of the membrane of the urethra and contiguous parts, gives a local affection only, without being productive of any general disease of the constitution. From this view of the subject, it is obvious that no great advantage is 54 GENERAL OBSERVATIONS ON THE Ch. II. to be expected from remedies applied to the system at large, and that a cure is to be looked for from the use of local remedies only. In the treatment of a simple sore, of a cut, a burn, or excoriations from any cause whatever, we would not surely expect to succeed by mercury, purgatives, or any remedies directed to the constitution. In all such affections we trust to local remedies, unless the presence of fever, or some other general affection, render other remedies necessary. For the same reason we ought, in Gonorrhoea, to de- pend entirely upon such remedies as act chiefly upon the parts affected ; no others being necessary if it be not occasional blood-letting, and other evacuations, and these only where fever, plethora, or much inflam- mation take place. In local affections of other parts, our remedies are easily and directly applied : in the urethra some nice- ty and attention is necessary, not only in the mode of applying them to the diseased parts, but in judging of the period of the disease, or rather of the state of the parts to which they are to be applied : in other situ- ations these circumstances fall directly under view, and we judge from appearances of the propriety of ap- plying one remedy or another. In the urethra we are directed entirely by the symptoms, and we judge from these of the remedies to be employed, as well as of the parts to which they are to be applied being in a fit state for receiving them or not. If the parts affected in Gonorrhoea were always the same, no difficulty would occur in the application of our remedies ; but, although the matter in the com- mencement of the disease proceeds in perhaps every instance from inflammation, yet, in some, parts are affected with inflammation, to which it would be im- proper and even hazardous to apply the same reme- dies which in a great proportion of cases are used with much safety and advantage. We shall afterwards have occasion to shew that, in certain circumstances of Gonorrhoea, bougies may be used with much benefit; but, for the most part, we Sect. in. cure of gonorrhoea virulenta, 55 depend entirely upon injections, and chiefly upon such as are of a drying astringent nature. Now it is obvi- ous, that although we may with safety apply an astrin- gent solution to an inflamed surface, as happens dai- ly where the membrane of the urethra only is affected, yet that much risk may ensue from the same solution being applied to the ducts of inflamed glands : in the one case the discharge produced by the inflammation will be lessened and soon removed, and the inflamma- tion itself will subside, while, in the other, by a sud- den stop being put to the discharge of a gland already in a state of increased irritability, more inflammation will be excited, the parts affected will become swelled and painful, and at last the discharge will burst forth with redoubled violence. That this frequently happens in the course of busi- ness, every practitioner of candour will admit: nay, there are few paiients who have been liable to differ- ent attacks of this discharge, who have not met with it in some degree. For a day or two the running will olten disappear, and they consider tile cure as com- plete, when after some degree of tension and uneasi- ness along the greatest part of the penis, particularly in the perineum, the discharge recurs as before, with every appearance of a recent infection. As there are many who condemn the use of injec- tions in Gonorrhoea, it is alledged that this is one of the inconveniences which they produce ; but we shall presently have occasion to shew that this is by no means the case, and that it proceeds entirely from a misapplication of the remedy ; from using it in a state of the disease for which it is impi per ; and not from the remedy itself being of a hazardous nature. This leads us to revert to the necessity there is for distinguishing between one state of Gonorrhoea and another. In the description of the symptoms, I re- marked that they are evidently distinguishable into four sets, indicating four states or stages of the dis- ease : and as it is a point of the first importance in prac- 56 GENERAL OBSERVATIONS, &C. Ch. II. lice to have these different states clearly marked, we shall now proceed to treat of them in separate sections, As the. author has mentioned the internal use of Mercury in Gon- orrhoea in this section, a few observations on its curative effects may not be misplaced. A notice of other remedies will be found in succeeding sections. The idea that mercury operates in Gonorrhoea in a similar manner to what it does in Lues, namely, by a specifick action, ap- pears at present to be generally abandoned. The point is indeed con- clusively decided by the fact, that the former disease is in numerous instances cured without the exhibition of a single grain. Its utili- ty must of course be derived from other properties, and those are probably its powers in changing a diseased to a healthy secretion. Analogy is in favour of this opinion, as well as the testimony of prac- tical men. Mr. Howard recommends its use in the form of calomel after the inflammatory symptoms have subsided, and the chordee is gone. At this period, the urethra is in a state of debility, and the stimulus of the medicine which in the preceding stage, would have been injurious, is not at present to be dreaded. The quantity administer- ed should not exceed two or three grains of calomel during the twenty-four hours, and this to be continued for a few days only. The exhibition of mercury by friction (Ung : Hydrarg : fort : ) either to the perineum, glans penis, or thigh, is seldom, if ever, proper. In the Contributions to Medical Knowledge, published several years since by Dr. Beddoes, there is a paper by Mr. Addington, a sur- geon in the west of England, in which he states his having cured hundreds of cases of Gonorrhoea, in a very short space of time, by giving Corrosive Sublimate internally. Three grains of it are to be dissolved in one ounce of rectified spirits of wine, and half of this mixture is to be taken undiluted when going to bed. On the second day after, a dose of Sulphate of Soda is to be taken, and in the even- ing, the remainder of the mixture. The salts are repeated in two days after. A violent and profuse salivation for one or two hours, is the consequence of this treatment, but there is no doubt of it& curative effects. It has lately been used with success in this city. As a general rule of practice, we must take the liberty to ob- serve, that with proper care and attention, mercury is but little need- ed as an internal medicine. In ordinary cases, other remedies will suffice. In instances however, where the discharge from the ure- thra is acrimonious and large in quantity, the exhibition of calomel will be found useful. This is also the case in some of the conse- quences of Gonorrhoea,. Ed. Sect. IV. OF THE FIRST STAGE, &C. 57 SECT. IV. Of the First Stage of Gonorrhoea. IN the first stage of Gonorrhoea, the running is never accompanied with violent symptoms. The extrem- ity of the urethra becomes red, full, and somewhat prominent. The glans become tender and irritable, and ardor urince takes place in a greater or lesser de- gree, according to the extent of the inflammation. For the most part the heat of urine is inconsiderable; but in some instances, even in this stage of the dis- ease, it is so severe as to excite a good deal of dis- tress. Chordee sometimes occurs, but seldom in any considerable degree. In the history of the disease we have seen, that in this stage of it, the membrane of the urethra alone is affected, that is, the inflammation by which the dis- charge is produced has not extended to any other part. We judge that this is the case when these symptoms only occur which have just been enumerated ; when no glandular swellings are discovered along the course of the urethra, and particularly when the running pro- ceeds entirely from within an inch, or an inch and a half of the extremity of that canal. Tills circumstance of the discharge in Gonorrhoea proceeding from the extremity of the urethra, is at all times a proof of the inflammation not having adranced farther than to constitute what I have denominated the first stage of the disease. No glandular swellings are ever discovered while the running proceeds from these parts ; and on dissection after death, the membrane of the urethra alone is found inflamed : but in some in- stances the discharge proceeds even from the superior parts of the urethra, while none of the contiguous glands are affected. This I consider as constituting the first stage of the disease, equally as when the ex- tremity of the urethra is alone affected. The symp- 8 58 OF THE FIRST STAGE Ch. II, toms are not more violent in the one than in the other, and the method of cure is the same in both. It must, however, be admitted, that we do not frequently meet with this; for where the upper part of the urethra is affected, the inflammation is very apt to spread to the contiguous glands, and thus terminates in the second, third, or, perhaps, fourth stage of the disease. We ascertain the place in the urethra, from whence matter is discharged, not merely from the height to which the pain or uneasiness with which it may be ac- companied extends, for this proves often an equivocal mark of distinction, but from compressing the passage at any given spot, and pressing out all the matter be- tween it and the end of the urethra. If, on removing the pressure, more can be brought down, we are sure that it must come from a greater height, and by pro- ceeding in a gradual manner upwards we may thus, with very little attention, discover almost the exact spot from whence the discharge proceeds. It will af- terv\ards appear that our being able to do so is of im- portance in conducting the cure. From what has been said it will appear, that in this stage of the disease the running proceeds entirely from inflammation of the membrane of the urethra, with- out any affection of the glands which open into it ; and in the removal of this, the cure entirely consists. Where the inflammation is considerable, as we judge to be the case when the ardor urinal is severe, and especially when it occurs in a very full habit of body, it may be proper to prescribe blood-letting, a dose or two of any gentle laxative, and a low, cooling diet. At the same time violent exercise of every kind should be avoided, particularly riding on horseback. Inflammation, however, in this state is seldom so considerable as to render blood-letting necessary : in ordinary cases we now trust to the use of injections alone, and in all periods of the discharge I use them with equal freedom. Even where blood-letting, and a strict attention to an antiphlogistic regimen is neces- sary, I have never any difficulty in beginning immedi- ately with the use of injections. Sec. IV. OF GONORRHOEA. 59 Those who are not in the daily practice of using in- jections, are afraid of prescribing them so generally as they ought to do ; some, indeed never employ them in any case, from the prejudice being strong which still prevails against them among almost all the older prac- titioners, while others admit that they may be used with safety and advantage, in the latter period of the disease, but never in the beginning, or while the inflam- mation continues in any degree severe. This, however, is a timidity that will soon vanish with all who venture upon a more general use of them. They will find that injections, of a sufficient degree of astringency for removing the discharge, may in this state of Gonorrhoea be employed with perfect safety, even in the commencement of the disease, and whether the inflammation which takes place be mild or severe. An idea is still entertained by many, that the run- ning should not be stopped till some of the virulency by which it was produced is carried off ; and hence they object, as we have just observed, to the early use of injections. But, as we have seen that Gonorrhoea is a local affection, and as we know that in other parts of the body local inflammation may at all times be re- moved with safety, nay, that it is the best practice to attempt it, we might from this alone infer, that it would be equally proper here. But independent of this, I can with confidence assert, and all who employ injections generally will do so, that they may in this stage of Gonorrhoea be used at all times, and with more certainty of proving successful the more early they are applied. Of this I am so clearly convinced, that I would advise all who have it in their power, to em- ploy injections instantly on the discharge taking place. They commonly, indeed, prove successful at whatever period they are used; but I have uniformly found that they act more quickly in the commencement of the disease than in the latter stages of it. While practitioners differ in opinion respecting the most proper period of Gonorrhoea for using injections, 60 OF THE FIRST STAGE Cll. II. they likewise differ in their ideas of the kinds of these remedies best calculated for the periods in which they are employed. In the commencement of Gonorrhoea, and at all times when much pain takes place, it is the opinion of many that emollient injections only ought to be used, such as warm oil, emulsions of almonds, in- fusions of althea, and lintseed : but in this there ap- pears to be some mistake ; and I can decidedly say so from having often experienced the inefficacy of the practice. On first entering upon business, I found it the opin- ion of many who used injections with freedom, that those of the emollient kind ought alone to be advised while much heat of urine, or any considerable degree of inflammation continued. These, it was imagined, would sheath and protect the parts from the acrimony of the urine, and on the inflammation subsiding, they conceived that injections of an astringent nature might be used with more safety. The opinion was plausible, and supported by some of our best practitioners ; I was therefore induced, along with others, to go into it ; but it soon appeared that no advantage was to be derived from it : on the contrary, it was evidently the cause of much distress, by rendering the cure of Gonorrhoea much more tedious than it otherwise might have been ; for injections of the emollient kind never tend to shorten the continuance of the discharge, and often render it more fixed and permanent, by relaxing the parts from whence it proceeds. Neither are injections of this description necessary as a preparative to those of the astringent kind : in this conviction I have for many years past laid them alto- gether aside, and during this period have used none but such as are evidently astringent ; and although I employ them with all manner of freedom, I have never perceived any bad effects arise from them. In this stale of Gonorrhoea, injections of the astrin- gent kird may be used with safety and advantage, from the very commencement of the discharge, as well as at any period of the disease, whatever the degree of in- SeC. IV. OF GONORRHOEA. 61 flammation may be. Instead of increasing the in- flammation, they tend, when of a proper strength, to lessen it ; they relieve more immediately than any oth- er remedy, the ardor urinae; and they commonly les- sen or remove the discharge in a very short space of time. In all cases, therefore, of this kind, where we sup- pose the disease to proceed entirely from the mem- brane of the urethra, I pay no regard to the continu- ance of the running ; the patient is immediately put upon the use of injections, and no harm ever ensues from it. There is only one symptom which, in this stage of clap, precludes the immediate use of injections, viz. pain and swellings of one or of both testes : a persever- ance in the use of injections during the continuance of this symptom very commonly does harm, and ought not therefore to be advised ; not that they tend to increase the inflammation, even of the testis, but by removing the discharge from the urethra, they de- prive us, as we shall afterwards see, of one of the most effectual remedies for a swelled testicle, proceeding from Gonorrhoea. >, A variety of astringent injections are employed by practitioners, but some proving more effectual than others, an investigation of this part of our subject is thereby rendered necessary. Almost any astringent injection will lessen the dis- charge. Port wine, and elaret, duly diluted, some- times answer. I have often succeeded with a tea-spoon- ful of brandy added to half an ounce of rose water : nay, rose water itself, or even cold water directly from the spring, will often give a stop to the discharge ; but, for the most part, the effects of these are only temporary. In slight affections, indeed, they some- times complete the cure, but in general we are under the necessity of employing astringents of a more pow- erful kind. Among the first injections used in Gonorrhoea, mer- cury, in one form or another, was a constant ingredl- 62 OF THE FIRST STAGE Ch. II. ent. It was not, however, employed as an astringent ; for at that period the use of astringents of any kind would have been considered as hazardous. Being ap- plied in this manner directly to the seat of the disease, it was supposed that it might act as a specific in the cure of it. But although I have given full and com- plete trials to injections of the mercurial kind, and in every variety of form, I have npt, in any instance, found them to prove more effectual than other astrin- gents. In order to ascertain the point to which I al- lude, with as much certainty as possible, I have re- peatedly made it the subject of experiment. Of dif- ferent patients in Gonorrhoea, all nearly distressed with similar symptoms some have been made to employ a mixture of calomel with mucilage and water ; others have used quicksilver dissolved in mucilage, while some have at the same time been using injections in which mercury did not enter as an ingredient. I admit that in most of these instances mercury prov- ed serviceable, but by no means in such a degree as many of the articles with which it was put, upon this comparative trial. There is no cause, therefore, to imagine that it acts as a specific in the cure of clap. To prevent interruption in this part of the work, formulae will be given in the Appendix to this volume, of ail the preparations I wish to recommend. Of mer- curial astringent injections, the prescriptions No. I, 2, and 3, are perhaps the safest and best that can be used. Calomel used in injections seems to act in a similar manner with lapis calaminaris, armenian bole, and oth- er astringent earths; not by any specific virtues with which ihey are endowed, but by restoring tone to parts weakened by the disease. It is in this manner, I con- clude, that ail of these articles act in the cure of Gon- orrhoea ; and in cases that are not particularly obsti- nate, they very commonly prove effectual. Lapis calaminaris, ortutia finely levigated, suspended in thin mucilage, makes a very safe and useful injection. No, 4th and 5th are formulae of these ; and No. 6 is a pre- SeC. IV. OF GONORRHOEA. 63 scription of a gentleman retired from business, who, at one period, was in very extensive practice in Lon- don, and who in the course of much experience in this particular branch, gave the preference to articles of this kind over all others that he ever employed. These earths possess one important advantage for this purpose : they never do harm, in whatever quanti- ty they are used. If levigated with sufficient care and attention, they may be used in any quantity that the liquid in which they are conveyed can be made to sus- pend. Alum dissolved in water makes a safe and useful injection. It proves equally safe, and still more pow- erful, when conjoined with a decoction of oak bark, or an infusion of galls, for which prescriptions are given No. 7th, 8th, and 9th. Kino, an astringent lately much used in Diarrhoea, proves also an useful ingredient in injections for Go- norrhoea. I have in various cases found it prove suc- cessful where other articles had failed, and I have not observed that it ever does harm. As it is not very soluble in water it becomes necessarry to suspend it when in fine powder, by means of mucilage, as is pre- scribed No. 10th and 11th. Opium proves often an useful ingredient in injections of this kind ; and as it is equally serviceable whether much pain takes place or not, I conclude that it does not act so much as a sedative as it does as an astringent. No. 12th and 13th are formulae of injections with opium. Some of the astringent balsams, properly combined with water, make a good variety of injection for Go- norrhoea, particularly the balsamum canadense, and balsamum copaiba, as in No. 13th, and 14th. Lead, in various forms, proves highly serviceable in these injections. Cerusse suspended in mucilage and water is often employed with advantage ;but ace- tum lythargyri, and saccharum saturni dissolved in water are most to be depended on. Formulae of these are given in No. 15th ? 16th, and 1 7th. 64 OF THE FIRST STAGE CI). II. Of all the astringent injections, however, which I have used, none prove so powerful as white vitriol dissolved in water. In the quantity of a grain and half to an ounce of water, it seldom creates much ir- ritation, and it does not often fail in this variety of the disease, in which alone injections of any kind ever prove materially useful. No. 18th is the form of in- jection, which, in the common occurrences of daily practice, I am in the habit of using ; and No. 19th is a combination of vitriol and acetum lythargyri, which, in a few cases, I have found to answer better than either of these articles separately. Many other astringents might be enumerated, from which very useful injections might be prepared, but the formulae which I have given contain the most pow- erful of any with which we yet are acquainted. None of them will at all times prove successful ; for even in this the most simple variety of the disease, the most active remedies will in some instances fail : but I can from experience in this branch of practice assert, that it will seldom happen where the injection is properly managed and duly persisted in. The vitriolic injection, No. 19, I have mentioned as the most useful formulae of any ; but it will some- times happen that a case will readily yield to others which has long resisted this. When we do not, there- fore soon succeed with one injection, we ought, with- out loss of time, to have recourse to others, by which our purpose will be more easily accomplished than by continuing to employ the same for any length of time together. In all these injections the different ingredients are in such proportions as best suit the general course of business. This was a point of much importance to ascertain, and so far as my observation goes, I have done so ; but cases will no doubt occur from time to time, in which some variety of strength is necessary. All injections of this kind should be of such a strength as to excite some degree of irritation in the urethra, but by no means so strong as to create much pain : Sec. IV. OF GONORRHOEA. 65 hence, where the preparations I have mentioned do not answer the purpose, they should be made stronger; and when of such a strength as to excite severe pain, they should be more diluted. This, I may remark, is an object requiring much attention, for while it is obvious that injections must do harm when their strength is more than it ought to be, it is equal!}' certain that little or no advantage will be derived from them when they are too weak. I have known a cure accomplished in three days, merely by making an injection of a sufficient strength, where the disease had previously gone on for two or three months, from want of attention to this point. I consider this, indeed, as one of the most important points in the treatment of Gonorrhoea, nor does any thing distinguish the practitioner of experience with such certainty, as his being able to adapt the strength of the injections which he employs to the particular circumstances of every case which falls under his man- agement. In the application of injections there are two cir- cumstances which more particularly require attention, viz. the manner of throwing them up, and the frequen- cy of using them. They may be thrown up either with a small bag of resina elastica, fitted with a pipe, or with a common small syringe ; whether the bag or syringe be used, the pipe should be perfectly smooth, of a conical form, not above half an inch in length, and the cone of such a thickness near to the root, as not to allow the pipe to pass above a quarter of an inch into the urethra. The bag or syringe being filled with the injection, and the patient seated with his breech over the side of a chair, so as to prevent the perineum from being pres- sed upon, the pipe, when well oiled, should be insert- ed into the urethra, as far as it will go, with the right hand, while, with the left, he grasps the penis, and pulls it forward upon the pipe. He must now throw the in- jection up in such a manner that it may reach the far- 66 OF THE FIRST STAGE Ch. II, thest part of the urethra that is affected, but not with such force as to excite pain. When the discharge proceeds from near the extrem- ity of the penis, very little force is required for this purpose ; but when the upper part of the urethra is affected, if the injection be not thrown up with some degree of firmness, it will not reach the seat of the disease, and hence no advantage will be derived from it- Previous, therefore, to the use of injections, the part of the urethra, whence the discharge proceeds should be ascertained, and it can be easily done in the manner we have mentioned above. In using injections it is judged proper by some to desire the patient to prevent them from passing farther in the urethra than the seat of the disease ; lest, by forcing some of the matfer along with the liquid, the infection should be carried to parts which otherwise might not have been injured. For this purpose the patient must compress the urethra with the middle ringer of his left hand, at that point to which it is meant the injection should go ; while the syringe or elastic bag is employed for throwing it up in the other. But although there is necessity for throwing injections farther than ttie seat of the disease, there is no cause for this anxiety in preventing them. It does not appear, that in this manner, the infection is ever communicated from one part of the urethra to another; at least I have never met with an instance of it, and I have seldom pointed out this to my patients as a necessary piece of attention. While it does not therefore, answer any good purpose, it certainly renders it more difficult for the patient to throw the injection properly up, as he cannot both make pressure upon the upper part of the urethra, and, at the same time, manage the syringe with that exactness which it requires. The point, however, of most importance in the use of injections is, the frequency with which they should be thrown up ; it is not enough that we discover a composition that will establish a cure, if we do not use it with that frequency which the nature of the disease Sec. IT. OF GONORRHOEA. 67 requires. In common practice the patient is desired to inject the liquid two or three times a day : this, if the injection be of a proper strength, will in course of time effect a cure ; but I am perfectly convinced from much attention to the subject, that cures would be much more speedily obtained were injections to be more frequently thrown up. Instead of two or three times a day, I cause them to be used seven, eight, or ten times daily ; by which the cure, instead of being protracted for several weeks, is often completed in as many days. This, I must observe, is a point of such importance in the cure of Gonorrhoea, that nothing can compen- sate the neglect of it. The inefficacy of injections is frequently held forth as one material objection to them, but, for the most part, their failure will be found to depend in a great measure, upon this circumstance. Patients ought, therefore, to be urged to use them, at least as frequently as I have mentioned. When in- deed the discharge lessens, or disappears entirely, there is no necessity for using injections so frequently, but while it continues undiminished, the more frequently the remedy is applied to the parts from whence it pro- ceeds, the more quickly will it be removed. On laying injections aside, even after the running has disappeared entirely, and when there is therefore cause to suppose that a cure is obtained, the discharge often returns with equal seventy as at first, either from excess in wine, or over exertion in bodily exercise. In such circumstances the injections must again be em- ployed, and used with as much frequency as before, care being taken not to leave them off till some time after the running has again disappeared. When the discharge returns repeatedly it is apt to weaken and relax the parts so much, that this alone comes at last to constitute a new disease, forming a variety of what in general is termed gleet. This, how- ever, requires remedies of a different kind, and will fall to be considered in a different chapter. 68 OF THE FIRST STAGE Cb. II. It will be remarked that I have only slightly taken notice of any other remedies in treatment of Gonor- rhoea : I have purposely done so, from full conviction of the inefficacy of ail remedies that are not immediate- ly applied to the urethra, and from finding that a proper use of injections never fails to prove successful, where a cure by any means can be obtained. Where much pain and inflammation takes place, I have observed above that some advantage may be ob- tained from blood letting, and a strict attention to an antiphlogistic regimen. I think it right, however, to say, that few cases occur in which this becomes ne- cessary. A patient under Gonorrhoea should live moderately, but by no means upon such low diet as in former times was prescribed in such cases. He ought to live in such a manner as may prevent the inflamma- tory symptoms from becoming severe, but not so low as to run any risk of inducing relaxation or de- bility. The circumstances which most particularly require attention are, abstinence from all manner of connec- tion with women, and from bodily exertion, such as much walking and riding on horseback, which more es- pecially affects the parts concerned in this disease. In the treatment of Gonorrhoea, where no injec- tions are used, where the disease is either left entirely to nature, or treated with demulcents and purgatives, a regular progress towards amendment is, for the most part, observed in the discharge. The matter from be- ing thin, and of a greenish hue, or perhaps of a red colour from being tinged with blood, becomes of a thicker consistence, tough, ropy, and of a white or yellow colour : but. where injections are employed this seldom happens. This natural*" process is thereby in- terrupted ; and a cure often takes place without any change being perceived in the colour or consistence of the discharge. There are some symptoms which occasionally take place in every stage of Gonorrhoea, and which, it might be expected, ought to have been more particularly no- SeC. IV. OF GONORRHOEA. 69 ticed here, such* as chord ee, and evacuation of blood from the urethra. But these symptoms being attend- ed with circumstances requiring a peculiarity of treat- ment, quite inapplicable in the ordinary state of Gon- orrhoea, and being all of them highly important in their nature, a separate section will be allotted for the consideration of each of them. We shall now, therefore, proceed to consider the second stage of the disease. On the subject of injections we are sorry to say that we cannot agree with the author, as we are confident that in many instances, from a careless use of the syringe and want of attention in compres- sing the sides of the urethra immediately above the part affected, the disease has spread along the whole course of the canal, even to the neck of the bladder ; not only protracting the complaint, but also greatly aggravating its symptoms, and inducing frequently one of its most troublesome consequences, stricture. We have heard the same remark made by many physicians and surgeons of extensive practice, more particularly by a British sur- geon of celebrity, who informed us as early as the year 1804, that for the reasons above stated, he had not for several years made use of injections, and had employed as a substitute the Calx Hydrargyi alba, and furnished us with the following prescription: R, Calx : Hydrarg : Alb : Uol : Armen : aa grs. x. Mel : Despumat : ^ji. — tere : simul in mortar : marmor : lit fiat linamentum. This furnishes a linament of the consistence of the honey itself, and is applied by means of a bougie, directly to the part affected, by dipping it in the linament about an inch, sometimes more, sometimes less, according to the nature and extent of the case, and introducing it into the urethra about the same distance, rolling the bougie two or three times round in the part, so as to leave as much of the lina- ment behind as possible. This operation is repeated five or six times for the first two or three days, during which time the running- is considerably increased in quantity; the re-petition of the linament is then gradually diminished; till the running ceases altogether, which it sometimes does in three days, often within the week, and seldom exceeds a fortnight. We have used this prescription exclusively, for eight years, and have not as yet known it fail in a single instance, nor have we ever met with a single case of stricture, in any of our patients, who had confined themselves to this application. It has obviously one advan- tage over injections, that of remaining a much longer time in con- tact with the diseased part, which it must do, from its consistence, and from which circumstance it requires to be less frequently re- peated. 70 OF THE SECOND STAGE Ch. 11. We have not used the oxymuriate of mercury internally our- selves, in this complaint, but are assured by some of our friends that they have employed it with great success, and that a mechanic of this city who is noted for his skill in curing this complaint, uses this medicine solely. Vid: Parrs. Mel : Diet : Art : Gonorrhoea, Thatcher's Dispensatory, 2nd edit. Of the muriate of gold as a remedy in this complaint, we shall speak hereafter. Ed. SECT. V. Of the Second Stage of Gonorrhoea. IN this stage of the disease all the symptoms are more violent than in the first. The heat of urine is much more severe ; the whole body of the penis be- comes tender, and even painful ; and chordee takes place to a very distressful degree. The matter dis- charged from the urethra is either of an ugly green colour, or deeply tinged with blood, and commonly very foetid. It is found, on examination, to proceed from the more superior parts of the urethra, general- ly from about the middle of the perineum, where the patient complains of a smart pain upon pressure, and where one or more small tumours are often perceptible, produced by the inflammation having extended to Cowper's glands. Although the symptoms of the first stage of Gonor- rhoea are commonly very distinctly marked, yet they frequently proceed to, and terminate in one of the other stages of the disease, particularly in this which we are now considering. This happens from the in- flammation extending along the urethra, either from the matter producing the disease being more than usually acrimonious ; from the effect of improper man- agement on the part of the patient ; from the impru- dent use of irritating or very astringent injections ; or from the patient being of a habit of body rendering him particularly liable to be acted upon by causes apt to excite inflammation. Sect. V. OP GONORRHOEA 71 I conclude that it happens most frequently from the first and last of these causes, or, perhaps, from a com- bination of them both; as in a great proportion of cases of this second state of the disease we find it taking place almost from the first day on which the running appeared. It must, no doubt, have fallen under the observation of every practitioner that this, as well as the third and fourth stages of Gonorrhoea, are often induced by the patient living in a state of riot and de- bauchery, and, in some cases, by the immoderate use of irritating injections. But although these are cir- cumstances which in every case of Gonorrhoea ought to be rigidly guarded against, from their tending to excite one of the most distressful complaints to which the human species is liable; yet I am convinced, from what has been mentioned, that the worst states of the disease will frequently occur, notwithstanding all that can be done either on the part of the patient or surgeon to prevent them. As the practice in this state of Gonorrhoea is materi- ally different from what we have recommended in the fust stage of it, the utmost attention becomes ne- cessary in distinguishing between them. In the first the matter is, for the most part, discharged from within an inch and a half of the extremity of the penis ; and where the disease does not extend farther up the urethra, although the ardor urinse is sometimes con- siderable, yet the pain is never so severe as that which arises from the inflammation in the second stage of the disease. In this last, the whole body of the penis, as we have observed above, is tender and painful ; the chordee which takes place is highly distressful, and one or more inequalities, accompanied with pain on pressuse, are discovered in the perineum : whereas, in the former, any chordee which occurs is for the most part very moderate. The pain is considerable at all times when the patient is not passing water, and no hardness or inequalities are perceived in the peri- neum. 72 OF THE SECOND STAGE Oh. II. It is proper to remark, that even in the second stage of the disease, these glandular tumefactions in the pe- rineum are not always at first obvious; but upon pressure with the fingers they are easily discovered, even on their first commencement ; and in the more advanced stages of the disease they become perceptible, both to the touch and to the eye. Whenever chordee occurs in a severe degree, the whole penis acquires a firmness and tension, particularly where it runs along the perineum. This, however, is very different from the glandular affections to which I allude: the one is a diffused swelling, extending over the whole, or a considerable part of the penis; it does not con- tinue fixed or permanent, and seems to depend upon a morbid irritability in the muscles of the penis, by which they are easily excited to violent and unequal contractions. The others are, at first, small, circum- scribed swellings, painful to the touch, which do not rise and fall speedily, and which remain more or less permanent according as the symptoms with which they are connected are more or less violent. These swellings proceed, as I have already observ- ed, from an inflamed state of Cowper's glands, induced by the inflammation extending along their ducts, which terminate in the urethra, to the glands them- selves. Inflammation here, when it comes to a height, in a manner similar to what ensues from it in other parts, is very apt to terminate in suppuration ; and as the formation of matter in the substance of these glands is apt to excite the most distressful consequences, nothing should be omitted that can tend to prevent it. When matter forms in them, if it be not immediately dis- charged by an external opening, it is very apt to burst into the urethra, and to produce runnings, which, in some cases, do not terminate but with the life of the patient. On the first approach, therefore, of this second stage of Gonorrhoea, all our endeavours should be employ- ed to remove or lessen the inflammation. If the pa- SeC. V. OF GONORRHOEA. 73 tient is plethoric he should lose a considerable quantity of blood with the lancet, and ten or a dozen leeches should be applied to the pained part. Whatever his habit of body may be, the application of leeches should not be omitted, and they ought to be repeated once and again, according to their effects, and to the degree of inflammation and swelling which take place ; saturnine poultices should be applied over the part af- fected, the bowels should be kept open with gentle laxatives, and the patient should be put upon a low, cooling diet. If, either by the violence of the inflammation, or by an imprudent use of astringent injections, a stop has been put to the discharge, much advantage will be de- rived from our soliciting a return of it. This however, must not be done with applications of an irritating na- ture, such as bougies, and stimulating injections, as some have advised, but it may be attempted with safety by throwing up, from time to time, injections of warm oil and other emollients, such as warm decoc- tions of lintseed and althea. But although we find from experience that much harm is done by the application of stimulants directly to the urethra, we know that they may be applied to the skin both with safety and advantage. Thus, when the swelling does not soon lessen, by blood-let- ting and the other remedies mentioned above, I have, in different instances, derived advantage from the ap- plication of blisters to the parts affected, and by cover- ing the bites of the leeches with adhesive plaster; this practice may be adopted even the day after they have been applied. The blister should be made to cover the whole perineum. When the remedies we have advised are tirr.eously and properly applied they will not often fail to re- move the inflammation; but when this is not accom- plished, and when the swelling or swellings proceed to a state of suppuration, nature should be as much as possible assisted by a frequent and free use of emollient poultices and fomentations ; and as soon as a fluctuation 10 74 OF THE SECOND STAGE Cll. II. of matter is discovered, it ought to be discharged by an opening made the full length of the tumour. In this manner a sore will be produced that will be difficult to heal ; but if the habit of body be sound, a cure will be obtained at last, and there is no other method with which I am acquainted that will so readily prevent the matter from bursting into the urethra. When this unfortunate circumstance takes place, of matter collected in one or more of these glands, find- ing access to the urethra, scarcely any advantage is to be derived from art in the treatment of it. Injections, as we remarked in the last section, instead of proving serviceable, rather do harm. They cannot reach the cavity of the gland, where alone they might prove useful, and by preventing for a time that free dis- cbarge of matter, which, in every abscess is desirable, they cause it to collect, and alternately burst out, in greater quantities than before. When the cause of such an occurrence is not sus- pected, both the patient and practitioner are apt to imagine that it proceeds from the fault of the injection : every variety of the remedy is therefore employed, but nearly the same effect results from all of them, and the patient, after being teased and perplexed for a great length of time, finds himself in no degree bet- ter than he was at first. By some practitioners a course of mercury has been advised in this state of the disease, and particularly frictions with mercurial ointment on the perineum ? but although I have often seen the practice fairly and completely tried, I never knew any advantage derived from it. Neither does mercury prove useful in the sores whirl] ensue from opening abscesses in the perin- eum, proceeding from Gonorrhoea. On the idea of these sores being of the same nature with such as suc- ceed to buboes in Lues Yenerea, mercury is commonly prescribed ; hut although I have known it repeatedly used, not only for the cure of these sores, but for the discussion of the previous tumefaction of the glands, J never knew any evident benefit derived from it. SeC. V. OF GONORRHOEA. 75 All that in such circumstances can with propriety be done is, to cause the patient to live in such a man- ner as will most effectually brace his constitution ; his diet ought to be of a nourishing; kind ; cold bathing, particularly in the sea, proves sometimes useful, and, in some instances, Jesuit's bark, in large quantities, is given with advantage. In no period of this state of Gonorrhoea are injec- tions admissible, and I suspect that the discredit into which they have fallen with many is owing to their being employed promiscuously in every state of the complaint. We have just seen that they cannot be used with any prospect of success, when suppuration has actually taken place, and a very little attention will make it appear that they ought not to be advised during the inflammatory state of the complaint. While the parts are inflamed, instead of endeavouring to re- move the discharge, we ought rather to try to promote it. Nothing tends with such certainty to moderate all the symptoms; and I have repeatedly observed that they are all rendered much more severe by what- ever tends, in any degree, to give a check to the run- ning. It is proper, therefore, that the younger part of the profession be put strictly on their guard against the use of injections in every period of this stage of Gonorrhoea ; a practice which, in the first stage of the disease, is the only remedy, as we have seen, upon which any dependence ought to be placed, but which in this is evidently fraught with danger to the patient, and therefore with discredit to those who advise it. Besides the glandular abscesses of these parts, which we have just described, collections of matter are apt to occur in this state of the disease, not only in the cellular substance of the perineum, but in the corpus cavernosum of the penis, as well as in the corpus spon- geosum urethra?. The treatment of these, however, ought to be so exactly what we have pointed out for the others, that nothing farther need be said upon it. To prevent, as much as possible, the risk of such col- lections bursting into the urethra, the matter should 76 OF THE SECOND STAGE Ch. II. be discharged by a free opening the whole length of the tumor, as soon as it is found to be completely form- ed. When collections of matter in these parts, whether seated in Cow per' s glands, or in the contiguous soft parts, terminate, as they sometimes do, in external openings, at the same time that a communication is formed with the urethra, the urine escapes at the sore, and thus another disease is produced, termed a sinus, or fistula in perineo. This falls to be treated like sinuses in every other part : the seat of the abscess must be laid open from one end to the other, and by enlarging the .opening in the urethra, if the patient be otherwise in sound health, a cure will, for the most part, be obtained, by endeavouring to heal the sore liom the bottom in the usual way.* It may be aile(*ged, if this proves successful where the matter has already formed an opening, both in- wardly and outwardly, for itself, that a similar prac- tice should be adopted where the abscess has only burst into the urethra. That a free incision should be made into it, and a cure, attempted in the manner we have ai ready advised. Where the opening into the urethra is such as to admit the u: ine to pass into the abscess, the practice to which I allude ought undoubtedly to be adopted, for no other will prove successful, and the patient must remain in a state of great distress and misery while this continues ; but while the external tegu- ments remain entire, and while the urine does not find access to the abscess, no attempt of this kind ought to be made. However inconvenient the discharge of mat- ter from the urethra may be, and however long it may continue, the patient ought rather to submit to it than to the uncertain event of a fistulous opening, which al- ways proves tedious and distressful, with whatever judgment the disease may be afterwards treated. * V. System of Surgery, chap, xv. SeC. VI. OF GONORRHOEA. .,7,7 SECT. VI. Of the Third Stage of Gonorrhoea Viruknla. IN this stage of Gonorrhoea, along with ardor urinae, and the other ordinary symptoms of the disease, the patient complains of a severe fixed pain in the upper part of the perineum, accompanied with a sensation of fullness, and tension in all the parts contiguous to the anus. The desire to void urine is more frequent than in either of the two preceding states, and it is com- monly passed with much pain and difficulty; often drop by drop. Tenesmus, or a painful and frequent desire to go to stool, often takes place, and, in some instances, to such a distressful height, as adds greatly to the misery of the patient. Even in the commencement of tfee disease the pain in making water is in some cases so severe as to excite heat and other symptoms of fever ; and, in the more advanced stages of it, I have known the fever rise to a very alarming height. This state of Gonorrhoea, in some instances, proceeds from the inflammation spread- ing backward in a slow, gradual manner, from the point of the penis, which we have shewn to be the seat of the first stage of the disease, but more frequent- ly it takes place suddenly either from the imprudent use of injections, from the patient being in a riotous course of life, or from his being exposed to violent ex- ercise, either on foot or on horseback. On examining the parts affected, the penis is, for the most part, in a state of tenderness and irritability, nearly indeed, as we have described it to be in the second stage of this disorder ; but, together with this, on compressing the parts about the end of the rectum a sense of pain arises, which is never experienced in either of the states already described, and on intro- ducing the finger into the anus, the prostate gland is found considerably swelled, and in such a state ot irri- tability that it can scarcely bear to be touched. 78 OF THE THIRD STAGE Ctl, II. Even the slightest degree of this affection excites much uneasiness, and the desire to pass water seldom ceases for above a few minutes together ; but when the disease has been of long duration, the prostate gland, which nearly surrounds the urethra, or which rather appears, as it were, to form the passage of urine at this part, becomes often so much swelled as nearly to obstruct the discharge of urine as completely as when the urethra is entirely stopped. Those, indeed, not versant in this branch of practice are apt to mistake this affection for strictures in the urethra ; # of course a delay takes place in using the proper remedies, and at- tempts which are frequently made to overcome the supposed strictures, too often do mischief. Frequent* ly, indeed, neither a bougie, nor catheter, when em- ployed for removing a suppression of urine, proceed- ing from this cause, can be passed ; for the gland is in some cases so much swelled as to obliterate the passage almost entirely, and in others, by swelling on one side only, the passage is thrown altogether over to the other ; circumstances which render the introduction of a bougie either impracticable, or at best difficult and uncertain. As it is in the commencement only of this affection that any material advantage is derived from the inter- ference of art, and as it is a disease which, in the more advanced states of it excites the greatest possible distress, we ought instantly on the first approach of it, to apply such remedies as experience has proved to be the most effectual in removing it. Of all the remedies that I have ever employed, ear- ly blood-letting is almost the only one from which any obvious advantage has been derived. It ought to be advised immediately on the first approach of pain, nor should we be deterred by a weakly or delicate consti- tution. In a person of this description the evacuation ought no doubt, to be more sparingly administered than where plethora takes place ; but even in the most delicate habit of body, a quantity of blood should * Vide Strictures. SeC. VI. OF GONORRHOEA. 79 be discharged in proportion to the strength of the pa- tient, in the first place by the lancet, and afterwards by leeches applied to the parts affected. The prac- tice of blood-letting I consider to be equally necessa- ry here as in cases of pleurisy ; in the latter, indeed, the life of the patient is in greater hazard, but in this his future comfort and enjoyment of life are at stake. It ought not, therefore, in any instance, to be omitted. I speak the more decidedly upon this from various instances having fallen within my own observation, of the most distressful consequences taking place from this remedy having been omitted, and from many others having ended easily where it was employed with freedom. It is in the first stages only of the disorder, however, in which it acts with much ad- vantage ; chiefly, indeed, on the first symptoms of inflammation taking place, for when the prostate gland becomes swelled and inflamed in any considerable de- gree, neither this nor anv other remedv can be de- pended upon for removing it. After a long course of time, an enlarged prostate will sometimes be found much diminished, but this happens more frequently without our being able to account for it, than as a necessary consequence of any medicine employed for it. Blisters do not afford that relief here that we some- times derive from them in swellings of Cowper's glands, neither is much advantage ever obtained from saturnine applications. Opium, whether given by the mouth, or in clysters, proves more useful than any other remedy for removing the pain and lessening the irritation; but probably from coming more directly into contact with the diseased parts, it proves evident- ly most successful when given in clysters, and it seems to answer better in small doses, frequently repeated, than in large quantities given at once. Thirty drops of laudanum, mixed with two ounces of thin starch, and thrown easily into the rectum, very commonly gives immediate relief, and as long as this dose proves ef- fectual it ought not to be increased, 80 OF THE THIRD STAGE Ch. II. While opiates, given in this manner, lessen the irri- tability of the organs of urine, they also give much re- lief by removing that painful and frequent desire to go to stool, with which patients in this disease are often afflicted. Hitherto I have said nothing of the use of injections, which are frequently employed in this, as in other stages of Gonorrhoea, for removing the running. This, however, is a practice that ought by no means to be a- dopted. It has at first been gone into without reflect- ing upon its tendency, and afterwards persisted in mere- ly from having once been adopted. In the second stage of Gonorrhoea I had occasion to remark that the dis- charge, instead of being stopped, ought rather to be encouraged. The same observation applies still more forcibly here, where a stoppage of the running tends always to aggravate every symptom, and where we find considerable relief often obtained by our bringing on a return of it. This, as we observed in the last section, should rather be done by the use of warm emollient injections, than by such as stimulate and give pain. These, I know, are advised for this pur- pose, but as I have known them evidently do much harm, even when managed in the most cautious man- ner, and as we find, indeed, that the disease is often at first induced by this very practice, I do not hesitate to say that it ought very universally to be laid aside. For a similar reason bougies ought never to be employ- ed here. Emollient injections prove useful not merely by so- liciting a more plentiful discharge from the urethra, but by soothing the irritability in the parts affected, and thus lessening the pain : and where opiates are conjoined with them they act still more powerfully in this manner. An infusion of the heads of poppies and althea root, used warm, answers particularly well for this purpose. Warm poultices, applied external- ly over the fundament and perineum, also prove use- ful. Some advantage too is derived from warm fo- mentations ; and I have known the warm bath afford much relief SeC. VI. OF GONORRHOEA. 81 All these remedies, however, act as palliative on- ly ; by their use the present distress may be much mitigated, while nature, in the course of time, aided by cautious management on the part of the patient, may at last accomplish a cure. At least, this, in the course of my observation, has happened in several in- stances where the swelling of this gland has not arriv- ed at any great height; but it has been more frequent- ly the consequence of rigid attention to regimen than the effect of medicines. We constantly find, in this complaint, that whatever excites much heat of body does harm ; whether bodily exercise, or heating food and drink ; hence every thing of this kind should be avoided, particularly much walking and riding on horseback ; and full meals of animal food, especially when wine or other strong drinks are likewise indulg- ed in. The diet should consist of milk and vegetables, with no greater proportion of animal food than is ne- cessary to support the strength of the patient. Such drinks should be chiefly used as tend to blunt the acrimony of the urine, and to sheath the parts which it passes over ; such as infusion of lintseed and althea, emulsions of almonds, and water in which gum arabic is dissolved. I have insinuated that I have little confidence in the activity of any medicine for removing swellings in the prostate gland, when it has unfortunately acquired a considerable bulk. A deference to the opinion of others requires that I should state the grounds upon which this opinion is formed ; this I shall do in notic- ing shortly the medicines which have been employed with the view of obviating this complaint. AVhen other remedies fail, and in some cases even before they are fairly tried, mercury is, in ordinary practice, recommended ; but I have much reason to think that it very commonly, if not always, does harm. Even in early practice I had frequent opportunities of seeing this complaint, and being led by conversa- tion with others to expect substantial relief from mer- cury, I used it freely for several years : I must ac- 11 82 OF THE THIRD STAGE Ch. II. knowledge, however, that I never perceived any ad- vantage arise from it, while, in some cases, evident mischief was the effect of the practice. Mercury never had any obvious effect in diminish- ing the tumour, and by increasing the irritability of the system, even when given in small quantities, and in the most cautious manner, it usually rendered the parts affected more painful than they were before. On these accounts mercury appears to be not only an use- less but a dangerous remedy so that I have now, in swellings of this gland, laid it entirely aside. Cicuta has also been much recommended in swel- lings of this gland ; but although I have given it very full and complete trials, I am not sure that in any in- stance it ever proved useful. The disease, in some, has appeared to yield while cicuta was employed, but this was only where a great length of time had elaps- ed, and not in a greater proportion of cases than where this remedy was never used. But as it may be em- ployed under proper management without any risk to the patient, where other remedies do not succeed, and where it is necessary to be doing something, it may be proper to give it a farther trial before any final opinion is formed of it. Having, in tumours of other parts, observed obvi- ous advantages from a decoction of the root of mezere- on, I have, in various instances, used it in swellings of the prostrate gland. In some it has appeared to prove useful, but never so evidently as to enable me to speak with certainty about it. When conjoined with sar- saparilla*, it seems, in other cases, to be rendered still more active, and the mucilage contained in that root, by blunting the acrimony of the mezereon, renders it both more agreeable to the palate and more grateful to the stomach. Among other remedies employed in swellings of the prostate gland, sea bathing and drinking sea water has been one of the most frequent. Where this dis- * Vide Appendix, No. 45. Sec. VI. OF GONORRHOEA. 83 ease is connected with a scrophulous constitution this remedy certainly proves useful. It will never remove the tumour speedily ; but, by strengthening the con- stitution, it seems, in such circumstances, lo render the swelling less permanent than it usually proves to be where this remedy is not employed. It ought, how- ever, to be remarked, that all strong purgatives do much harm. This happens in every stage of Gonor- rhoea, but especially where the prostate gland or blad- der are affected. By the irritation which they excite they not only induce a more copious discharge, but render the inclination to void urine much more fre- quent and more painful. When salt water is used, therefore, it ought not to be in greater quantities than will answer as very gentle laxatives. Swelling of the prostate gland does not terminate as tumours in the other glands of the urethra frequent- ly do, in suppuration. When Cowper's glands, or any of the smaller glands of the urethra become in- flamed, they either suppurate or a cure is obtained by discussion : but, in similar affections of the prostate this very seldom happens. When the tumour does not yield to timeous blood-letting, or when it does not afterwards crraduallv subside, it either remains nearly of the same size and hardness, or becomes both, larger and firmer till it ends in real schhrus, of con- siderable magnitude. In this state of the disease the discharge is, for the most part, thin and acrid ; together with matter from the contiguous parts of the urethra, which are usually more or less diseased, a considerable quantity is thrown out of the gland itself, forming, as we will afterwards see, one of the most obstinate varieties of gleet. Even in the commencement of this affection of the prostate, the passage of urine, as we have already re- marked, is often much obstructed; but, in the more advanced stages of it, this, in some cases, comes to such a height as to be insurmountable. Whether from the passage being completely obliterated by the sides of the swelled gland adhering together, which is 84 OF THE THIRD STAGE CI). II. alledged lo happen, but which T never saw, or from the passage being contracted by the sides of the gland swelling unequally, it sometimes happens that neither a bougie nor catheter can be introduced. In this case, as a total obstruction is formed to the passage of urine, we are obliged to draw it off by puncturing the blad- der, which may either be done above the pubes, or by passing the trocar into the bladder from the rectum, or pushing it up by the side of the diseased gland.* It must be remarked, however, in forming an opening with a trocar for drawing the urine off from the blad- der, that a very enlarged state of this gland precludes every attempt for this purpose either in the perineum or rectum. In which case it must necessarily be done above the pubes. In such circumstances, all that art can do, is to pre- serve a passage for the urine, by retaining a canula in the opening, and keeping the patient as free from pain as possible with doses of opium adequate to the distress T in which he happens to be. * Vide System of Surgery, chapter xiii. The author observes in the commencement of the section, that a swelling of the prostate gland may be mistaken for a stricture in the urethra, and a dangerous delay in the use of remedies will- be the consequence. The following distinction Mr. Home observes 1 , will occur between the two diseases. Let a soft bougie be introduced into the urinary canal as far as possible and per- mitted to remain for a minute or two until it can receive an impres- sion from the obstruction. If it does not pass farther than seven inches, and the end is marked by an orifice of a circular form, the disease is a stricture, but if it passes farther and the end is blunted, the prostate gland is probably affected. In addition to the symptoms mentioned above, may be added the flattened stool, which is indeed a diagnostic of a diseased prostate. Most of the remedies which prove useful in a swelling and enlargement of this organ, have been enumerated, and in most cases a correct opinion is given. Gentle laxatives are perhaps improperly omitted, as they are useful in diminishing irritation.. The warm sea bath is considered by some writers, as of more importance than the author is willing to attach to it. When the inflammation is subsiding, and there is danger of a permanent en- Sec. VII. OF GONORRHOEA. 85 largement, it has been found by many practitioners, in opposition to the experience of Mr. Bell, that mercury is a valuable medi- cine in reducing the gland. " As to schirrous enlargement" says Mr. Samuel Cooper " no certain mode to diminish it is known to surgeons." He mentions however the Pilule Hydrargyri cum cicuta* as a useful remedy, Mr. Home states a case in which suppositories of opium and hemlock were introduced per ano, and allowed to be dissolved there. They allayed the irritation, as well as diminished the size of the gland. When it becomes necessary to puncture the bladder, it is advisa- ble, if possible, to do so through the coats of the rectum. This is the opinion of the most distinguished surgeons of the present day. ^Nothing but an enormous enlargement of the gland need prevent it, " and in a case," says Charles Bell, " of the largest gland I ever " saw, I still prefer the attempt to puncture by the rectum, for I " conceive it still to be practicable while we can feel any part of ••' the bladder." Operative Surgery, Vol. 1. Chap. 4th. *R. Hydrargyri purificati X\ Gummi Mimosa miotic ae pulverisatse Xi Succi Cicutae spissati Zi Herbae cicutae fbliorum, in pulverem Tritorum q : s : Triturate the quicksilver, with the gum arabic moistened with a little rain water. Then add the inspissated juice, and lastly the powdered leaves, in sufficient quantity to make a suitable mass for pills. Cooper's Surgical Dictionary. Ed. SECT. VII. Of the Fourth Stage of Gonorrhoea. IT sometimes happens that the inflammatory symp- toms pass easily over the anterior part of the urethra, and shew themselves in more force and violence high- er in the passage. Thus, although the third stage of the disease, in which, as we have seen, the prostate gland is chiefly affected, is sometimes produced by the inflammation spreading from those parts which are only concerned when the second stage of it takes place, yet instances often occur of the inflammation passing 86 > OF THE FOURTH STAGE Ch. II. from the point of the urethra along the whole course of the passage, without any intermediate part of it being much affected, and fixing in the most violent manner, upon the prostate gland or bladder. In some cases the prostate is affected while the bladder itself remains sound, while in others it passes easily over that gland, and seizes with much violence upon every part of the bladder. In some cases the bladder becomes affected almost on the first attack of the disease. The inflammation spreads so quickly alon^ the urethra that the bladder is pained in the course of a few hours from the com- mencement of the discharge. It more frequently oc- curs, however, after the running has been of some duration, and, for the most part, can be traced as the consequence of much exposure to cold and dampness ; of violent exertion in walking or on horseback, or, as the effect of an injection thrown with too much vio- lence into the upper part of the urethra. The patient, from the first approach of the disease, complains of much uneasiness, which at last termi- nates in severe pain over all the region of the bladder, particularly about the neck of it; accompanied with a frequent and painful desire to make water, and of- ten with tenesmus. In some cases the pain is chiefly seated about the anus, but, in general, all the under parts of the abdomen, particularly about the region of the pubes, are greatly pained, and in some instan- ces, even the kidneys become affected, either from nervous sympathy, or from the inflammation spread- ing from the bladder along the ureters. In general the pain, especially after voiding urine, extends to the glans penis, and as this, with the stop, page which occurs to the flow of urine, are symptoms which always accompany stone, cases of this kind, when the history of the disease has been concealed, has been mistaken for stone in the bladder. If the running from the urethra has not been stop- ped by injections, it continues as if no affection of the bladder had occurred ; and in geneial any interrupt Sec. VII. OF GONORRHOEA. 87 tion that takes place to the discharge proves only tem- porary ; but along with the usuai running from the urethra, such as takes place in one or other of the dif- ferent stages which we have described, a considerable quantity of matter passes off with the urine. This gives the urine a turbid appearance, as if purulent matter was mixed with it, but on examining the depo- sition, which is usually made in the course of a few hours, it is found to consist almost entirely of mucus. On a further continuance of the disease this matter contained in the urine assumes a very different appear- ance. Instead of being broken and divided into flakes, as at first, it now becomes tough and viscid, in a very remarkable degree, resembling isinglass diluted with water to the consistence of jelly. This gelatinous matter is suspended in the urine when first voided, but it soon separates, and falls to the bottom, where it adheres so- firmly to the sides of the vessel in which it is received, as to be separated from it with difficulty. In some cases this substance is clear and transparent, but. for the most part, it is tinged of a yellow hue, and somewhat opake. When any considerable quantity of this matter has passed off; the patient is commonly relieved, and con- tinues easy for a longer or shorter period, according to the degree of inflammation that takes place. In some cases the quantity of this viscid matter is very inconsiderable, being no more than what slight- ly covers the bottom of the pot, while in others it seems to form more than half of all that comes from the bladder. When in such considerable quantities, it tends greatly to reduce the strength of the patient, insomuch that few constitutions are able to bear it long. From the nature of the parts in which this disease is seated, we would expect that it should be the most formidable complaint that Gonorrhoea could induce ; but this is by no means the case : the disease describ- ed in the last section, viz. swelling of the prostate gland, proves always more so. Few recover from the one.. 38 OF THE FOURTH STAGE Ch. II. while cures are obtained by a great proportion of all who are seized with tire other. At least in healthy constitutions this commonly happens, if the disease has not been much neglected at first. In general, in- deed, a considerable time passes over before a perfect cure is obtained ; nay, some degree of uneasiness, and certain deranged sensations, will often continue for a number of years, but after the first violence of the symptoms is over, they generally become, in a gradual manner milder, till at last they vanish entirely. On the first approach of the disease, blood-letting is the only remedy upon which most dependence ought to be placed, and, when freely practised, it seldom fails to render the symptoms moderate, and of shorter duration than they otherwise probably would be. A quantity of blood should be taken with the lancet in proportion to the strength of the patient, a num- ber of leeches should be repeatedly applied to the neighbourhood of the anus. With respect to diet, and other circumstances, the patient ought to be treat- ed in the manner we have advised in the last sec- tion. His bowels should be kept moderately open with castor oil, or other gentle laxatives, and opiates should be exhibited in sufficient doses for lessening, or even for removing the pain. When treating of swel- ling of the prostate gland we advised opiates to be given in the form of clysters, rather than by the mouth, and this mode of exhibiting the remedy proves equal- ly useful here. With a view more certainly to allay the irritability of the bladder, it has been proposed to inject opium dissolved in water into it, but this appears to be a dan- gerous experiment. I have known it done, but the patient was nearly killed by it. Convulsions and oth- er alarming symptoms occurred, but not in such de- gree as to prove fatal. W 7 arm emollient injections, such as warm oil, or the form of injection in the Appendix, No. 23, fre- quently give relief from pain, and give a temporary suspension of that constant desire to pass water which SeC. VII. OF GONORRHOEA. 89 often prevails here ; and in some cases the semicupium proves successful when these have failed. A plentiful use of mucilagenous drink* such as in- fusion of lintseed and althea root, and a solution of gum arabic in water, afford relief in all affections of the urinary passages, but in none more than in the one of which we are now treating. All these remedies are meant to alleviate pain and irritation in the commencement of the disease, and when timeously applied, and duly persisted in, they very commonly prove effectual ; but in the more ad- vanced stages of the disease, when the pain is not so severe, but when a good deal of uneasiness continues, accompanied with a discharge of that viscid matter which we have described, remedies of this kind do not afford so much relief. Opiates will no doubt tend at all times to allay irritation, by blood-letting, which at first never fails to give relief, tends now only to weaken the patient, without being productive of any advantage. In this situation Jesuit's bark sometimes proves use- ful; and I have seen instances where a few grains of alum added to each dose, seemed to render it more ef- fectual. Balsam of copaiba, and Canada balsam, prove likewise useful here : but where much benefit is ex- pected from them they should be given in as large do- ses as the stomach of the patient will permit. Of all the remedies, however, which in such circum- stances I have ever tried, uva ursi is the most effectual. No advantage is derived from it where the prostate gland is diseased ; but in unmixed affections of this kind, where the bladder only is affected, it seldom fails to procure relief. It may be given to the extent of a scruple at first, and afterwards half a drachm of the powder three times a day, in which quantity it seldom fails, in the course of a few days, to lessen the pro- portion of viscid matter in the urine; by which, and the abatement of pain which at the same time takes place, we are always certain that the inflammation al- so is diminished. ]2 90 OF THE FOURTH STAGE, &C. Cll. II. On the idea that this affection of the bladder pro- ceeds from a translation of the matter of Lues Vene- rea from the urethra, mercury is commonly used in it.; but although I have often given it, I never knew any advantage derived from it; it sometimes even does harm. It increases the irritability of the system in general, as well as of the parts more particularly afiectedJ Wlien affections of this kind have continued long, the bladder is apt to become much thickened and les- sened in diameter: hence, even after all the other svmptoms are gone, the frequent inclination to pass urine continues. In some cases this goes on for years : nay, I have known it endure for a great length of time, and only terminate with the life of the patient. It seem3 evidently to be the effect of inflammation, for it succeeds to inflammation of the bladder, by what- ever cause it may be induced. It also occurs from strictures in the urethra, when they happen to be con- siderable and of long duration. For the removal of this thickened state of the coals of the bladder mercury is often prescribed, and in some cases it has certainly proved useful ; but it seems to prove equally so from whatever cause the dis- ease may at first have arisen^. * This practice of giving- mercury in the thickened state of the urinary blad- der which succeeds to inflammation, we find recommended by the late Doctor Ebenezer Gilchrist of Dumfries, to whom we are indebted for much valuable in-> v formation in different parts of the practice of medicine. The warm bath and opiate clysters, are remedies of great value in an inflammation of the bladder. Mr. John Hunter recommends an opiate plaster, on the pubes or loins, where the nerves of the bladder originate, provided the disease should prove obstinate. Di- luents are indispensible, in large quantities, and among these, barley -water will be found most useful, Ed» Sec. vm. of chordee. 91 SECT. VIII. Of Chordee. CHORDEE is a painful, involuntary erection of the penis. Patients in every stage of Gonorrhoea are, in some degree, liable to Chordee ; but it occurs much more frequently and to a much greater height in the second stage of the disease, than in any of the others. It happens at all times of the day, but most frequently when the patient is warm in bed, when it is in some instances so severe as to deprive him en- tirely of rest. During a fit of Chordee the penis be- comes hard and painful to the touch, and for the most part it is curved downwards in a considerable de- gree. Chordee occurs in every period of this stage of Gonorrhoea, and it sometimes remains after the heat of urine and all the other symptoms are gone, but it is usually most severe during the continuance of the inflammation, and becomes more or less so ac- cording as that symptom is in a greater or lesser de- gree. I therefore conclude that Chordee is an effect of in- flammation, and that it proceeds from irritation, com- municated from the nerves of the urethra to those of the contiguous muscles, by which those unequal de- grees of contraction are produced over the whole substance of the penis, which universally take place ia this disease. Were it owing to effusions of lymph into the re- ticular parts of the penis, as some have imagined to be frequently the case*, Chordee would be of a more permanent nature than we ever find it to be, and these effusions would be apt to terminate in suppuration. Now, although suppuration is sometimes the conse- quence of inflammatory tumours in these parts, I have never observed thatit happens in those tumefac- * V. John Hunter on the Venereal Disease, 92 OF CHORDEE Ch. II. lions which accompany Chord ee. The latter com- monly rise and disappear again in the course of a few hours, and they are more diffused than tumours usu- ally are which proceed to suppuration. The others rise more slowly, and they terminate, whether by dispersion or suppuration, in a much more gradual manner. Of aM the remedies I have ever employed opiates prove most useful in Choi dee. The pain and tension are sometimes removed by rubbing the parts affected with laudanum, or with a strong solution of opium in water, and by keeping pledgits immersed in either of these, constantly applied to them ; but the greatest advantage is obtained from the internal exhibition of opium. Thirty or forty drops of laudanum, given at bed-time, or on the accession of the Chordee, very seldom fails in preventing or removing it. Emollient injections thrown up the urethra, particu- larly when impregnated with opium, have also a pow- erful influence in lessening the violence of Chordee ; and as the heat and irritation produced by costiveness tend greatly to augment the violence of this symptom, I have known much advantage obtained from the ope- ration of a gentle laxative. A temporary relief is often derived from the ap- plication of a cold solution of saccharum saturni and I have known the external application of camphor prove serviceable ; when dissolved in spirit of wine it proves useful, but it acts with more advantage when dissolved in oil. Frictions with mercurial oint- ment have been much recommended for the removal of Chordee, but as I have commonly found more ad- vantage from rubbing with camphorated oil, I conclude that it is chiefly the emollient properties of the mercu- rial ointment which render it useful, and, therefore, that the inconveniencies which sometimes occur from mercury, may here be avoided. In some cases we derive advantage from tying the penis down with a fillet to the thigh, but it only an- swers in very slight affections, and the practice ought Sect. VIII. OF CHORDEE 93 never to be advised in the more severe attacks of the disease. Being an obvious remedy for counteracting an erection, it is not unfrequently employed in the first instance by the patient; but I have frequently known it do harm, either from the fillet being appli- ed too tight, or from the parts being in such a state of tenderness as to render it altogether inadmissible. When none of the&e remedies succeed, blood-letting sometimes proves useful ; particularly by the applica- tion of leeches to the parts affected, nor ought this ev- er to be omitted when the patient is of a plethoric hab-; it, or when the pulse is full.- When Chordee takes place in a slight degree only, blood-letting is never ne- cessary ; but whenever it is severe, and resists the oth- er remedies we have mentioned, we ought never to hes- itate in advising it. Blood-letting proves more effect- ual than any other remedy in preventing that perma- nent kind of Chordee, which sometimes continues very distressful long after every other symptom of Gonor- rhoea has disappeared. Opium is one of our most effectual remedies in eve- ry stage of this symptom, but particularly where it has been of long continuance. In this state of the disease I have sometimes found, where opium has failed, that henbane, the hyocyamus niger of Lin- naeus, has proved useful. A grain of the extract, prop- erly prepared, may be given three times a day at first, and the dose increased to two, three or more grains, according to its effects. I have given to the ex- tent of seven and eight grains three times a day, with no inconvenience whatever ; but this was after the patient had been for some weeks accustomed to the remedy. stinate, after the symptoms of inflammation are re- moved, the disease is then termed a gleet. From this definition we might be led to imagine that the import of the term Gleet would be clearly and generally understood, and that no risk could oc- cur of its being misapplied. This, however, is not the case ; for the symptoms which one practitioner consid- ers as Gieet, are by others said to be Gonorrhoea. Some assert that Gleet does not lake place till the dis- charge becomes colourless, and resembles mucus ; while others are of opinion that Gonorrhoea changes into Gleet before this change of colour is perceptible. All agree in this, that Gleet does not take place so long as the discharge is capable of communicating in- fection; but no precise marks have yet been discov- ered by which we can judge of this circumstance with certainty. When the discharge becomes trans- parent and viscid, like mucus, I believe that no in- fection will ever ensue from it; but I also suppose that it is often equally harmless long before this change has appeared in it. By the use of astringent injec- tions, demulcents, and cooling purgatives ; and, in some cases, by the lapse of time alone, the running in Go- norrhoea will lose its colour, acquire a mucous ap- pearance, and even abate in quantity, and yet it will again become yellow, and appear in larger quantities than at first. In such circumstances the discharge may be considered as altogether deprived of the pow- er of communicating infection , at least no instance of the contrary has ever occured to me, and I have rea- 14 106 OF GLEETS. Cb. III. son to think, that, in every instance it will be found to prove inoffensive where the inflammation by which it was at first induced has been once completely re- moved, whatever the method of cure may have been by which this was accomplished : while, on the con- trary, I am convinced, from a variety of facts which might here be enumerated, that so long as the pri- mary inflammation of Gonorrhoea continues, however long this may be, the matter produced by it is equally capable as at first of communicating infection. Ad- mitting, therefore, that the running should not be denominated Gleet, so long as it is in any degree infec- tious, it is evident that this term ought not to be applied to it, till it has become clear and transparent, or till the inflammation by which it was at first in- duced is removed, and of which we can only be certain by the ceasing of the pain which accompanied the inflammatory state of the disease. The discharge in Gonorrhoea frequently disappears altogether, and the patient considers himself, for the space of several da}s, nay, in some instances, for weeks, as completely cured ; when, either b}~ violent exertion on horse- back or on foot, by excess in drinking, or too earlv connection with women, the running will again take place, with every mark of a new infection. When the patient, however, is conscious of not having ex- posed himself to the risk of being infected, he may always consider this renovated discharge as of a harm- less nature, provided the inflammation and pain by which it was at first excited had previously disap- peared. Among other proofs of this, I might men- tion various instances of married men, who, from Gonorrhoea contracted in youth, have frequently, during life, from one, or other of the causes I have mentioned, experienced frequent returns of this dis- charge, who, in this situation, have had frequent con- nexion with their wives, without communicating the disease. In some of these, the discharge will be absent for several weeks, nay, for months together ; while in others it has not disappeared for more than SeC. II. OF GLEETS. 107 two or three days at once, during the space of twenty years. In all of them, upon its first recurrence, it has ex- actly the appearance of a new infection ; but the event soon shews it to be materially different. If as- tringent injections are employed, they, for the most part, put an immediate stop to the running ; an 1, when left to itself, the matter becomes more quickly colourless than it ever does in a recent case of Go- norrhoea. In one instance, a gentleman applied to me in a state of the greatest distress, the day alter his marriage. He came upwards of twenty miles from the country, with every appearance of a recent clap ; which, he assured me, had broke out that very morning, although no appearance of an infection, under which he former- ]y laboured, had been perceived for upwards of three months, nor had he, during that period, been exposed to the risk of getting a new one. This, in the state of temporary frenzy, under which 1 found him, led to the distressful idea of his having been infected dur- ing the preceding night, by his newly married wife. I assured him that this was impossible ; for that, inde- pendent of the surity which he derived from tne un- blemished character of his wife, no infection could have appeared with such violence in such a short space of time; and on hearing that he formerly laboured under Gleet, I also ventured to say, that the discharge would probably disappear almost as suddenly as its approach had been rapid. My prediction proved true, I immediately threw up a vitriolic injection, and caus- ed him to repeat it three or four times in the course of a few hours. By five or six o'clock in the. afternoon nothing but a slight oozing from the urethra was per- ceptible; I furnished him with more of the injection, and he went home perfectly satisfied in the evening. This happened several years ago, and the same ap- pearances have uniformly recurred since that period, upon every connection with his wife, but no infection has ever been communicated to her. For a considera- 168 01 GLEETS. Cb. III. ble time he always bad recourse to the inject ion on the running taking place, but at last, being perfectly con- vinced of its being perfectly harmless, be allowed it to go on ; so that for these last three or four years, he has seldom been many days together free of it. But although patients, from being long accustomed to this discharge, come to find that it does not commu- nicate infection, still they can never look upon it with indifference; they all find it troublesome and distress- ful, and are therefore, at times, anxious to get free of it. When, at the same time we consider, that a long continued Gleet is apt to lay the foundation of some very obstinate and perplexing affections of the urethra, it will at once appear, that in every instance, this symp- tom merits our serious attention. Gleet seems evidenlly to arise from different causes, requiring different modes of treatment: it will there- fore be proper to consider them separately. 1. The most frequent variety of Gleet succeeds to the first stage of Gonorrhoea, in which we do not sup- pose that the original inflammation proceeded farther than the urethra itself, or the small mucous glands im- mediately emptying into it. When the cure of this variety of Gonorrhoea is in- terrupted either by improper treatment, or by negli- gence on the part of the patient, and when the dis- charge is thereby allowed to go on for any unusual length of time, Gleet is thus frequently produced. Astringent injections will, for the most part indeed, put a stop to the running, but the slightest excess very commonly excites a return of it. This variety of the disease we conclude to proceed from relaxation and debility in the parts first affected, and that the obstinacy with which it often continues depends upon a farther degree of weakness, induced in these parts by the longer continuance of the run- ning ; by which it would appear to have a power, if not counteracted, of continuing or propagating itself. By some, this idea of Gleet proceeding in any in- stance from weakness, is ridiculed; and as the sugges- SeC. II. OF GLEETS. 109 tion comes from very respectable authority I think it right to take notice of it.* Mr. Hunter observes, that by mechanical weakness is understood the not being able to perform some ac- tion, or sustain some force ; by animal weakness the same; but he cannot understand the expression when applied to an animal performing an uncommon, or an additional action, as seems from the quantity of mat- ter discharged, to happen in Gleet. This opinion appears to be founded upon the idea of an increased discharge being alw ays the consequence of an increased actions in vessels of the part from whence it proceeds ; and it originates from his not dis- criminating between general debility and local relaxa- tion, or loss of tone in a particular part. Although an increased discharge in the vessels of any part would seem to imply an increased action in these vessels, yet the reverse of this will, I believe, in most instances, be found to happen ; and that affec- tions of this nature proceed chiefly, if not entirely, from local debility. Loss of tone in the exhalents will necessarily produce a more copious discharge of their contents than will probably happen while their power of retention remains entire. Were these vessels unconnected with the rest of the system this would not take place ; but connected as they are with the arterial system, while the vis a tergo remains the same, any partial debility to which they may be lia- ble, must, perhaps universally, be attended with a preternatural effusion of their contents. There is much reason to suppose, from the phe- nomena which occur in inflammation, that an increased action takes place in the vessels of the part affected : but during the existence of this increase of tone, we commonly find that in Gonorrhoea, the discharge is not so considerable as it afterwards becomes when the symptoms of inflammation abate. Nay, it is univer- sally known that the running is apt to stop entirely * Tide Treatise on the Venerial Disease by John Hunter, p. 100. 1 1© OF GLEETS. Cb. III. when the parts affected inflame to a greater degree than usual, and that nothing so readily solicits a re- turn of it as the removal of this inflammation, by the use of emollient injections. This is an argument of some importance in favour of our opinion, and it is farther confirmed by the na- ture of all the remedies which we employ in Gleet, which are either of an astringent, strengthening kind, or consist of stimulating injections, and other applica- tions of a similar nature, which seem to act by excit- ing an increased exertion in the vessels of the affected parts, by which they are enabled to resist the action of the arterial system from behind. I therefore consider it as clear and decided that this variety of Gleet proceeds from relaxation and debility of the exhalents of the urethra, and, perhaps, of the excretory ducts of the smaller mucous glands of that passage. This opinion of Gleet being connected with debili- ty, may indeed be carried too far, as happens, I be- lieve, daily in common practice. Where Gleet has run on for any length of time, many think that it has either at first proceeded in a great measure from gen- eral weakness of the constitution, or that it has tended to excite such a general degree of debility as will ef- fectually obstruct every attempt, towards a cure, till this state of the system be removed. Hence the patients are with much care and anxiety enjoined the use of bark, steel, and other t nics, with a view to remove the general debility ; while less at- tention is usually given to the real cause of the dis- ease, the local relaxation of the parts originally af- fected. That general weakness often takes place in Gleet, and that it may even be induced by a long continuance of the discharge, will not be denied ; but I have much reason to think, that in practice, this idea is often car- ried farther than it ought to be. This must necessarily be the case whenever it makes us lose sight, as I have observed above, of the real origin of the disease ; but SeC. II. OF GLEETS. HI there is also cause to imagine, that in giving additional vigour to the system at large, we tend to increase the discharge by the urethra, unless the tone of the parts which have been more particularly weakened be at the same time restored. The reason of this has been explained above, and I have often had evident proofs of the hurtful tendency of the practice ; by which, while the patient, from the effects of sea-bathing, a full diet, and the use of tonics, was daily getting more full in flesh than he was before, the disease has evi- dently been gaining ground, from no particular atten- tion being given to the state of the parts from whence the running proceeds. In a stale of universal debility, whether .induced by a long continuance of the discharge, or any other cause, the greatest attention ought certainly to be giv- en to it; but what I wish to inculcate is, that in com- mon practice we rather do harm by considering this general relaxation of the system as the first object of attention, when, in fact, it often either does not take place at all, or only in such a degree as to render it a matter of very trifling importance, when compared with the disease in the urethra. In a great proportion of cases of this variety of Gleet, our attention should be almost entirely direct- ed to this affection of the urethra ; and by experience we find that such remedies are chiefly to be depended on as act directly upon the seat of the disease. A variety of medicines have been employed for this purpose, but they may all be comprehended under the two general heads of astringents and stimulants; for all that have yet been found useful in Gleet seem ei- ther to act by their astringent properties or by their power of stimulating the parts to which they are ap- plied. When astringent injections have not been already employed, they ought, in the first place, to get a full trial ; for although they do not always prove success- ful, yet they frequently do so, and we seldom or nev- 112 OF GLEETS. Ch. Ill, er find that any risk ensues from them, as sometimes does from stimulating injections. Any of the astringent solutions for which preserip- tions are given in the Appendix, may be employed, but the vitriolic solution, No. 18, is one of the safest, and very commonly proves the most effectual. In the use of all injections of the astringent kind it is necessa- ry to throw them frequently up, not less than six or eight times a day. This was particularly inculcated in the use of injections in Gonorrhoea, and it proves equally proper in this variety of Gleet. But where astringent injections have already been employed for the cure of the preceding Gonorrhoea, and where there is no doubt of a complete trial hav- ing been given them, in such circumstances, as there would be no cause to expect advantage from a farther use of them, they ought to be laid aside. In that state of the disease where a plentiful dis- charge takes place, with little or no pain, and where astringents have been employed with no advantage, stimulating applications become particularly proper. The stimulants we employ are of two kinds; acrid solutions and mixtures in the form of injections and bougies. Which ever of them are used must be of such a nature as to stimulate the parts gently to which they are applied, but not so strong as to excite inflam- mation in any considerable degree. They prove most successful where they give only a moderate degree ot pain and heat in the urethra; such as is felt in the commencement of the first stage of Gonorrhoea. In- stances, indeed, often occur of a newly contracted clap carrying off a Gleet that has been of long dura- tion ; and as this is always productive of some degree of inflammation, we conclude that the remedies em- ployed in Gleet must act in a similar manner, viz. by gently stimulating and exciting tlie parts \o inflame in such a degree as experience shews to prove useful. To excite violent pain would at all times be improper, as the inflammation which this would produce might go farther than we would incline it to do. Much harm, SeC. II. OF GLEETS. 113 indeed, has been done by want of attention to this cir- cumstance. A swelled testicle is not an uncommon effect of it; and I have known the inflammation carri- ed to the prostate gland and bladder. This, however, may always be prevented; nor can it ever occur but from great inattention. Wherever injections are used, they should at first be so weak as to excite only a very slight degree of uneasiness. In the formula? annexed to this they are of such a strength as to act in this manner in a great proportion of people, although, in some instances, 1 have found them rather weaker than necessary. An addition of strength, however, is so easily given, that at first they ought never to be stronger. One of the best injections for ordinary use is a weak solution of corrosive sublimate in water.* That is, in the proportion of an eighth part of a grain of the mercury to an ounce of water, which is as strong as it ought ever to be used at first; although I have met with some, who, in a gradual manner, have been brought to bear half a grain to an ounce. I know that some have advised it of a still greater strength, even to the extent of a grain of mercury to the ounce of water; but although I am in the daily practice of using this remedy, I never found any person who could bear it of this strength. I therefore suspect that those who advised it, have never known it used. I have taken the more particular notice of this, from several instances having fallen within my own observation, of very pernicious consequences ensu- ing from the use of injections containing too great a proportion of mercury, while no inconveniency arises from them when not stronger than those I have point- ed out. In some cases, where a solution of corrosive sub- limate by itself has failed, I have known the addition of saccharum satui ni prove useful ?; and in same very * Vide Appendix, No, 24. § Appendix, No. 25 15 114 OF GLEETS. CIl. III. irritable patients, in whom even the smallest quanti- ty of the mercury excited too much pain, an addition of mucilage has enabled them to bear it. Of this a formula is given in the Appendixf. A solution of crude sal ammoniac provesj sometimes effectual in tins state of Gleet. The volatile alkali, such as spiritus corn, cervi, and spiritus salis ammoni- aci, properly diluted, make likewise useful injections for this purpose, as in formulae No. 28 and 29 ; and verdigrise, dissolved either in oil, or in spirit of sal- ammoniac, afford also a very effectual form of injec- tion for the same purpose : formulae of these last are gi- ven in Nos. 30 and 31. ; and in some instances tincture of cantharides, properly diluted, as in No. 32, has been found to answer. Besides the circumstance of ascertaining the pro- per strength of these injections, a good deal of address is required in the application of them. They must not be employed either so long or so frequently as is requiied for astringent injections ; with these no harm can occur, however frequently they may be applied ; but injections of a stimulating nature should not be continued longer than is just necessary for exciting some degree of pain and inflammation in the affected parts. This being accomplished, a few days should elapse before any other remedy is employed ; for it some- times happens that the running will stop after these stimulating injections are laid aside, although, during the use of them, it appeared to be increased. But when, after an interval of three or four days, this does not appear likely to happen, injections of an as- tringent kind should be immediately employed, as we have already advised in the first stage of Gonorrhoea. Even these will not always succeed; for it some- times happens that the running, although it may dis- appear for a few days, will }et return again and again, with equal violence as at first. In such circumstances, the stimulating injections f Vide Appendix, No. 26, * No, 27. SeC. II. OF GLEETS. 115 must be again renewed, and the inflammation ought now to be excited in a degree somewhat greater than before; fori have commonly found that this may be done with more safety in the subsequent applications of this remedy ; and in the more advanced stages of Gleet the higher the degree of inflammation that can with safety be excited, the greater certainty there is of its proving effectual. When injections do not accomplish a cure, we en- deavour to effect our purpose by the use of bougies. By irritating the urethra, bougies answer the same pur- pose with stimulating injections; and, in some instan- ces, they have appeared to prove more effect ual, per- haps from the support which they afford to the parts which have been deprived of their tone. This, how- ever, does not happen with any kind of cerlainty, in- somuch that I always give the preference to injections in the first instance, as being less formidable in the ap- plication to all such patients as have not been accus- tomed to the use of bougies. Bougies composed of the most simple mate' ials com- monly answer all that we expect from mis kind o.f rem- edy ; but when these fail in exciting a sufficient degree of inflammation, they are easily rendered more active by dipping them in oil of turpentine, in a thin liniment of wax and oil with a small proportion of red precipi- tate, or in common basilicon reduced with oil of tur- pentine, to the consistence of a liniment. I have no reason to think that mercurials act in the cure of Gleet in any respect as specifics; but the stim- ulus which mercurial ointment gives to the urethra, when applied upon bougies, proves often as effectual as that from any medicine which we employ. It is proper, however, to observe, that the ointment for this purpose ought to be strongly impregnated with mer- cury : there should not be less than equal parts of quicksilver and hog's-lard ; and I have sometimes thought that mercury, extinguished by triturating with honey, acts more certainly as a stimulant than it usually does in the form of an ointment. 116 OF GLEETS. Ci). III. If the constitution has been much debilitated, we ought, while the application of remedies to the dis- eased parts is going on, to advise a nourishing, invigo- rating diet. The patient should be allowed animal food, and a moderate portion of red wine daily ; and in such circumstances bark may with propriety be ex- hibited as a tonic : but for the reasons I have given above, I have much cause to think that the general practice of giving bark, steel, and other tonics, in eve- ry case of this kind, is by no means well founded, and in many instances that it does harm. Some of the stimulating astringent balsams, given internally, frequently prove useful here; probably from their tendency to stimulate in a more particular manner the organs of urine than any other part of the body. Balsamum 'copaiba is chiefly used for this purpose, but Canada balsam, and all the turpentines, may be employed with perhaps equal advantage. Fifteen or twenty drops of any of these may be given three or four times a day. A cautious use of cantharides has also proved ser- viceable in this variety of Gleet. Ten drops of the tincture may be given two or three times a day. But although some advantage mav be derived from all of these remedies, when employed along with local stimulants, as we have advised above, yet no depend- ance is to be placed upon them when they are not con- joined with these. This, it may be said, renders the advantages to be expected from them doubtful and equivocal ; but in different cases I think T have perceived greater advantages from a combindiion of these two sets of remedies, than usually occurs from a separate use of either of them. Cold bathing is a remedy commonly advised in Gleets, and where the constitution is so much debili- tated as to require attention, it will very generally an- swer a good purpose ; otherwise no advantage can pro- bably accrue from it, if it be not from the local appli- cation of cold to the parts chiefly affected, fn this SeC. II. OF GLEETS. 117 view, the daily effusion of cold water upon the penis, and the bathing of the perineum, proves sometimes useful. 2 The next most frequent variety of Gleet succeeds to the second stage of Gonorrhoea. After all the symp- toms excited by the actual presence of inflammation have subsided, this variety of the disease is very apt to terminate in Gleet. In the third section of the last chapter I endeavour- ed to shew, that in this stage of Gonorrhoea, Cowpers glands are chiefly affected, and that they afford a great proportion of all the matter that is discharged. Any inflammation which occurs along with this in the mem- brane of the urethra, is, for the most part, easily re- moved, so that the Gleet, which often succeeds, pro- ceeds either altogether, or nearly so, from the cavities of these glands. Gleet, proceeding from this cause, is, for the most part, easily distinguished from that which we have described as the first or most frequent variety of the disease. In this last, the matter usually proceeds from within an inch, or little more, of the glans, or when pa ris farther back are affected, the discharge is forced off from them by very gentle pressure upon the pe- rineum : but, in the other, the matter is, in every instance, found to proceed from the upper part of the urethra; a greater degree of pressure upon the perineum is necessary to force it out ; and some de- gree of fulness, accompanied with irritation, and even pain, is experienced on the perineum being pres- sed upbn for this purpose. We are also assisted in the diagnosis by the history of the preceding Gonorrhoea ; for it will be uniformly found that the first variety of Gleet has succeeded to the first stage of Gonorrhoea, and that the second stage of Gonorrhoea has given rise to that which we are now considering. In the treatment of Gleet it is of importance to have this difference ascertained, for the remedies which commonly accomplish a cure in the one, are used in 118 OF GLEETS. Cll. III. the other either without any advantage whatever, or even with evident proofs of doing harm. Thus, al- though in the first variety of Gleet, we depend so much upon stimulating injections, that a cure in most instances cannot be accomplished without them ; in the other, where the larger glands of the urethra are affected, they very commonly render every symptom worse than it was before. They at least do so where ihe injection is of such a strength as to excite pain and inflammation ; and if weaker than this, it may be used for an indefinite length of time, without any effect re- sulting from it. The glands opening into the urethra being here the seat of the disease, astringent injections, applied as we have elsewhere observed, to their excre- tory ducts, may produce a temporary stoppage of the discharge ; but, as they do not reach the cavities of the glands, no permanent advantage can be expected from them. While, again, when an injection is used of such a strength as to excite inflammation upon the ends of these ducts, it is vei'3 7 apt to produce swellings in the glands themselves, which at last commonly terminate in suppuration, to the great distress and disappoint- ment both of the patient and practitioner. Whenever it is therefore discovered with certain- ty, that this variety of Gleet exists, injections should be no longer employed ; or when, for the satisfaction of the patient, a farther trial of this remedy becomes necessary, such preparations only should be used as are moderately astringent. In such circumstances bougies, and blisters to the perineum, are the most effectual remedies I have ever employed. The bougies should be of the mildest kind, such as stimulate the parts gently, without ex- citing inflammation. By this, and by the support which their size and form afford to the weakened parts, they often prove highly serviceable ; and even when they do prove more powerfully stimulating than we may have wished or expected, they do not so readily do harm as injections; for the inflammation with which SeC. II. OF GLEETS. 119 this may be attended is always accompanied with an instantaneous discharge of matter, by which the incon- venience that otherwise might result from them is very effectually prevented. Bougies ought, for every purpose, to be as large as the capacity of the urethra will admit; but their be- ing of a full size is more particularly necessary in this variety of Gleet than for any other malady; for it is chiefly by their size that they prove useful here. In most instances of this kind it appears, in the course of a few days, whether bougies are to be of service or not; but no permanent advantage is ever to be expected from them if they are not continued for a considerable time. When the disease has been of long duration, the bougies ought to be applied for the space of ten or twelve weeks, and not even desist- ed from then if the cure be not completed. Tt is proper, however, to observe, that after bougies have been used for such a length of time as ought to accom- plish a cure, they should from time to time be laid aside, that the effects produced by them may be discov- ered; for while they are daily introduced we can nev- er know with certainty whether any discharge which takes place is the effect of the disease, or of the irri- tation which they excite; as bougies can never be ap- plied for any length of time together, not even to a sound urethra, without being found covered with mat- ter, or with mucus in the form of matter, on their be- ing withdrawn. When bougies fail, a blister applied over the whole perineum sometimes proves serviceable. Whether it is by the stimulus which they give to the parts affect- ed, or by the discharge which they excite, is uncer- tain : for in some an evident advantage ensues upon the first or second day from their application, and be- fore any quantity of discharge can have occurred, while in others no effect is observed to result from them till the second, third, or perhaps, fourth blister ha^ been applied. In a few instances, some advantage 120 OF GLEETS. Ch. III. has appeared to be derived from a small portion of the blistered part being kept open with epispastic oint- ment, which, in two cases of much obstinacy, led me to advise the introduction of a small seton on one side of the perineum ; but although this seemed like- wise to lessen the discharge, the advantage derived from it was neither so great nor so obvious as to com- pensate the very disagreeable nature of the remedy. In very obstinate cases of this variety of Gleet, the patient will frequently be found to be of a scrophulous constitution. If the disease has not already appeared in a more evident manner in other parts of the body, it will at least often happen that the glands of the neck, and other suspicious parts, will appear to be tumefied, and that the complexion of the patient, which is com- monly delicate, gives much cause to conclude that the system is not free of it. In such circumstances, all the remedies usually em- ployed in serophula will from time to time, be advis- ed. Bark and hemlock have sometimes proved useful here ; but no remedy that has yet been employed in serophula is in any degree equal to sea-bathing. In enumerating the different varieties of Gleet, I have proceeded in the order in which they most fre- quently appear. The next of which I shall take no- tice proceeds from strictures in the urethra. In an ensuing section I shall find it necessary to en- ter more minutely upon the consideration of venereal strictures in the urethra: at present, therefore, it seems only requisite to sa} 7 , that they are to be con- sidered as a very frequent cause of Gleet. The spon- gy surface of the substance from which these strictures are produced is very apt to become tender and excori- ated. A slight degree of ulceration thus takes place which continues to give out matter while any degree of the stricture remains, and where the extent of the disease is considerable, this of itself would afford a very copious discharge; but besides this, the remora which every stricture produces, of urine and rrtueus Sec. II. OF GLEETS. 121 between the part on which it is seated and the bladder, acts as a very powerful cause of irritation, and in this manner renders the discharge more abundant than we almost ever find it to be in Gleet, proceeding from any other cause. Where strictures are not suspected as the cause of the discharge, as often happens where the obstruction to the flow of urine is not remarkably great, the pa- tient as well as the surgeon is apt to be deceived, and to proceed daily with the plan of effecting a cure by injections, balsam of copaiba, and other astringents. None of these remedies, however, have any influence, and the discharge, after many years continuance, is found to be nearly in the same slate, either as bad, or perhaps worse, than at first. Of this every practition- er must have met with instances, and they always prove the source of much perplexity and embarrass- ment. In every case, therefore, where Gleet resists the usual remedies, and is thus particularly obstinate, it ought to be our first object to ascertain the real state of the urethra, and to learn whether strictures are present in it or not. In some cases this will at once be known from the state of the symptoms obtained from the patient, as well as from external examination of the urethra from the point of the penis, to the fundament. This, however, will only happen in the more severe degrees of the disease. Where the ob- struction is slight, it may, as we have already ob- served, pass unnoticed ; so that in all such circum- stances, and where there is any cause for doubt, the passage should be examined with a bougie, by which alone any certainly upon this point can be obtained. When the existence of stricture is discovered, all other remedies ought at once to be laid aside, and the cure trusted entirely to bougies. Hereafter we shall have occasion to speak more particularly of bougies; at present we need only say, that they are the only remedy upon which we can depend for the removal of 10 122 OF GLEETS. Ch. III. strictures, and that they very commonly prove effectu- al when duly persisted in. When the discharge proceeds entirely from stric- tures, it will, for the most part, soon subside on these being removed ; but when it continues more than a few days after the bougies are withdrawn, it will be proper to employ astringent injections in order to car- ry it off. Lime-water answers well ; for this particu- lar purpose, indeed, it answers better than any other form of injection I have tried, but it requires to be diluted with an equal quantity of common water. 4. The last variety of Gleet of which we have to take notice proceeds from a swelled state of the pros- tate gland, and succeeds, as we have already had oc- casion to see, to the third stage of Gonorrhoea Viru- lenta. In treating of Gonorrhoea the symptoms were enu- merated by which affections of the prostate gland may be discovered ; but we have no certain means of know- ing to what extent it may be swelled but by examin- ation with the finger in ano. Besides the inconveniency which occurs here from the discharge itself, and which is common to this with every variety of Gleet, there is always a good deal of uneasiness, and even pain, produced by the swel- ling of this gland, which excites a more frequent de- sire to pass water than any other variety of the dis- ease, together with a sensation of heat and fulness over the whole parts contiguous to the anus. The tenesmus which often takes place is also a very trou- blesome symptom. Gleet, proceeding from this cause, is sometimes combined with other varieties of the disease, particu- larly with that which was last described. In this case the discharge has most frequently the appearance of being a mixture of pus and mucus; but when the run- ning proceeds entirely from an affection of the pros- tate gland, it is thinner than purulent matter, and, al- though sometimes tinged of a white or yellow colour, it is more frequently of the consistence and colour of SeC. II. OF GLEETS. 123 mucus. This makes it often be mistaken for a dis- charge of semen. No injections are of any utility in this variety of Gleet ; nor is any advantage derived from bougies. On the contrary, they are both apt to do harm, par- ticularly a perseverance in the use of them; a prac- tice which those not accustomed to this branch of bu- siness are very apt to fall into. Swellings of this gland are very commonly attended with some degree of ob- struction to the passage of urine, and when this is mistaken for strictures, as often happens, bougies are immediately advised in order to remove it. Bougies, however, never prove useful here : on the contrary, they very commonly irritate the gland to such a degree, as to excite both an increase of the pain and of the discharge. Opiates are the remedies upon which, we place most dependence. By allaying irritation, they not only- keep the patient free from pain, but in doing so they tend more than any other remedy to lessen the dis- charge. It must, however, be acknowledged, that they act chiefly as palliatives; but the mere preven- tion of pain is a point of no small importance in a dis- ease which otherwise is apt to render the patient mis- erable. In speaking of affections of this gland in the third stage of Gonorrhoea, I advised opiates to be used in clysters, instead of being taken by the mouth. They d<» not, in this form, so readily induce sickness, and they usually prove more effectual in relieving pain. In several instances, where no great advantage was derived from all the quantity of laudanum that durst be given by the mouth, patients have been kept ea v by a grain or two of opium dissolved in a small quantity of mucilage, and thrown from time to time, into the rectum. Where this disease occurs in scrophulous constitu- tions, an occurrence by no means uncommon, hyoscy- amus, cicuta, and sea-bathing, are the remedies usual- ly employed: and although they do not often accom- 124 OF GLEETS. Ch. III. plish a cure where the gland is much swelled, yet they frequently afford relief; and slighter degrees of the disease have, in some instances been removed by them entirely. Some practitioners, as I have already had occasion to remark, give mercury in every variety of Gleet, but I have never known any advantage derived from it, and where the prostate gland is affected it very com- monly does harm. As I have mentioned above, that in Gleet proceed- ing from strictures in the urethra, some slight degree of ulceration takes place, it may be imagined that mercury ought in such instances to prove useful, from its well known powers of healing venereal ulcers. It is not, however, found to promote the cure of these ulcerations; a circumstance that may be consider- ed as a farther proof of the difference between Gonor- rhoea Virulenta and Lues Venerea ; for if affections of this kind were induced by the matter of Lues Vene- rea, mercury would seldom fail in curing them, while no other remedy would ever prove successful. But, instead of tiiis, I have repeatedly found, that no ad- vantage is derived from mercury in the treatment of this symptom, while bougies, when properly managed very commonly prove effectual. What we have hitherto said upon the subject of Gleets relates chiefly to the disease as it occurs in men, it being in them both more frequent, and of much more difficult treatment than it usually is in wo- men. We often meet with it, however, in women ; but it is proper to remark, that it is equally difficult to distinguish it from fluor albus, as in a former section we have observed Gonorrhoea to be. Referring- to "what was then said upon the means of distinguishing between the two diseases, we shall at present proceed shortly to observe, that in women we depend entirely for the cure of Gleet upon a proper perseverance in the use of injections. When after a due continuance Sec. II. OF GLEETS. 125 of such as we reckon astringent,* if the discharge still continues, those of a stimulating nature should be em- ployed, particularly Nos. 24 and 25. When the disease is seated in the vagina, as is gen- erally the case, these injections may be thrown up with freedom; but, when the discharge proceeds from the urethra they ought, on account of the contiguity of the bladder, as we had occasion to remark in a for- mer section, to be thrown up with much caution. In women I have sometimes found that a Gleet has proceeded from ulceration within the verge of the va- gina. In such instances injections have little or no in- fluence; and as sores of this kind -are commonly con- nected with Lues Venerea, they can only be cured by a course of mercury. It is proper, however, to remark, that women are liable, as men are, to excoriations from the acrimoni- ous nature of the matter of Gonorrhoea. A discharge of matter from this cause will be most readily cured by astringent injections, or bathing the parts with lime- water, or a saturnine solution. I have never known the real venereal stricture oc- cur in women. Excrescences form in the urethra from other causes; but stricture from Gonorrhoea must ne- cessarily, in this sex, be a rare occurrence. If it is ever met with, bougies must here, as in men, be de- pended upon for a cure. * Vide Appendix, Xos. 18, 19, and 20. We find the acetite of lead in solution is a favourite prescription of our author, as well as of many others, especially young practi- tioners. We have sometimes used it but not lately, having as we are convinced, observed Gleet to be a frequent consequence : — From our own observations we cannot help thinking that in this complaint, the lead acts as a sedative, and that in some cases an almost incurable degree of local debility is induced. On this subject we are happy to have it in our power to quote a very accurate observer, Dr. Hosack of New-York; He observes, " In Gonorrhoea lead water is the usual prescription, especially of young practitioners. The writer of this article, many years since 126 OF IMPOTENCY FROM Ch. III. became acquainted with the pernicious consequences of that injec- tion. Indeed, in every case of Gleet following Gonorrhoea, for which lie has been consulted within twenty years past, he has, with- out a single exception, traced it to the debilitating sedative effect of that metal. Most cases too of the inflamed testis, which he has seen attendant upon Gonorrhoea, have been produced by the same cause, viz. the too early and sudden check of the secretions of the urethra by the use of lead injections." Vid. Med. and Philosoph : Register, vol. iv. page 159. Mr. J. Robertson, surgeon in Edinburgh some years since pub- lished a book on the use of the tincture of cantharidcs in the cure of Gieet and Leucorrhoea. This remedy unquestionably acts from its stimulant properties, and we know that it has frequently proved successful. It must be employed with caution, commencing sel- dom with more than fifteen drops, as from the great irritability of the parts a distressful decree of inflammation might be the conse- quence : this quantity may however be gradually increased, often to thirty drops, two or three times a day. We have frequently succeeded in performing a perfect cure, with the linament, page 69, Ed. SECT. III. Of Impokncy from Seminal Weakness. WE here mean by mrpotency a deprivation of the power of propagating the species. This may proceed from various causes: but it is that variety of it only which is usually supposed to arise from weakness in the seminal vessels that we are now to consider. It is an occurrence which, in young people, either in idea or reality, takes place daily; and as it proves at all times a source of much anxiety and distress, it necessarily becomes a frequent object of attention to practitioners. A degree of debility inducing want of retention in the seminal vessels is, no doubt, occasion- ally met with; but the strong desire which Nature has wisely implanted in all men to be complete and entire, in whatever relates to the propagation of his species, is often in early youth, the cause of much ill-founded fteC. HI. SEMINAL WEAKNESS, 127 suspicion on Ibis point, and of circumstances respect- ing it being considered as real which never took place. Thus there is .nothing more common than vouns: people supposing they are weak and debilitated, on perceiving an oozing of mucus from «he urethra, or a discharge of semen when at stool. The first, howev- er, is natural to many when in full health, and where no suspicion of weakness exists; and the latter, or a discharge of semen, must at all times be the conse- quence of hardened iceces compressing the vesiculse seminales, when these vessels are full of semen. But suspicion on Ihis point being once awake, it is often difficult, and sometimes impossible, to remove it ; in- somuch that many have been rendered miserable by this alone, where no vestige of disease existed. It is considered as one of the most certain proofs of weakness in the seminal vessels when a discharge of semen instantly succeeds to an erection, or, perhaps, to an imperfect degree of it. But this may also happen from a state of over-excitement in the other parts of generation, and I also believe that it often occurs from the seminal fluid being collected in too great quantity in the vesiculse seminales. I have reason indeed to im- agine, as will appear in the sequel, that this is the most frequent cause of all such affections* It may be said, if the disease exists, and the patient is rendered completely impotent-- that the cause of his being so is a point of little importance. It will appear, however, that this is by no mea [he case; for while real impotency is in a great proportion of cases to be considered as incurable, we have it in our power, per- haps, in most instances of approach to this slate to ac- complish a cure. In the last section we have seen that Gleet proceeds at one time from an affect ion of the glands in other parts of the urethra, but in some cases that it arises from a swelling of the prostate gland. When this ex- ists for any length of time, we find that not only the duct of the prostate gland becomes weak and relaxed, but that a loss of tone takes place in some of the con 128 OF IMPOTENCY FROM Cb. III. tiffuous parts, particularly in the excretory ducts of the vesiculse seminales; insomuch that a great propor- tion of all who have long laboured under Gleet from affections of this gland, have likewise been liable, in some degree, to seminal weakness. It is well known that long continued Gleets, are often the cause of Impotency. For the most part, it is supposed, that this happens from the general debility which they induce. In some instances this may be the case ; but J have much reason to think that they act much more frequently by inducing a local weakness only iri the parts destined for the reception of the semen. This I conclude to be the case from this kind of debility tak- ing place where there is no appearance whatever of general weakness, for instances often occur in consti- tutions apparently firm and healthy, of such degrees of weakness in the seminal organs, that emissions take place, not merely from partial erections and lascivious ideas, but from the ordinary friction applied to the pe- nis in riding and walking, and, in some instances, from the effect of heat alone, whether excited by wine, ex- ercise, or sitting near a fire. In people who have suffered much from frequent returns of Gonorrhoea, particularly where Gleet has taken place from the cause I have mentioned, I have known several instances of the semen running off by the slightest application of any of the causes just enu- merated. The local weakness thus induced in these parts by Gleet seems very much to resemble the effects of Onanism ; a habit so baneful to many of our youth, that I believe it to be more destructive in its conse- quences than a great proportion of all the diseases to which in early life ihey are liable. Were it to prove hurtful to those only whose self indulgence gives rise to it, there would be less cause to regret the effects of it; but, besides rendering the parent himself misera- ble, it evidently entails the highest distress upon pos- terity, by generating languor, debility and disease instead of that strength of constitution, without wliicjj there can be no enjovment. SeC. III. SEMINAL WEAKNESS. 129 Some, I know* have entertained a different opinion upon this point, and imagine that no bad effects are to be dreaded from the habit of which we are now speak- ing*. But this is so directly contrary to the expe- rience of others, and I have had so many instances in the course of my own practice of constitutions being irretrievably ruined by indulgence in it, that I cannot avoid, in the strongest manner, giving my opinion of it : nor does it appear that any benefit could result to society from a contrary opinion being admitted, even allowing it to be well founded ; for although no imme- diate harm might ensue from it to the constitution, it ought to be discouraged as unnatural, and from its tending to divert the attention from an enjoyment of a much superior kind. While, therefore, there is much cause to consider the practice as highly dange- rous to all who follow it, and while such a propensity prevails towards it in that early age when boys cannot form a judgment of its deleterious tendency, I consid- er it as incumbent on those who write upon it to paint it and the baneful effects which result from it in their true and proper colours. In the treatment of this variety of Impotency, wheth- er it has been induced by Onanism, or whether it be the consequence of Gleet, it is proper to distinguish it into two stages. 7'he one, so far as I have seen, be- ing of a nature that does not admit of any certain rem- edy, while the other may, in most instances, be com- pletely cured. Many consider it so certainly as incu- rable that the patient is led to despair from the first approach of it, and the opinion is often unfortunately realized merely from the cause I have mentioned, our not distinguishing the two stages of the disease, and allowing that which I suppose may be easily removed, to proceed without any attempt for this purpose, to that state of it, which, in most instances, may be con- sidered as incurable. Practitioners are frequently applied to by young * Vide Treatise on the Venereal Disease, by John Hunter chap, xii, 17 130 OF IMPOTENCY FROM CI). III. men labouring under what I shall term the first stage of Gleet ; who, finding that a seminal discharge takes place from the slightest causes, perhaps merely from their being in company with women ; from lascivi- ous dreams; or from the parts of generation being in any degree overheated, begin to be afraid that they shall never again have the power of retention, and conclude therefore that they cannot with propriety enter into a matrimonial connection. We often find that they admit Onanism to have been the primary cause of their distress, although, for a great length of time, perhaps for a number of years, they assert, and with no reason on our part to doubt them, that they have been entirely out of the practice of it. In this situation, whatever may be the appearance and habit of body of the patient, strengthening astrin- gent remedies are prescribed, such as bark, steel, bal- sam of copaiba, cold bathing, &c. ; and whatever are bis views, he is advised to avoid matrimony and all venereal intercourses. In a great proportion of cases, however, I am con- vinced that this practice and this advice are errone- ous. Following the bulk of practitioners, I easily adopted them ; but no good resulting from them I have long since relinquished them, and I have seldom failed of success by advising measures of an opposite nature. In a great proportion of all that are injured by this destructive habit, a morbid irritability of the or- gans of generation seems to be excited. By this a greater quantity of the seminal fluid is secreted than the vesicular seminales can retain : in consequence of which, it either bursts out during nocturnal dreams, or is easily excited to flow by the application of any of the causes above-mentioned. Even after the habit has been long left ofT I have known the effects of it continue in a very distressful degree, and I conclude that they proceed chiefly from too plentiful a secretion of semen, from the na- ture of the remedy which in most instances has prov- ed successful. SeC. III. SEMINAL WEAKNESS. 131 Instead of advising abstinence from women, I al- ways inculcate as frequent connection as natural de- sires seem to require ; and when matrimony is in view, instead of being afraid of it, as often happens with this class of patients, from a fear of their not performing the functions of it properly, I uniformly bold it forth as the most certain remedy. The idea of inability is so strongly prevalent with many, that they are with difficulty prevailed upon to make the attempt; but the effects of it are so cer- tain, that with patients in such circumstances as we are now considering, it may always be advised with the greatest confidence of success. Nor is the assist- ance of other remedies required in this plan of cure ; at least in various instances, patients, who, for ma- ny years together had been almost constantly taking such remedies as they judged to be of an invigorating nature, without any advantage resulting from them, and who therefore were induced to consider their complaints as incurable, have, on laying ail of these aside, become completely and entirely well in the space of a few weeks after marriage. The irritabil- ity of the organs was thus diminished ; the morbid increase of the secretion was removed ; and the se- minal receptacles, not being over distended, were soon found to be endowed with a sufficient degree of retention. This being a very frequent variety of the disease, I can speak of it, and of the remedies employed in it, with some degree of certainty ; and I can with con- fidence say, that none of those commonly advised have ever, in the course of my observation, had any obvious influence ; while the plan I have pointed out, very generally surpasses in its effects all that the patient could hope from it. When a swelled state of the prostate gland is con- nected, as I have sometimes found, with this variety of the disease, it. necessarily renders the event m >re doubtful, and the effect, even of this and every other remedy, more uncertain. But even here the 132 OF IMPOTENCY FROM Ch. III. course I have advised will sometimes prove success- ful. It will uot remove any affection of the gland, but where the disease of that organ is not in a great degree, it proves equally effectual in removing the other, as if the gland was entirely sound ; and this obviates one ot the greatest sources of misery to the patient. It may be said, that while this or any other varie- ty of Gleet exists, the remedy I have pointed out cannot with any propriety be advised, from the risk of communicating infection. We know, however, that real Gleet does not communicate infection to others ; and the means of distinguishing it from Gonorrhoea are by no means equivocal. Many in- stances have fallen within my own observation, and others must often meet with it, of this being clearly the case. I know, at this time, several instances of men who have been married for many years, who, during the whole period, have laboured under dif- ferent varieties of Gleet, and who have never com- municated the disease either to their wives or chil- dren. Gleet in men seems to be equally incapa- ble with flu or albus in women to communicate infec- tion. In that stage of the disease which we have just been considering, a cure, we observe, may, perhaps, in every instance, be accomplished. But when it has been of such duration as to form what may more pro- perly be termed seminal weakness, and what I shall term the second stage of the disease, a very different prospect presents itself. The patient may even, in very advanced periods of the disease, derive advan- tage from a well-regulated diet and other circum- stances, by which his situation will be rendered much more comfortable than it otherwise would be ; but in this situation a complete removal of the disease is scarcely to be expected: at least little dependence is to be placed upon the remedies usually employed for that purpose. Tliis very distressful stage of seminal weakness is SeC. III. SEMINAL WEAKNESS. 133 often the consequence of Onanism long persisted in ; and it is, as we have remarked, the frequent conse- quence of Gonorrhoea and Gleet. In all such cases the disease seems to proceed from real weakness, or debility in the excretory ducts of the vesiculae semi- nales ; for it commonly happens where the whole sys- tem is much relaxed and emaciated ; where there is therefore no cause to imagine that it can arise from too plentiful a formation of semen ; and of which, in- deed, we often meet with a very decisive proof, from a constant mucous-kind of oozing being perceived in the urethra, while no ordinary cause of excitement is capable of producing any regular discharge or emis- sion of semen. In this situation a variety of remedies are employ- ed, chiefly with a view to restore and invigorate the tone of the weakened parts ; such as bark, steel, hal- samum copaiba, and cold bathing. At other times, where the disease is supposed to proceed from a defi- ciency of semen, provocatives are prescribed; such as high seasoned foods, all the terebinthenate balsams, and cantharides. But although I have had many op- portunities of observing a complete trial of these, I never knew any advantage derived from them. The only course, which in such circumstances I ever knew prove useful, was such as merely tended to restore the patient to his usual state of health. If Onanism has induced the disease, nothing will afford even the chance of a recovery till this is left off. Whatever may have been the cause of it, he ought to be put upon a nourishing diet ; and he should live in an ele- vated, dry situation. Sea-bathing should be advised; and costiveness, with every thing that might tend to irritate the parts chiefly affected, should be avoided. With a view to lessen that degree of irritability with which this disease is usually connected, opiates have been advised ; but although I have often given them a full trial, I never knew any real advantage obtained from them. On the contrary, they have often appear- ed to do harm ; for although they procure rest, yet 134 OF IMPOTENCY FROM Ch. III. the sleep which they give is always disturbed ; the pa- tient awakes in a state of more anxiety and distress than he experienced on going to bed ; and when opi- ates are habitually used, costiveness can scarcely be prevented by means of remedies, which, in this situa- tion, ought not to be given. Hemlock is often used here; but I have never known any obvious advantage derived from it. Hyos- cyamus, by acting as an anodyne, while it does not produce costiveness, has, in different instances, ap- peared to prove serviceable. One grain of the ex- tract may be given at first, and the dose increased in a gradual manner to three, five, six, eight, and even ten grains. Conceiving, from some circumstances connected with the disease, as well as from many of the symp- toms which ensue from it, that it may in some instan- ces be of the same nature with paralysis, I have, in several cases, advised electricity, and in one or two of these it appeared to prove serviceable, but never so decidedly, as to enable me to speak of it with confi- dence. SECT. IV. Of Obstructions in the Urethra from Gonorrhoea Vir- ulcnta. WHEN speaking of Gleet we had occasion to ob- serve that it is often the consequence of Obstructions in the Urethra. But Gleet, although the cause of some inconvenience and distress, is by no means the symp- tom of most importance with which Obstructions are accompanied. Strictures may take place in a certain extent, without giving much uneasiness, but whenever they arrive at such a height as to impede the flow of urine,they prove always the cause of distressand misery to the patient, and of much embarrassment to the prac- titioner. Sec. IV. SEMINAL WEAKNESS. 135 Obstructions proceeding from Gonorrhoea Virulen- ta may be reduced to four general heads ; tumours in the substance of the urethra and contiguous parts ; spasmodic affections of the urethra ; caruncles, or fleshy excrescences, in the urethra ; and strictures, properly so called. i i. Of Turnouts in the Substance of the Urethra and con- tiguous Paris. WE have already had occasion to speak of Tu- mours, or swellings of the prostate gland, of swellings of Cowper's glands, and of the other smaller glands of the urethra. All of these produce obstruction to the flow of urine whenever they become of such a size as to diminish, in any degree, the magnitude of that canal. Referring to what has already been said upon this part of our subject, I have at present to observe, that in the commencement of all Tumours in these parts we ought, by every method in our power, to endea- vour to remove them by discussion, for which purpose local and general blood-letting are the remedies chief- ly to be depended on; and as these, when carried a sufficient length, and when assisted by a cooling regi- men, and the external use of cold saturnine applica- tions, seldom fail in removing them, they should al- ways be persisted in as long as there is the least chance of their proving serviceable. For although tumours. in this situation are often easily removed after suppu- ration has taken place, by the matter being freely dis- charged, and the sore treated in the usual way, yet, before arriving at this size, a good deal of distress al- ways occurs from them, and, in some instances, the sores heal with difficulty, while in others the matter bursts into the urethra, where it continues often dur- ing the life of the patient to excite a great deal of dis- tress.- 136 OF TUMOURS IN THE Ch. III. In others again it bursts into the scrotum, and from thence into the surrounding cellular substance, and openings forming in consequence of this, commonly between the scrotum and anus, a very troublesome dis- ease is thus produced, termed fistula in perineo.* It is therefore obvious that it is much for the advan- tage of the patient that all tumours of this kind should be removed by discussion ; but when our endeavours for this purpose do not succeed, and when suppuration takes place, we have it often in our power to prevent many of the bad consequences which otherwise are apt to ensue. By opening such tumours immediately on matter being perceived in them, we prevent the risk of their bursting into the scrotum and urethra, so that in this situation we ought never to wait till they are so fully matured as otherwise might be proper : and when once they have come so far as to render it pro- per to discharge the matter, it ought to be done, as we have formerly observed, oy making an opening the whole length of the tumour. This prevents the matter from lodging, and from insinuating into the contigu- ous parts, while the sores which ensue heal more kind- ly than they usually do when smaller openings have been made. Among other consequences which sometimes occur from matter bursting from abscesses in this situation into the contiguous parts, it is proper to mention that the most distressful effects occur from its finding access to the corpus cavernosum of the penis. It usually spreads suddenly over the whole substance of the pe- nis; small openingstakes place in different parts of the swelling, at which the matter is discharged ; and these are always very difficult to heal : or, if the matter does not find a vent in this manner, it either bursts into the urethra, or the surrounding parts are apt to mor- tify. When mortification occurs in this situation, it either soon proves fatal, or terminates in the entire loss of the * For the treatment of this, vide system. of surgery, chapter xy. SeC. IV. CRETHRA. 137 penis ; for a stop is seldom put to the disease till all the parts surrounding the urethra are destroyed, when am- putation of the remainder becomes unavoidable. Indeed the hsemorrhagy which is apt to occur from deep seated mortification of the penis is commonly of itself a suffi- cient motive for amputation being advised, for we can seldom put an effectual stop to the discharge till the mortified parts are all removed. For preventing mortification in this situation from spreading, opium has been recommended. I have cer- tainly observed it prove useful in gangrene, both in these parts and in others ; "but more dependence is for the most part to be placed upon a plentiful use of bark. Whether or not opiates act in the cure of gangrene as antiseptics, is not, or perhaps, cannot be ascertained. I rather believe that they do not: and I am inclined to think that they prove serviceable only by allaying irri- tation. In this manner they may be employed with advantage wherever gangrene appears to be the con- sequence of a high degree of inflammation. By les- sening or removing pain they may diminish the cause of exertion in the vessels of the part affected, and may thus tend to prevent mortification from extending so far as it otherwise might do : but I have never known them to prove useful where the disease seemed to de- pend upon the loss of tone, either of the part itself, or of the constitution. i 2. Of Spasmodic Obstructions of the Urethra. IRRITATION of the Urethra, from whatever r ause it proceeds, has an evident effect in lessening the diameter of the passage. Hence, in cases of stone in the bladder, the irritation, and consequent con- traction of the urethra, is sometimes so great that a staff, even of a moderate size, cannot be introduced. Stones in the kidney have frequently the same effect. Nay, I have known this contraction of the urethra 18 138 OF SPASMODIC OBSTRUCTIONS Ch. III. induced by sand passing along the ureters. In like manner the irritation produced in the urethra by Gonorrhoea, is in some cases so great as to excite con- traction of the passage in a very distressful degree. I have known the urine so completely obstructed by this alone, as to give cause to suspect that strictures were formed of the most alarming nature ; in which neither staff', catheter, nor bougie, could be introduc- ed, but with more force than can ever with safety be applied. We judge that obstruction, proceeds from this cause, when at one time it occurs in a severe degree, and soon thereafter, perhaps in the space of a few hours, it appears to be entirely or nearly gone. Of this I have met witli various instances; in which, from the anxiety of the patient, and from suspicion of a more inveterate kind of stricture, repeated attempts have been made in vain to pass a bougie, and in which the stoppage has gone of!' entirely upon the exhibition of a dose of laudanum, or rubbing the perineum with anodyne balsam. As the urethra itself does not appear to be muscu- lar, as a small portion of it only can be compressed by the muscles of the penis, and as the obstruction of Which we are now speaking occurs in parts of the pas- sage where these muscles do not exist, it has been im- agined that this temporary accession of stricture must be owing to some other cause. It may perhaps hap- pen that the violent irritation excited by chordee may in some instances produce such effusion into the cellu- lar parts of the penis as may compress the urethra ; and that this may soon be removed by absorption, on the irritation by which it was produced being taken away. But although this may be the case in a few in- stances, I am convinced that it is not a frequent occur- rence, and that the urethra itself is endowed with a contractile power, by which, for the most part, this kind of obstruction is produced. Were it to proceed from any kind of effusion com- pressing the urethra, the tumefaction thus produced SeC. IV. OF THE URETHRA. 139 would be obvious. Partial circumscribed tumours would either be discovered in the course of the ure- thra, or the whole body of the pen?? or a considera- ble part of it, would be swelled. We do not find, however, that this is apt -to happen ; at least, in most cases of this kind no tumefaction of the penis is per- ceptible. This kind of spasm or cramp occurs occasionally in every part of the urethra. I have met wlii il w it in an inch of the extremity of the gjans, but for tl e m >st part it happens behind the scrotum, or nearer the pros- tate gland, in the membranous part of the passage. In the treatment of Obstruction in the Urethra it is a matter of the first importance to determine the cause by which it is produced. It is particularly neeessa v \o distinguish between obstruction arising frouj spasm, and that which proceeds from stricture of the passage. In the latter, bougies, as we shall afterwards see, are almost the only remedies upon which we can depend, while, in cases of spasm, they very commonly do harm. In the one they remove the disease by acting as wee - ges; in the other they add to the violence of the ex- traction by increasing the irritability by which it was at first excited. As the degree of obstruction produced by spasm alone is, in some instances, equal to what usually oc- curs from the most obstinate kind of stricture, if is on- ly from an exact account of the rise and progress of the disease by which we can judge of the difference. When the flow of urine has at fiisf been perceived to be slightly obstructed, and when this has gradually become worse, without ever being in any instance ma- terially better, there will be much cause to imagine that it proceeds from a cause of a n\ed nature : while, on the contrary, however complete an obstruction may be, if it came on suddenly, and if it frequently be- comes quickly well without any obvious reason, there will be no cause to doubt of its proceeding from spasm. We find too, in obstruction proceeding from causes 110 OF SPASMODIC OBSTRUCTIONS Ch. III. of a more fixed nature, that some pain is always dis- covered at one or more fixed points. In some cases a degree of hardness is perceived on the urethra being pressed at these points; while in others, although no- thing can be discovered on external pressure, the pa- tient feels a degree of heat and pain, as if the parts affected were excoriated, or even ulcerated. Besides, in real stricture, a discharge of matter very universal- ly takes place from the urethra ; forming, as we have ai ready had occasion to see, a very frequent cause of Gleet. But in obstruction proceeding from spasm, any pain which occurs in the urethra does not proceed from one point. It appears to be more diffused ; and is seldom in any distressful degree, if it be not by the stoppage which it gives to the flow of urine. No par- ticular spot is discovered to be hard or sore upon pres- sure, and a discharge of matter does not necessarily take place in it. Spasm, indeed, may be accompanied with a flow of matter from the urethra. This will always happen where Gonorrhoea or Gleet have previously existed ; but it will never, on enquiry, be found to be the cause of the discharge. The remedies to b^ employed for the removal of this variety of obstruction are, warm emollients, ano- dynes, blood-letting, blisters, and electricity. Bou- gies, in certain circumstances, may be also employed. Rubbing the parts affected, whether the perineum, or more interior parts of the penis, with warm oil, proves sometimes useful. Oil, strongly impregnated with camphor, and Goulard's form of the unguentum saturninum, when applied warm to the parts affected, also tend to remove this cause of obstruction. I have sometimes known it instantaneously removed by fo- menting the perineum with a decoction of chamomile flowers or althea, or by the application of a bladder filled with warm water. The common anodyne balsam makes an useful ap- plication here. The parts in which the spasm is seated should not only be rubbed with it, but pledgets im- SeC. IV. OF THE URETHRA, 141 mersed in it should be kept constantly applied to them. But one of the most powerful antispasmodics among external applications is, a mixture composed of three parts of laudanum and one of .aether. Frequently, however, little or no advantage is de- rived from the external application of anodynes ; while opium, given internally, is productive of the best ef- fects. Forty drops of laudanum, given by the mouth, will often remove a spasm of the urethra that has re- sisted every variety of this remedy applied to the skin; and when thrown up the rectum, in the form of injection, it proves still more effectual in removing pain, irritation, and spasm about the anus, and in the organs of urine and generation, than when received into the stomach. Whether this may proceed from the remedy getting niore nearly into contact with the nerves of the diseas- ed parts, or whatever may be the cause of it, is per- haps difficult to determine • but, from much experi- ence of their effects, I am convinced, that in all such affections, opiates prove most powerful when given in this manner. In plethoric constitutions blood-letting is often the most effectual remedy, not only in carrying off the spasm which presently subsists, but in preventing re- turns of it in future. Besides the discharge of blood from the arm in quantities proportioned to the strength of the patient, leeches should be applied along the course of the affected parts, and they seldom fail where the constitution can support the evacuation, of giving very effectual relief. From an idea of spasmodic affections proceeding in most instances from what is termed a weakness of nerves, and from a dread which very universally prevails, of all such affections being rendered worse by blood-letting, this is a remedy we find very rare- ly, employed. But it is proper here, as well as in sim- ilar affections of other parts, to observe, that morbid irritability may be excited by causes of a very oppo- site nature. It sometimes takes place where the con- 142 OF SPASMODIC OBSTRUCTIONS CI). III. stiiution is relaxed and reduced ; and, in such cir- cumstances, evacuations of every kind very common- ly do barm. But it more frequently happens from a state of plethora, in which blood-letting proves the most certain remedy, and where opiates, warm bath- ins;, and other antispasmodics are often used for a great length of time, without any effect resulting from them. We find from experience, that a stimulus applied to the skin proves often useful in relieving pain and spasm, in parts that are very deeply seated ; and upon trial, the same remedies are sometimes found to remove similar affections of the urethra. Obstructions of this kind have, in different instances, been relieved by the application of volatile liniment, a strong impregnation of oil with volatile alkali, to the parts affected. A blister applied over the perineum, has in different in- stances carried off obstructions of the urethra ; arid in some cases where blisters tailed, the disease has been completely removed by the application of a warm plaster. In such cases blisters do not seem to act so much by the evacuation which they produce, as by the irrita- tion which they excite ; for it often happens that the pain and spasm are removed as soon as the skin be- comes in any degree uneasy, and long before vesica- tions can be formed. Hence, a warm plaster, which does not contain such a quantity of cantharides as to render it capable of acting as a blister, by keeping up a more continued stimulus than blisters, proves, in some instances, more effectual. Electricity has sometimes proved useful in removing spasm of the urethra ; but it requires to be managed with caution, otherwise it is apt to add to the violence of the disease. In plethoric habits it always does mis- chief and ought never to be advised in these till blood- letting has been premised. 1 have 1 ad occasion already to remark, that in this variety of obstruction, bougies are very apt to do harm. This proceeds from their being pushed with violence. SeC. IT. OF THE URETHRA. 143 when the parts, from being under some high degree of irritation, are in a state of strong contraction. This ought never, therefore, to be done ; for while the parts remain in this situation we seldom succeed ; or if w r e do get the bougie passed, it is always from the use of more violence than ought to be employed. But bougies prove highly serviceable, even in Spas- modic Obstructions of the Urethra, when the violence of the disease is so far removed that they can be in- troduced with ease, and without exciting irritation : so that, whenever we find this can be accomplished, whether the spasm has been lessened by the use of emollients, anodynes, blood-letting, or any other reme- dy, it ought always to be advised. Beskles the pres- ent relief which it affords, by removing any degree of the obstruction which may remain, it tends more ef- fectually than any other remedy to prevent a return of it. This is particularly the case where spasm is conjoined, as sometimes happens, with the more fixed kind of obstruction, which we are presently to proceed to consider. When this takes place all our other reme- dies are to be considered merely as preparative to the use of bougies, which, in such circumstances, are alone to be depended on for a cure. It must always be remembered, however, that bougies are only admis- sible when they can be introduced and retained in the passage, without exciting much uneasiness. In all diseases of the genitals the state of the intes- tines require particular attention. So much sympathy subsisisbetween these parts that in people liable to ob- struction in the urethra, I have known a severe fit of the disease induced by a costive stool. Neither is much purging necessary or proper. The bowels should be kept in such a state as to prevent in itafion, as far as it can be done, in the rectum and contiguous parts. 144 OF OBSTRUCTIONS Ch. Ill $ 3. Of Obstructions in the Urethra from Fleshy Excrescent* ces, or Caruncles. OBSTRUCTION to the passage of urine has long been considered as one of the most distressful, as it is one of the most frequent consequences of Clap ; and Caruncles, Fleshy Excrescences, or Carnosities, as they are sometimes termed, are mentioned by all the older writers upon this subject, as the most frequent cause of it. This idea naturally arose from their perceiving that warty substances were sometimes formed within the urethra, near to its extremity, similar in appearance to those which often occur upon the prepuce and glans ; and not prosecuting the subject by opening the parts after death, they were led to suppose that the more deep-seated obstructions were all of a similar na- ture. So universally did this opinion prevail, and it was so strongly asserted in books, that although it was long ago, by some individuals, particularly by Saviard and Dionis, supposed to be ill-founded, yet even in our times it has been very generally admitted. This is so far the case, that in common conversation upon this subject, Caruncles are usually considered as the most frequent cause of all such obstructions. It is now, however, very certainly known that this cause of obstruction is an uncommon occurrence in the more remote parts of the urethra. Of late years this has become a very frequent object of anatomical investigation; and I have reason to suppose, from all that I have yet heard, as well as from the result of my own inquiries, that it seldom exists farther up the ure- thra than half an inch or so from the point of the glans. Warty excrescences are not im frequently found to- wards the orifice of the urethra ; but I have seldom seen them, even in this situation, where they did not likewise prevail upon the glans and prepuce, SeC. IV. IN THE URETHRA, 145 The obstruction to the flow of urine from this cause is seldom considerable ; but^t always occasions much anxiety to the patient, from a fear which he is apt to entertain of its becoming worse. When seated just in the opening of the urethra, as sometimes happens, I have, in different instances been able to remove them with scissors, and with small lig- atures passed round them; but they are seldom so sit- uated as to admit of our taking them off in this man- ner. Neither are we at liberty to destroy them bv the application of escharotics, the irritability of the ure- thra rendering this a very hazardous attempt. In all such cases we place our chief dependance up- on bougies; and, when duly persisted in, they seldom fail in effecting a cure. Some difference of opinion has arisen as to the man- ner in which bougies act in removing these excrescen- ces. In strictures of a different kind there is no cause for doubt upon this point, as they evidently act entire- ly as wedges, and prove useful in proportion to the ex- tent of mechanical pressure which they afford; but in the cure of Caruncles they have been supposed to act chiefly by inducing suppuration upon the diseased- parts, and dissolving them in this manner. It is obvious, however, that in the cure of these ex- crescences, there is something farther necessary than the formation of matter, Indeed instances occur dai- ly, of their being constantly immersed in matter, some- times proceeding from their own surfaces, and at oth- er Times from the contiguous parts, without their being diminished. I rather conceive that bougies, even in this variety of obstruction, operate partly by mechan- ical pressure, and partly by exciting inflammation in the excrescences. We shall hereafter have occasion to see, that some of the remedies employed for the re- moval of warts in other parts, prove chiefly useful by making them inflame; and as bougies are well caicu- lated for this purpose, I think it probable, that while they evidently answer a good purpose by the pressure which thev afford, they prove likewise serviceable by 19 146 tfF OBSTRUCTIONS Ch. III. exciting over these excrescences that slight degree of inflammation, which, intfhe treatment of common ve- nereal warts very commonly makes them drop off. i 4. Of Obstruction in the Urethra from Strictures, property so called; of Bougies, and Fistula in Perineo. IN the more fixed kinds of Obstruction, proceeding from Gonorrhoea, the diameter of the Urethra is les- sened in two different ways. For the most part it is diminished by a thickening taking place at some par- ticular point in the membrane of the passage itself or lather in the corpus spongiosum urethra, in a similar manner to what frequently happens in the membrane of the nose in cases of catarrh. At other times the urethra is drawn together, or contracted, as if a cord was tied round it, without any other disease being per- ceptible. In some cases, again, these two affections are con- joined ; and we find, in the same person, the diameter of the passage lessened in one part by a mere contrac- tion, and in another, by a swelling and thickening in the substance of the urethra itself. Every part of the passage is liable to strictures ; but they are more frequent behind and immediately above the scrotum, than in any other part. In some cases a single stricture only takes place; but when the disease has subsisted for a length of time, we very commonly find the passage contracted in different parts. Where the urethra is merely drawn together, the disease seldom extends, at any one part, above the eight part of an inch, but where the stoppage proceeds from a swelling of the substance of the urethra itself, it sometimes extends to the length of an inch. From whatever cause the stricture may proceed, we commonly find that the urethra is affected equally all round ; but it is very properly remarked by Mr. Hunter, that, in some cages, the disease seems to be SeC. IV. IN THE URETHRA, &C. 147 fixed entirely on one side of the passage, in which case the canal is thrown over to the opposite side. This seems to happen only where the obstruction is produced by swelling of the urethra, and not where it proceeds solely from contraction. Where this unequal diminution of the canal takes place, even in one part only, it is obvious that it- must add greatly to the difficulty of introducing bougies ; and where more than one affection of this kind occurs, if they be not exactly opposite to one another, a kind of twisting of the passage takes place, which renders the passing a bougie impracticable. It must, however be admitted, that instances of this are rare. It is somewhat remarkable that the formation of strictures is often so gradual, that a patient is not sen- sible of their taking place till the disease has been of long continuance. Being seldom attended with pain till the flow of urine is much impeded, any partial de- gree of it passes without notice, by which they are apt to be rendered much more fixed and permanent than otherwise they would be. The patient indeed 1 as sel- dom any suspicion of strictures, till the surgeon, for his own satisfaction, where Gleet continues more ob- stinate than usual, proposes to introduce a bougie. Gonorrhoea having given rise to the Gleet, any diffi- culty that occurs to the passage of the urine is eons.d- ered to arise from the same cause; and thus a great length of time often elapses before any such examina- tion is made as can with certainty lead to a discovery. This proves often, in its consequences, highly dis- tressful, and ought therefore to be as much as possi- ble guarded against; for strictures, by long continu- ance, become much more firm, as well as 'more ex- tensive, than they were at first, by which they be- come much more difficult to cure. Cases which at first would have yielded almost to the first attempt with bougies, are, by delay, often rendered so obsti- nate that nothing will remove them but the most exact application of bougies being continued for a great length of time. 148 OF OBSTRUCTIONS Ch. III. In all cases, therefore, in which there is the least cause to sus[>ect that strictures may exist, an examin- ation should he made with bougies. But as patients themselves are apt to be deceived upon this point practitioners ought, in every instance, to lead their attention towards it. In different parts of this work we shall have occasion to see that Gleet is frequently kept up by strictures: so that whenever a running becomes in anv unusual degree obstinate, if there be not some other evident cause for it, a trial with a bougie should be proposed. This however, is sel- dom attended to; by which much unnecessary trou- ble, as well as loss of character, falls upon the practi- tioner, while the patient is made to suffer a great deal of misery which might have been prevented. We have already had occasion to remark that the strictures of which we are now speaking are conse- quences of Gonorrhoea; but in what manner they are produced by Gonorrhoea is perhaps difficult to explain. They have been attributed chiefly to ulcers induced by the disease, and to inflammation. At one period I was induced to suppose, chiefly from the information I had from books, that strictures were in most instances produced by ulcers. But from more frequent opport unities of observing the seat of Go- norrhoea after death, I am now convinced that ulcers very seldom take place here, by no means so frequent- ly as strictures, the disease they are supposed to pro- duce. It sometimes indeed happens, that the mem- brane of the urethra covering strictures, is found in a state of tenderness, or of excoriation, but not com- pletely ulcerated. This appears too to be the effect of the disease rather than the cause of it. It seems to proceed, in some degree, from the tumefaction of the membrane of the urethra, which often occurs in strictures and in some measure from the acrimony of the matter which these very strictures produce. When ulcers are met with in Gonorrhoea, they are in most instances, I believe, produced by the rup- ture, of one or more blood-vessels. If it be not at See. IV. PROM STRICTURES, &C. 149 the very point of the urethra, they never proceed from the matter of Lues Venerea. Now we can scarcely imagine that any ulcer which the rupture of a blood- vessel in the urethra could probably produce, would be of such depth or magnitude as to be attended with any important consequence of this kind. Neither are 'haemorrhages from the urethra frequent ; nor have I found that strictures have been particularly apt to hap- pen, even where haemorrhages have taken place in an alarming degree. I consider it, therefore, as decided, that strictures in the urethra seldom or never proceed from ulcers. Inflammation, when violent, may certainly tend to produce them ; and I think several instances have fallen within my own observation where this actually happened. I do not suppose, however, that this is Such a frequent cause of strictures as is commonly ima- gined, nor do I agree with those who think that in- jections often produce them. As it was observed, that strictures were, in some instances, induced by inflammation, and injections be- ing supposed, by those who are prejudiced against them, very apt to inflame the urethra, it was long ago asserted, and has since by many been believed, that they tend more frequently than any other cause, to produce strictures. This, indeed, is held forth as the most important objection to the use of injections, and were it in any degree well founded, I admit that it would be a strong reason for laying this remedy en- tirely aside ; for however desirable it may be to have the running in Gonorrhoea quickly carried of, and however efficacious injections may be, no practitioner would advise them were it to be with the risk of indu- cing such a formidable disease as strictures often are. Where strong stimulating injections are unguarded- ly used, such a degree of inflammation may thus be induced as may be productive of the most obstinate strictures. But this is not the fault of the remedy, as I have elsewhere observed, being entirely the effect of an improper application of it. We might with 150 OF OBSTRUCTIONS IN THE URETHRA Cb. III. equal propriety condemn the use of some of our most effectual and safest medicines, merely from an over- dose having done harm. Instead of injections- being a frequent cause of stric- tures, I have much reason to think that they are more effectual than any other remedy in preventing them. Although I have admitted that strictures are sometimes produced by severe degrees of inflammation, I do not consider this as a frequent occurrence. Strictures I conceive to be most frequently the consequence of a state directly the reverse of inflammation. In a great proportion of cases they will be found to take place, where, either from no injection being used, or from some other cause, the discharge has gone on to a very unusual length, where all symptoms of inflammation were gone long before, and where nothing but a Gleet remained. At least this has been very generally the result of my observation, and, I believe, it will be admitted by all who have paid attention to the point in question. 1 therefore conclude from this, as well as from the appearances which these parts exhibit on dissection, that this variety of obstruction proceeds most frequently from a state of morbid relaxation or debility, induced in these parts of the membrane of the urethra upon which the inflammation at first fixes with most violence, and from which the subsequent discharge is in a great measure produced. Where stricture succeeds immediately to inflamma- tion, it appears to be that variety of it in which the urethra is compressed, or tied, as it were, with a cord : but where it does not appear till the inflamma- tion subsides, and the discharge has been of long du- ration, the substance of the urethra is found, at those parts where the strictures exist, spongy, soft and prom- inent, bearing every mark of having completely lost its tone. r J he existence of this variety of stricture being as- certained, and it will not be confounded with any oth- er disease where the observations contained in the pre- SeC. IV. TROiMf STRICTURES, &C. 151 ceding parts of this section are kept in view, our next object is to fix upon the method of cure. While the opinion prevailed of strictures being most frequently produced by ulcers in the urethra, as this led to the suspicion of their being connected with Lues Venerea, mercury was advised in almost every instance. Mercurial ointment was regularly rubbed upon the seat of the disease, in order to dissolve the cause of the obstruction, and the patient was put un- der a salivation, witn a view to the safety of his con- stitution. As this was the prevailing practice of our best sur- geons, both here and in other parts of Europe, when I entered upon business, I was necessarily led to adopt it, but late experience having shewn that mercury is never necessary in the cure of strictures I have now for many years past lair! it altogether aside. Niy, I readily own that I never knew any advantage derived from it, while in many instances, when long persisted in, it evidently did harm. It will not be imagined, that during this late period of time, mercury was ever alone depended upon for the removal of strictures in the urethra. Bougies were then very generally employed ; but mercury, for the reason I have mentioned, was always advised along with them. Bougies had long been known to practi- tioners, but they were so coarsely formed, and their application so little understood, that scarcely any ad- vantage was derived from them, till Mr. Daran, about fifty years ago, brought them into more general notice. By forming them with care, and introducing them with address, Mr. Daran had the credit of giving us the only remedy upon which we can place any depend- ence for the cure of strictures. At least we are cer- tainly in a great measure indebted to him for bringing them into general use. It is true that Mr. Daran attributed virtues to his bougies which they did not possess. Being much in- terested in the sale of them, he wished to throw a mys- tery, over their composition. They acted chiefly, he 152 OF OBSTRUCTIONS IN THE URETHRA Ch. Ill, said, by their suppurative qualify : in consequence of which, and by the great discharge of matter which they produced, tumours, and other causes of obstruction in the urethra, were, he alledged, dissolved by them, which could never otherwise have been removed. The con- fidence with which this was asserted, by a man of Mr. Daran's experience, and the considerable discharge of purulent-like matter which usually accompanies the use of bougies, gave weight to an opinion which at last came to be very generally adopted. We now know, however, that it is not by exciting a discharge of matter that bougies act in the cure of stric- tures. Even the mildest bougie we can employ, when kept in the urethra for an hour or two, is covered with a kind of matter on being withdrawn ; but this happens- as readily where the urethra is sound as when it is ob- structed in various places, and it proceeds entirely from the natural mucus of the passage being increased in quantity, and somewhat altered in appearance, by the irrigation excited by the bougie. Even admitting the obstructed parts to be more par- ticularly acted upon, and a greater discharge of matter excited from them than from the other parts of the urethra, and which Mr. Daran asserted to be the case under his management, of the bougie, still this would not account for the removal of excrescences ; for we know, from daily observation, in other parts of the body, that the whole surface of excrescences of a sim- ilar nature to those which Mr. Daran supposes to tako place here, may be kept in a state of complete ulcera- tion, and a great quantity of matter discharged from them for a great length of time, without any diminu^ lion of their size. Bougies, in the cure of these strictures, seem to act solely by pressure, and t he support which they afford to the diseased parts, If a bougie, of sufficient firm- ness, exactly or nearly the size of the urethra in its contracted state, be passed at first, and others of a larger size afterwards introduced, we know from ex- perience, that if done with caution, no harm will ei> Sec. IV. FROM STRICTURES, &C 153 sue, and (bat (he stricture for which it was employed, will thus, in a gradual manner, be removed, merely by the pressure of the bougie* In this view, our chief object in the forming of bou- gies should be, to give a firmness sufficient to afford support to the parts which we wish to compress, and a smoothness and flexibility which will admit of their being introduced and retained in the urethra with the greatest possible ease. Numbers 34, 35, 36, and 37, in the Appendix, con- tain prescriptions for bougies of different colours and consistences, with some directions for the method of preparing them ; but the exact formation of bougies being a matter of the first importance, and this being only to be acquired by extensive experience, it is bet- ter for surgeons to procure them from those whose sole profession it is to make them, than to attempt to form them themselves. Besides the forms of plasters mentioned in these prescriptions, other articles have been employed for the construction of bougies, particularly cat-gut and resina elastica. Of these the latter is by much the best, and for all the smaller kinds of bougies, I now 7 find it to be preferable to the best bougies of the common kind. Even when of the smallest size, it can be made of such a degree of firmness as to admit of being push- ed with considerable force, which is not the case with the smaller kinds of common bougies, which are apt to bend, and to become twisted, although introduced with much care and attention. The great expeiice of bougies of this kind has hith- erto prevented them from being so generally known as they ought to be: besides, they were at first made so soft that they nearly dissolved in the urethra on being allowed to remain in it for the space of an hour or two ; but this fault is now so entirely removed, that I have known them remain in the passage seven or eight hours at once, and yet as firm on being withdrawn as when first introduced. This renders it a valuable article, not only for bougies, but flexible catheters, 20 1 54 OF OBSTRUCTIONS IN THE URETHRA Ch. III., This resin has one very essential advantage over ev- ery composition that has yet been employed for bou- gies. It does not crack or break while in the urethra, however frequently it may be introduced. When the common bougies are prepared with much attention, and the composition of which they are formed is not too much boiled, they may sometimes be used two or three times with safety; but, in most instances, they cannot with propriety be introduced more than once. Nay, many of them, on remaining: an hour or two in the passage, are so much cracked as to excite a great deal of irritation and pain even on their first introduc- tion, insomuch that I have met with different instances where patients had been deterred by this cause alone from using bougies, the irritation which they excited being so great as to be perfectly insupportable ; while, on having recourse to those formed ofresina elastica, they were found to create no kind of uneasiness. These bougies are formed of fine silk, or linen, dip- ped in the resin dissolved in aether. They were ori- ginally invented by Mr. Thedn, of Berlin, and now are made by different artists in Paris. There is cause to regret that the art of forming them is as yet confined to a very few, so that our supplies have hitherto been both scarce and uncertain. In the use of bougies the following are points which particularly require attention : 1. T! ey should be provided in such numbers, and of such variety of sizes, that there may be no doubt of as many being at hand as in any case may be requisite. 2. On proceeding to introduce the first bougie, care should be taken to fix upon one of such a size as will probably pass without exciting much pain. It is better at first to have it rather smaller than might be made to pass, than be afterwards under the necessity of with- drawing it. Of this we may in general judge by the size of stream in which the urine is observed to flow. It is often indeed found to be forked, and sometimes flattened, owing to the form and nature of the strict- ure, but, with some attention to this circumstance, we Sec. IV FROM STRICTURES, &C. 155 may, for the most part, be determined in the size of bougie that will answer. 3. The patient should be placed in such a posture, as tends, in the most effectual manner, to relax the ure- thra. He may either be made to stand, with his thighs separated, and his body bent gently forward, or he may be laid upon his back, with his thighs not only sepa- rate, but raised. He ought, on no account, to be sea- ted. In sitting the urethra is apt to be so much com- pressed that no space is left for the passage of a bou- gie. I have known several unsuccessful attempts to pass a bougie from this cause alone. 4. The surgeon being seated on the right side of the patient, should grasp the penis with his left hand, and, at the same time should draw it gently forward, so as to stretch the urethra to such a degree as may prevent it from catching the point of the bougie. With the bougie previously well oiled, in his right hand, he should insert the point of it into the urethra, when it must be passed slowly, though firmly on, till it meets with resistance. Neither should he desist at once on the stricture being met with. It answers better to continue to push on the bougie with a due degree of firmness, than to withdraw it immediately, as is often done. The first application of a bougie to the obstruc- tion, is very apt to excite irritation and spasm, even in the stricture itself; and I have often thought that this was more easily overcome by pushing the bougie on at first than by any subsequent introduction of it. 5. A knowledge of the force that may with safety be employed in passing a bougie, can only be acquired by experience. Tne less violence that is done to the ure- thra, or to the cause of contraction, the better. It can- not, in some cases, be done without pain, but it should never be made to force a discharge of blood. When blood comes away, the instrument should be instant- ly withdrawn ; for when this takes place, we may always be certain that some parts have been injured which ought not to have suffered, and by contin- uing to force on the bougie, that there is a con- siderable risk of its forming a new passage for itself 156 OF OBSTRUCTIONS IN TH3 URETHRA Ch. III. 6. The distress which ensues from a new opening being formed by a bougie is apt to be so great, that no- thing should be omitted that can in any way tend to prevent it. When there is cause to suspect, from the quantity of blood discharged, that the membrane of the urethra is injured, the bougie ought not to be again introduced for several days ; not till there is reason to suppose that the wound in the urethra is healed, for, till this takes place, it is obvious that it would be very apt to renew the injury. 7. As bougies ought all to be of a conical form, they should not be pushed farther at first than freely through the first obstruction, otherwise the contracted part is apt to be torn open with too much force. It answers better to proceed gradually, and to increase the size of the bougie, or to push one of the same size farther on, in such a manner, as may avoid every risk of injuring the membrane of the urethra. It is true that cures will be obtained where bougies have been introduced with much violence; where vio- lent pain, accompanied with haemorrhage, has been excited ; but this is a practice, which, for the reasons I have mentivjned, ought never to be adopted. 8. The bougie being introduced, some attention is re- quired to prevent it from slipping altogether into the uremia, as well as for retaining it in the depth at which it is inserted. We obtain tne first of these objects by bending the end of the bougie, which, for this pur- pose, should be left at least half an inch out of the ure- thra ; and the usual method of retaining a bougie in its place, is, by tying a piece of soft cotton thread to the end of it, and fixing it with this either directly to the penis, by passing it once or twice round about the glans, or connecting it to the circular belt of a com- mon suspensory bandage. But the most effectual me- thod, as well as the easiest, which I have tried, is fit- ting the penis with a small bag or pouch of cotton oi- lmen. The bougie being int induced with its end bent down, the bag must be put over the penis, and SeC. IV. FROM STRICTURES, &C. 157 being fixed with two pieces of tape to a circular belt round the body, the bougie is in this manner easily retained. Common bougies being of no great value, may be cut of such a length as to leave half an inch or so, out of the urethra, for the purpose of bending down in the manner I have mentioned ; but those of the elastic gum should be kept of every variety of length, from three or four inches to nine or ten ; and being easily formed with a knob at the large end, they are thus, in the most certain manner, prevented from slipping in. When this caution has been neglected, and when a bougie is thereby allowed to slip completely into the urethra, it is sometimes, by the aukward attempts of the patient, forced altogether into the bladder. In this situation, it cannot be removed but by cut- ting into the bladder, as is done in the operation of li- thotomy, and extracting it with forceps. But while the bougie continues in any part of the urethra it may be taken out by an operation of much less importance and hazard. When the end of the bougie can be seen, it may with some care and attention be laid hold of with a small hook, or with narrow-bladed forceps, such as are used for extracting stones that fix near to the end of the ure- thra. But when it has passed so far in, that it cannot be perceived, this method of extraction will not suc- ceed. In this case it can only be got out by making an in- cision upon it directly into the urethra. The skin should be first drawn back, when a cut should be made through the teguments and urethra at once, of at least half an inch in length, when, if the end of the bougie can be laid hold of, it may be taken out at this open- ing ; or if this be not practicable, it may be pushed forward till the end of it passes out at the end of the urethra. This may be done either with small forceps or pliers, or by sticking a pin into the bougie at the opening, and pushing it slowly on. The wound for the most part heals easily. 153 OF OBSTRUCTIONS IN THE URETHRA €1). III. 10. The circumstances which next require attention in the use of bougies are, the time they should be allow- ed to remain in the urethra, and the frequency with which they should be introduced. As bougies act, perhaps, entirely in the cure of stric- tures by the pressure which they afford, and prove chief- ly useful by the total change of stricture. which they in- duce in the parts to which they are applied, they must necessarily require a considerable time for effecting this. The longer, therefore, that they are retained in the urethra, the sooner this will be accomplished. But w mile we attend to the removal of the stricture, care must be taken to prevent injury by their exciting too much irritation. This, indped, is the circumstance by which we ought to be chiefly directed. It may be laid down as a general rule that bougies may be retained in the urethra as long as they excite no pain or irritation; while, in every instance, they should be withdrawn as soon as much pain is produced by them. At first they can seldom be allowed to remain lon- ger than half an hour at once; but, on the urethra be- ing for some time accustomed to receive them, they may, for the most part, be left in it for several hours ; and this may be repeated once and again during the course of the day. 11. During the time that bougies remain in the ure- thra the patient should be prevented from walking or moving more than is absolutely necessary. This is not usually attended to with necessary strictness, by which many are prevented from deriving that advantage from bougies which otherwise they would receive. In walking, with a bougie in the urethra, the irrita- tion induced by it is at all times considerable ; but this more especially, when common bougies are employed. The motion in walking is apt to crack and break the plaster of which they are formed, which renders their surfaces rough and unequal, by which it is obvious that much harm must be done. 12. In order to obtain the advantage of perfect rest while bougies are introduced, we are advised by many SeC. IV, FROM STRICTURES, &C. 15^ to employ them only at bed time, and to allow them to remain in the passage during the night. This may an- swer when the patient is not liable to nocturnal erec- tions, but where these are apt to occur it ought never to be permitted. I have known several instances of much pain and inflammation induced by it. It may, in some circumstances, be more convenient to apply bougies during the day, but it is evident that it may be done with more safety. 13. To admit as long a retention as possible of bou- gies in the passage, some have alledged, that the pa- tient may, with safety, be allowed to void urine while they remain in it. I have known this done, and no harm ensue, where the urine was passed slowly, and with much caution : but I have also known the attempt do much harm, and as the trouble of introducing the bougie a second time is not equal to the hazard of al- lowing it to remain, I always advise it to be withdrawn on a desire to void urine taking place. Besides the pain and inflammation which want of at- tention in this matter is apt to induce, and erections oc- curring during the introduction of bougies have like* wise this effect, I have known different instances of its appearing to lay the foundation of spasmodic affections of the urethra, which afterwards proved very obstinate, even after the original strictures were removed. Id. By gradually increasing the size of the bougie, the stricture through which it is passed will at last be removed ; but before it is entirely destroyed, it will be proper to push forward the bougie, to discover wheth- er there is any other cause of obstruction or not, It is better, however, not to make the attempt till the open- ing through the first is considerably enlarged, when it will much more readily succeed. Whatever other strictures are discovered, they must be managed in the manner we have advised for the first; the bougie must, if possible, be made to pass through them all, and the size of it gradually increased till the urethra is opened to its complete, natural size. J 5. In passing bougies for this purpose, it has been a 160 OF OBSTRUCTIONS IN THE URETHRA Ch. III. point in dispute, whether they should be carried the length of the bladder, and allowed to remain in it or not. I am decidedly of opinion that they should be pas- sed completely into the bladder, as soon as this can be done, in order to discover the utmost extent of the strictures; but 1 also think that they should never be allowed to remain in the bladder. The common bou- gies are so apt to crack, and pieces of the plaster to fall off, that this might very possibly happen from their being immersed in urine ; and we all know, that if a particle should drop, not small enough to pass off with the urine, that it would probably serve as a nucleus for a stone. This would not so readily happen with bougies of elastic gum; but even these, where there is so much hazard, ought not to be trusted, particular- ly as there Is no real necessity for it in the management of strictures ; for it is found upon dissection, that they are always seated anterior to the neck of the bladder. They are often in the membranous part of the urethra ; but they have, perhaps, never been met with in the prostate gland, I mean in the urethra as it passes through this gland. It must be admitted that the urine is often obstruct- ed by affections of this gland ; by inflammation, as well as by a more indolent kind of swelling, to which, as we have elsewhere had occasion to see, it is some- times liable. But this variety of obstruction, instead of being removed by bougies, is always injured by them. We are sometimes under the necessity of pas- sing a catheter, even during an inflamed state of the prostate gland ; but this should only be done for draw- ing off the urine when it has been completely suppres- sed. When the gland has been for some time swelled in such a manner as to create a stoppage to the flow of urine, it is obvious, from its firmness, that bougies cannot remove it, while, by the irritation which they excite, they never fail to do harm. 16. Besides the length of time which bougies should be kept inserted daily, it is an object of importance to determine at what period they may, with safety, be Sec. IV. FROM STRICTURES, &C. 161 laid aside. This, I must acknowledge, is difficult to do, as it depends upon a variety of circumstances with which it is impossible, at all times, to be acquainted. Even where the stricture is so completely removed that bougies pass with ease, and the urine is voided in a full stream, the disease is apt to recur if the bougies be too soon left off. They should, in every instance, be worn for a considerable time after all appearances of stricture are gone, and the more obstinate the dis- ease has been, the longer they should be continued. Even after a patient considers himself as so entirely well that he may conceive no hazard to ensue from the farther use of bougies being entirely dropped, still he ought to have them, at all times, in his possession, so as to be able, on the least return of obstruction, to employ them instantly. This is a precaution not often adverted to, but which ought never to be disregarded by any who has suffered in this manner: and I think it the more necessary to insist upon it, from several in- stances having fallen within my own knowledge of the most distressful consequences ensuing from a neglect of it. It is more particularly proper for all people, in this situation, going upon a journey, to be well pro- vided with bougies; for, when from home, they can- not always readily meet with them, while, at the same time, they are more exposed to the various causes most apt to excite a return of the disease. These par- ticularly are, exposure to cold and dampness; much fatigue, whether on foot, horseback, or in a carriage y and excess in wine and spirituous liquors. All of these causes act with such certainty in indu- cing a return of affections of this kind, that I have seldom known them fail where people have been much exposed to them ; and, in most instances, their effect is perceived soon after their application, I have known a person, who, after being completely cured of stric- tures, for several years, has been seized with a very hazardous and painful return of the disorder, in the course of an hour or two after being much exposed to a cold, east wind. It is particularly apt to occur from 21 162 OF OBSTRUCTIONS IN THE URETHRA Cb. Ill, violent exertion on horseback, and from being much- overheated with wine; more especially from excess in port wine. A return of stricture is also apt to arise from the urine being;, at any time, too long retained after a desire takes place to pass it. This ought always to be guard- ed against ; but I also think it right to mention, that patients sometimes err in getting into the habit of void- ing urine too frequently. By yielding immediately to every impulse, such a habit takes place that they are apt, from this cause alone, to continue, during life, to pass it every hour or two. This proves not only very inconvenient, but it is also apt to induce a contracted state of the cavity of the bladder, together with a thickening of its coats, its full distension, which natu- rally ought to occur from time to time, being thereby prevented. Hence it is a matter of no small impor- tance for patients, in this situation, to observe as just a medium as can be done between the two extremes w hieh we have mentioned. On the least return of stricture being perceived, whatever the cause may he, a bougie should be imme- diately introduced. The patient, if he is plethoric, should be blooded in proportion to his strength; his bowels should be opened with a gentle laxative, or with a clyster; and lie should be kept in bed till the violence of the disease be removed. In this manner I have known the most formidable attack soon carried off, while, from treating them with inattention, even the most trifling symptoms have been rendered severe, and in the highest degree obstinate. The sudden and unexpected manner in which pa- tients are often attacked with a return of these affec- tions, has given cause to suspect that they must, in such instances, proceed from spasm. But the obstinacy with which they often continue, as well as every other circumstance attending them, renders it obvious, that, in a great proportion of cases, they proceed from caus- es of a more permanent nature than spasm is almost ever found to be. Sec. IV. FROM STRICTURES, &C. 163 17. We have hitherto been supposing that the stric- tures are of such a nature as to permit a bougie to be passed with no great difficulty ; in which case, no doubt can.be entertained of our being able, by perseverance, either to accomplish a cure or to afford at least very effectual relief, and to prevent any alarming obstruc- tion from taking place to the passage of the urine ; for however bad a stricture may be, if bougies of a small size can be passed at first, we may always be able, as I have already observed, in a gradual manner, to in- troduce those of a larger size. But frequently, either from the passage being contracted to a very small size, or from the stricture being altogether on one side of the urethra, by which the passage is thrown over to the opposite one, after a variety of attempts we find no progress made, or if any thing is gained, it is so in- considerable as to afford no kind of relief. This proves always very dispiriting to the patient, and is apt to dis- pose practitioners not much versant in this branch of business to desist from all further trials: considering the disease to be incurable, they prescribe a course of palliatives, which, for the most part, avail little, while the oaly remedy from which advantage could be ex- pected is deserted. This ought never to be done, at least it ought never to come on the part of the practitioner, nor can any thing warrant the measure but the patient himself be- ing determined against the farther application of bou- gies. This, from impatience and disappointment, is apt to happen; but it ought at all times, to be as much as possible resisted. Even in the most obstinate ob- struction that occurs, if the passage be not altogether obliterated, a surgeon of experience will scarcely fail, if he be not prevented by the impatience or timidity of his patient from persevering for a due length of time. 18. When there is cause to suspect that the passage is thrown over to one side of thcurethra, by the stric- ture being fixed in the other, a point in which we may sometimes be determined by external examination with 164 OF OBSTRUCTIONS IN THE URETHRA Ch. III. the fingers, and most frequently by the feelings of the patient, the extremity of the bougie should be slightly curved or bent before being inserted, and the point of it being turned towards that side where the passage is understood to be, if carried on in this direction, we will sometimes succeed, when various attempts have failed in the usual manner. It will be readily suppo- sed that the curvature given to the bougie must be ve- ry inconsiderable ; but even the slightest will some- times give it the direction which we wish it to take, while it does not prevent it from passing, with suffi- cient ease, along the urethra. 19. In the introduction of a bougie it ought to be kept firm between the finger and thumb of the right hand, and pushed gradually forward till it reaches the stricture; but, when it has got this length, it common- ly answers better to twirl it between the finger and thumb, taking care to push it gently forward at the same time. At least I often succeed in this manner when the usual method of pushing it directly on, has failed. 20. I have already observed that no more force should be used in the introduction of a bougie than is merely necessary for making it pass ; but it is proper to remark, that, in the hands of a surgeon of experi- ence, much more force may with safety he applied than others can, with any propriety, venture to em- ploy. By pushing a bougie slowly and gradually for- ward, we often force it through strictures without any discharge of blood taking place, while much pain and laceration is sometimes produced even by less violence, when applied in a hurried or quick manner. 21. When we find upon trial that a small bougie, nearly the size of the opening, is made to pass, no force will be afterwards required, if the bougies be gradually increased in size. But when we find upon repeated trials, that the remaining passage cannot be discovered, and when we therefore mean to employ more force, a bougie of greater strength should be used in place of the smaller one. The small-sized SeC. IV. FROM STRICTURES, &c. 165 bougies, particularly those of the common kind, are so easily bent that they should never be employed where much force is required. I have known even surgeons of experience push forward bougies of this kind, and concluding that they had passed the stric- ture, have carried them on till they imagined they had nearly reached the bladder, when, on being withdrawn, they were twisted up in the form of a corkscrew, hav- ing never gone farther than the stricture. With a firm, well-polished bougie of elastic gum, well rounded at the end, and not smaller than a crow's quill, such a force may be applied as will often suc- ceed when no advantage can be derived from those of a smaller size ; and we should not be deterred from proceeding, although the first trials prove unsuccess- ful ; for we often pass the stricture by perseverance when no advantage was gained at first. I have reason, indeed, to imagine, from what has happened in the course of my own practice, that few cases will occur which may not ultimately be cured by bougies. But when they do, in what manner are we to proceed? When every trial that we dare venture upon with bougies fails, what are we to do ? This, it is evident, must depend entirely upon the state of the parts affected, and upon the degree of obstruction which takes place. If there is still such an opening left as admits of the urine passing off with tolerable ease, I would advise nothing farther to be done. A patient, in such a situ- ation, had better submit to the inconvenience of pas- sing it slowly, and even frequently, than to the ope- ration of removing the stricture, which consists in lay- ing the obstructed part of the urethra open, and in the frequent introduction of a bougie during the process of the reunion of the divided parts. This, however, is an operation of much importance : it is attended with so much pain, and with such uncertain success, that no practitioner of experience would recommend it while the urine is not totally obstructed ; and long before this could probably happen the situation of the 166 OF OBSTRUCTIONS IN THE URETHRA Oil. III. parts lying between the stricture and the bladder is commonly such as to induce the patient to submit more readily to any operation that may be necessary, than he ever would have done in a more early stage of the disorder. Whenever the stricture occasions much difficulty to the flow of urine, that part of the urethra lying between the stricture and bladder, is ne- cessarily distended on every attempt to void urine. This frequent stretching at last weakens the lining membrane of the urethra; the urine is at first in small quantities, and afterwards in larger, forced into the surrounding cellular substance: this, forming one or more small tumours, at last bursts out through a cor- responding number of openings, either in the perine- um, or in the cellular part of the scrotum. At least this is the usual progress of such tumours when the strictures in the urethra, by which they were produced, cannot be removed. This is the most frequent cause of the disease we have already had occasion to mention, Fistula in Pe- rineo, in which the urine continues to flow out at the newly forced openings, as long as the strictures in the urethra are allowed to remain and which accord- ingly, as we have already observed, makes the pa- tient easily submit to whatever may be necessary for removing them. In such circumstances nothing will prove successful if the diseased parts be not freely laid open. A stalf being introduced the length of the stricture, and a small probe passed in at one of the openings, and carried to the opposite side of the stric- ture, the intermediate space should be laid open by an incision in the direction of the urethra. In this man- ner the cause of obstruction will be discovered and re- moved, and the other sinuses communicating with the urethra being likewise laid freely open, a cure even of the worst cases that occur, may thus be frequently obtained. To enter more fully into the consideration of this operation, and of the after treatment of the sores, would here be improper, as it w T ould extend this article to too great a length. It could not be done §eC. IV. FROM STRICTURES, &C. 16? with precision and clearness without entering upon the general doctrine of fistula, and upon different methods of cure that have been proposed for it; and as this has been done in a different work, I must now refer to what I had then occasion to say upon it.^ Before concluding the consideration of strictures in the urethra, I think it necessary to notice a method of cure that has been proposed where we fail in the in- troduction of bougies, the repeated introduction of caustic into the urethra, with the view of destroying the cause by which the stricture is produced. This practice prevailed upwards of a hundred years ago, but was soon relinquished. It has lately, how- ever, been revived, or rather a proposal made for re- viving it, by Mr. Hunter of London, under whose di- rection, it is to be hoped that it will soon become as generally useful as we can ever expect it to be. But as T consider this practice as more or less hazardous, and not likely to prove often effectual, T shall briefly state what leads me to form this opinion, that others may be on their guard against too implicit an adop- tion of it. The introduction of caustic into the urethra must prove hazardous from two circumstances, our not be- ing able, even with all the pains we can take, to ap- ply it to the stricture alone, without injuring the con- tiguous parts of the urethra, and the risk which there must always be of some small portion of the caustic breaking off and being left in the passage. Mr. Hunter has indeed invented a very neat appa- ratus for the introduction of caustic. It consists of a silver tube, open at both ends, nearly the thickness of a common catheter, with a port-crayon, somewhat longer than the tube, into which the caustic is fixed. A stillette, with a perfectly round end, is first passed through the tube, and if it be exactly fitted to the end of it, the two together may be carried with perfect ease along the urethra till they come in contact with * V. S}-stem of Surgery, chapters xv. and xx, 168 OF OBSTRUCTIONS IN THE URETHRA Cll. III. the stricture, when the stillette to be withdrawn, and the port-crayon, with the caustic fixed in if, introdu- ced. The caustic being applied to the stricture for about the space of a minute, must be withdrawn along with the instrument, and this must be repeated every two or three days till the cause of obstruction is re- moved. This, from description, appears perfectly simple, and of easy execution : but notwithstanding the ingen- uity of the invention, it is obviously liable to the two objections which 1 have mentioned. We know even where parts are uncovered, and therefore immediately under view, that it is exceedingly difficult to destroy diseased parts with caustic, without injuring the con- tiguous sound parts. In the urethra, therefore, where we receive no advantage from the eye, and where the slightest deviation of the instrument may fix the caus- tic upon the urethra itself, instead of the stricture, there must evidently be a good deal of hazard from this circumstance alone, independent of the chance of injuring the contiguous parts merely by the spreading of the caustic, admitting it to be applied with all man- ner of exactness. Besides, as the size of caustic that can be passed in this manner is necessarily very small, there must always be some hazard of its dipping out or breaking off, an occurrence from which the highest degree of distress w ould ensue ; for it could not be extracted, and dilution could not be employed with such effect as to prevent it from doing a great deal of mischief. Another very important objection occurs to this practice. A great proportion of all strictures, perhaps nearly ninety of a hundred, are seated beyond the curve of the urethra, to which an instrument sostreighfc as a tube acting as the conductor of another body ought to be, cannot be carried. But Mr. Hunter, fore- seeing the difficulty, has endeavoured to remove it by proposing that the end of the tube should be flexible, and of the same form with the common flexible cathe- ter of silver. But this, while it apparently adds to the Sec. IV. FROM STRICTURES, &C. 169 ingenuity of the invention, renders it evidently more hazardous. The small point of caustic contained in the port-crayon will be more apt to be broken 01 loos- ened in passing through a curved tube than through a straight one, while it will not be possible to apply it to any one point with such firmness and steadiness. But even admitting that caustic may with safety be conveyed to strictures in the urethra, yet, in those cases which do not yield to the use of bougies, tie obstruc- tion is generally of considerable extent, and the quan- tity of caustic necessary for removing it so gteac trat the contiguous sound parts of the passage must be much injured, whatever care and attention we bestovr in the application of so active a remedy. On these accounts, it would appear, that for the removal of strictures in the urethra, the application of caustic is either impracticable or unsafe. In all slight obstruc- tions of the urethra, a 0- , forte may be used with bougies, sufficient ior removing them. YV henever this can be done, no person will doubt of the pro- priety of preferring them to the use of caustic ; and when the cause of obstruction is of such extent as to render cur attempts with bougies unsuccessful, there will be little or no room to hope that caustic will an- sner the purpose. In other parts of the body we all know how difficult it is to remove even the callous edges of an ulcer with caustic. Nay, in many in- stances, new parts seern to form before the eschar pro- duced by the previous application of the caustic has come oft. I have no hesitation, therefore, in saying, that in similar affections of the urethra, proceeding to the extent which we here suppose them to do, caustic would either be altogether inadequate for the purpose, or must be applied in such quantities as would be at- tended with a great deal of hazard. In all such circumstances, I consider it as preferable to let the disease take its usual course. The worst that can happen is, the formation of sinuses behind the strictures, and the discharge of urine from the open- ings which these produce. Few patients incline long 22 270 OF OBSTRUCTIONS IN THE URETHRA Ch. Ill, to submit to this ; but I consider the cure of this state of the disease, by the mode of treatment already pointed out, as more certain, while it is obviously much less hazardous than the means proposed for pre- venting it by the application of caustic. Since the time our author wrote on the subject of Stricture, a very important improvement in the method of treating them has been introduced, viz their destruction by the use of caustic. We do not mean to say ti.at its use is entirely novel, as we knew that a variety of caustics were used by the older surgeons, as Daran, Paree, Hildanus, Astruc, and others, who used Lunar Caustic, Lapis- infernalis. Red Precipitate, &.c. ; but that the use of it is now re- duced almost to a system, by which we can frequently relieve this most troublesome complaint in one tenth part of the time, that is required, in the use of the merely mechanical remedy, the bougie. For the revival at least, of this method of treating strictures, we are indebted to the ingenious Mr. J. Hunter, whose repeated fail- ures in the ordinary method, ^by the bougie,) induced him to at- tempt their destruction by the caustic ; and had he been as success- ful in the mode of applying, as he was judicious in the choice of the application, he would have left little for his successors to do, at least, in those cases ol stricture to which this method of treat- ment is applicable. Fortunately, wtiat the Z'_ai of Mr. Hunter did not accomplish, has been atchieved by the science and perseverance of some modern surgeons, at the head of whom we must unques- tionably place Mr. Home, surgeon to St. George's Hospital, Lon- don. We cannot pretend to give even an outline, of Mr. Home's " Practical Observations on the treatment of stricture in the ure- thra, &c." in the short compass ot a note ; yet we cannot refrain from abridging some of the practical maxims which they contain, as a hint to those who unfortunately do not possess the entire work. Of Strictures properly so called, there are three kinds, viz. the true or permanent stricture, arising from an alteration in ihe structure of a part of the urethra, the mixed, or that in which the former is combined with spasm, and lastly, what has (perhaps im- properly) been termed he true spasmodic stricture. The first of these species most unequivocally demands the use of the caustic, and in such cases Mr. Home makes use of the lunar caustic (nitrate of silver) which he applies in the following manner. " He takes a bougie which can be easily passed down the urethra to the stricture, and inserts a piece of lunar caustic into the end of it, in such man- ner, that while the caustic is even with its surface, it is surrounded every where literally by the substance of the bougie." This he directs to be clone some time before it is to be used, in order that Ihe soft materials of which the bougie is composed may have time to fix more firmly about the caustic, and prevent its slipping cut ; Sec. IV. FROM STRICTURES, &C. 171 when prepared in this way, it is oiled and is then ready for use. The bougie thus armed, is used in the following manner, a common bougie of he same size is passed down to the stricture, in order to clear the canal, and to measure the exact distance of the stricture from the orifice of the urethra This distance being marked upon the armed bougie, it is to be passed down to the stricture, as soon as the other is withdrawn. The caustic in its passage is scarcely allowed to come into contact with any part of the membrane, be- cause the point of the bougie, of which the argentum mVatum forms the central part, always moves in the middle line of the canal ; and indeed the quickness with which it is conveyed to the stricture, prevents any in-jury of the membrane lining the passage, when the caustic accidentally touches it. In this mode the caustic is passed down with little or no irrita- tion to the lining of the urethra, it is applied in the most advanta- geous manner to the stricture, and can be retained in that situation, sufficiently long to produce the desired effect. The arguments in favour of this mode of treatment over that by common bougies, are first, that a permanent cure is effected, which is seldom the case when the common bougie is only used ; secondly that the application produces little 01 no pain, and that inflamma- tion, a common consequence of the application of the common bougie, does not ensue. It is not pretended by Mr. H. that every stricture is curable in this manner, but that in all cases, which have come under h : 'S care, in a very extensive practice, it has proved the most efficacious, and even in cases where it failed of effecting a cure, that it was at- tended with no bad consequences. In the application of the caustic to the second or mixed species of stricture, Mr. Home claims the merit of originality, and observes " having met with a number cf facts, from which a general principle appears to be estabiisned, chat the irritable state of a stricture is ke^t up, and even increased, by the use of the bougie, but lessen- ed and entirely destroyed by the application of lunar caustic ; 1 ana desirous to communicate my observations upon these facts, and to recommend tne use of the caustic, in many cases of irritable strict- ure, in preference to the bougie. As the use of the caustic upon this principle is I believe, entirely new, and is contrary to every no- tion that had been formed upon the subject, it will require some- thing more, than general assertion, to gain even the attention of many of my readers, still more their belief ; I shall therefore detail the circumstances, as they occurred, by which I conceive the pro- priety of this practice, to be established ; and afterwards make some observations, upon the principle on which it depends" Mi\ Home proceeds, " ray connection with Mr. Hunter, afforded me opportunities of attending to cases of stricture, in all their different sta-es ; many of tnem brought on during along residence in India, attended with great irritability, and exceeuinglyclifncu.it of cure.'' 372 OF OBSTRUCTIONS IN THE URETHRA Cb. III. One case of this kind admitted the passing of a small bougie ; but. in the course of three years, very little was gained by a steady perseverance in the use of that instrument, either in dilating the canal, or palliating the symptoms of stricture ; this made me loot upon ihe bougie as Kss efficacious, than I had always been taught to believe it. I was willing, however, to consider this as an uncommon case, de- pending more on the peculiarity of the patient's constitution, than on the nature of the disease : but I found on a particular enquiry, that several other gentiemen from India, were under circumstances nearly similar; the bougie only preventing the increase of the stricture, but being unable to dilate it beyond a certain size; and was left oft*, the stricture in less than two months returned to its' former state of contraction. What plan ought to be followed in such cases, I was then unable to determine ; but, that the bougie e aid not be depended on was evident. During this suspense, the following case came mader my care. In August, 1794, a gentleman consulted me, for some symp- toms which had been considered as indicating the presence of Gon- orrhoea; but as they did not yield to the common treatment in the usual time, he was induced to take my advice respecting the nature of is cmpiainc. In the necessary enquiry, to obtain a perfect his >ry of the case, among other things it was stated, that, nineteen years before, there was a stricture, which became very trouble- Some, and tlfet Mr. Hunter, by the desire of the patient, had appli- ed the caustic, by which the stricture was removed, and never afterwards returned. He said that he was one of the first per- sons, on whom the caustic had been used. From this account, I TYas naturally led to believe, that the stricture had gradually re- turned, and was now increased so much as to produce the present symptoms ; a discharge being almost always a symptom of stricture wnen it is much contracted : but, upon examining the canai a bougie of a full size passed on to the bladder without the smallest im- pediment. I therefore took up the case as an inflammation in the uretr.ra; and hrge doses of the balsam copaibse effected a cure. The circumstance of a stricture having been removed nineteen years before, and not returning, made a strong impression on my mind; and made me desirous to ascertain, Whether this practice couid be employed in cases of stricture if \ efrerftt, and the cure prociuced by it." equally permanent. A short lir for wards I had an opportunity of trying it in the following case. A captain in the Ease India company's service, in Sept 1794, applied to me for assistance. His complaints were, great irritation in the urethra and bladder, constant desire to make water, and an inability to v >id it, except in very small quantities. These symp- toms had been at first supposed to arise from Gonorrhoea, after- wards rendered more severe by catching coid ; but not yield- ing to the usual remedies for Gonorrhoea, they were investi- gated more minutely and a stricture was discovered in the urethra, ffne mode of treatment was now changed, and the bougie employ- ed \ but, its use aggravated all the symptoms, ana brought on so SeC. IV. FROM STRICTURES, &C. 173 great a degree of irritability on the bladder and urethra, that there -was an alarm for the patient's life which was the reason for applying for my assistance. Besides the local symptoms, this patient had those of quick pulse, white tongue, hot and dry skin, loss of appetite and total want of sleep, with frequent attacks of spasm on the bladder and ure- thra. A very small flexible gum catheter was passed, and the water drawn off, in quantity about a pint, which gave him great re- lief ; this was repeated morning and evening, to keep the bladder in as easy a state as possible ; but, in other respects he continued much the same. As the present symptoms were brought on by the use of the bougie, little good was to be expected from that instrument ; and when the urethra had been so easily irritated, and was disposed to continue in that state, there was no prospect of the bougie after- wards effecting a cure. These circumstances I explained to the patient ; and mentioned, in proof of my opinion, the case, in which so little had been effected in three years. I then proposed to him a trial of the caustic, with a view to deaden the edge of the stricture, as the only probable means of effecting a cure. The degree of irritation was already great ; I was however, led to believe, that the application of the caustic would not increase it, since by destroying the irritable part, it might les- sen, and even remove the spasmodic affection ; but if, contrary to my expectation, the irritation continued, we still should be able to draw off* the water, as the slough formed by the caustic, would pre- vent the edge of the stricture from acting, and obstructing the in- strument. The application of the caustic was upon these grounds, determined on ; and it was applied in the following manner. I passed a common bougie, nearly the size of the canal, down to the stricture, to ascertain its exact situation, and to make the canal of the urethra as open as possible. The distance was then marked upon a bougie armed with caustic, of the same size, which was conveyed down as quickly as the nature of the operation would admit. It was retained upon the stricture, with a slight degree of pressure ; at first there was no pain from the caustic, but a sore- ness from pressure j in less than a minute, a change was felt in the sensation of the part, it was at first a heat, succeeded by the burn- ing pain peculiar to caustic ; as soon as this was distinctly felt, the bougie and caustic were withdrawn, having remained in the urethra about a minute altogether. The soreness he said was entirely local, by no means severe, was unaccompanied by irritation along the canal, and he thought the uneasiness in the bladder diminished by- it. He described the pain as resembling very exactly the first symp= toms of Gonorrhoea. Tnis sensation lasted half an hour after with- drawing the bougie. The caustic was applied in the forenoon, and he passed the day more free from irritation, than he had been since the beginning of the attack, which had lasted six days. In the evening the water v/as drawn off with more ease ? than, the night beiore. He passed a 174 OF OBSTRUCTIONS IN THE URETHRA Cb. III. tolerable night, and the next day continued free from irritation. On the third day, the caustic was again applied in the forenoon ; the painful sensation was less, than on the former application, lasted a shorter time, and in an hour after the armed bougie was withdrawn, he made water freely, for the first time since the commencement of his indisposition. He said the irritation in the bladder was re- moved, and he felt very well. His appetite returned, he siept very well, and continued to void his urine with ease. In this state nothing was done till the fifth day, leaving always a day between the applications of the caustic. On this day a common sized bougie went readily into the bladder ; it was immediately withdrawn, and the cure was considered as complete ; no bougie was afterwards pass- ed, lest it might bring back an irritation upon the passage. I met this gentleman twelve months after, and he assured me, he had continued perfectly well, and I have since learned, that, in three years there has been no return. The result of this, and some other cases, induced Mr. H. to adopt it, as his general practice in strictures : He does not pretend Iiowevev, that it will answer in every case, and it is well known that in some irritable cases it is altogether inadmissable ; in gouty dis- posed persons, it has induced a fit of the gout : in persons who have been afflicted with intermittents, it has excited a return of that complaint, and both of these disorders have been brought on by the use of the caustic, in so distressful a degree, that it was impossible to repeat the remedy. As the arming of the bougie, is a matter of very great im- portance, and as the mode already described, is occasionally liable to the unpleasant accident of leaving the caustic in the urethra, we insert from Mr. Home, the process pursued by a Mr. Puss of London, in the preparation of bougies for this operation. u In forming the bougie, a piece of wire of the size of the caustic is rolled up along with it, passing into the substance for half an inch ; when the bougie is nearly finished, the wire is withdrawn, and the caustic inserted in its place ; after this the bougie is rolled again, so that the sides of the caustic become firmly cemented to the linen, by means of the composition of the bougie, and when cold cannot be separated by any force. In this way bougies are now generally armed." The caustic should not be applied oftener than once every other day, unless in very obstinate cases, in which Mr. Home observes, he has applied it daily, without detriment. The preparative bougie, or the one first passed down in order, to ascertain the seat, size and shape of the stricture, is termed by Mr. Home the soft bougie, and is made of oii, wax, and resin, in such quantities, as to render it sufficiently firm for introduction, yet yielding enough to receive an impression from the stricture into which it is passed. It should be of a light colour, that these im- pressions may be more custinctly seen. When the soft bougie passes through the stricture, by leaving it in the canal a few minutes it can be known whether the stricture is completely destroyed or only relaxed ; in the last case there is SeC IV. FROM STRICTURES, &C. 175 an impression on the side of the bougie. So necessary is the infor- mation acquired in this way, says Mi\ Home, to enable the surgeon to prosecute the cure of stricture by means of the caustic, that without it I should have been unable to pursue this mode of prac- tice. I should have wanted a sufficient degree of confidence to car- ry me on, which nothing but an accurate knowledge of what had been already done, couid ha\e given, and, in no other way, is that to be acquired. We offer these as a few of the more important practical remarks, and directions, contained in Mr. Home's Treatise on Strictures, &c. It is however but a very imperfect hint, and we cannot leave his work without recommending it to the most serious and attentive perusal of every surgeon ; being perfectly satisfied that no abridg- ment of it can clo justice either to the work itself or its author. Mr. Whately, another surgeon, to whom we are much indebted for many valuable communications on different subjects, has also furnished us with a treatise on strictures, in which he maintains, that they are not merely a contraction of the fibres of the urethra, but actually diseased portions of the membrane lining that canal, with a continued disposition to increased contraction, and concludes that tire caustic is a remedy calculated to remove the diseased affec- tion, and to dilate the contracted part, effecting a perfect cure, without the troublesome and painful inconvenience of wearing a Mr Whately does not, however, use the nitrate of silver as re- comm ended by Mr. Home, but states, that he has discovered in the kali purum, a most efficacious and valuable substitute, for that pai tin application ; indeed he considers it more efficacious as well as less painful and hazardous. When it is determined that the use of this remedy is admissible, the following are a summary of his directions for its application, viz " Put a small quantity of kali purum upon a piece of strong paper, and break the bit of caus- tic with a hammer into small pieces of about the size of large and small pins' neads. In doing this, care should be taken not to reclece it to powder. Thus broken, it should be kept for use in a phial, closed with a ground stopper. The bougie should have a proper degree of curvature given to it, by drawing it several times between the finger and thumb of the left hand. Mr. Wnately next acquaints us, that before the caustic is insert- ed into the bougie, it is necessary to ascertain the exact distance of the stricture, (to whica the caustic is to be applied) from the ex- tremity of the penis. For this purpose, the bougie, which should be just large enough to enter the stricture with some degree of tLhtness, ought to be gently introduced into the urethra ; and when its point stops at the stricture, which it almost always does, before it will enter it, a notch is to be made with the finger-nail, on the upper or curved portion of the bougie, on the outside of the urethra, exactly half an inch from the extremity of the penis. Wnen the bougie is withdrawn, a small hole, about the sixteenth part of an inch deep, should be made at the extremity of its round- ed end. A iaige biaiiKet-pin two inches and a halt in length, with 176 OF OBSTRUCTIONS IN THE URETHRA Ch. III. the head struck off, will answer the purpose ; the hole being made with the point of the pin. The extremity of the bougie should then be made perfectly smooth with the finger and thumb, taking care, that, in doing this, the hole in its centre be not closed. Some of the broken caustic should then be put on a piece of writing paper, and a piece less in size, than the smallest pin's head, should be selected ; the particle, indeed, says Mr. Whately, can- not be too small for the first application. Let this be inserted into the hole of the bougie with a pocket-knife, spatula, or some such instrument ; and pushed down into it with the blunt end of the pin, so as to make the caustic sink a very little below the margin of the hole. To prevent the kali from coming out, the hole should then be contracted a little with the finger, and the remaining vacancy in it is to be filled with hog's lard. This last substance (continues Mr. Whately) will prevent the caustic from acting on the sound part of the urethra, as the bougie passes to the stricture. When the bougie is quite prepared, let it be first oiled, and immediately afterwards introduced, by a very gentle motion, with the curvature upwards, as far as the anterior part of the stricture, upon which the caustic is to be applied. In doing this, the end of the bougie, that is held by the finger and thumb, should be a good deal inclin- ed towards the abdomen, on the first introduction of the instru- ment, in order to preserve its curvature. After it has passed about five inches, this end should be gradually brought downwards, as the bougie passes on, till it forms a right angle with the body. The bougie is known to have arrived at the stricture by the resist- ance made to its progress. As soon as the bougie has reached the anterior part of the stric- ture, it should rest there for a few seconds, that the caustic may begin to dissolve. It should then be pushed very gently forward, abouL one eighth of an inch ; after which, there should be another pause, for a second or two. The bougie should then be carried for- ward in the same gentle manner, till it has got through the stric- ture. The sense of feeling will generally inform the operator when the point of the bougie has proceeded so far ; but, the notch in the bougie is to be an additional guide, by becoming very near the orifice of the urethra, when the end of the instrument has just got through the stricture. The bougie should now be immediately withdrawn by a very gentle motion to the part, at which it was first made to rest awhile. Then it should be very slowly passed through the stricture a second time ; but, without letting the bougie stop in its passage. If the patient complain of pain, or be faint, the bougie should be imme- diately withdrawn ; but, if these effects are not produced, we may repeat the operation of passing and withdrawing the bougie through the stricture once or twice more, before we finish the operation, which will take up, in the whole, about two minutes. The first application of the kali purum, in this manner, gives, according to Mr. Whately's account, a very little pain. A slight scalding in making water, and a trifling discharge, during the first day or two, however, are commonly produced. SeC. IT. FROM STRICTURES, &C* 177 At the end of seven clays- the application of the caustic is to bs repeated in the same manner. When the first application has en- larged the aperture of the stricture, which may be known by passing- a bougie through it, of the sarhe size as that by which the caustic was conveyed, the bougie used in the second operation, should be a size larger, than the one, used in the first; but it must not be too large to pass through the stricture. If the patient had no pain on the first application, the bit of kali purum may also be trivially lar- ger. At the end of seven days more, the armed bougie should be introduced a third time. At this, and all future applications, the bougie should be increased in size, in proportion as the aperture in the stricture becomes dilated. The quantity of caustic, however, is never to be increased in a ratio to the size of the bougie. In no cases whatever, does Mr. Whately apply more of the kali purum at a time, than a piece about the size of a common pin's head. Twelve bits of the largest size, which this gentleman ever Uses.) "Weigh one grain. When there are several strictures, the kali purum should be generally applied to only one at a time. An interval of seven days is what Mr. Whately generally allows to elapse between the application of the caustic. The rule, how- ever, may now and then be deviated from ; but the kali purum ought never to be re-applied, till the action of the last application has completely ceased. In a few instances, the interval may only be five days ; in some others, it may be eight, nine, or even a lon° ger space. In the above method of using the kali purum, Mr. Whately re- presents, that this substance is equally diffused over every part of the strictUred surface, and only abrades the membrane of the stric- ture, without producing a slough. The degree of this abrasion, he says, may be increased, or lessened, as circumstances dictate, by pa\ing attention to the quantity of the caustic.'* Mr. Charles Bell, another author to whom we owe much both for the variety and value of his publications, has lately presentect Us with some important observations on the subject of strictures" in his « Letters concerning the Diseases of the Urethra." The varieties of stricture enumerated by this author are con- siderably greater than those of former writers. He divides then* into simple (permanent) stricture, ulcerated stricture, stricture from inflamed lacunse, stricture near the orifice of the urethra, dilatable stricture, spasmodic stricture, stricture with stone in the- urethra, callous strictures, and narrowness of the urethra with, wasting of the spongy body. , Of the first, or simple stricture^ Mr. Bell observes, that it frequently has the appearance described by Mr. Hunter, as if a thread were tied round the urethra and a& if there were a membrane tucked and hanging across the canal, " In introducing the bougie or probe, we feel the point start over the stricture so as to convey to us precisely this notion." When this stricture, is newly formed and the inflammation continues, there is around the firm line of it, a thickened baseband if iheia* 23 178 OF OBSTRUCTIONS TN THE URETHRA r Cb. III. flammation occurs as a consequence, Mr. Bell observes, that not only the stricture will increase, but the passage is apt to be further choaked by a crust of coagulable lymph, which forms behind. This disease is ascertained by the use of the soft bougie and the introduction of the urethra sound,* (see plates J and is cured by the operation of the caustic. Mr. Bell approves throughout, of Mr. Home's practice in tnis variety As to ulcerated stricture, Mr. Bell observes, that he has met with it on dissection. ' k I have found (says he) a firm stricture, in the centre of which there was an excavation by ulceration, and we must conclude that either the stricture must have ulcerated, or the original uicer must have hardened, so as to condense the sur- rounding cellular substance, and produces a very firm cicatrix and consequent stricture." An ihllamed lacuna sometimes produces the symptoms and sen- sations of a stricture, but we muy often ascertain the nature of this case by examining with the finger on the outside. We feel a small hard body, like a seed or pea within, or rather attached to, the canal, and a bougie on being introduced, will be flattened or* one side. To remove this complaint, Mr. Bell prefers the alka- line caustic used by Mr. Whateiy. The stricture near the orifice of the urethra is generally of a grey or ash colour, and hard as cartilage. Mr. Bell prefers the frequent use of the bougie to the caustic in this variety, which latter produces great distress and no ultimate benefit. He has al- so used the knife, — by making two transverse incisions upon it. The consideration of stricture from stone in the urethra does not properiy belong to this place. For the removal of callosities, which Mr. Bell supposes to originate from high inflammation, he prefers the alkaline to the lunar caustic, as the latter does not kill the part to which it is applied, thus producing a slough, and laying the foundation for increased obstruction, but only subdues the sen- sibility of the part and facilitates the operation of dilatation by the bougie. A narrowness of the canal attended with wasting of the spongy body, may be removed by the occasional use of the bougie. Mr. Bell observes that stricture and inflammation in any part of the urethra are apt to produce inflammation and irritation near the neck of the bladder and for the removal of these, he advises the usu- al remedies, viz. leeches, fomentations, mild purges, and the use of the bougie or urethra sound On dissection, where persons have died, in consequence of stricture and an acute attack of inflamma- tion, Mr. Beil has found, the whole extent of the urethra inflamed, but chiefly that portion which lay between the stricture and the blad- der, and a firm coat of coagulabie lymph is generally depositee', on the inflamed surface of the urethra. Cavities were found on the side of the canal where it passes into the prostate and sometimes a minute crop of soft warts growing from the membrane of the ure- * Mr. Bell prefers the previous introduction of the Urethra Sound to that of the Bougie, as the former does not produce that general irritation along" the whole canal of the. urethra, which is caused in many cases by the latter. Sec. IV. FROM STRICTURES, &C. 179 thra were found in the vicinity of a stricture. The bladder, if the 'disease be of long* standing, is thickened in its coats ; and some- times much increased in size. An enlargement of the ureters and kidneys is a frequent occurrence. To the subjects of dilatable and spasmodic strictures, Mr. Bell has devoted separate letters. We proceed to an analysis of them. The author considers the dilatable stricture as a consequence of severe Gonorrhoea, in which the directions of the medical atten- dant have not been properly attended to, and although the discharge has sometimes disappeared, yet occasionally the symptoms return. A heat of urine often occurs, with a diminution of the stream and a frequent call for evacuation. Any irregularities with women or wine, cause an increase of the symptoms with a considerable dis- charge from the urethra On introducing the bougie, there is se- vere pain, and the urethra is unusually sensible, but if allowed to pass, a resistance and a grasping of the bougie as in common stric- ture will be experienced. The urethra sound may be passed with more ease, but there is considerable uneasiness when it touches the diseased part. The urethra in this complaint is less rigid and firm, but the dilatable stricture is not unfrequently combined with an unelastic and confirmed stricture. Mr. Beil observes that the dis- ease often continues for a length of time in this state, the symptoms neither increasing or diminishing in severity. The cause he consid- ers to be a diminution of the natural elasticity of the urethra, ori- ginating from the previous inflammation of Gonorrhoea, which prevents a due distention of the part when the push of urine is made or the bougie is introduced. In speaking of the method of cure, Mr. Beh opposes the use of the bougie and remarks that the pressure on the inflamed part by this instrument and the consequent stretching of the membrane, causes increased pain and soreness, but adds, however, that the peculiar irritability of its former mor- bid state is diminished. " The caustic is a milder and more effec- tual remedy." In using the kali liurum, as recommended by Mr. Wnateiy, he found much immediate benefit, such as a freer dis- charge of urine and less disorder in the functions of the parts, but soon observed that it made little impression on the stricture, only destroying the attendant irritability without removing the disease— By applying the lunar caustic in the same way that he had clone the kali purum, viz. by drilling a hole in one of the ball probes (see plates J and loading it with a small portion, he found that the irrita- bility which is frequently produced by it was avoided and a cure ef- fected. The subject of Spasmodic Stricture is introduced by an endeavour to prove that no such disease can exist. The cause assigned for this opinion is that the canal of the urethra, anterior to the muscles, is destitute of muscular power, and experiments on the living sub- ject ; dissections of the part of the urethra in the neighbourhood of the stricture, where no muscular fibres were discerned ; and the proposition that stricture is a callous part, incapabie of contraction an4 relaxation are adduced as the proofs. ISO ©P OBSTRUCTIONS IN THE URETHRA Cll. Ill, The true nature and cause of spasm attending strictures in the lirethra, Mr. Bell supposes to depend on the following changes for a healthy state of the urethra and bladder. He premises by observe iiis, that the sole origin of all strictures is inflammation, and of these, most commonly, the Gonorrhceal inflammation. The gleety dis*- charge which follows this disease, is not the effect of mere relaxa- tion, allowing too profuse a discharge, but the vestiges of infiam- inflation in a milder and more chronic form. If this state of the parts t>e permitted to continue, a firm stricture will in the end be formed and the degree and firmness of the contraction will depend on the length of time and the frequency of the occasional increase of the Irritation, pain and discharge. The spasm am 1 difficult flow of urine attending on ail the stages of stricture is attributed by Mr. Beli to an over action and irritability of the bladder, and the muscles con- tiguous to the bladder, prostate gland, and the urethra, antagonize lng with the muscular coat of the bladder, and thus producing the various states of contraction of the bladder and relaxation of the, vrethra, or the relaxation of the urethra and quiescence of the blad- der. The introduction of the bougie causes a distention of the mus- cles and a consequent contraction of the bladder, with a flow of urine. A mutual disorder of these different organs will therefore account for the above phenomena, Another and more frequent cause of spasm in the urethra and neck of the bladder, Mr. Bell states to bean increased sensibility. This accompanies inflammation and where the stricture is exqui- sitely sensible, there the functions of the muscles will be deranged. Contraction, spasm and obstruction, follow this disorder of the mus- cles surrounding the stricture, provided it be seated within five inches of the bladder. In the application of lunar caustic to the? spasmodic stricture, the sensibility will be deadened and the patient will feel relieved. But in many cases, after a few days the slough Is thrown off, and a spasm and irritability greater than before fakes place. To prevent the caustic from sloughing the parts, it was in- troduced at the end of a soft bougie, so that it could affect the stric- ture only in solution and not in sufficient strength to produce the former effect, whilst repeated introductions of the bougie, but for a space of time not exceeding two minutes, removed the disposi- tion to spasm. The following case by Mr. Samuel Cooper, author of several approved surgical works, is copied as an instance of the. conse- quences which may occur from the application of the lunar caus- tic. It is extracted from the Edinburgh Med. and Surg. Journal, for July 1S09, ami contains that gentleman's opinion on the sub- ject of armed bougies^ to the correctness of which we fully sub- scribe, V Most practitioners in surgery, who are in the habit of treating strictures on the plan recommended by Mr. Home, must have had repeated occasion to observe a troublesome degree of bleeding, after applying the caustic to the disease. Mr. Home, himself, has. related several such instances., and I hay© in my recollection a few Sec. IV. FROM STRICTURES, &C. 1 SI which have fallen under my own observation. The cases which have been published by the above gentleman, only interrupted the pro* stress of the treatment for a short time ; about a week afterwards, the use of the armed bougie was generally resumed, and a cure ul- timately accomplished. Of late, however, I have met with an example, in which the bleeding- was so profuse, and productive of such debility, that it would be the height of imprudence ever to subject this particular patient again to another haemorrhage of the same kind. A medical gentleman, from the West-Indies, consulted me, a- bout a fortnight ago, on account of a discharge from the urethra, and a fluctuating, circumscribed, prominent, and painful swelling in the perinaeum. As the feel of the tumor clearly indicated the presence of a fluid, I made an opening with a lancet, and gave vent to about a table-spoonful of purulent matter, apparently quite unmixed with urine. A linseed poultice, and a T bandage were applied. At the next visit, I learnt, that at the time of making water, a part of the urine was discharged from the wound in the perinaeum ; and, on attempting to introduce a flexible gum catheter into the bladder, an obstruction was discovered in the urethra, about six inches from the orifice in the glans penis. The following morning a trial was made to introduce a small -sized bougie, through the stricture, but this could not be done ; and, the day afterwards, it was determined to apply an armed bougie, which "was performed in the manner dictated by Mr. Home Some little degree >f bleeding ensued, and the pain was much less than the gentleman had apprehended. After waiting one or more days, the caustic was again passed down to the stricture, kept applied about a minute, and then with- drawn some little time to see whether the haemorrhage would stop of itself, and finding that it still continued in a very copious man- ner, I dipped a large towel in cold water, and put it over the penis and perinaeum. Some abatement in the bleeding now took place, and a clot of biood stopping up the mouth of the urethra, I was induced to hope the haemorrhage would soon cease alto* gether. In this expectation, however, I was greatly disappointed ; for, on my return home in the afternoon, I found a letter from one of" my patient's relations, desiring my instant attendance, as he had almost blecl to death. The note having been brought to my house when I was out, Mr Cline was sent for, who appeased, in a veiy material degree, the fears which had disturbed both the patient and his friends. When I entered the room, about four o'clock in the afternoon, I found several towels, all completely soaked in blood, a great part of the bedding wet through with the same, and a large bason, such as is used for washing one's hands, neaily full of coagu- Jated blood. Were I to guess the quantity iost, I should certainly not estimace it at less than five pints. The gentleman was so re- duced, that the. mere exertion of turning in bed would make him. 182 OP OBSTRUCTIONS ITS THE URETHRA, &C. 61). HI. faint ; and the great loss of blood he had sustained, considered with Ms general appearance, made me seriously apprehensive of the consequences. The bleeding began about a quarter before eleven in the forenoon, and continued, more or less, till eight in the evening. The case seems to me worthy of being recorded, on account €f its exhibiting an example, in which the quantity of blood lost was unusually great, and in which the effects of the haemorrhage on the constitution were such, as to forbid exposing the patient again to the same accident j lest it should bring on fatal conse- quences. The gentleman's health has been already so much re- duced, that both Mr. Cline and Mr. Abernethy, who have been consulted, recommend no attempt to be made to remove the stric- ture, till the state of the constitution has been improved. Having always been an advocate for Mr. Home's plan of treat- ing strictures, no one can suspect me of publishing this case with a view of bringing the method into disrepute. I still give a general preference to the employment of armed bougies, because they seem to me most efficacious ; and the above case is the only one in which the fear of haemorrhage has ever induced me to abandon this mode of treatment." In the preceding observations, we have endeavoured to give a faithful account of the cases, and arguments adduced by the most distinguished of those writers, who in opposition to Mi.B ja- inin Bell, Howard and ©tlaers, prefer the application of bougies armed with caustic, to the use of common bougies. On a s/dbject where such diversity of opinion exists, and so much mutual iii-will has been produced, we hardly dare offer any thing more than a few observations on the various points under discussion, and we pre- sent these rather as suggestions to assist the inexperienced, than as matured remarks for tho^e who have seen and reflected on the dis- ease. We consider in the first place, the observations of Mr. Charles Bell and others on the anatomical structure of the urethra, as for the most part conclusive, proving that the canal of the ure- thra at its anterior part is destitute of muscular fibres ; and indeed most of his remarks on this subject and on the mutual influence of the bladder and urethra, are highly important. His assertion how- ever, that no disease like spasmodic stricture exists, whilst he al- lows that spasm is a common and indeed inseperable attendant on this species, is merely stating the difficulty in other words, and the surgeon has still to contend against this troublesome symptom. — The use of the common bougie ought in all cases to precede the application of the caustic, and as a general rule, it must be ob- served, that the latter is improper, where the former can be passed without much difficulty. Mr. Hunter himself allows the common bougie to be adequate to the cure, except where the permanent stricture is so complete as not to admit the point of one, and to this may be added the case of an inability to introduce a full siz- ed bougie after a persevering trial with those of inferior magni- tude. On the question of permanency of cure, Mr. Home in his Sec. T. OP DERANGED SENSATIONS, &C. 183 "Work on strictures, mentions that in cures affected by caustic, there is often a return of this disease ; but as a general observation it is a more certain remedy than the common bougie, which is not unfrequently a palliative only. The decided superiority of lu- nar cuustic over kali purum, in removing the diseased part of the canal and affecting a certain cure, is so well settled by the concur- rent testimony of practitioners, that «\ve need not dilate on it.— As to the danger from hemorrhage, a sufficient answer is found in the fact that it may be induced as well by the simple as the arm- ed bougie. We conclude by again refering the reader to Mr. Home's work, in which he will find the subject better treated than in any other production of the present day. A deliberate and able statement of the advantages of the common bougie is con- tained in the Appendix to Mr. Howard's work on the Venerea! Disease. Ed, SECT. V. Of deranged Sensations in the Bladder, Urethra and contiguous Parts. ON the running and other leading symptoms of Gonorrhoea becoming moderate, all the others usually abate, and the patient, for the most part, is perfectly well, soon after the discharge leaves him. This, however, is by no means universally the case, for it sometimes happens that a good deal of distress remains long after the discharge is completely remov- ed, and as the symptoms which take place in this state of the disease are of a nature which cannot be referred to any particular head, I have judged it proper to speak of them in a separate section. Without any fixed pain, a patient, who, from the discharge and other symptoms of Gonorrhoea leaving him, has cause to imagine that his cure is completed, will be suddenly seized with uneasiness over his loins ; painful feelings over all the region of the bladder, particularly about the neck of it ; sense of weariness on the kidneys which sometimes become much pain- ed ; a considerable degree of uneasiness over the whole J 84 OP DERANGED SENSATIONS Ch. lit. course of the urethra, particularly about the glans, and a painful sensations of rolling, and other unusual motions, in the testicles. In some cases these symptoms, which seem to be Confined to the organs of urine and generation, take place either in whole, or in part by themselves. At other times they are conjoined with affections of other parts, chiefly with those of the stomach and alimentary canal. In one case 'they were accompanied with regular attacks of cholic, which had all the appearance, from the violent degree of pain which occurred, of proceed- ing from inflammation, but which always subsided im- mediately on the symptoms being removed by which it seemed to be induced. In different instances I have known sickness and vomiting succeed to that painful uneasiness to which patients in this situation are sometimes liable in the kidneys. Distressful feelings frequently occur in the rectum which give cause to suspect, in some instances, that they proceed from piles, a*id in others from tumours form- ing in the end of the gut. A painful tenesmus often accompanies this set of symptoms. In some, almost every symptom occurs which usual- ly takes place in stone in the bladder. A dull, heavy pain is f^H at the neck of the bladder, which spreads along the urethra, and fixes upon the glans. The pa- tient is distressed with frequent desire to pass water, ^nc\ in passing it, it often stops suddenly When coming off in a full stream. In a few cases symptoms of paralysis occur, both in the bladder and urethra. The patient at one time find- ing it difficult, or even impossible, to force the urine: out of the bladder, while at others, it runs off in drops, without his being able to retain if. These unequal states of the power of passing and retaining the urine will sometimes occur alternately, several times in the course of the same (lay ; while at times one of them will continue for several days togeth- er, and at last will disappear suddenly, after hrving re- sisted every remedy that had been employed for it, SeC. Y* Itf THE BLADDER, &C 185 It will readily be supposed however, that all of these symptoms cannot probably occur at the same time in the same patient, but every practitioner must have met with all of them in different patients^ At the same time that they take place with som^ va- riety, they likewise occur in very different decrees* In some they are so slight as merely to excite some tri- fling degree of uneasiness, and so transient, that V ,s ^y come and go frequently in the course of the sane day ; while, in others, they are so fixed and permanent that the patient remains in a state of constant distress, and experiences such a degree of it as he is scarcely able to support* In women, the bladder, kidneys, and abdominal viV Cera, are equally liable to be affected as in men ; and they are also apt to be distressed with uneasiness about the neck of the womb, and bearing-down pains, stretch- ing to the thighs* Even in the most firm-minded people the symptoms I have described prove frequently very distressful ; but where the mind is weak, and the imagination easily af- fected, they arrive in some instances at the most alarm- ing height. In whatever degree they may appear, they* are attributed to the preceding disease having either been improperly treated or not completely cured ; and when tliis occurs in a mind prone to fears and anxiety, the distress which they are apt to excite, is in so ne instances so great, as can scarcely from such a cause be supposed to exist. Whether a course of mercury be advisable or not, the patient is never satisfied till this medicine be prescribed ; for he is always afraid that his constitution will be ruined if mercury be omitted. If this proves successful, or if he gets well when under it, he remains completely satisfied; but when tins does not happen, as is the case in most in- stances, he then believes that he is incurable, and that hi& situation is desperate. Every variety of nostrum is now had recourse to ; by the effect of these, and still more by the agony of mind under which he labours, his constitution at last begins to suffer* he gradually 186 OF DERANGED SENSATIONS Ch. III. becomes weaker and emaciated ; and if his life is pro- longed, it is almost always a scene of anxious inquie- ti.de and distress. The cause of all or any of these symptoms it is of- ten impossible to explain. Were they to happen.chief- ly wl ere the previous inflammation has run high, or where tie patient, when under cure, had been partic- ularly apt to indulge in venery, excess of wine, or bodily fatigue, one or other of these causes would lend to account for them. But this is by no means the case. They are met with as frequently where the dis- ease has been of a mild nature, and where it was cur- ed in an easy manner, as where the symptoms have been severe and obstinate. Where this takes place we are apt to suppose that they are mostly,, if not en- tirely, of an imaginary nature, and to treat them ac- cordingly. This, to a certain decree, may often be proper, as it may fortify the mind of the patient against those ill grounded fears to which he might oth- erwise be exposed; but we are not to suppose that symptoms of this kind are always ideal, merely from our not being able to account for them, or from the previous Gonorrhoea having been of such a mild na- ture as we may imagine ought not to have produced them. J met with instances of this, where the previous disease was exceedingly mild, and where no obvious affection of the parts was perceptible, and yet the vio- lence of the distress in such a degree as kept the pa- tients in a state of constant misery. Many of the symptoms enumerated above are sucli as are produced by tumours about the neck of the blad- der, particularly by affections of the prostate gland, and by a contracted state of the bladder itself. In such cases, the cause of the disease is at once render- ed obvious by examination with the finger in ano ; but at present we are supposing that no organic affection can be discovered either inwardly or outwardly, an occurrence by no means uncommon, and in which I therefore conclude that the symptoms proceed from a deranged state of the nerves, produced by the previous SeC. V. IN THE BLADDER, &C. 187 affection of the urethra. I have accordingly arrang- ed all of them under one general head of Deranged Sensations, nor is there cause, from the nature of the remedies found to prove most successful in removing them, to treat of them separately, nearly the same general treatment being found to answer in all of them. Before proceeding to enumerate the remedies for af- fections of this kind, I may observe that although we cannot in any case say positively what will accomplish a cure, I can with certainty say what will not answer, I have already remarked, thai patients, in this situa- tion, are apt to suspect that their symptoms proceed fro n the previous disease having been improperly treated? This leads them to imagine that a latent poi- son is still lurking in the constitution, and mercury be- ing the only certain antidote for the venereal poison, they always ins st upon this being prescribed. Some practitioners still entertaining the opinion of Gonor- rhoea and Lues Venerea proceeding from the same in- fection, consider it necessary to prescribe mercury for all the consequences of each of them, while others are readily prevailed upon, by the solicitation of their pa- tients, to permit what they may suppose it would not be in their power to prevent. But from all the expe- rience which I have had of it, I am clearly of opinion tuat no advantage is ever derived from it, while, in a great proportion of cases, it evidently does harm. By relaxing the constitution, it renders it much more irri- table than it was before, and thus tends to aggravate all such symptoms as those we are now considering. Trie remedies upon which we chiefly depend are, blood-letting, opiates, warm bathing, blisters, cicuta, hy- oscyamus, electricity, Jesuit's bark, and cold bathing. When the constitution is already much reduced and debilitated, blood-letting must necessarily be inadmissi- ble ; but whenever plethora takes place, nothing proves more useful than blood-letting, both general and local, particularly the discharge of blood from the perineum, and parts contiguous to the anus, by the application of leeches. In such circumstances it removes or lessens irritability with more certainty than any other remedy. 18S OP DERANGED SENSATIONS Ch. III. Even where there has been cause to suspect a tenden- cy to para'ysis in the bladder and contiguous parts, leeches applied as near as possible to the seat of the disease have proved serviceable ; nor need we ever hesitate in advising them where the patient is not much emaciated. But the remedy which, in all affections of this kind, proves most universally useful is opium. Il not only soolhes and allays the present distress, but when, by a well judged, timeous application of il, we can, for a week or two together, prevent the accession of pain, we in this manner often accomplish a cure. Ii answers the purpose whether it be given by the mouth or in cl)sters, but it proves always most eff'ec- tuabwhen given in sufficient doses by the anus. The exier nal application of laudanum, and of arm- dvne balsam, in some cases affords relief, particularly when conjoined with aether. In those deranged sensa- tions which sometimes occur in the perineum and about the neck of the bladder, immediate relief is of- ten obtained by rubbing the parts affected with a mix- tine of warm laudanum and aether ; and I have known the suppression of urine, which occurs from this cause, relieved in the same manner. When opiates fail in procuring relief, or when they disagree with the patient, the semicupium sometimes succeeds. Warm fomentations applied to the perin- eum, and over the loins, often prove useful ; and the steams of warm vinegar, conveyed with attention to the parts affected, have likewise been used with ad- vantage. The best article we can employ in such ca- ses for fomentations is a strong decoction of the heads of poppies. Blisters, in all such affections, are perhaps the most effectual of all our external applications. It is chief- ly, however, where the urethra seems to be the seat of the disease that they prove useful, and where the neck of the bladder is affected with such a degree of weakness as prevents the urine from being retained by it. In the former, blisters act with most advantage "when applied to the perineum, and in the latter they should be, applied to the loins. The most distressful SeC. T. IN THE "BLADDER, &C. 189 sensations produced by this cause, and which for ma- nv years have obstinately resisted every other remedy, have, in some instances, been removed by the appli- cation of a blister to the perineum. In some cases one proves sufficient ; but in others they require to be re- peated once and again before all the symptoms disap- pear. Upon the same principle with blisters, exciting a return of the running after it has stopped, or after it has been diminished in quantity, has at times been productive of some benefit. This may be done by fo- menting the penis and perineum with warm water, the application of warm poultices to the perineum, and by a cautious use of bougies. The practice was probably- suggested by symptoms of this kind having in some instances been removed by the, patient getting a fresh attack of Gonorrhoea from a new infection, different cases of which f have met with. In all such instances, where the inflammation recent- ly induced is considerable, the previous symptoms are either much diminished in violence, or entirely remov- ed. This would lead to the practice of exciting an in- flamed state of the parts in a considerable degree, and which bouaies will never fail to do, if covered with oil of turpentine, with a small quantity of common resin melted in it; but as it is obvious that much harm would ensue from this practice being carried any great lei gth, it ought to be managed in every instance with the greatest delicacy and attention. It may be proper to remark, that it proves chiefly useful where the disease is confined to the urethra ; al- though, in some cases, it has succeeded even where the bladder and kidneys have been affected. Where the urine in such cases passes off involunta- rily, blisters, we have said, answer with most certain- ty when applied to the loins. This probably proceeds, from the disease in these instances arising, for the most part, from an affection of the bladder itself; but where it proceeds, as it may sometimes do, from a tendency to paralysis in the urethra and muscles connected with 190 OF DERANGED SENSATIONS Ch. IIT. it, blisters will prove most useful when applied to the perineum. Where the urine passes off in this manner, balsam of copaiba, and other astringent balsams, are usually given. The)' are supposed to act chiefly by restoring the tone of such parts as appear to be relaxed and weakened, and which it is imagined they must do, from their hav- ing a peculiar tendency to pass off by the organs of mine. In like manner the internal use of cantharides is prescribed, from an idea of this symptom depend- ing, in every instance, on a loss of tone in the parts af- fected, and from our knowing, that in most cases, can- tharides proves a powerful stimulus both to the kid- ne) s and bladder. All of these balsams, as well as the common turpen- tines, which are not essentially different, may in all such cases be used with safety. In some instances they may perhaps prove useful, and I do not imagine they will ever do harm. This, however, cannot be sail of the internal use of cantharides. In large quantities they act as a poison : and even where managed with caution, the principle of the practice seems, in such cases as we are now speaking of, to be doubtful ; for as there is cause to suppose that the disease proceeds more frequently from too much irritability about the neck of the bladder and urethra, than from any defi- ciency of tone, there is reason to fear, that by increas- ing the sensibility of the parts affected, they would in many instances be more apt to do harm than good. It is therefore proper, previous to the internal exhibition of cantharides, to determine with accuracy whether the disease proceeds from real weakness or morbid ir- ritability. In the one case they may sometimes prove useful ; in the other they will be apt to add to the vio- lence of the disease. Cicuta has been frequently prescribed here ; and when given to such extent as to act as an anodyne, it may sometimes prove useful. Upon the same principle, hyoscyamus may with propriety be prescribed ; but we have no reason to suppose that either of these arti- cles act in any manner in curing the disease. As no Sec. V. IN THE BLADDER, &C. 191 organic affection appears to take place here, they can- not act by dissolving hard or enlarged parts. Any ad- vantage derived from them will therefore be nearly in proportion to the anodv ne effects which occur from them ; and in this view, they may prove useful when opiates disagree with the stomach, as in such circum- stances it is of consequence to have it in our power to employ remedies of a similar operation. Electricity has now and then given a temporary re- lief to symptoms of this kind. It should be exhibited in the form of sparks drawn from the parts chiefly affected, particularly from the perineum, and parts most contiguous to the ne< k of the bladder. It is proper however, to remark, that the same ob- servations are applicable in advising electricity that were made upon the internal exhibition of cantharides. Both of these remedies, as well as the application of blisters to the loins, have been chiefly prescribed, where in affections of this nature, the urine passes off invol- untarily, and they are advised upon the idea of this symptom proceeding from paralysis of the neck of the bladder. But as there is much cause to imagine that the frequent discharge of urine, which patients in this situation are sometimes distressed with, proceeds more from irritability in the neck of the bladder than from real weakness, there is reason to think that electricity, by increasing the sensibility of the part affected, and which, in many instances, it evidently does, will rath- er tend to aggravate the complaint. Blisters, whether applied to the loins or perineum., may prove useful, not merely by the discharge which they excite, but by the irritation which they produce upon the skin. There is nothing more certain than our being often able to remove pain and irritability from one part by exciting it in others. Of this we have frequent proofs in the application of blisters and other stimulants, in deep-seated pain in the side, where the distress is otten removed as soon as the skin becomes warm and uneasy, and long before any vesications are produced. Sinapisms applied to the feet, have, in some instances, removed head-ache when every other 192 OF DERANGED SENSATIONS Cb. IM. remedy has failed. In like manner blisters seem to op- erate when applied to the perineum, for the removal of those sensations to which patients in this situation: are someti es liable. But electricity, as well as the internal use of cantharidcs, by tending to irritate the very parts in which the disease is seated, seem often to increase the violence of the symptom they were meant to rem* ve. By a due perseverance in the use of one or other of these remedies we commonly succeed in lessening of even in removing the violence of the distress; but as the symptoms are apt to recur, even after the patient considers himself as well, it becomes an object of much importance to obviate this. For this purpose, nothing proves so effectual as Peruvian bark and cold bathing. A free exhibition of the bark should therefore be pre- scribed, as soon as the pain and other symptoms have begun to diminish, and sea-bathing should be advised whenever it can be obtained. When this cannot be procured, cold water should be applied locally, both to the perineum and loins. Some advantage is derived from the parts being bathed with it, but it proves more effectual when forcibly dashed upon them. An involuntary discharge of urine, which we have already had occasion to speak of, proves always trou- blesome; but the distress which it excites, is trifling when compared with what arises from the patient not being able to expel it. Even without any inflamma- tion, and where no cause of obstruction can be dis- covered in the urethra, a patient will sometimes find it impossible to pass a single drop. This, no doubt, oc- curs frequently from other causes; but every now and then we meet with it as an evident consequence of ir- ritability in the parts chiefly affected in this disease. All the remedies we have already advised will be equally applicable in tiie treatment of this symptom* as for the removal of any of the others. Opiates* however, and warm bathing, prove chiefly useful ; but wl en relief is not soon obtained, it becomes necessary to draw the water off with a catheter'; and, as much harm is apt to ensue horn this being long delayed, it Sec. V* iN THE BLADDER, &X. 393 ought to be advised as soon as the bladder appears to be sensibly distended. In some cases the introduction of a bougie will prove effectual ; and as this gives less pain and irritation than the passing of a catheter, it ought in the first instance, always to be preferred. One of the largest tSiat will easily pass should be made use of; and, after allowing it to remain in the bladder for a few minutes, the pa- tient should be desired to pass his water instantly on the bougie being withdrawn. This ought not to be done wilh much force and pressure, otherwise the neck of the bladder and urethra are apt to contract instant- ly on the bougie being taken out ; while the whole will pass completely off if it can be made to flow easily at first, along with the bougie. When this our intention in employing bougies is frustrated, we are under the necessity of employing the catheter; and, as it is of much importance, in all such cases, to prevent irritation as far as it can possibly be done, catheters of resina elastica should be employ- ed, instead of the common instrument of silver. It not only passes more easily, but when any difficulty occurs in getting it into the bladder, it may, in some instan- ces, be proper to allow it to remain for a day or two together, which can never, with any propriety, be done with catheters of silver. The practice of leaving catheters in the bladder is spoken of by some with much ease, and they advise it whenever any permanent stoppage occurs to the urine ; but I have in different instances seen so much mischief produced by it, that it is a measure I never advise but where much pain and difficulty occurs in the introduc- tion of a catheter. In most instances, more pain is ex- perienced from the instrument being allowed to remain in the bladder, than ever occurs from its being fre- quently passed. Besides the irritation, which even the smoothest and softest instrument of this kind excites, they are apt to prove hurtful by incrustations of calcu- lous matter forming upon them, in consequence of de- positions from the urine. There are few people whose urine is so free of this kind of matter as to prevent a 25 194 OF SWELLINGS OF THE TESTICLES. Ch. III. catheter, inserted into the bladder, from becoming rough with it in a very short space of time. This prac- tice, therefore, ought never to be adopted but where the greatest difficulty is experienced in introducing the ca- theter. SECT. VI. Of Swellings of the Testicles. A Swelling of one of the Testis is a very frequent oc- currence in Gonorrhoea. From the resemblance which it bears to a hernia, and from its being supposed to proceed from the running or humour in Gonorrhoea falling down upon the testes, it is usually termed a Hernia Humoral is. Tn some instances both testicles swell. They sel- dom, however, swell both at once; but the swelling, on leaving one testicle, is very apt to go to the other ; and when both have in this manner been affected, they sometimes swell alternately for a considerable time to- gether. J have known this happen for the space of a year and upwards, where the patient, during the whole period, was never completely free of the disease. In long continued affections of this kind, the pain becomes inconsiderable , but the first attack of the disease is always accompanied with severe pain. The first warning which the patient receives of it is a very painful sensation in one of the testis, striking along the spermatic cord, near to the middle of his back. On examining the testes he finds it swelled, and so tender that he can scarcely bear it to be touched. He feels himself hot, and a general uneasiness prevails over his whole body, particularly over his thighs and abdomen. Neither can lie move without increasing the violence o f e v e r y s v m p t o m . At first the swelling is confined to the epididymis ; the hack part of the testicle feels hard and enlarged ; but in a very short space of time, often in the couise of Sec. VI. OP SWELLINGS OF THE TESTICLES. 195 an hour, the whole body of the testicle becomes swell- ed. In this state of the disease a difference is still per- ceptible between the testis itself and the epididymis. The latter is hard, and somewhat unequally so ; being, for the most part, hardest and most prominent at the bottom, whereas, a soft uniform sv\elling prevails over al! the anterior part of the testicle. In the progress of the disease, indeed, even the tes- tis itself becomes hard, and if the means employed for preventing it do not prove successful, the swelling of the epididymis and testis together come to form a tu- mour of very considerable magnitude, accompanied with a red inflammatory affection of the scrotum. In tliis state of the disease, the pain is often intense, accompanied with a very distressful sensation of the testis moving or rolling about. The skin is dry and parched, the tongue foul, thirst prevails, and the pulse is full, and quick. In short every symptom takes place vvhich usually attends a high degree of local inflamma- tion. There is no period of Gonorrhoea in which this af- fection of the testis does not occasionally supervene. It occurs in all stages of the disease ; even towards the end of it, when both the patient and surgeon are apt to consider the cure as nearly complete : and in some we find it take place where no cause can be assigned for it, where neither the degree of the previous inflamma- tion, nor the mode of life of the patient, were such as could in any satisfactory manner account for it. ft is proper, however to remark, that swellings of the testis which take place in this manner, seem, for the most part, to be of a very different nature from those which occur during the virulent state of the disease, and while the inflammation in the urethra is considera- ble. The latter appear to be altogether inflammatory. The disease proceeds more slowly to its height or acme. It remains more permanently at the size to which it arrives, and it disappears more slowly than the others, vvhich come to their utmost height? i^ some instances in an hour or two from the first approach of the swelling, and again disappear with equal rapidity. These I conceive to be partly inflammatory, and that 196 OF SWELT INGS OF THE TESTICLES. Ch. Ill, in part (hey proceed from that kind of sympathy which evidently subsists between the penis and testis, and which renders the one very apt to sutler from any dis- ease with which the other may be affected. That sympathy has much influence in the production of this variety of the disease, is obvious from the swelling be- ing apt to leave one testis, as we have already observed, and to fix, perhaps instantly, upon the other. This does not occur so frequently as the alternate affection of the eyes, from one of them only being at first allectcd, but every practitioner must have met with in- stances of it. As it is observed that the running in Gonorrhoea is apt to stop on the first appearance of a swelled testicle, 1 is gave rise to the idea of the affection of the testis proceeding from the matter falling down upon it, in consequence of being thus obstructed in its passage through the urethra. It is now well known, however, that no communication subsists between the urethra and testis, by which matter can pass from the one to the other ; nor does the appearance which a swelled testicle affords, give reason to imagine that it proceeds fiom this cause. Instead of being soft and compressi- ble, which it necessarily would be were it produced by matter, it becomes daily harder, till it arrives at a cer- tain magnitude, when if gradually becomes softer again, hut without any fluctuation of matter being perceived in it. There is reason to imagine, that in most instances the testis become affected by the inflammation spread- ing from the urethra along the vasa deferentia. This has been doubted by some, but without any good rea- son being assigned for it, nor has any other mode of accounting for it been suggested. VVe see that by the vasa deferentia a direct communication takes place be- tween the urethra and the testis, and the first appear- ance of a swelled testicle commences in the epididymis, formed as it were by the termination of this very line of communication. In a great proportion of cases loo, the patient is sensible of a pain stretching from the swelled testicle along the groin, which we know to be fjie direct course of the vas deferens, SeC. VI. OF SWELLINGS OF THE TESTICLES. 197 A variety of other causes might be mentioned, which tend to excite inflammation in the testis in a sim- ilar manner with Gonorrhoea : among these are, the- irritation produced by a stone in the neck of the blad- der ; by the irritation on the introduction of a cathe- ter or bougie ; and the inflammation which takes place in these parts after the operation of lithotomy. A swelling of one or both testes is not an unfrequent oc- currence from all of these, particularly from the latter, and from the use of bougies, especially when they are not properly introduced ; and we see no manner in which it can be so readily produced as by the irritation excited about the neck of the bladder, carried along the vasa deferentia. The consequences of swelling of the testis, which we have most to dread are, a hardened state of the part3, chiefly of the epididymis, which, even when one, but more certainly when both testis are swelled, is apt to be followed by impotency ; and a morbid irritability, which is sometimes so great as to prevent the patient for a considerable time from using any kind of exer- cise, and from following the ordinary occupations of life, without hazarding a return of the swelling of the testis. Suppuration in the body of the testis, from the inflammation induced by Gonorrhoea, is hardly an ob- ject of regard, for it does not take place in one of five hundred cases. But the two circumstances I have mentioned of a permanent hardness in the epididymis, and that distress- ful irritable state of the testis itself, which are apt to succeed to this disease, are objects of the first impor- tance, and require an immediate application of every remedy that can probably tend to prevent them. Scarcely any occurrence can prove more troublesome or inconvenient than swellings of the testis ; and an enlarged state of the epididymis, when it takes place in any considerable degree, has, in many instances, as I have already observed, the effect of inducing impoten- cy. To a certain degree, a swelling of the epididymis often continues for a great length of time ; in some in- stances, during the life of the patient, without any bad 198 OF SWELLINGS OF THE TESTICLES. Ch. III. consequence faking place, particularly when one testi- cle only is affected. But I have known so many instan- ces of the contrary, and of such distressful effects ensu- ing from it, as makes me with confidence say, that no- thing should be omitted that can or might probably tend to prevent or remove it. As we find that all the symptoms of this disease, as well as the consequences which ensue from it, are usu- ally severe in proportion to the degree of inflammation which takes place, it ought to be our view, in every instance, to prevent' lb is from arriving at any great height* This is most effectually done by blood-let- ting ; a proper use of laxatives; opiates; the applica- tion of anodynes and astringents to the parts affected; preserving t lie body in a proper posture, and suspend- ing the testicle. Of all these remedies blood-letting is the most effect- ual and certain, particularly local bloodletting by the application of leeches. Jn plethoric patients, or where the swelling arrives at any considerable bulk, blood should be taken from the arm in such quantities as the strength will permit, while, at the same time, a num- ber of leeches should be applied over the testis. But in weakly people, particularly where none of the symp- toms are violent, the abstraction of blood by means of leeches alone will commonly prove sufficient. The first application of leeches to a swelled testicle excites a good deal of uneasiness. They increase the irritability of the parts, and an increase of the tumour seems to be induced by them ; but the discharge has seldom continued for the space of an hour or two till the pain abates, the tension, which before was consid- erable, becomes much less distressful, and the swelling even appears to lessen in bulk, and in the course of tie following day the patient can allow the parts which he could not previously bear to be touched, to be hand- led with freedom. For the most part one application of leeches, if a proper number has been used, proves sufficient ; but when any of the symptoms still continue severe, par- ticularly when the swelling does not diminish, when rSeC. VI. OP SWELLINGS OF THE TESTICLES. 199 the pain does not lessen, and when the febrile symp- toms do not abate, it becomes in some cases necessary to repeat the application of leeches once and again. I think it here proper to remark, that we should never hesitate in this situation to take blood with freedom. A constitution must be delicate indeed that will be in- jured even with repeated applications of leeches; and I am satisfied that very important advantages ma} he derived in all cases of swelled testes from a timeous and proper use of them. Abstraction of blood by means of leeches is not on- ly useful in shortening tie duration of the inflamma- tory symptoms, but, in consequence of this, it proves serviceable in preventing two very distressful conse- quences, which swelling of the testes is very apt to in- duce, viz. that swelled, indurated state of the epididy- mis which I have mentioned, and the most frequent variety of hydrocele, formed by serum collected in the tunica vaginalis. We have already had occasion to remark, that a permanent swelling of the epididymis is a very frequent effect of an inflamed testicle, and I have met with several well-marked instances of hydro- cele proceeding from the same cause. That blood- letting in any way, whether general or local, will at all times prevent the accession of these symptoms, I will not pretend to assert; but, from the result of much observation, I am convinced that it answers this purpose with more certainty than any other remedy that has vet been employed. In many situations leeches cannot be procured; when this happens to be the case, nearly the same ad- vantage may be derived from small punctures being made on different parts of the swelling. The punc- tures should be made with the point of a lancet, and if the scrotum be previously immersed in warm water, nearly the same quantity of blood will be obtained from them as from the same number of leeches. As swelling of the testicle in Gonorrhoea seems in every instance to proceed from the irritation excited in the urethra, it is an object of the first importance to remove every cause that can in any degree tend to irri- 200 OF SWELLINGS OF THE TESTICLES. Ch. HI. tale either the urethra or contiguous parts. Hence, where costiveness prevails, gentle laxatives prove par- ticularly useful. I have known different instances of hardened feces collected in the rectum inducing swel- lings of the testes; and nothing tends more certainly than this to keep up the disease, by whatever cause it may at first have been induced. But although cos- tiveness is to be guarded against, we are, for a similar reason, to shun the opposite extreme. Strong purga- tives alwa\s excite much irritation in the rectum, and are therefore to be caiefully avoided in Gonorrhoea. It must consist with the knowledge of every practi- tioner that they universally do harm. Where the bow- els are moderately easy, no medicines for this purpose can be required, but when they are not in this situa- tion, castor oil, flowers of sulphur, cream of tartar, or any other gentle laxative, should be employed. Even these should be given in small doses, repeated at pro- per interval?, rattier than that any risk should be in- curred of exciting irritation in the rectum by their be- ing exhibited in larger quantities. With a view to lessen and remove the irritation and pain in tlietu nour with as much certainty and expedi- tion as possible, opiates should be prescribed imme- diately on the pain becoming severe. When they can be avoided till one or more easy stools have been pro- cured, they prove most useful ; but when much irrita- tion prevails, no regard should be paid to this. As the sickness and general uneasiness which sometimes occur from a swelled testis are evidently the effect of irritation, nothing proves so effectual m removing these symptoms as adequate doses of opiates ; and at the same time that they remove this distress of the system by lessening the pain, they also tend to carry off the swelling of the testicle. From an idea that opiates tend to increase the heat and other symptoms of fever, many practitioners are afraid of using them wherever fever takes place in any considerable degree : but mu< h experience of their influence enables me to say, that they may be employed with much sa fetv and advan- tage in every stage of swelled testis where the degree of pain is considerable SeC. VI* OF SWELLINGS OF THE TESTICLES. 201 This is so remarkably the case, that I have known instances of the hernia humoralis, as it is termed, being cured by opiates alone, which did not yield to the usual remedies.* In whatever manner Gonorrhoea may act in exciting swelling of the testis, the tumour, when once produced, excites so much irritation, that, till this be lessened, the swelling for the most part contin- ues obstinate. Next to blood-letting, opiates prove the most effectual remedy for this purpose. While the internal exhibition of opiates thus proves useful, advantage is often derived from applying them to the swelling itself. This may be either by the ap- plication of soft pledgiis, soaked in laudanum, or ano- dyne balsam, or by poultices made with a strong de- coction of poppy heads and crumb of bread. All the saturnine applications prove useful here. When Goulard's extract, as it is termed, is employed, or what is nearly the same, the acetum lythargyri, it ought to be in greater quantities than are used in other parts of the body ; for the testes being protected by different coverings, remedies of this kind, when of the ordinary strength, do not readily affect them. When saccharum saturni is employed, as it will not dissolve in sufficient quantity in water, if vinegar be not added, and as vinegar proves an useful application, even by itself, these two remedies ought always to be combined. The steams of warm vinegar act as an useful discu- tient here. In applying them, the testes should be properly suspended over a vessel in which boiling vin- egar is contained ; or the swelling may be fomented from time to time with flannel immersed in warm vin- egar, and so strongly wrung, that nothing but steam remains upon it. Vinegar, in every form, acts with much advantage in this disease, and this gives a plea- sant variety in the way of applying it. Whatever remedy is employed, the body should be kept as much as possible in a horizontal posture, at the same time that the scrotum should be properly sus- pended. We find by experience that no remedy will prove effectual while the patient continues to walk 26 202 OF SWELLINGS OF THE TESTICLES. Cll. TIT, about ; while, in many instances, a horizontal posture of itself, will have a considerable effect in removing the disease. In suspending the scrotum, care should be taken to do it in such a manner that the testicle be completely supported without being compressed. Pres- sure, even in a slight degree, always does harm, and ought to be avoided. We have already had occasion to observe, that in Gonorrhoea a stoppage of the discharge often takes place on the first approach of a swelled testis. This leads to the idea of some advantage being to be deriv- ed from our exciting a return of the running; and there is not a doubt of this proving in some instances useful. The discharge from the urethra not only les- sens the inflammation in the part from whence it pro- ceeds, but it has also an influence on the tumour of the testis. As it is now universally admitted that a re- turn of the running does not act by drawing matter di- rectly from the testis, some have suspected that it never can prove useful. But why may not a discharge exci- ted in the urethra act in a similar manner in removing an inflammation of the testis, that we know from daily experience happens with setons and other issues in the treatment of inflammatory affections of other parts? The fact indeed, is, that a plentiful return of the dis- charge very commonly relieves all the symptoms of this disease. For the purpose of exciting a return of the runnings bougies prove most effectual; but in affections of the testis they require to be managed with a delicacy not usually observed in this branch of practice : foi v if more pain or irritation be produced than is necessary for the purpose, instead of acting as a remedy, they necessarily aggravate every symptom. In common practice, I think it better to trust to the frequent ap- plication of warm emollients; such as the immersion of the penis in warm milk, or in decoction of althea, or lintseed ; applying warm poultices over the penis, and injecting warm oil or milk into the urethra. From the instantaneous manner in which swellings ©f the testes sometimes succeed to a stoppage of the SeC. VI. OF SWELLINGS OF THE TESTICLES. 203 discharge in Gonorrhoea, and from their appearing, we are told in some instances, even to precede this stop- page of the running, some have doubted whether they are to be considered as the cause or effect.* That the testes may first inflame and the running afterward stop, cannot be doubted. But although this may happen in a few instances, the very reverse is what we common- ly meet with, insomuch that patients who have once been affected with swellings of the testes, are very apt to experience a return of the disease in every Gonor- rhoea to which they may in future be liable, solely from the running being carried off in the usual way. I know several, who, for this reason, dare not use even the mildest astringent injection; otherwise they are sure to have a swelling of the testis induced : while, in others, it swells at the termination of the running, whether injections have been used or not. In the course of my observation, therefore, do cause for doubt has occurred upon this subject. By a proper application of the different remedies we have mentioned, swellings of the testes are for the most part soon relieved, and at last carried off entire- ly excepting that permanent hardness to which the epididymis, as we have seen, is particularly liable. But although this is the common event of the disease, yet instances are not wanting, most frequently indeed from the patient's misconduct, of the whole body of the testis remaining swelled, and obstinately resisting all those remedies which usually prove effectual. If, in this situation, some application be not made, by which the size of the tumour is soon diminished, and if it be allowed to remain stationary for any length of time, it is very apt to continue much enlarged, and sometimes of a schirrous hardness during the life of the patient. I may also remark, that it is this state of the disease which is most apt to terminate in hydro- cele ; or effusion of serum into the tunica vaginalis tes- tis, with which it is sometimes attended. In this situation mercury is commonly employed^ * Vide John Hunter, on the Venereal Disease. 264 OF SWELLINGS OF THE TESTICLES. Cb. Ill, and, in some instances when given slowly, as an alter- ative, I have seen it prove useful ; but it is. doubtful whether a complete course of mercury should ever be advised or not, for when it does not carry off the swel- ling, which seldom happens, it is apt to increase it, and to induce pain and irritation in the tumour when none existed in it before. Whenever mercury, therefore, is advised, it ought to be in such quantities as cannot tend to quicken the circulation or excite fever. A decoc- tion of mezereon has in some instances been given with advantage along with mercury.* It is in this state of a swelled testis, where the tu- mour does not yield, but remains nearly of the same size after the inflammation by which it was induced is gone, that emetics are most likely to prove useful. They have been used, I know 7 , in all periods of the disease ; but it is chiefly in the situation we are now speaking of that I have seen them act with advantage. A smart emetic, carried a proper length, will some- times, in the space of an hour or two, lessen the bulk of a tumour which had for several weeks obstinately resisted every other remedy. In some cases one eme- tic proves sufficient, while, in others, it requires to be repeated once and again. Mercurials were formerly used for this purpose. This was done from the dis- ease being considered as a symptom of Lues Venerea,, and for which mercury was known to be the only anti- dote. But we now know that tumours of the testes, which take place merely from Gonorrhoea, never par- take of the Venereal Virus; and accordingly emetics, of whatever nature they may be, prove equally use- ful here with mercurials, provided the shock which they give to the system is equally considerable. I have sometimes, in this state of a swelled testicle, applied a blister with advantage. It might not perhaps be altogether safe to apply blisters while the scrotum continues much inflamed ; hut when the external inflam- mation and tension subside, they may be advised with safety ; and, in different instances, I have known them f Vide Appendix, No. 45'. Sect. VL OF SWELLINGS OF THE TESTICLES. 205 accomplish a reduction of the swelling of the testis, where other remedies had for some time been employ- ed without any effect. A due perseverance in the use of some or all of these remedies will seldom fail where a swelling of the testi- cle is altogether inflammatory; but where it proceeds in a great measure from irritability, as we judge to be the case where the swelling comes and disappears sud- denly, or where it comes and goes from one testicle to another, other remedies are, in this situation, found to prove more effectual. Even in this variety of the disease, blisters some- times prove qseful; and I have known the irritation removed, and the swelling carried off in the course of a short time by opiates; but these afford only a tem- porary relief, and do not prevent the disease from re- turning on the slightest application of any of the exci- ting causes which usually tend to induce it. The remedies which here prove most effectual are cold bathing, and a plentiful use of bark. Sea bathing, when the season permits, should in the first place, be advised, but when this cannot be obtained, cold water may be used at home, with a proportion of common salt dissolved in it. It answers a good purpose wheth- er the whole body be immersed in it, or merely the scrotum bathed in it, but for the most part, I have thought that it proves most effectual when applied to the scrotum only. As bark and cold bathing act upon the same principle, that is, by giving tone and vigour to parts which we suppose to have been deprived of them, they may either be used together, or exhibited separately, as the patient may incline. The testes, we find, are apt to decay. One of them will begin to lessen in bulk, and, in a gradual manner, disappear entirely, or leave only a thin membranous substance in its place. Generally the other remains sound ; but I have known instances of both becoming affected at the same time, and others where the one remained entire as long as any part of that which was first affected was perceptible, but where it also began to decay as soon as the other was entirely destroyed. 206 OF SWELLINGS OF THE TESTICLES, Ch. Ill, This affection occurs at all periods of life, but most frequently after the 40th year. In many instances, no cause whatever can be assigned for it ; but I have ob- served that it is most frequent in people of delicate con- stitutions, where the muscles are soft and relaxed, and the complexion wan and sallow. I have also found that those in whom it occurs, have, in almost every in- stance, been in early life particularly addicted to Onanism. In a few cases it has appeared as an evident conse- quence of a swelled testicle. On the fulness produced by the disease being removed, the process of absorp- tion by which this was accomplished does not stop, but goes on till the whole testis is carried off. In some in- stances this takes place while the testicle continues to the last of its natural degree of firmness, or even while the hardness still prevails which occurred during the state of inflammation by which the swelling was at first induced : but, in others, before this wasting pro- cess commences, the testicle becomes soft and pulpy, or even dissolves into a fluid. It is seldom attended with pain, the patient being, in many instances, igno- rant of his lo-s till one, or perhaps both, testes are nearly consumed. Hitherto no certain remedy has been discovered for putting a slop to this complaint. Mercury, hemlock, and electricity have been tried, but with no advantage The cold bath has for a time seemed to prove useful, but the disease returned again, and both testes were dissolved. In one case, Where one of the testes was consumed before the patient perceived it, and where the other was evidently affected, I applied a blister over it. This wasting process stopped, and never re- curred again. The patient, is about 36 years of age. His inclination and powers of propagation, he says, are still as strong as they were before, and he has late- ly had a child. Among the causes of hernia humoralis, the authors partiality has prevented him from naming injections. The early use of these in the inflammatory stage cf Gonorrhoea, by checking the discharge from the urethra, has often given rise to this peculiarly distressing Sec. VI. OF SWELLINGS OF THE TESTICLES. 207 complaint. It is generally observed that when the swelling has been removed, the running is less in quantity than it was previously. A disease termed Fungus of the Testis, has been mentioned by some writers and particularly by Mr. Lawrence, the Demonstrator of Anatomy at St. Bartholomew's Hospital, as an occasional. conse- quence of the hernia humoralis from Gonorrhoea. Injuries of va- rious kinds are also named among the causes and in some cases if has originated spontaneously. The following symptoms are stated by the writer named above. " It is preceded by a painful swelling of the testis, which is peculiarly hard to the touch. After a certain length of time, the scrotum, growing gradually thinner, ulcerates, but the opening which is thus formed, instead of discharging mat- ter, gives issue to a firm and generally insensible fungus. The sur- rounding integuments and cellular substance are thickened and in- durated by the complaint, so that there appears to be a considera- ble mass of disease. The pain abates and the swelling subsides considerably, when the scrotum has given way. In this state the disorder appears very indolent, but if the fungus be destroyed, the integuments come together and a cicatrix ensues, which is insepa- rably connected to the testicle." Mr. Lawrence considers that the glandular substance of the testis as the original seat of the com- plaint and that the confinement of this swollen substance by the dense and unyielding tunica albuginea is the cause of the peculiar hardness of the tumour and the pain attendant on it. The absorp- tion of the coats of the testis and the scrotum remove the tension? and give ease to the patient. It is conjectured by Mr. L. that the disease might be cured spontaneously, but from its being so indo- lent, this would not be effected until after a long time, The modes which he proposes for removing the fungus, are either, the knife, or if the nature of its attachment permit, the ligature, or it may be. freely treated with escharotic applications. Castration, he cos- siders as altogether improper and unnecessary. Nine cases are re- lated by Mr. L., in some of which, red precipitate or lunar caustic (nitras argenti) were used with success and in others the knife. The application of the ligature in one case caused severe pain, but since that time it has, in other instances effected a cure. It must be observed, that Mr. Lawrence considers the removal of the protuberance to a level with the scrotum, by means of the knife as the shortest and most effectual mode of treatment. (Edin- burgh Med, and Surg. Journal, vol. 4, 257.) Ed, 208 OF SWELLINGS OF Ch. Ill, SECT. VII. Of Swellings of the Spermatic Cord. THE Spermatic Cord is liable to swellings of dif- ferent kinds, but it is such only as proceed from Gon- orrhoea that we are here to notice. It sometimes happens that inflammation of the tes- ticle spreads to the cord, and excites pain and tume- faction along the whole course of it. At other times the cord inflames without any previous affection of the testis; it becomes tense, hard, and painful. The swel- ling, for the most part, is at first confined to the vas deferens, but at last the other parts of the cord suf- fer also. I have met with some in which one or two tumified parts were perceived in the course of the cord, while the rest of it remained sound ; but, in general, the cord is equally affected, from the testis along its whole course up the groin. On the first approach of this disease, as it is always accompanied with pain and tension, with some inabil- ity to walk, the patient is induced to treat it with at- tention ; but, where the swelling is not soon Carried off, the pain will sometimes abate, or even vanish altogeth- er; and in this state, where the tumour is not consid- erable, the patient is led to suppose that no harm can arise from it; by this neglect the swelling is often ren- dered so firm and hard that no remedies we can em- ploy have any influence in removing it. In some ca^ ses I have met with a hard ring, affecting the cord only at a particular spot, where the diseased part was near- ly as firm as bone, while the rest of it was in a soft natural state. While the tumour is confined to one part of the cord I have seldom known it increase to any alarming de- gree, but whether it be circumscribed, or extended over the whole length of the cord, no time should be lost in the application of remedies for removing it. In- See. VII. THE SPERMATIC CORD. 209» dependent of other reasons, if the vas deferens be chiefly affected or even only compressed in its course, the testicle will be rendered as certainly useless as if it were extirpated : even this, in some instances, where one side only was affected, has appeared to render the patient impotent, and it will never fail to do so where the disease affects both sides. The remedies that prove most effectual here are blood-letting, blisters, and such others as are usually employed with advantage in swellings of the testis. These we need not particularly enumerate, as they were fully treated of in the last section • but it may be proper to remark that blood-letting proves chiefly useful on the first approach of the disease, and in this state, when properly applied, that it seldom fails in removing it. It may in some cases, be necessary to take blood from the arm, but the local discharge of it by leeches applied to the part affected, is at all times to be morer depended on. Where the discharge of blood, however, does not soon lessen the size and hardness of the tumour, we need not afterwards expect any advantage from it. In this case I have repeatedly known blisters prove useful when applied along the course of the cord ; but neither are they to be depended on if some effect be not soon perceived to result from them. In partial affections of the cord a small blister appli- ed to the diseased part, and the part kept open with, ointment of cantharides, has tended to reduce the swelling. Mercury is commonly employed here, and where the disease does not soon yield to blood-letting and blisters it is perhaps the only remedy from which any advantage is to be expected; but I have commonly found, where the swelling has been carried entirely off by mercury, that there has been much cause to ima- gine that the patient at the same time laboured under Lues Venerea. In some cases, the disease has subsist- ed in an evident form of pox in othvr parts of the body, while, in others, there was only grounds for 27 210 OF SWELLINGS OF THE Ch. Ill, suspicion. In all of these the mercury seemed to operate with more certainty when a decoction of me- zereon and sarsaparilla was conjoined with it. Mercurial frictions prove more useful here than any other mode of giving the remedy, and the application of mercurial plasters to the swelled parts acts with more advantage in swellings of this kind than in any other in which I have employed them. SECT. VIII. Of Swellings of the Lymphatic Vessels of the Penis. WE know, from the history of the Lymphatics, that they serve to inhale, and to carry into the general course of the circulation, not merely from the surface of the body, but from every other part of it, fluids applied to their open extremities. In this manner they remove from some parts what might prove hurtful if allowed to remain, and they carry into the constitu- tion from others what is obviously meant for the nour- ishment and support of it. But while this is their chief purpose, we also know that they carry into the system what often tends to destroy it. They seem to have no power of rejecting what proves hurtful, hence they imbibe poisons, and the most inoffensive articles, with equal readiness. All our contagious diseases are probably produced through the medium of the lym- phatics, and we can prove by experiment that this is the case with many of them ; particularly with the plague, the small-pox, and Lues Venerea. So readily is the matter of these diseases absorbed by the lym- phatics, that it can never with safety be applied to any part of the body ; for so quickly does absorption, in some instances take place, that we have frequent proofs of infection being carried into the constitution, even after much pains has been taken to wash away the matter by which it was produced, in the space of a SeC. VIII. LYMPHATIC VESSELS OF THE PENIS. 211 minute or two after being applied to the surface of the body. For the most part we find that the lymphatics them- selves do not immediately suffer by the absorption even of the most noxious matter. They will convey the poison of a viper and other serpents into the course of the circulation, by which the animal will be killed in the space of an hour, while no vestige of its effects appears in the lymphatic vessels themselves. In like manner* the matter of Lues Venerea passes into the constitu- tion from the penis without any swelling or other mark of disease being perceived in the lymphatics through which it was conveyed. This, we must allow, however, is not universally the case. Instances sometimes happen of the matter of Lues Venerea passing through lymphatics that are hard and swelled, but we know from daily observation that it is not a frequent occurrence. We find, in- deed, that the lymphatic vessels in every part of the body are apt to swell and inflame on causes capable of exciting irritation being applied to them. Thus we often observe the lymphatics of the arm swell, become hard and painful from a prick in one of the fingers with a pin or a thorn, or even from a nail being cut too far in the flesh ; and in Gonorrhoea it is by no means un- common to find a hard lymphatic passing along the back of the penis, to the groin, arising in some instan- ces from the prepuce and in others from the urethra. But although this, as we have observed, occurs also in some cases of Chancre, we meet with at least twen- ty instances of the contrary, for one in which this af- fection of the lymphatics takes place. I think, too, that I have observed, where the lymphatics proceeding from Chancres have inflamed, particularly where the inflammation has been considerable, that the constitu- tion has not been so apt to suffer as where this did not happen. From all which, I would conclude, that in- flammation of the lymphatics, when in a high degree, instead of indicating an increased power of absorbing what is applied to them, as many have imagined, tends 212 OF SWELLINGS OF TKE Ch. III. in a great measure to lessen, and, perhaps to destroy it. Till the fact is farther ascertained, which experi- ence and observation alone can do, it would be impro- per to place any dependence upon this in the treat- ment of Chancres. In all cases of Chancre, whether the lymphatics inflame or not, it would be imprudent to omit whatever might tend to render the constitution safe; but finding that much inflammation seems not only to lessen the power of absorption in the lympha- tics, but that they inflame from causes in which we know that no infection exists, as often happens from a prick or a cut with a clean instrument, we would from this alone be led to think that this affection of these vessels which occurs in Gonorrhoea, proceeds more from irritation than from any other cause. This idea, however, is farther confirmed by the proofs we have already adduced of Gonorrhoea being a local disorder, as well as by our daily observation of the rise and pro- gress of these swellings which occur in this disease. They commence with all the usual symptoms of in- flammation. A hard string, or cord, is perceived along the back of the penis. It is painful to the touch, and the teguments above it sometimes acquire an ery- sipelatous redness. The whole penis becomes stiff and uneasy, and this renders erections particularly painful. In a great proportion of cases the inflammation sub- sides quickly and easily, the stiffness and pain gradu- ally abate and the hardness of the lymphatic disap- pears entirely: but where the inflammation has either been severe from the first, or not properly treated, it proceeds in some cases to suppuration, forming one or more small abscesses in the course of the affected part. The sores, however, which ensue from these, heal readily, when the constitution is otherwise heal- thy, forming a very manifest difference between Gon- orrhoea and Lues Venerea. Similar affections of the lymphatics, which occur in the latter, require, for fhe most part, a course of mercury to remove them. I say for the most part only, from having met with SeC. VIII. LYMPHATIC VESSELS OF THE PENIS. 213 more than one instance, of the sores which occur in Lues Venerea from this cause, healing without the use of mercury ; and which has induced me to think, that even in this disease, the lymphatics may swell and in- flame, merely from the acrimony of the matter, and that this inflammation may have some tendency, as I have observed above, to prevent the matter from pas- sing into the constitution. Where swellings of this kind in Gonorrhoea are con- fined to the lymphatic vessels, I have commonly found that cold poultices, prepared with crumbs of breads and acetum lythargyri, or saccharum saturni, prove more effectual than any other application. They re- move the swelling and hardness, and lessen the pain with more certainty, than warm emollient poultices. But where the inflammation spreads over the penis, as it sometimes does, it becomes necessary, not only to discharge blood from the arm, but to apply leeches over the pained parts. This, with a low diet, and con- fining the patient to a horizontal posture, very seldom fails in removing the disease. But it sometimes hap- pens, either from the neighbouring parts becoming se- verely inflamed, or from the diseased lymphatic burst- ing, that effusions occur in the contiguous cellular sub- stance, and small abscesses forming, they at last dis- charge their contents, and produce such sores as I have already had occasion to mention. The treatment of these should be the same as that of sores proceeding from any other cause in which the constitution is not affected. When their edges are hard and inflamed, emollient poultices will prove use- ful. For the removal of sloughs and foulness, red precipitate, or even caustic, may be necessary ; and for cicatrising them, nothing answers better than un- guentum e calce zinci, or ceratum e lapide calamin- are.* In two different instances of hardened lymphatics c in Gonorrhoea, besides the firm cord on the back of * Vide Appendix, No, xlvii. xlviil 214 OF SWELLINGS OF THE €h. III„ the penis, a thin, flat, hard tumour, proceeding from this cord, spread round the whole substance of the pe- nis, for the breadth of a quarter of an inch. One of them was contiguous to, and immediately behind the glans. The other was near to the pubes. This last passed round the urethra, which it grasped so firmly, as to give cause to suspect, that at last it might prove a total obstruction to the urine. A course of mercury was tried in each of them, without any advantage. A small piece of mercurial plaster was then applied over the swelling, and this, with a gentle purgative of sea- water every second or third morning, was all that was advised. The swelling in each of them became con- siderably less, but never disappeared entirely. It did not, however, give any disturbance afterwards. SECT. IX. Of Swellings of the Glands in the Groin, THE swelling and inflammation of the lymphatics, described in the last section, frequently proceeds no farther than the root of the penis. At other times it goes the length of the groin, and affects one or more of the contiguous glands, which become hard, swelled, and inflamed, putting on many of the appearances of the venereal bubo. At other times these glands swell and inflame, where no affection of the contiguous lymphatics is percepti- ble. But although in such cases, no apparent inflam- mation occurs in these vessels, there is, however, much cause to imagine, that in a certain degree it always takes place. There is not, at least, any other obvious route by which the inflammation can be conveyed from the urethra to the glands in the groin. In some cases these swellings become large, and, notwithstanding our endeavours to prevent it, suppura- tion at last takes place : but, for the most part, if they SeC. IX. GLANDS IN THE GROIN. 21 5 be not neglected af first, they may be very easily dis- cussed. In most instances, this may be accomplished by the use of saturnine poultices alone ; but where the pain and inflammation are severe, blood-letting, both general and local, becomes necessary. Laxatives al- ways prove useful, and a cooling, low regimen can sel- dom be dispensed with. The most perplexing part of the surgeon's practice here is, to determine the real nature of the tumour; to ascertain whether it proceeds merely from inflam- mation, or from the absorption of venereal matter. If from the last, mercury alone will prove effectual ; while no practitioner would consider mercury as necessary, for the removal of a swelling altogether inflammatory, Neither would it, in this case, answer any good pur- pose. It would not lessen the size of the swelling ' nay, by the fever which it sometimes excites, it might even tend to increase it, and disappointment to the practitioner, and much distress to the patient, might be the consequence. The circumstances upon which we chiefly form our judgment here, are these: if no chancre or excoriation has been perceived, either upon the glans or prepuce, and if the inflammation in Gonorrhoea has been con- siderable, there will be cause to imagine that the tu- mour is not venereal. When treating of chancre and venereal bubo, we shall enter more fully into the con- sideration of this ; but at present, I may observe, that buboes do not commonlv occur, without chancres go- ing before them. I know, indeed, from various cases which have fallen under my management, that, contra- ry to the general opinion, real venereal buboes some- times form without any previous chancre, or any ex- ternal affection ; but as it does not happen once in a hundred instances, we are sufficiently warranted in considering the absence of chancre, as a reason for supposing that swellings of this kind are not venereal. In such swellings as occur from Gonorrhoea, much pain and tension prevail, not merely in the diseased glands, but over all the groin ; and a general sympa- 216 OF SWELLINGS, &C, €1). II? thetic uneasiness spreads over the thighs, and undef part of the abdomen. Even the testes and abdominal viscera sometimes suffer, whereas, in the venereal bu- bo, it is commonly one gland only that is affected, and the contiguous pads seldom become uneasy till the disease is far advanced; not, indeed, till the tumour has acquired such a size, as to excite pain solely by distention. The swelled gland, it is true, is painful from the first, and the pain becomes gradually more severe as the tumour increases; but the pain is chiefly confined to one part, and seldom spreads farther till the teguments are much stretched by the subsequent for- mation of matter. And, lastly, when glands swelled from this cause burst, the sores which ensue have a very different appearance from those produced by real venereal buboes. Their edges, instead of being hard and retorted, have more the appearance of sores which occur from common abscesses, and they soon begin to heal, even when mercury is not employed, which the others, we may observe, seldom do. This circumstance of these sores healing, whether mercury be used or not, is the most decisive charac- teristic of their true nature, and when any doubts of this are entertained, either from the swelling having taken place without a previous chancre, or from any other cause, we ought to delay the exhibition of mer- cury till their tendency to heal, or to degenerate into a worse state, be ascertained. If they put on a healing appearance, and gradually become less, there will be much cause to hope that a complete cure will be obtained, whether mercury be used or not ; while, on the contrary, this remedy should be immediately advised when the sores become foul, and their edges hard ; and particularly when, instead of healing, they extend to a greater size. The progress of the swelling also affords a mark of discrimination. The venereal bubo proceeds more slowly to suppuration than the inflammatory swelling of which we now speak, which most frequently, in- deed, is easilv discussed, and seldom arrives therefore SeC. X. OF EXCORIATIONS OF THE GLANDS, &C. 217 at the state of abscess ; but when tumours of this de- scription do suppurate, it commonly happens in the space of a few days. I have known matter complete- ly formed in them in three or four days from their first appearance; a circumstance which perhaps never hap- pens in glandular swellings produced by the matter of Lues Venerea. SECT. X. Of Excoriations of the Glands dnd Prepuce BY the acrimony of the matter in Gonorrhoea the Glans and Prepuce are sometimes excoriated. A slight degree of inflammation takes place at first, either par- tially, or over the whole parts; and this being succeed- ed by a discharge of matter, the skin at last becomes fretted, and on being examined with a glass, the mat- ter is perceived to flow from an infinite number of small points, on the smallest pressure being applied to them. But, for the most part, this affection of the prepuce and glans takes place without any discharge from the urethra. In the course of a few days after connexion with an infected woman, and without any symptom of Gonorrhoea, a sensation of heat is perceived over the whole prepuce and glans, which soon terminates in a discharge of matter very similar to what comes from the Urethra in Gonorrhoea. From this circumstance, the disease has been termed Gonorrhoea Spuria. The matter indeed, is so similar to that of Gonorrhoea, that it is usually sometime before the patient can be con- vinced of its not coming from the urethra. It not on- ly resembles the matter of Gonorrhoea in colour and consistence, but likewise in quantity. In some cases, it is surprisingly great, owing to the great extent of in- flamed surface, in the numerous plies and doublings of the skin forming the prepuce. 218 OF EXCORIATIONS OF THE Ch. III. In slight, affections of this kind, the prepuce contin- ues to move upon the glans as it does in health ; but when the matter is either of itself particularly acrid, or allowed by want of attention to remain till it be- comes so, the skin forming the prepuce, becomes so much inflamed and swelled, that it cannot but with much difficulty be made to pass backward and for- ward. In some cases this becomes impossible. If this happens when the prepuce covers the glans and cannot be drawn back, a disease is thereby produced, which we teim phymosis ; and when the swelling takes place when the prepuce is retracted and cannot be pulled over the glans, the ofisease is termed paraphimosis. Of these affections we shall speak more particularly in the ensuing sections. By many, this discharge of matter from the prepuce and glans has been judged to be venereal ; that is, they have supposed it to be produced by the matter of Lues Venerea. They therefore conceived it to be always connected with an affection of the constitution, and have accordingly, in the method of cure, been chiefly directed by this opinion. This opinion, however, is evidently not well found- ed. From much observation, I am convinced, that this discharge is of a local naiure, and that it is no more capable of affecting the constitution than the matter of Gonorrhoea. I believe indeed that this is now very generally admitted ; and that it is those only who doubt of it, who, taking their information from books^ have not^paid that attention to the event of those affec- tions, which in forming a judgment of them is abso- lutely necessary. It will be universally found that the discharge may be more easily removed by remedies applied directly to the parts affected than by mercury, or any medicines, given internally. Indeed, no ad- vantage is derived from the internal exhibition of med- icines, while the disease seldom resists the application of an astringent wash: neither is the constitution ever affected with pox from excoriations proceeding merely from Gonorrhoea. Sec. X, GLANDS AND PREPUCE, 219 It is true that buboes and symptoms of pox some- times occur where the prepuce and glans have been previously affected in this manner, Of this I have seen many instances : but in all of these it has happened, that on enquiry, the patients were found to have had connection with diseased women during the continu- ance of the excoriation ; and whatever may be the opinion of some individuals upon this point, I believe few will doubt of an ulcerated or excoriated surface being particularly favorable for promoting the absorp- tion of any matter that is applied to it; insomuch, that it is the universal remark of patients, that they never escape being poxed, if in such circumstances they have connection with women that are infected. It is worthy of remark, that a small, partial excori- ation is always at first of a suspicious nature, while from any observation I have been able to make, every general affection of this nature, where the excoriation extends over the whole prepuce and glans, terminates easily without producing any constitutional taint. The disease sometimes at first, indeed, occupies a small spot, and afterwards extends gradually over t'e con- tiguous parts, and where, by the event, we judge of its being of the most innocent nature from no disease of the constitution being produced by it. But I have uniformly found, where a small part only has remain- ed for some time raw and excoriated, without ex- tending to the surrounding parts, that symptoms of pox succeed to it with as much certainty as they ever do to chancres. I therefore believe, that all partial af- fections of this kind, which remain for more than a day or two circumscribed, are produced by the matter of Lues Venerea, and that they ought accordingly to be treated as symptoms of that disease. Besides the other differences which we have elsewhere enumerated between the matter of Lues Venerea and Gonorrhoea Virulenta, it would appear that in this they differ in the most obvious manner. The matter of Lues Ve- nerea, however diffusible it may be when received into the system, from which indeed it is never expelled but 220 OF EXCORIATIONS OF THE Gil. Ill, with the assistance of mercury, is always slow in its progress while only locally applied either to the penis or any other part. Neither can it be applied, as we have already had occasion to remark, to the smallest point, without much risk of pox being produced by it : whereas, the matter of Gonorrhoea, whether it be applied to the urethra, to the glans, or prepuce, spreads quickly over all the contiguous parts; while it is ob- vious to daily observation, either that it is not absorb- ed, or if it be taken into the system, that no constitu- tional disease ensues from it. Excoriations of this kind not only resemble Gonor- rhoea, in being produced by the same matter, and in being entirely local, but in the method of cure. We have already had occasion to see, that the. discharge in Gonorrhoea cannot be certainly removed, but by the use of astringent injections. In like manner, bathing the parts affected in astringent solutions proves the most effectual practice here. Lime-water answers particu- larly well for this purpose : also solutions of saccharum saturni, and of white vitriol: immersing the parts in brandy, or in a strong infusion of red-rose leaves, will sometimes remove the discharge on the first application. It is proper, however, to remark, that the more fre- quently remedies of this kind are applied, the more effectual they prove. They should be used at least five or six times daily, and for the space of a few minutes at each application. Emollient ointments are. frequently employed in af- fections of this kind, but the very cause which renders astringents useful makes every application of this na- ture improper. They constantly increase the dis- charge, while no advantage of any kind accrues from them. Neither do we find that purgatives, or any of the cooling medicines usually prescribed here are of any real utility. When much inflammation takes place, ihey may, in some instances, prove useful, but in all mch cases blood-letting is more to be depended on ; particularly the application of leeches to the parts irn- Sec. X. GLANDS AND PREPUCE. 221 mediately affected, which, in all local inflammatory complaints, is to be considered as the most effectual remedy. It has been objected to the application of leeches in excoriations of the penis, that the wounds from the bites of these animals are apt to degenerate into vene- real sores. This proceeded upon the idea of all such affections being produced by the matter of Lues Vene- rea; but now when we know that this is by no means the case, it is obvious that the opinion must be ill found- ed ; and from various and repeated trials of the reme- dy in question I can decidedly say that it is so. But admitting that a case should occur, in which it might be doubtful whether the excoriation and swel= ling was truly venereal or not, still I would not hesi- tate in advising the application of leeches : they would prove more effectual than any other remedy in carry- ing off the inflammatory symptoms, while their bites, if they should put on the appearance of venereal sores, would immediately render the nature of the disease certain, which otherwise might long have remained in doubt. In all sores and inflammatory affections of these parts, the posture of the body and position of the pe- nis are circumstances requiring particular attention. The patient should be kept as much as possible in a horizontal posture ; and the penis should be elevated so as to prevent the glans from hanging pendulous. It often happens indeed, where this is omitted that swel- lings remain obstinate for many weeks together, which otherwise might have been carried off in a few days 222 OF EXCORIATIONS IN WOMEN, Ch. fill. SECT. XL Of Excoriations in the Parts of Generation of Women. THE parts of Generation in Women are liable to excoriations of a similar nature with those enumerated in the last section. In some cases they are confined to the clitoris, nymphae, and labia pudendi. In others they spread to the perineum, and even to the groins and thighs, where, from negligence, and want of at- tention to cleanliness, I have known deep and very extensive ulcers produced. Where the excoriations are confined within the parts of generation, the symptoms are nearly such as occur from Gonorrhoea in the usual form of the disease ; but where the inflammation and rawness spread to the thighs, a great deal of distress is experienced in walk- ing, and in every motion of the body. The method of cure is nearly the same in women as in men. Bathing the parts frequently with one or oth- er of the astringent applications mentioned in the last section, for the most part, proves effectual ; for the excoriated parts seldom lie so deep as to require the use of the syringe; but when the parts become evi- dently ulcerated, bathing alone is not sufficient. In this case the ulcers fall to be treated in the same man- ner with sores proceeding from any other cause. When they are foul and sloughy, an ointment strongly im- pregnated with mercur. precipit. rub. is perhaps the best application we can use; and for the purpose of healing them, nothing answers better than common eerate ? with a large proportion of lapis calammaris, or unguent urn e cake zinci, for which prescriptions are given in the Appendix. When sores of this description do not soon yield to these applications, and especially when they spread and become deeper while the patient is using them, there will be some cause to suspect that a venereal taint exists in the constitution: in which case a course of SeC. XII. OF THE PHYMOSIS, &C. 223 mercury should immediately be advised, being the only remedy upon which, in such circumstances,, we can place any dependence* SECT. XII. Of the Phymosis and Paraphimosis. IN section tenth we found it necessary to give a de- finition of these two diseases. Inflammation of the preputium always excites some degree of thickness and contraction. When the contraction occurs w-hile the prepuce covers the glans, and in such a degree as to prevent it from being pulled back, the disease thus produced, is termed phymosis. We say that paraphy- inosis takes place when the prepuce contracts behind the glans, and cannot be drawn over it. One of the most frequent causes of phymosis is chan- cres on the preputium. The thickening of the skin in- duced by chancres, and the inflammation with which they are apt to be attended, is often productive of phy- mosis ; but it also occurs from otlier causes. What- ever excites much inflammation of the penis will in- duce it. Hence it readily occurs in every case of Gon- orrhoea attended with any unusual degree of inflam- mation, particularly in the variety of the disease,, where the glans and prepuce are inflamed and excoria- ted. But although these excoriations often terminate in phymosis, it is certain that they are more frequent- ly productive of paraphymosis. The patient, in clear- ing away the matter necessarily draws back the prepu- tium, and when the parts are previously much inflam- ed and thickened, they are apt to contract so suddenly when in this state of retraction, that they cannot again be drawn over the glans. In the treatment of phymosis, we are often success ful by a proper application of emollients. No effect will result from them when the stricture has been of 224 OP THE PHYMOS1S Ch. III. long duration ; but, unless the inflammation is unusu- ally severe, they will often answer if duly persevered from the first. Immersing the penis, from time to time, in warm milk, or in a decoction of althea root, or of lintseed, is perhaps the most effectual method of applying remedies of this kind ; and when much matter is produced between the prepuce and glans, ei- ther by chancres or inflammation, these liquids should be injected from time to time with a syringe. But with a view to lessen the discharge, after washing out any matter that may be formed, a weak saturnine so- lution should be injected three or four times a day, This, with a low diet, abstinence from exercise, and suspending the penis, will, for the most part, prove successful; but when the parts are much inflamed, it becomes necessary to take blood in quantities propor- tioned to the symptoms, not merely from the arm, but from the penis itself, by the application of leeches, which may always be done with safety where the dis- ease is local, as we have shown to be the case where it proceeds from excoriation or from Gonorrhoea : but when it occurs from chancres, as venereal sores are apt to ensue from the bites of leeches, it is better to omit them. While any considerable 4 degree of stricture remains, It is always improper to force the prepuce back. This, however, is often done, but it very commonly termi= nates in paraphymosis ; for when the parts are much contracted it is almost impossible to get the prepuce again brought over the glans, if it has once been for- ted completely behind it. It is better, therefore, to wait till the stricture is entirely removed, before any attempt is made for this purpose. Besides the risk of inducing paraphymosis, the irritation which it gives, tends always to render the stricture more obstinate. When the inflammation is altogether gone^ it may be proper, after immersing the penis in any of the emol- lients abovementioned, and rubbing it gently over with warm oil, to endeavour, from time to time, to stretch it toils usual extent; but even at this period of the. Sec. Xtt. AXD PARAPHYMOSIS. 225 disease the prepuce ought never to be pushed back with such force as can excite any kind of uneasiness. In the treatment of phymosis it is proper to remark* that, in a great proportion of cases the stricture can never be altogether removed. In slight degrees of it we commonly succeed by the means I have mentioned* but whenever it is severe the parts remain under some degree of contraction, for the most part, during the life of the patient. We have it indeed in our power to remove even the most inveterate stricture that occurs* by laying the prepuce open, either by a partial inci- sion, or cutting it from one end to the other, accord- ing to the extent of the disease, but this is a remedy of too severe a nature for the removal of phymosis* in the ordinary form of the disease. Where the pre- puce is so much contracted as to interrupt the passage of urine, or to impede coition, it no doubt becomes proper to lessen or remove the stricture, but it is most frequently for obtaining ready access to concealed chancres that we advise this measure of laying the pre- puce freely open. Even chancres are often cured while the prepuce re- mains contracted; but this is only the slighter kinds of them. Whenever they are either deep or very exten- sive, although with much care and attention they may in some instances be cured, yet we are much more cer- tain of effecting our purpose, and of doing it speedi- ly, by laying the sores completely open. I am clearly of opinion* however, that a patient should rathqr sub- mit to an ordinary or slight degree of phymosis, where there is no disease concealed by it, than incur the pain and distress which must always ensue from this opera- tion. Many have it from their birth, and are not sen- sible of any inconvenience arising from it. It happens, indeed, in some instances, even of this natural phymosis, if we may so term it, that we are under the necessity of removing the stricture by an incision. This is particularly the case where the exu- dation natural to these parts is in such quantities as to excite irritation, which it is always apt to do when it 29 226 op The Phymosis Ch. m. adheres to the prepuce and glans. By much pains in washing with a syringe, the parts may be kept so clean as to prevent them from suffering with this mucus; but in general we find it necessary either to lay the con- tracted prepuce open from one end to the other, or re- move a portion of it entirely, so as to perform the ope- ration of circumcision. It may be proper to observe, that although this ope- ration of removing a portion of the prepuce is in itself exceedingly simple and easy, and never fails to answer the purpose where the parts are perfectly sound, that it is very apt to disappoint us entirely when they are under any degree of inflammation or irritation. In this situation, although the parts in which the stricture is seated be completely removed, the remaining ex- tremity of the prepuce contracts almost immediately after the operation, so as to create nearly the same de- gree of inconveniency which it did before. By the in- troduction of dossils of lint, sponge tent, and such other articles, we may for a time prevent the contrac- tion from becoming considerable, but the irritation which these applications excite, at last oblige us to lay them aside, when the stricture soon takes place in a degree equal to what it was before the operation. I have taken the more particular notice of this, from' different cases having fallen under my management, in which, by endeavouring to remove a contraction of the prepuce by the operation of circumcision, we were completely disappointed. In three of these the ope- ration was done by others. In one I performed it my- self. But although every thing was done in all of them that might probably render them successful, yet they all failed, and after a considerable time spent in trying to dilate the newly-formed stricture, I was in two of these instances obliged to perform the operation for the phyroosis in the usual way, by making a longitu- dinal cut through all the remaining part of the prepu- tiuvn. In one the stricture was not so considerable as to render it necessary, and in the other, the patient would not submit to it, SeC. Xli. ANB PARAPHYMOSIi. SMf Were we io remove the prepuce entirely, by dis- secting it completely away from that part of the perns where it begins to be formed by an elongation or pro- duction of the skin, the operation might probably an- swer our expectation, but it would leave the glans al- together uncovered, which in those who have been ac- customed to have it protected by the prepuce, is apt to excite very disagreeable sensations. Neither can I determine with certainty whether it would, in every case, answer the purpose of giving complete relief or not. Where the parts are previously in a state of irri- tation, the remaining skin might contract behind the glans, so as to produce some degree of paraphymosis; at least, in one of the four cases to which I allude, a very considerable portion of the prepuce was removed, and yet the remainder contracted in such a manner as to form a stricture which gave much distress. Different methods have been proposed for perform- ing the operation of a phymosis. For these the wri- ters on chirurgical operations must be consulted, but the easiest, and perl saps the simplest of any, is that which I have described in the system of surgery,* in which the incision is made by passing a sharp pointed bistoury along a directory between the prepuce and glans, and having pushed the point of the bistoury through the prepuce near to where it begins to form, the cut is completed by drawing the instrument for- ward ; in which manner it is done, not only more neat- ly, but with more expedition, and with much more ease to the patient than in the usual way of cutting the prepuce from before backwards. In this manner the incision is always made at different strokes, by which the cut is apt to be ragged and unequal, where- as in the other it is done at once, and in any direction that the operator may incline. Some advise the incision to run on the side of the penis, and others along the back of it. The difference in general is not material, but the former appears to * Chapter X. Section r. 228 OF THE PHYMOSIS Ch. Ill, me to be preferable, from the matter either of the cut itself, or of concealed chancres not being so apt to lodge between the prepuce and glans, as when the in- cision is made on the back of the penis. It is proper, however, to observe, that there are two circumstan- ces, which in this operation, require particular atten- tion: the large veins of the penis should be avoided, and when chancres are present, the cut ought to run as near to them as with propriety it can be made, so as to admit of the easy application of proper dressings. In the treatment of the parts after the operation, some attention is necessary to prevent the edges of the divided prepuce from adhering to the glans. I have known a good deal of inconvenience produced by this being overlooked, and it is easily prevented by insert- ing a small pledget of lint between the prepuce and glans at each dressing. Paraphymosis may happen either from a stricture of the prepuce, from a swelled state of the glans penis, or from a combination of both. When it appears to depend, either altogether or chiefly, on a contracted state of the preputium, the same applications should be made to it which we ad- vised for the phymosis. By the use of warm emol- lients the stricture, when in a slight degree, may be so far removed, as to admit of the prepuce being drawn over it. After immersing the penis for a few minutes in warm milk, and rubbing the contracted parts with any emollient ointment, we may sometimes succeed by applying the fore and middle ringer of each hand be- hind the contracted part of the prepuce, and pulling it gently forward, while, with the thumb of each hand placed upon the glans, we push it firmly backward. This I have done in different instances, which other- wise would soon have ended in strictures of the most confirmed kind. It must, however, be confessed, that it is only in the commencement of the disease that this, or an) other manoeuvre of a similar kind, will suc- ceed ; and there is no room for any such attempt when |J|g disease proceeds from a tumefied state ot the glan& SeC. XII. AND PARAPHYMOSIS. 329 When the disease seems either to be entirely owing to an enlarged state of the glans, or partly to this and partly to a stricture of the prepuce, as sometimes hap- pens, we may endeavour to relax the preputium by rubbing it with oil, or an emollient ointment; but in such circumstances it is evident that the application of emollients to the glans would rather do harm. By re- laxing the parts affected they would increase the swel- ling. Cold astringent applications prove more useful, and ought alone to be depended on. In this view we advised cloths dipped in brandy, vinegar, and cold wa- ter, to be applied to the parts, and poultices, with crumb of bread, and a solution of saccharum saturni in vinegar and water. But when these do not soon suc- ceed in reducing the swelling, we are under the neces- sity of removing the stricture by an operation, in or- der to prevent the accession of more serious symp- toms. When too long neglected the glans is apt to mortify, by the contraction of the prepuce putting a stop to the circulation of the blood. This operation consists in making one or more inci- sions into the contracted edge of the prepuce. We sometimes succeed by making two or three small cuts in different parts of the stricture with the shoulder of a lancet. They ought to be carried entirely through the skin, and into the cellular substance, and when they bleed freely they commonly give immediate re- lief; but it must be admitted that these small incisions* however numerous they may be, do not prove so cer- tainly effectual as one freecut made completely through the stricture. The easiest method of doing this is, by insinuating the end of a director beneath the stricture, and cutting upon it with a scalpel. For this purpose a short directory should be used, with a groove open at the extremity. The incision here does not require any particular at- tention. The divided vessels should be allowed to bleed freely. This generally lessens the pain, while it eo -operates along with the removal of the stricture in 230 OF THE PHIMOSIS, &C. Cll. Ilf. carrying oft* the swelling. Lint, spread with un^uen- tuni saturninum, makes the best dressing for the sore. It must be remembered that we are now supposing that no disease exists in the constitution. When either of these affections are conjoined with Lues Venerea, as we often find to be the case, the patient cannot be rendered safe, nor will the sores produced by the ope- ration heal, without the assistance of a course of mer- cury. As the first symptom of an approaching fihy?nosi$ y is a thickening of the prepuce and consequently a difficulty of retraction, our first care should be to prevent it : this is most easily effected by rest in a horizontal posture, being careful at the same time not to allow the penis to assume a depending posture, as in this manner we prevent the extravasated fluid from gravitating to the prepuce, which forms the principal hindrance to its retraction. Should it at any time be found necessary to slit open the prepuce, as is often the case when matter is confined under it, a director should first be introduced and a division made with a curved pointed bistoury, from within upward. It must however be recollected that in cases of great inflammation this operation is inadmissible, as there is much risk, according to Mr. Hunter, of inducing mortification. Some modern surgeons in the treatment of paraphyrnosis, have advised the compression of the swollen gland (so as to clear it cf the blood) with the fingers of the one hand, while with those of the other the prepuce is drawn forward ; and in this way they say a di- vision of the stricture seldom becomes necessary. Should a divi- sion of the stricture become absolutely indispensable, Mr. Hunter advises us to separate the two swellings as much as possible where you mean to cut, in order to expose the constricted part ; then take a crooked pointed bistoury, pass it under the stricture, and divide it. The prepuce is now to be drawn forward, or not, as may be found most convenient, Ed. SeC. XIII. OF WARTS OH* THE GLANS, &C, 231 SECT. XIII, Of War Is em the Glans and Prepuce, and Labia PudendL THE Glans, Prepuce, and Labia Pudendi, are fre- quently attacked with warty excrescences, on the termi- nation of Gonorrhoea. 'They sometimes appear during the continuance of the discharge, but more commonly at the end of it, when the patient having considered fhe cure as complete, is surprized with the appearance of this new symptom. They rise at first in the form of small points, which gradually become larger, and frequently so numerous as to cover a considerable part of the penis. In men they commonly begin immediately behind the glans, and extend, in the form of a ring, round the whole pe- nis, near to the junction of the glans and prepuce. They afterwards appear indiscriminately on ail the neigh- bouring parts, but they are usually more numerous upon the prepuce. In some cases they are first perceived in the urethra. The patient complains of an obstruction to the flow of urine, and on separating the lips of the urethra, a red, florid excrescence is observed to be the cause of it. I have also met with productions of this kind in the ure- thra of women. These warts are seldom painful ; never, unless they proceed to a state of ulceration, which, when they do, is always to be considered as the fault of the patient. On their first appearance they are always firm and entire,- but when they become numerous, if they be not regu- larly cleaned, the moisture natural to these parts be- comes acrid, and renders them tender ; and this, if it be not prevented by timeous assistance, soon terminates in painful ulcers. Excrescences of this kind assume various forms. For the most part they are single, and pendulous, with narrow necks, but in some instances they have broad bases; while, in others, a number of these smaller warts sprout all from the same root, and form excrescences of unequal cauliflower surfaces. 23£ OF WARTS ON THE GLANS When long neglected, as sometimes happens with poor people, they acquire such a bulk as to cover the glans entirely ; and when in this state they become ulcerated, the whole mass assumes such a diseased appearance, as with those not accustomed to this branch of business, gives a suspicion of their being cancerous. Of this I have met with different instances, where the penis, af- ter being doomed to amputation, has been saved, and the warty excrescences removed. It is difficult, perhaps impossible, to ascertain the cause of these warts. In some cases they are obvious- ly produced from the cuticle, their attachment being so slight, that on being removed, the cutis vera, is left en- tire : in others they proceed from the skin itself, but I never observed them to go deeper than this. Whatever tends to excite the flow of an unusual quantity of blood to the penis, seems to create a dispo- sition in these parts to formations of this kind : hence they succeed to various kinds of irritation. We know that they are a frequent consequence of the venereal irritation, for they often succeed to chancres ; and I have known them in different instances succeed to sim- ple excoriation, where neither Gonorrhoea nor Lues Ve- nerea ever existed. By whatever cause irritation is produced in the prepuce and glans, it seems to excite a disposition in the small blood vessels of the parts to sprout or pullulate, by which these warty productions appear to be formed. As warts on the genitals are a frequent consequence of chancres, they have been always considered as of a venereal nature, whether they are the immediate ef- fects of chancre, Gonorrhoea, or any other cause. This opinion, however, is by no means well founded. Warts on these parts may, no doubt occur, while Lues Vene- rea exists in the constitution ; and in such instances mer- cury must be given before a permanent cure can be ex- pected. But in a great proportion of cases, at least ninety-nine of a hundred, they appear to be entirely local, insomuch that remedies acting only upon the constitution have no influence whatever in removing them, while they are for the most part, easily carried See. XIII. AND PREPUCE, &C. &$S off by a variety of applications, which act solely upon the excrescences themselves, or rather upon the vessels by which they are produced. Nay, they are so evi- dently of a local nature, that when they occur in Lues Venerea, although they are very apt to return when removed while the infection exists in the constitution, yet it is very certain that this disease of the habit may be complete!} eradicated without any effect being pro- duced upon them. The warts which succeed to chan- cres commonly remain equally firm and obstinate after mercury has been given as they were before, and are to he removed by the same means as if the constitution had never been affected. This, I may observe, is a point which in a particular manner merits the attention of practitioners; I mean of such as are not daily ver- sant in this branch of business ; for while the opinion is retained, as is still the case with some, of warts on these parts being in most instances connected with Lues Venerea, much mischief is apt to be done by a great deal of mercury being given where no advantage can ever be derived from it. In the treatment of this af- fection I have known the constitution almost ruined by one course of mercury after another, without any ef- fect upon the warts, and which were afterwards easily and speedily removed by remedies applied directly to the parts themselves. I have mentioned irritation as a cause of these ex- crescences, but it is only the slighter kinds of it that seem to produce them. They often succeed to a slight degree of inflam nation, but I have never known them form on parts highly inflamed : on the contrary, much inflammation seems to destroy the tendency in these parts to the production of warts, insomuch, that our most effectual remedies in the cure of these excrescen- ces, and for the preventing a return of them, are such as always excite a good deal of pain and inflammation. They may no doubt be removed more quickly with a scalpel or scissars, by tying ligatures of waxed silk round them, when they are pendulous, and have nar~ row necks, but they are more apt to return when re* 30 254 OF WARTS ON THE GLANS. Ch. III. moved in this manner, or even when they are destroy- ed with caustic, unless some decree of inflammation has at the same time heen induced upon the parts. Be- sides, ligatures cannot be applied to warts with a broad base, which they frequently have; and few patients will submit to the use of the scalpel for the extirpation of the numerous warts, which in such instances for the most part prevail. Inflammation for the purpose of removing warts might be excited in various ways ; but we necessarily prefer that which is the easiest to the patient, and which at the same time proves effectual. We some- times succeed by bathing the warts and contiguous parts three or four times a day with a strong solution of crude sal ammoniac, or of corrosive sublimate. And a solution of mercury in the spirit of nitre at the same time that it acts upon the warts themselves as a caus- tic, seems also, by exciting inflammation in the vessels of the contiguous parts, to remove or destroy the dis- position which first produced them. Prescriptions are given for these solutions in the Appendix, Nos. 39, 40, and 41. The two former may be used with freedom, but the strength of the latter renders it necessary to apply it with much delicacy and attention. The parts should be merely moistened with a pencil dipped in it, nor should this be repeated above once e^ery second or third day. Tincture of cantharides, applied in this manner, sometimes answers; but we find by experience, that our success is more certain from the application of such powders as irritate and inflame the skin, than from the use of the same remedies in a liquid form, Savine in fine powder is one of the best for common use Common mustard, whether of the white or black kind, likewise answers; and I have known the powder of betony, and of white hellebore, both separately, and mixed in equal quantities, prove successful. It the warts and skin lying between them be sprink- led over with any of these daily, a sufficient degree of inflammation, is, for the most part, soon induced, and Sec. xiiL akd prepuce, kd 235 we know that it has gone far enough when some of the smallest begin to shrivel and drop off* At this time we ought therefore to desist from any further use of the powder, always taking care to renew it from time to time, if the inflammation subsides before the excrescences are entirely removed. In few instances, the warts sprout up again after they were altogether carried off. When this takes place, the powder should be again applied over the whole seat of the disease, and continued till such a degree of inflammation is in- duced as the patient can easily bear. They will sel- dom or never return again, if the parts at this second application of the remedy have been made to inflame sufficiently. These powders, even in a simple unmixed state, ve^ ry seldom fail, but in some patients the warts are so firm, and the skin of the prepuce so thick and corru- gated, that powders of a more powerfully irritating nature become necessary* In such cases a small pro- portion of red precipitate, finely levigated, being ad- ded to the pulvis sabinse, commonly answers. Calo* mel sometimes proves effectual, whether used by itself, or mixed with any of these powders, and a pow- der composed of equal parts of alumen ustum and mercur. precip. ruber, seldom fails. Even when warts are seated in the entrance of the urethra, they may be treated in this manner, at least I have often removed them in this situation by theappli-* cation of these powders, and I never knew any harm produced by them. In one instance when the wart was farther up the urethra than usual, the excrescence was completely removed by the puhis sabinse alone, but a considerable degree of pain was induced by it, which ended in a very copious puriform discharge* The urethra became tender and inflamed, through the whole length of it, and the running having all the ap- pearance of the matter of Gonorrhoea, I suspected that a new infection had been communicated. My patient, however, assured me that this could not possibly be the case, as he had not for many months had any connec- tion with women, and there wag no cause to doubt his 236 OP GONORRHOEA SIMPLEX, Ch. Ill* assertion. The running: continued for tlie space of two or three weeks, with all the symptoms of a common clap, and was cured precisely in the same manner, viz. by the use of astringent injections. We have succeeded in removing warty excrescences of every description, including those of a venereal nature, by the application of the undiluted tincture of the oxymuriate of iron. This remedy apparently acts solely by its powerful astringent properties ; and we have observed that they are much less liable to recur after re- moval by this remedy, than after the stimulant and corrosive appli- cations of Mr. BelL Ed SECT. XIV. Of Gonorrhoea Simplex, I HAVE endeavoured in different parts of thie work to slew that the discharge in Gonorrhoea Viru- lenta is the effect of inflammation excited in the ure- thra and contiguous parts by the matter of infection being applied to them. In the end of the preceding section a case is mentioned, in which symptoms occur- red exactly similar to those produced by Gonorrhoea Virulent a from the application of an irritating powder to the urethra ; and there is reason to suppose that they may at any time be induced by whatever excites in- flammation in any part of that membrane. A puri- form discharge from the urethra, induced in this man- ner, and without any connection with an infected per- son having taken place, may be denominated Gonor- rhoea Simplex, We have already had occasion to see that a discharge frequently occurs in females, usually termed fluor al- bus, which, in particular circumstances, very much resembles Gonorrhoea Virulenta** * Vide chapter ii. section 10- SeC. XIV. OF GONORRHOEA SIMPLEX. 237 In men, we often meet with a disease exactly similar to this ; where a copious discharge of matter takes piacc from the urethra, attended with a scalding heat in voiding urine, and all the other symptoms of Gon- orrhoea, and where there is no suspicion of infection being communicated. There is nothing more necessary than for practition- ers to be aware of this, particularly the younger part of the profession, who are apt to suppose that every discharge of matter from the genitals, especially in men, ought to be considered as venereal. But al- though this is undoubtedly true in a great proportion of cases, yet every practitioner of experience must have met with many instances of the reverse, and in which the reputation of the most virtuous people might have been ruined, were the distinction of which we are now- speaking overlooked. I have met with different in- stances of men newly married being seized with this symptom, in some of which, although there was at first sight much cause for suspicion and anxiety on the part of the husband, yet on being informed by a per- son on whose judgment they placed confidence, that a running of this kind is not unfrequently induced by other causes, and that the discharge which liad newly taken place, would probably shew 7 , by its ending more quickly than Gonorrhoea Virulenta usually does, that it uas of a different nature, they soon became less anxious, and at last were convinced of their fears hav- ing been altogether groundless. In like manner, I have in different instances been consulted by women, who, on finding their husband's linen stained with matter, have fancied that they them- selves had been injured by them; and the imagination being once affected, we all know how difficult it is in such matters to set it right. I was some time ago con- sulted by a lady in circumstances of this kind, who, from the cause I have mentioned, had long been redu- ced to a state of the greatest distress and misery. Her mind was in the first place deeply afflicted with the supposed misconduct of her husband ; and she wa$ 238 OF GONORRHOEA SIMPLEX. Ch. lit fully convinced that she herself laboured under almost every symptom which attends the venereal disease* To this she was in a great measure led, by the opinion of a midwife, who unfortunately informed her, that from much experience in matters of this kind, she w 7 as con- vinced that she was poxed, and desired her to apply to me. Instead of this, she put herself under the care of one at a distance from town, where she resided, and who, from not having much experience in matters of this kind, was easily induced to believe that symptoms took place which did not exist but in the imagination of the patient. There was no external mark of dis- ease, but she complained of pains in her bones; se- vere pains in the parts of generation and loins ; uneasi- ness in the nose, throat, &c. In short, she had perused a modern treatise on the Lues Venerea, by which she had become acquainted with the symptoms of that dis- ease, almost all of which she now imagined that she laboured under. A complete course of mercury, besides a variety of other medicines, were given in the country, but no ad- vantage being derived from them, the patient came un- der my care. It appeared at once that she was diseas- ed in imagination only, for I did not find, on the most minute inquiry, that any symptom of the Lues Venerea had existed from the first. She acknowledged, that at different times, both before and after marriage, she had been much distressed with the fluor albus ; but this was the only disease of which she ever complained ; and it never was of long continuance. I endeavoured to convince her that she was perfectly sound, that she never had the disease, and that the matter which she had seen on her husband's linen, and which was the only foundation of her suspicion, was either produced by his connection with her while she was distressed with fluor albus, or by some other cause of a nature equally innocent. All this, however, would have proved ineffectual, but I luckily had an argu- ment in my power which brought conviction along with it, and which in the course of a few days, made SeC. XIV. OF GONORRHOEA SIMPLEX. 239 all her symptoms vanish, which otherwise might have been of the most permanent nature. At the very time when she suspected her husband to have given her the infection, he had consulted me by letters, which I preserved, in which he expressed his astonishment at the sudden appearance of a discharge of matter from the urethra, accompanied with heat and uneasiness along the whole course of the passage from the glans to the bladder. He never had been infected with Gon- orrhoea, and having had no connection with any other woman than his wife, of whom he could not entertain the least suspicion, he concludes his first letter by enquiring whether or not such symptoms ever originate from other causes than intercourse with an infected person, and at the same time wished that such medicines might be sent to him as would as quickly as possible put a stop to the discharge. In my answer to this, which I also preserved, I mentioned several causes by which a discharge from the urethra may be excited, and especially the effect of repeated intercourse with wo- men labouring under fluor albus, where the discharge is more acrid than usual. I at the same time sent him an astringent injection, desiring that it might be used if the discharge did not soon disappear. In a subse- quent letter he informed me that he had been perfectly convinced by. my account of it that his disease was of an innocent nature; and as a proof of it he mentioned, that it went entirely off in the course of eight or ten days, without the injection, or any other remedy, be- ing employed. A sight of this correspondence, which I was enabled to shew, could alone remove the distress under which my patient had long laboured. I have since that period had occasion to know that her husband has at different times had a return of the discharge from the urethra, in some instances from ex- posure to much cold, fatigue, or wetness, and repeat- edly from connection w 7 ith his wife when she laboured under fluor albus. This happened with a patient w T ho never before had any discharge from the urethra ; but a running is more 240 OF GONORRHOEA SIMPLEX. C!l. HI. particularly apt to occur from causes of this kind, in such as have been frequently liable lo Gonorrhoea Vir- ulenta. I know many of this description who uniform- ly experience a return of the discharge on being; ex- posed to much bodily fatigue, particularly much rid- ing on horseback, orjoltingina carriage on a rough road, on (heir being overheated with wine, or having more connection than usual even with sound women. The irritation excited in the urethra by a stone in the bladder will, in some instances, induce a very co- pious discharge of matter. When this takes place from the bladder itself, the matter comes off mixed with the urine, and in no other manner; but when it proceeds from the urethra only, as often happens, it assumes all the appearances of Gonorrhoea Virulenta, and passes off whether any exertions be made to emp- ty the bladder or not. We are led to understand that people who are much employed in working among the warmer kind of spi- ces are very liable to a scalding in making water ac- companied with a discharge of purulent-like matter from the urethra. It is more particularly apt to occur in those who work chiefly among Cayenne pepper: Nay, it has been known to happen from a person car- lying a few pounds of this article about with him for sale. The most frequent cause of strictures in the urethra is Gonorihcea Virulenta; but they also occur from other causes. They have been met with in all periods of life, even where patients have never had any pre- vious discharge from the urethra. They are particu- larly apt to occur in people advancing in years, be- tween the sixtieth and seventieth year of age and some- times later. A person who in his youth has suffered much with Gonorrhoea Virulenta, is very liable to be attacked about this period with strictures in the ure- thra but, i hey likewise iiappen, as I have observed above, where no car.se of this kind can be given for ■them; and in whatever manner thev are induced, they SeC. XIV. OF GONORRHOEA SIMPLEX. 241 are very constantly attended with a plentiful discharge of purulent-like matter. In some, these strictures have been attended with such a concurrence of circumstances, so similar to those which occur in Gonorrhoea, that the best practi- tioners have at first been deceived with them. Where the irritation in the urethra has been considerable, sym- pathetic swellings have occurred in the glands of the groin; and one or both testicles have swelled from the same cause. It is generally known, that a discharge may at any time be excited from the urethra, by the use of stimu- lating bougies. This has in different instances been put in practice, where violent pain and other bad symp- toms have been induced by the sudden stoppage of a Gonorrhoea, but it has also been advised for the same purpose, that is, for exciting a discharge of matter, merely for the removal of pain, where neither Gonor- rhoea nor any venereal symptom had ever taken place; and it has never failed when the stimulus is of a suffi- cient strength of being attended with this effect. We are informed by authors, that gout has in some instances been productive of a discharge of puriform matter from the urethra ; and I have not a doubt of its happening in rheumatism. Of this I have met with different well-marked instances, where a flow 7 of mat- ter from the urethra has alternated with pains in the knees, and other large joints; and among labouring people accustomed to work much in water, such as ditchers, a discharge of this nature is by no means un- frequent. A patient of mine, who annually takes a great deal of exercise in following game, is always seized with a discharge of matter from the urethra when he goes in search of ducks, by which his feet and legs are kept immersed in water for several days together. Other causes might be mentioned, by which a dis- charge from the urethra is at times produced, in every respect similar to the matter of Gonorrhoea Virulenta, but these are sufficient to shew that it mav frequently 31 242 OP GONORRHOEA SIMPLEX. Ch. Ill, occur from causes of ' the most innocent nature, and in persons entirely blameless. Of this, all who have done much business in this branch of practice will be easily convinced, as instances of it are often occurring ; but the distress which the want of discrimination in mat- ters of this kind is apt to excite, is often so great, not to individuals alone, but to the families with which they are connected ; and I have happened to meet with so many disagteeable occurrences of this kind, which might easily have been prevented, that I judged it proper in this manner to take particular notice of it. The fact being established that all the usual symp- toms of Gonorrhoea Virulenta may be excited by a variety of causes, may be considered as an additional proof of the matter of Lues Venerea, and of that disease being different ; for although the matter produ- ced in this manner in the urethra is so similar to that of Gonorrhoea communicated by impure coition, that the one cannot be distinguished from the other, yet no person ever imagined that the symptoms of Lues Ve- nerea could be produced by any of these, n^r by any cause whatever, but the absorption ol the matter of that disease itself. It may also be remarked, that this opinion of the difference between these two diseases is farther con- finned by the method of cure being the same, what- ever may have been the cause of the running. Whe- ther the matter discharged from the urethra be excited by infection communicated by a person labouring un- der Gonorrl oea Virulenta, or by any of the causes I have enumerated of Gonorrhoea- Simplex, the method of treatment might not to be varied. It is true that the latter will, for the mos! part disappear, whether any remedy be employed for it or not ; but this will also happen with Gonorrhoea Virulenta. A cure, how- ever, will be obtained much more speedily by a time- ous and proper use of injections than inany other man- ner ; and if this is admitted in one variety of the dis- ease, it will be found equally applicable in the other. So far, indeed, as my observation goes, the discharge SeC. XIV. OF GONORRHOEA SIMPLEX. 243 in Gonorrhoea Simplex is not more readily affected by the internal exhibition of medicines than we have shewn to be the case in Gonorrhoea Virulenta, while a proper application of an astringent injection very seldom fails in removing it. When, however, it seems either to depend upon general debility, or to be much connected with this state of the system, we find from experience that cold bathing, and whatever tends to restore the loss of time that has taken place, proves more obviously useful here than in Gonorrhoea Viru- lenta. « Such a complaint," says John Hunter, " as a discharge (from the urethra) without virus is known to exist by its coming on when there has been no late connection with women and likewise by its coming on of its own accord where there had never been any vene- real complaint, nor any chance of infection." Having neglected the opportunity which occurred in the early part of this volume, of offering some remarks on the subject of Ophthalmia as proceeding from Gonorrhoea Virulenta, wc now pro- ceed to notice it. It will not be much misplaced", since Gonorrhoea Simplex is frequently productive of the same disease, and the ob- scurity which appears to envelope the history of both, leaves us only the power of stating a few opinions which of late years have been introduced into notice by writers of some celebrity. That Ophthalmia Of a violent kind sometimes occurs from a sup- pressed Gonorrhoea, is not only the opinion of our author,* but of other medical writers, among whom we may name Van Swieten. Swediaur, Plenek and Scarpa. — The symptoms are peculiarly vio- lent, the tunica conjunctiva and eye-lids become highly inflamed, there is great intolerance to light, a purulent discharge from the eye similar to that which had been suppressed in the urethra, and not unfrequentiy the disease becomes so deep seated, as to destroy the organ. Cases of this kind are related in which the suppression of the Gonorrhceal discharge proceeded from the use of astringent injections, and it has been observed that the ophthalmia chiefly occurs in the inflammatory state of Gonorrhoea! — Swediaur remarks that the disease has never occurred in women. The method of cure should be of the most speedy and powerful kind. Frequent bleed- * See page 29. f Edmonston on Ophthalmia. Mr. "Ware has however observed, that it com- monly appeared some time after the exhibition of mercurials for the cure of Gonorrhoea and the Editoi-s of the Edinburgh Med. and Surg. Journal remark that in a most violent case which occurred to them, and m which there was a. total destruction of the eyes, the Gonorrhoea! discharge was not suppressed 2H OF GONORRHOEA SIMPLEX. Ch. IIL ings, powerful purges, and in fact all the agents calculated to di- minish inflammation are indicated. In spite of these Dr. Edmon- ston observes, that " the disease often runs its rapid course without being apparently affected by any application, and the loss or recovery of sight seems to depend entirely upon the comparative mildness or severity of the attack." Mr. Ware, a surgeon of eminence in England has advanced an opinion in a late publication, that the disease, called Egyptian Oph- thalmia, which proved so destructive to the army serving under Sir Ralph Abercrombie, both during and subsequent to the campaign, is intimately connected with and resembles the Gonorrheal Ophthal- mia, particularly since he has observed in most of the cases a con- nection between the ophthalmy and a morbid affection in the urinary canal : — He also argues their identity from a resemblance in the course of the disease. In reply it has been urged that the symp- toms in Gonorrhceal Ophthalmia are rarely of so violent a nature in proportion to the frequency of the complaint, whilst in the Egyp- tian disease, the sufferings of the patient are almost intolerable, and blindness is a common consequence. By some writers, the latter disease is sup posed to originate from a specific contagion, and it is objected that if a transfer of matter from the urethra to the eye was the cause of it, it would have occurred much more frequently.— The subject requires further investigation in order to place either opinion on a firm basis. For some ingenious remarks on the sympathy supposed to exist between the urethra and the eve, we refer the reader to Edmonston's Treatise on Ophthalmia, in which the probability of the disease ori- ginating in some cases from the direct application of the Gonor- rhoea! matter is also investigated. Ed, KM) OF THE FIRST VOLUME TREATISE on GONORRHOEA VIRULENTA, AND LUES VENEREA, BY BENJAMIN BELL* &IJTBER «F THE ROYAL COLLEGE OF SURGEONS OF IRELAND AND EDINBURGH/ ONE OP THE SURGEONS TO THE ROTAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. WITH NOTES, .frDAPTED TO THE PRESENT STATE OF PRACTICE IN THOSE DISEASE?, VOL II. ALBANY : PUBLISHED BY E. F. BACKUS, KO, 65, STATE-STREET, 1814, TREATISE ON GONORRHOEA VIRULENTA, AND t LUES VENEREA. CHAPTER IV. ON LUES VENEREA. SECT. I. General Observations on Lues Venerea. THE Lues Venerea, Syphilis, or Venereal Disease, was first described with accuracy by the authors who flourished about the end of the fifteenth century. This induced many to imagine that it was not previ- ously known in Europe; and Columbus with his fol- lowers having about this period returned from their first expedition to the West Indies, it has been suppo- sed that they brought this disease along with them. That the venereal disease might be met with by Columbus when he first landed in Hispaniola, I will not dispute. Like many other diseases, it might not be peculiar to one set of people, or confined to one hemisphere of the globe; but mrny arguments might be adduced to shew that it was well known in the old continent, and that it prevailed among the Jews, Greeks, and Romans, and their descendants long be- fore the discovery of America. This would lead, however, to a great length of discussion ; and being 8 GENERAL OBSERVATIONS, Cll. IV C more a matter of curiosity than of real utility, I shall not enter farther upon it at present. Various definitions have been given by Nosologists of Lues Venerea, but the symptoms of the disease are so numerous, and the appearances which it assumes are so complicated, that no definition sufficiently com- prehensive and accurate, can be given of it. In some instances it appears in a particular spot only, and con- tinues apparently local for a great length of time ; while in a great proportion of cases it soon contami- nates the whole system, producing a greater variety of symptoms than perhaps any other disease with which we are acquainted. Different opinions have prevailed respecting the manner in which Lues Venerea may be communica- ted, but it is now certain, that it can be produced in no other way than by direct application of the matter of contagion to the surface of the body ; or by passings as other hereditary diseases do, from parents to their children. The virus cannot be carried, as was once imagined, from one person to another by the atmos- phere, but it may be applied in various ways so as to communicate the disease. 1. In a great proportion of cases the disease is giv- en by one person to another in coition. The venereal matter resting upon one or more points, excites small inflammatory pimples termed chancres, from which it is carried by the absorbents into the system, for the most part producing, in its way, obstruction and swel- ling in the contiguous lymphatic glands; and thus forming buboes in the groins. 2. It is frequently given by a diseased child to a nurse, in which case the nipples first become sore, and the matter as it passes into the circulation, excites swellings in the glands of the axilla. 3. An infected nurse can scarcely give suck with- out communicating the disease to the child. When this happens from venereal sores in the nipples, sores of a similar nature form on the lips of the child, and the matter from thence is taken up by the absorbents. But a child may a!?o be infected merely by sucking Sec. I. ON LUES VENEREA. 9 the milk of a diseased worrlan. In this case, the dis- ease does not always appear at first about the mouth of the child : It proceeds more readily to contaminate the system than to produce any local effects, Many indeed allege that the disease cannot be communica- ted in this manner, and are of opinion, that a child can- not be infected merely by the milk of a nurse; I am convinced, however, from a variety of facts, that the opinion I have adopted is well founded ; but we shall have occasion to consider it more particularly here- after. 4. The foetus may also be infected as it passes from the uterUs by the matter of venereal sores in the pu- dendum of the mother. Of this I have known differ- ent instances. In such cases, one or nrrore sores first appear in particular parts, from whence the matter is carried by the absorbents into the system. 5. I have known different instances of the disease being given to midwives in delivering women with venereal sores about the pudendum. 6* In whatever manner the matter of Lues Venerea is applied to a wound, or to an inflamed or ulcerated surface, the disease will, in a great proportion of cases, be produced. Surgeons, in dressing venereal sores, are -sometimes infected in this way ; and the disease has been communicated by performing the operation of blood-letting with a lancet that had previously open- ed a bubo. 7. Although we find in most instances of this dis- ease, either that the matter has been directly applied to a wound or to an ulcer, or that by its own acri- mony it had induced both inflammation and suppura- tion before absorption took place, yet cases some- times occur in which nothing of this kind can be dis- covered, and where the matter is absorbed while both the cutis and cuticle remain entire, This will most readily happen where the cuticle is thin, as is the case in the glans penis and lips. Hence the sys- tem has, in different instances, been infected by mat- ter left upon the lips in kissing, and in drinking out VOL. II. 2 10 GENERAL OBSERVATIONS Ch. IV. of a cup recently used by an infected person, and in some of these without any ulceration being induced. This mode of receiving venereal infection is not a frequent one, but as I have met with it in various in- stances, while the possibility of its existence is deni- ed by many, I thought it right to mention it, in order to prevent those mistakes, and that mischief in prac- tice which might arise from the prevalence of such an opinion. So readily does the venereal poison enter the sys- tem, that it can scarcely be applied to any part of the surface of the body but with considerable hazard. For the reasons that I have mentioned, absorption will occur with more certainty in some parts than in others ; but I know, from various facts, that scarcely any part of the skin is too thick to prevent it, particu- larly if the parts have been rendered tender or irrita- ble, either by inflammation or any other cause. Nay, it sometimes happens where no affection of this kind is perceived. In two instances buboes occurred in the axil la, and the patients were poxed by the matter of venereal sores being applied to the fingers where the skin was sound ; and in another, the disease was communicated by the patient wearing the same breeches which he had used three months before, when labouring under extensive venereal sores of the penis and scrotum, but of which he had been entirely cured. He knew that some of the matter had occa- sionally dropped upon the breeches, but this did not occur to him till the disease appeared about the time I have mentioned, in the form of a large ulcer on the upper part of the penis, and without even the possibil- ity of his having received the infection in any other manner. It is somewhat remarkable that the venereal virus should so readily enter the system when applied to any part of the surface of the body, when we find, from a variety of facts, that the absorbents of the stomach and intestines do not receive it. The mat- ter of venereal sores, when mixed with water used for washing them, has, in various instances, been Sec. I. ON LUES VENEREA. J 1 swallowed by mistake ; but we have no instance of pox being produced by it. , In whatever way the matter of Syphilis is applied to the absorbents, when it has once entered the sys- tem, the effects which result from it are nearly the same; but at present, I mean, in a great measure, to confine the description of the disease to its rise and progress in the most ordinary form of it, where the in- fection k communicated by one person to another in the act of coition,, The plan which I mean to pursue is, in the first place, to give an account of the different symptoms of Lues Venerea in the order in which they commonly appear; and as our being able to ascertain the appear- ance of every symptom with as much certainty as pos- sible is an object of the first importance, I shall de- scribe each symptom under a distinct head, and at the same time shall point out such circumstances as most clearly serve to distinguish it from other affections to which it bears a resemblance. 2. I shall offer a few observations on the nature of the venereal poison. 3. An account of the different remedies used in Lues Venerea, particularly of mercury, and its prepa- rations. 4. I shall treat of the employment of these remedies in the different symptoms of the disease. 5. Of Lues Venerea, as it appears in new-born in- fants. 6. Of some peculiarities of form under which this disease has appeared in Scotland and in Canada. 7. I m^an next to treat of prophylactics, or the means of preventing infection. 8. To consider how far Lues Venerea is ever pro- ductive of other diseases ; and, 9. To give in an appendix formulae of the medicines enumerated in the preceding parts of the work. • 12 OP THE SYMPTOMS Cil. IV, SECT. It Of the Symptoms of Lues Venerea. \ J J. General Observations. THE venereal disease appears occasionally, as I have already observed, in a great variety of for ins. For the most part it occurs locally at. .first upon some part of the surface of the body, usually upon the ge- nitals, from whence it proceeds, and commonly with some regularity, to affect every part of the system, In others, the first symptoms which take place indi- cates an affection of the constitution, and the disease, instead of appearing upon the surface of the body, af- fects either the throat, bones, or tendons. When Lues Venerea is not interrupted in its pro- gress by the use of mercury or other remedies, the fol- lowing is the order in which the symptoms commonly appear, viz. chancres ; buboes; ulcers and inflamma- tion in the throat; ulcers in the mouth and nose; erup- tions, or blotches, on the surface of the body; ulcers in different parts; nodes, and swellings in the perios- teum, bones, and tendons; excrescences about the anus; swellings of the testes; loss of hair from all parts of the body; blindness, loss of hearing, and oth* er anomalous symptoms. In this order I shall proceed to treat of them. $ 2. Of Chancres. The first effect which usually results from the ap- plication of the matter of Lues Venerea to any part of the surface of the body, is a slight degree of inflam- mation. The part becomes itchy, red, and in some degree painful ; and nature endeavouring to wash away the irritating cause, a quantity of serum is thrown oyt under the cuticle, in the form of a small bqil or SeC. II. OF LUES VENEREA. 13 pimple. This soon bursts, and leaves a sore of a cor- responding size, foul and sloughy at the bottom, with hard retorted edges, and which, from the corroding appearance which it assumes, has by the French been denominated Chancre, a term which we have also adopted. Chancres do not appear at any certain period after the application of the virus 1 have known them form in less than twenty-four hours, while in others six weeks have elapsed. Three or four days is the most frequent period. The patient at first feels a sense of litulation over all the glans, and this is often produc- tive of a frequent desire to void urine. On examin- ing the parts some degree of tenderness is often per- ceived over the whole, but the chancre itself is seldom at first larger than a millet seed. The cause of chancres appearing at such different periods after the matter of infection has been commu- nicated, is not always obvious ; but we may suppose it to depend in some degree upon the acrimony of the matter, and this again upon the matter being more or less diluted with serum, mucus, or pus. It may also in some measure depend upon the state of the parts to which the matter is applied. As these are more or less irritable, inflammation will more or less readily take place from the application of the virus ; and where the parts to which it is applied cannot be irritated, and where inflammation is not therefore produced, no chancres will ensue. Chancres appear occasionally over all the external parts of generation, and in some instances, even on the contiguous parts. I have known them form over the whole scrotum, on all parts of the penis, and even on the lower region of the abdomen, immediately above the pubes. They may indeed form on all the soft parts of the body, "but they are most frequently seated on the glans penis, and on the preputium near to its connection with the glans; the former being cov- ered with cuticle only, and the latter being a thin pro- duction of the cutis vera, both are easily made to in« flame. We also remark that chancres are frequent 14 ' OF THE SYMPTOMS Ch. IT. about the frcenum, from the doublings of the skin be- ing here particularly apt to retain the matter by which they are produced. In some instances they form on the very point of the glans, and even altogether within the verge of the urethra. Here, as well as when near to the frcenum, they prove always more troublesome, and more difficult of cure, than in other parts of the penis. There is sometimes only one chancre, but for the most part we meet with two, three, or even more; nay, in some instances, they cover the prepuce almost entirely. In this case, when they run into one ano- ther, none of them are distinct, and the whole, when thus connected, give the appearance of a foul ulcer, with hard edges, an unequal surface, and discharging a foetid, ill-conditioned matter. The colour, quantity, and consistence of the matter of chancres is exceedingly variable. It is usually of a dirty green colour, and often tinged with red, the consistence thin, and the quantity large in proportion to the size of the sores. This last circumstance may be owing to the contiguous parts being apt to inflame, and although not ulcerated, to afford matter which we cannot easily discriminate from the discharge of the chancres. In a great proportion of cases the appearances of chancres are so nearly the same that no person of ex- perience can be under any doubt concerning them ; but, as they sometimes vary in size, form, and other circumstances, some discernment is occasionally re- quired to distinguish between them and sores of a dif- ferent kind. The diagnosis of chancres is indeed a point of much importance in practice. We are apt to conclude that every sore upon the genitals is of a ve- nereal nature, a circumstance which has subjected many to much inconvenience and distress. Mercury is commonly prescribed, but where the case is not ve- nereal no advantage is derived from it, and the patient, after a tedious and painful confinement, finds the sores in no better state than at first. In all such affections we Sec. ir. of lues venerea, 15 should recollect that the penis and contiguous parts are liable to excoriations, pimples, and other eruptive com- plaints, equally with the rest of the body ; nor should we too rashly suppose, as is frequently done, that all such appearances proceed from a venereal cause. It is not often indeed that we can be in doubt upon this point, for chancres, in most instances, are so distinctly marked that there is no room to hesitate concerning them ; but where they do appear in a doubtful form, and especially if the patient has been liable to affec- tions similar in appearance, and where no venereal taint could be suspected, some time should always be allowed to pass before any decisive opinion is given, When sores of this kind are of a siaiple, innocent na- ture, they usually heal in the course of a short time, merely by being kept clean, while they will gradually become worse, if they are venereal, if mercury be not employed, or if they are not treated with eseharotie or astringent applications. In all such circumstances no remedy should be made use of that can either pro- mote or retard the cure of the sores, till we are ena- bled by farther observation to ascertain of what na- ture they really are. We are most apt to dnubt of the nature of these sores, when, instead of being small and circumscribed, they spread and occupy more space than chancres usu- ally do. A real venereal chancre is seldom so large at first as the base of a split-pea, and the edges of the sore are elevated, somewhat hard, and painful ; but although this is very commonly the case, yet, in a few- instances, it is so much otherwise, that instead of a small circumscribed sure, we observe a slight superficial ulceration, not attended either with pain or hardness, and which, by the consequences alone, we find to be venereal. In all such cases certainty will be obtained from time and observation, and in no other manner. Nor can any harm ensue from a short delay ; for while this will commonly determine the question, the same course of treatment will afterwards prove effectual which would have done so at first ; and in this man- ner sores may be often cured in the course of a few 16 OF THE SYMPTOiYife th. Vti days, in which, if a course of mercury had once been entered upon, confinement for several weeks would have been judged adviseable. Besides the variety of chancres which I have men- tioned, there is another, which it is proper to notice* Instead of appearing in the form of small circumscri- bed pimples, or superficial sores, such as I have de- scribed, they become suddenly elevated into extensive vesications* In these, a thin, clear lymph is some- times contained ; but more frequently the lymph is tinged with blood. The livid appearance with which this is accompanied gives at first cause to suspect that mortification may ensue, and accordingly chancres of this description have usually been judged to be of a more dangerous nature than others. I have not found, however, that this is the case. Their colour seems to depend entirely on the quantity of blood mixed with the serum which they contain, and on their contents being discharged, and the cuticle removed, the parts beneath have the appearance of a clean, ex* coriated surface^ without being afleeled in any other manner. When chancres are properly treated from their commencement, they commonly assume a healing ap- pearance in the course of a few days ; but in some in- stances owing to neglect, in others to some peculiarity of constitution, and perhaps occasionally to the mat- ter of infection having been particularly virulent, in stead of becoming clean, and of a red, healthy com- plexion, and which they always do before a cure takes place, they become daily more foul, and at the same time more extensive, and if their progress be not stopped by a judicious external treatment, combined with a proper course of mercury, they proceed to form sores of a very considerable magnitude. The danger from these, when seated in the preputium, is inconsiderable; but in the glans, this variety of chan- cre is apt to go to such a depth as to prove very alarm- ing. The danger is sometimes great from the hcemor- ihages with which they are accompanied, and we are often astonished at the rapid progress of the sores, In Sec. iio of lues venerea; 17 some instances (hey extend so quickly as to destroy a great part of the penis in the course of a few days. This rapid progress, which chancres in some instances make, is, for the most part, supposed to depend upon some peculiarity in the constitution of the patient ; for, in general, chancres remain circumscribed, and nearly stationary, for a great part of their duration. But I have reason to think, that in some instances it proceeds from the nature of the matter by which they are pro- duced: I conclude that it is so from chancres of this description being much more frequent at particular times than at others, and from observing them at the same time in different people receiving the infection from the same woman. About two years ago I met with more instances of this phagedenic chancre in the space of three or four months than I had seen for sev- eral years before, and in four of them the infection was traced to the same woman : The chancres in all of them appeared early, and made such rapid progress that very troublesome haemorrhages occurred from them in the space of three or four days from their first appearance; and in a small town to which I was lately called for an alarming haeuiorrhagy, produced by an ulcer of this kind, the surgeon in attendance informed me that in the space of a few weeks he had met with three instan- ces of the same nature, in which the infection was also traced to the same woman. Chancres of every kind, and in all their stages are liable to inflame when roughly treated, particularly when the parts are much fretted by walking, or riding on horseback. This ought to be attentively guarded against, for inflammation not only promotes the absorp- tion of the venereal virus, as we shall more particu- larly hereafter have occasion to mention, but when it affects the preputium, phymosis is commonly the con- sequence, and it proves always an untoward occur- rence, as it prevents free access to the sores beneath, a point of the first importance in the treatment of chancre. In women, chancres have precisely the same appear- ance as in men. They occur chiefly upon the internal parts oHhe labia pudendi, on the nymphee, clitoris, and . vol. u, 3 1# OF THE SYMPTOMS Cil. IV. entrance of the vagina and urethra, but they are sel- dom or never altogether within either of these passa- ges. They are most frequent about the under part of the labia, owing to the matter producing them being most apt to rest here, and from the same cause they often form upon the perinaeum, near the anus. In this situation they prove always highly distressful, and are more apt to terminate in deep and extensive ulceration, than in parts not so liable to be injured; for here they are fietted by every motion of the limbs, nor can the patient be seated without pressing upon them. Whether in men or women, chancres on parts cov- ered with firm skin have a very different appearance from such as occur upon parts more thinly protected. Instead of small circumscribed pimples, such as I have described, the skin appears red and tender for a day or two, and without being previously elevated into small vesicles, ulcerations breakout at once. A foetid viscid matter oozes out, which, on being removed, leaves the bottom of the sores of a deep red colour, and their edges inflamed and ragged, and however entirely this matter may be wiped off, it is soon renewed, and in the space of a few hours forms into a thick firm crust, which either remains till it be torn off, or till it be com- pletely separated from the contiguous parts by the for- mation of new matter beneath. This kind of sore is most frequent in parts covered with hair, particularly about the root of the penis in men, and above the pubes, and on the perinseum in women. On the subject of Chancre we take the liberty of offering a few remarks, in addition to those of our author ; rather as references to the authorities on this subject, than as even an abstract of their observations. Mr. Howard in his Treatise on the Lues Venerea, notices, what lie terms, "the slightly irritable aphthous Chancre," from its resem- blance to the Aphthae in children. He observes that the two first stages of it, viz: that of /rimfile, and that of pustule, are generally passed over unnoticed before the disease is suspected, and the first symptom that gives alarm is an uncommon itching on one or more points of the glans or prepuce. Upon inspection a small ulcer is perceivable, not deep, nor perhaps larger than a moderately sized pin's head, the circumference and bottom of which are thickened SeC. II. OF LUES VENEREA. 19 and hard, with a surface yellowish, or resembling a small slough, but with somewhat of the orange coloured tint, like the fat of rusty bacon. — This singular appearance is frequently discoverable by the flaked eye at an early stages but will be best known by viewing the part with a good lens. At this stage it smarts a little on being irri- tated, but the most common inconvenience is a slight itching, and very moderate inflammation. — In this species of chancre the poison sometimes appears to remain dormant for a considerable length of time, and Mr. Howard observes that in one case a chancre was so inconsiderable at the end of six weeks, after the infection had been received, that the patient was only ordered an alterative course of mercury, the consequence of which was that it terminated in a ve- nereal eruption. This he states as a case which seldom occurs. — The older the date of the infection, no matter how slight or trifling the ulcer may seem, the more difficult it will be to assure the pa- tient from secondary symptoms in future ; because the disease is, in this case, quickly verging towards the time of eruption. — The chan- cre or chancres are for the most part devoid of pain, or considerable inflammation, for many days ; and in some instances for weeks ; they are small in size, and though attended with considerable itch- ing, yet the glans and prepuce, continue uninflamed, and without phymosis, — This state continues often for weeks, producing only a solutio continui ; but local irritation, intemperance of any kind, and even the stimulus of mercury, before the decisive change has been produced on the disease, will change the condition of these ulcers from a quiet to a very uneasy and painful state. A symptom in this stage sometimes occurs, which has been thought peculiar to Gon- orrhoea, a slight chordee from the extension of the inflammation to the cellular texture of the urethra and corpora cavernosa penis. Mr. H. notices what he terms, , for distinction sake) the livid ir- ritable chancre. It is, from the beginning, painful to the touch; instead of the aphthous it has a livid or somewhat blackish hue, with a corroded kind of surface and hollow ragged edges ; it creeps on at a great rate, eating away and undermining the surrounding skin, irregularly, like a small spreading phagedaenic sore ; it is attended from the beginning with much more discharge, than the preceding species, and that discharge seems to be highly acrimonious. The ulceration is extremely irritable, producing great pain, and phymo- sis. — Excoriation and bubo come on much sooner in this, than in the preceding species of chancre, probably on account of the matter being taken up from an abraded surface of larger extent. Between these two kinds of chancre, Mr. Howard observes there are seve- ral intermediate varieties, all however referable from their ap- pearances, to one or other. — He describes a particular form, which he considers more malignant than either of the above. It commences with a brownish kind of scab, somewhat depressed, as if the parts were rotten beneath, with the margin of this scab separa- ting from the sound skin. Intimately connected with the livid irritable chancre descrioed above, is a Chancrous Excoriation extending over the glans and prepuce, and originating probably from an abrasion of the sebaceous glands. Chancrous Excoriations maybe distinguish; 20 OF THE SYMPTOMS 01). IV. ed from similar affections of these parts, by their sooner degenera- ting into ulceration. Should the prepuce become inflamed, and a phymosis take place, the complaint may still be known by the vio- lence and pain of the inflammation and the colour of the discharge, which is most frequently of a greenish yellow. The surfaces of these sores appear as if they were covered superficially with half melted lard or tallow. All excoriations however, on these parts are not chancrous, and the latter should be carefully distinguished from mere irritation from violent friction, from the excoriation which frequently arises from the sebaceous matter of the glandular odoriferse becoming acrid from neg- lect, particularly in hot weather ; from scorbutic and scrophulous affections of the glans and prepuce, £cc. For a more detailed ac- count of the nature and variety of chancre, we refer to the work of Mr. Howard, which we have so frequently quoted. Also, the Trea- tise on Morbid Poisons, by Dr. Joseph Adams, Chap. Chancres^ and particularly to the very learned work of Mr. John Hunter on this subject, Ed. $ 3. Of Buboes. A venereal bubo is a painful swelling of a lymphatic gland, produced by absorption of the venereal virus. The. whole surface of the body having absorbents spread upon it no contagious matter can be applied to any part of it but with the risk of injuring the consti- tution. In various instances of Lues Venerea the sys- tem is infected by the matter being carried directly in- to the blood, but in others a swelling previously takes place in one or more of the lymphatic glands lying be- tween the part to which the matter is first applied and the heart. These glands being formed by convolutions of the lymphatic vessels, are apt to be obstructed by any ir- ritating matter which enters them. Hence a venereal bubo is a very frequent symptom of the disease ; and, as it is also one of those which give the greatest dis- tress and perplexity both to patients and practitioners, I shall give a more minute description of it than might otherwise have been necessary. The points of most importance in the history of buboes, and which we shall therefore be particularly anxious to ascertain, are, the state of parts most fa- vourable to their production ; their most frequent situ- ation ; the appearances which they assume at different Sec. II. OP LUES VENEREA. £\ periods of their duration, and the means of distinguish- ing them from other swellings which they resemble. I have already observed, that the venereal virus may be absorbed where the skin is sound and entire : Hence Lues Yenerea may take place where no external mark can be discovered upon the part to which the matter of infection was applied. It must be admitted that this is by no means a common occurrence ; but I have met with it in such a number of well marked instances, that I have no more doubt of the fact than of any oth- er that falls daily and clearly within our observation. It has happened too in almost all of these, that a bubo was one of the first symptoms of the disease. I have now upwards of twenty cases recorded of bubo taking place where not a vestige could be traced either of previous Gonorrhoea, chancre, or excoriation. As the first two or three cases of this which occurred to me gave rise to a good deal of difficulty, by the uncertain and undecisive practice w 7 ith which they were attended, I think it right in this manner to make it known. At the time it was an established opinion, as it still is with many, that buboes cannot take place without some previous formation of matter in the con- tiguous parts. In the cases to which I allude the cure was therefore protracted to a great length ; for till the nature of the disease became more obvious, and which sometimes did not happen till other symptoms appear- ed, the use of mercury, from which alone relief could be obtained, was commonly postponed. The swelling was either supposed to proceed from a strain in walk- ing or riding, or to originate from scrophula, by which a good deal of time was lost to no kind of purpose. In a former part of this work we have seen that swel- lings take place in the glands of the groin from inflam- mation produced by Gonorrhoea: These have, with sufficient propriety, been termed sympathetic buboes, and they are by no means uncommon ; but the real idiopathic bubo, proceeding from absorption of syphi- litic matter, is, in a great proportion of cases, preced- ed by some obvious local mark of the virus in the con- tiguous parts, most frequently by chancre. The mat- 2*2 OF THE SYMPTOMS Ch. IV. fer passes so evidently from the chancre along the lym- phatics to the contiguous glands, that one or more of these vessels are often found hard, and in a state of enlargement, in their course from the sores to the glands. This, in some instances, may happen from inflammation excited by the virus ; in others, it may he altogether the effect of obstruction to the passage of the lymph. In some cases the lymphatics in this state- of enlargement become totally unfit for the pur- poses of absorption ; abscesses form in them ; and on these bursting, they are succeeded by troublesome sores. Chancres, in all their stages, and in every period of theii duration, will occasionally produce buboes; but it is worthy of remark, that they seldom occur but with previous marks of inflammation : Hence buboes are most frequent in the incipient state of chancres, while the inflammation by which they were produced still prevails. Indeed more buboes take place during the first eight or ten days from the appearance of chan- cre than in any other period of equal extent in the whole course of the disease. When the original in- flammatory state of chancres is over, and the parts are merely ulcerated without being painful, they will continue in this situation for a great length of time, without any tendency to buboes being perceived, till inflammation is by some cause or other induced upon them: Hence we find buboes very frequently occur soon after caustic has been applied to chancres, and not uncommonly after the parts have been dressed with precipitate or any irritating ointment. The pain which these occasion tends, in the first place, to create some degree of inflammation, to which buboes very frequently succeed. Ii is not however the higher degrees of inflammation which prove most favourable to the production of bu- boes. When inflammation suddenly takes place to a great height, and spreads along the lymphatics leading from chancres the system is not apt to be infected. These vessels appear to be deprived by a great degree of inflammation, of the power of absorption, probably SeC. II, OF LUES VENEREA, 23 by their being rendered impervious ; but it is equally certain, as I have ai ready observed, that every slight degree of inflammation, as well as whatever tends to stimulate the extremities of absorbents, excites them more or less to action, and thereby tends to increase their power of absorption. Of this we have daily proofs in the practice of inoculating for the small-pox, where we find that infection verv rarely takes place* perhaps not once in a thousand instances, if the wound at which the matter of infection was introduced is not excited to inflame : Hence the more irritation that is excited at the time of inoculation the more certainly the disease is communicated. We may here mention another instance of the eff-ct produced by the irritation of lymphatics in promoting absorption. In the application of unctuous substances to the surface of the body, particularly in the use of mercurial ointment, the power of friction is universal- ly admitted ; and we cann >t suppose that it acts in any other manner than by stimulating the absorbents of the parts. Some indeed have asserted, that in matters of this kind no advantage is derived from friction, and that the absorbents would act with equal influence al- though the ointment was merely applied to them ; but this is so directly contrary to the observation of all who have attended to the effects of friction in such ca- ses, that no farther notice need be taken of it* 1 It has be en remarked that old venereal ulcers do not produce buboes, and this has given rise to an opinion that the matter produced by these sores is not of a ve- nereal nature, that is, that it would not contaminate the system were it carried into the blood by the ab- sorbents. Mr. Hunter was, I believe, the first who ad- vanced this opinion, and I do not know that it has yet been publicly controverted ; but so far as my observa- tion goes I can decidedly say that it is not well found- ed. I admit that buboes, or swellings of the lymphat- ic glands, do not often proceed from venereal sores of long duration, particularly from such as arise from in- * It seems to be surprising- that Mr. Hunter should hazard an opinion te this effect. Tide Treatise en the Venereal Disease bv John Hunter. 24 OF THE SYMPTOMS Cb. IV fection of the system; but although they are not fre- quent, yet in various instances we meet with them. I have seen them in the neck, from ulcers in the throat; in the groin, from sores on the toes and feet ; and in the axilla, from ulcers on the fingers and hands : and the cause of their not being more frequent may be ea- sily explained. We have just had occasion to remark^ that absorption of the matter of Lues Venerea does not often happen if the parts to which it is applied do not inflame. Now we know that it is one of the most characteristic circumstances of old venereal sores, their being seldom accompanied with inflammation. This is particularly the case in ulcers of the throat, where in- flammation seldom takes place to any distressful height. Swellings of the glands in the neck very seldom hap- pen therefore from thjs cause, but still they are occa- sionally met with ; and I believe that they happen as frequently here, in proportion to the frequency of the true venereal inflammation which takes place in these sores, as in any other part of the body. They occur more frequently in the groin and armpit, from ulcers on the extremities, than they do in the neck from ul- cers in the throat ; but this happens obviously from ul- cers of these parts being more apt to inflame than ve- nereal ulcers in the throat ; and it serves as a farther proof of the effect of inflammation in increasing the absorbent powers of the lymphatics. In a former work I have shewn the propriety of diV linguishing venereal ulcers into two kinds. Chancres I would denominate primary ulcers, being the root or source of all farther infection, while all those may be denominatedsymptornatic which arise from the syphilit- ic virus havingentered the system. That chancresshould be more of an inflammatory nature than symptomatic ul- cers, and therefore that the matter produced by them should be more apt to stimulate the absorbents is not sur- prising ; for we can readily suppose that the matter of these old ulcers must be rendered mild by being dilu ted. Even the matter of chancres become Jess viru- lent when the disease has been of long duration ; and the discharge of an ulcerated bubo, although the bu- Sec. II, OF LUES VENEREA. 25 bo itself was produced by a chancre, is evidently of a milder nature than the discharge of chancres ; for we seldom or never see new buboes arise in the glands ly- ing contiguous to an old bubo in a state of ulceration : But we cannot surely imagine that this proceeds from the matter of these sores not being venereal. I believe it to depend upon the cause which I have mentioned- The matter of a sore in this situation must be contin- ually diluted by the lymph which is at all times pas- sing into the gland. This may render it so mild that it will not be capable of stimulating the contiguous glands, so as to form obstructions in them. It will rather pass easily along with the lymph into the general mass of blood ; nor will it produce any immediate or obvious effect, even when it has entered the system ; for when thus 'diluted by all the blood in the body, some quantity must be required to accumulate before any irritation will ensue ; and till some degree of irri- tation is excited no evident effect will take place. It must either exist in such a state of acrimony, or in such quantity as to be capable of exciting irritation in some part of the solids, otherwise no mark of disease will occur from it : Hence may be accounted for all those instances of Lues Venerea breaking out at ve- ry distant periods after infection was communicated, and of the difference which in this respect we meet with in different patients ; the disease in some break- ing out in the course of two or three weeks from the time of infection, while in others it does not appear for eight, ten, or twelve months. Nay, there is rea- son to think that in some it has not appeared till several years have elapsed, and of which I could adduce such proofs as seem to render it certain. That the matter of old venereal sores is capable of communicating infection few I believe will doubt. Many decisive proofs might indeed be given of it, but I shall only mention the following. When the mat- ter of a chancre excites swelling hi the contiguous glands we have few instances of the virus passing into the constitution. The glands will remain enlarged for a considerable time without any mark of the system VOL. II* 4 26 OF THE SYMPTOMS €b. IV. being injured, probably from the mailer of infection being stopped in its progress by the diseased state of the glands; but when buboes become ulcerated, if mercury be not employed, the disease, for the most part, soon breaks out in the throat and other parts of the body from the matter of these secondary or symp- tomatic sores Laving entered ttie circulation. In some instances, as I have mentioned above, a considerable time elapses before the constitution is affected by the matter of these sores, but it scarcely ever fails of shewing itself at last, and not unfrequently in the course of a short time from the ulceration of the bubo taking place. When to this we add, that sores of this description are cured in the same manner 'with every other symp- tom of the venereal disease ; that they daily increase in depth and extent till mercury is employed ; and that they commonly put on a healing appearance in the course of a short time after this medicine has been used, no doubt can remain of their being altogether venereal. Every practitioner knows that in the treat- ment of venereal ulcers, sores sometimes remain after every attempt that we can make for curing them, and long after the virus of the disease is removed by mer- cury. This, as we shall hereafter have occasion to mention, may happen from various causes; but it is not this state of these ulcers which we have now been considering: It is the real venereal ulcer of which we are now speaking, where the nature of it has not been changed, nor the virus of the disease removed by the use of mercury. Venereal buboes are most frequently seated in the groin. This necessarily happens from the manner in which Lues Venerea is usually communicated ; for it is the lymphatic glands most contiguous to the parts first infected that most commonly swell. There are few instances indeed of the virus passing through these and fixing upon others : Hence buboes arising from ulcers of the lips and gums are seated under the tongue, and beneath the lower jaw ; from ulcers in the throat, the glands of the neck become affected ; SeC. II. OF LUES VENEREA, 27 from sores on the fingers and bands, the glands swell about the wrist, elbow, and in the axilla ; and the glands about the knee, and on the upper part of the thigh, are most apt to swell from sores of the toes and feet In each groin, and somewhat higher than the root of the penis, there is a cluster or string of lympha- tic glands, chiefly formed by the lymphatic vessels of the penis and contiguous parts. It is the most contiguous of these glands to the penis that are most frequently obstructed by the matter of chancres. It is proper, however, to remark, that buboes some- times occur from the same cause in a siring of glands lying upwards of an inch lower than these, owing to the lymphatic vessels of the penis passing in some in- stances out of their usual course and stretching down to these glands. From want of attention to this struc- ture of parts, buboes in this set of glands have com- monly been supposed to proceed from the system be- ing infected, unless where they could be obviously traced to an ulcer in the foot or leg ; but we may here observe once for all, that buboes never occur from a general affection of the system alone. They proceed, I believe, in every instance from matter absorbed from a particular spot, and producing, as we have already perceived, obstructions in the lymphatic glands lying in its course to the heart So evidently do bu- boes originate from local affections, that in chancres of the perns it is commonly the glands in the corres- ponding groin that swell. When a chancre is seated upon the freenum,.or on any other part of the middle of the penis, the glands in both groins are equally apt to be affected ; but when the chancre is confined to one side of the penis, or to one side of the scrotum, we meet with few instances of the glands in the oppo- site groin being obstructed. In a great proportion of cases only one of the whole string of glands becomes affected ; but occa- sionally it is otherwise. I have known four distinct buboes on one side, and three on the other at the same time, but here there have always been more 28 OF THE SYMPTOMS Ch. IV. chancres than one ; for the most part indeed the pe- nis in such cases is nearly covered with sores. Were the whole lymphatic glands between the heart and the part at which the matter of Lues Venerea enters the system, liable to be affected with it, this disease would be productive of still worse consequen- ces than commonly ensue from it. Glands situated wit: in the cavity of the abdomen would swell and suppurate, from which the greatest danger might be ex eeted ; but this does not happen. Scarcely an instance can be adduced of any internal glands being affected by the matter of syphilis ; but this does not depend, as some have imagined, upon the tendency of tiiis disease to affect the more external parts of the body only. The most obvious cause of it is, that the venereal virus is always absorbed from the surface of the body • we have seen that it is always the first glands it meets with in which obstruction occurs ; and I have suggested what appears to be the most proba- ble reason of the glands situated beyond such as are affected at first not being liable to suffer in future, viz. the stop which the swelling of the first of these glands gjves to the farther absorption of matter, and the di- luted state of the matter in the progress of the disease, by which it becomes incapable of exciting that de- gree of irritation necessary to produce absorption, or, if absorbed, that it is rendered so mild as not readily to produce obstruction in any of the glands to which it is carried. If the matter of Lues Venerea was ap- plied to any internal part of the body, so as to excite ulceration, we have no cause to doubt of the effects resulting from it being the same that ensue from the external application of it. The contiguous glands would be first affected, and from thence it would pro- ceed to the rest of the system; but the disease never being communicated in this manner none of the glands seated internally can ever be affected. These circumstances being premised, I shall now enumerate the appearances and symptoms of buboes, with the means of distinguishing them from swellings T?bi'ch resemble them. It must be kept in view that if SeC. II. ©F LUES VENEREA, &9 is the real venereal bubo of which we are now speak- ing, and not that inflammatory swelling with which the glands in the groin are often attacked in Gonorrhoea. A description of that swelling is given in Chap. III. Sect. IX. The most frequent seat of bubo, as we have seen, is in the groin, and a description of it in this situation will be sufficient. The first symptom* of bubo is a slight degree of pain. This excites the attention of the patient, when on handling, a small hard knot is discovered. In some cases this is accompanied both with pain and tension, stretching along an enlarged lymphatic vessel, in the form of a small cord, all the way to the penis; but for the most part the tumour is distinct, and not apparently connected with any other affection. Even where two or more buboes take place at the same time, although near each other, they are always distinct and unconnected at first, insomuch that the patient himself very commonly points them out. If mercury or other discutients be not now employ- ed the tumour becomes gradually larger, and from be- ing, as it commonly is when first perceived, of the size of a kidney bean, by the eighth or tenth day, and often sooner, it is usually of the size of a pigeon's egg. From the first appearance of a bubo there is some de- gree of rotundity in the form of it. In the middle it is somewhat raised and prominent, and becomes flat- tened towards the sides, and this continues during the whole progress of the swelling. As the size of the tumour increases it also becomes more painful, and the pain, which at first was confined to the bubo itself, spreads over all the contiguous parts. The patient complains upon the slightest degree of pressure, and he cannot walk or move but with much uneasiness. Even when of this size, buboes will sometimes be removed by discussion; but when this does not hap- pen, the swelling, which till this period usually retains a considerable degree of firmness, becomes in a grad- ual manner softer and more prominent; the skin, which for some time retained its natural colour, becomes red and tender; some degree of fever is apt to take place. 30 OF THE SYMPTOMS Ch. IT. and it is often accompanied with slight shivering fits, A fluctuation of matter is at length discovered, at first upon the surface of the tumour, and afterwards through a considerable part of the whole of it, and on this being discharged, either by the tumour bursting or by an opening being made into it, the parts are found to have all the appearances of a common ab- scess containing purulent matter. The time which elapses in this progress of bubo, from the first appearance of the swelling till matura- tion is completed, is exceedingly variable, and de- pends upon a number of circumstances; upon the age and habit of body of the patient; upon the degree of pain and fever which take place; and on the gland be- ing superficial or deeply seated ; for we find by expe- rience that deep-seated swellings do not so easily or so quickly suppurate as those which are immediately be- neath the skin. Where the constitution is much re- laxed and debilitated, buboes often remain indolent and stationary for a great length of time, while during the full vigour of health and youth, they usually come quickly forward : When accompanied with much pain and some degree of fever, from the first their progress in general is rapid, while they always advance slow- ly when the pain is inconsiderable. This general ob- servation may be made upon the maturation of vene- real buboes, that they suppurate more quickly than glandular swellings of any other kind, and more slow- ly than common abscesses in the cellular membrane. Those who have not had much experience in this branch of business are apt to imagine, from the de- scription which they have perused of the appearances of buboes, and perhaps from their having met with a few instances of the disease in its ordinary form, that no difficulty or doubts can occur concerning them ; but this is far from being the case. Where a glandu- lar swelling, such as I have described, appears in the groin, either during the continuance of chancres, or soon after sores of this nature have healed, there will be no cause to doubt of its being venereal : But bu- boes do not always appear in a simple unmixed state, Sec. II. OF LUES VENEREA, 31 They are sometimes combined with other affections, where they necessarily assume other appearances; and they occur in some instances, as I have already men- tioned, without being preceded by the least vestige of ulceration. This last circumstance of itself is com- monly productive of doubt, but the difficulty is al- ways increased when the swelling which takes place is not altogether venereal. Swellings with which buboes may be confounded, and from which therefore it is proper with as much ac- curacy as possible to distinguish them, are of different kinds. In some cases these swellings occur hi a simple unmixed state, in others they are blended with the real venereal bubo. 1. The most frequent cause of this kind of perplex- ity, is scrophula. When the venereal disease takes place in scrophulous constitutions, buboes as well as almost every other symptom, not only become much more obstinate, but assume appearances perfectly dif- ferent from such as occur in the ordinary form of ei- ther of these diseases. Nor is it necessary that prac- titioners only should be acquainted with this. It ought to be made known in the most unequivocal manner to patients, otherwise they are apt to be perplexed and disappointed, and to biame those who have the charge of them, for what it is not often in the power of art to prevent. Where evident symptoms of scrophula have previ- ously taken place, or where that disease obviously ex- ists at the time, there is no great difficulty of convinc- ing patients of any symptom of Lues Venerea with which they are attacked, being likely to partake of it ; but they should also know, that during the continuance ot Lues Venerea, symptoms of scrophula frequently appear where that disease was not previously suspect- ed to exist, and which otherwise might never have ta- ken place. Of this I have met with many instances, where a scrophulous taint, which had till then remain- ed concealed, broke out at once with much violence on the system being infected with Lues Venerea. We judge that a swelling of this kind partakes of 32 OF THE SYMPTOMS Gh. IV scrophula when, instead of yielding to a proper appli- cation of mercury, or coming forward to suppuration in the time which venereal buboes commonly require, it either remains stationary or advances in that slow gradual manner peculiar to tumours of a scrophulous nature. Tumours altogether venereal do not advance so rapidly as common abscesses, but they come much more quickly forward than scrophulous swellings. In most instances, a venereal bubo that is allowed to suppu- rate arrives at full maturity in the space of four or five weeks ; often in less time than this, from its first com- mencement; whereas, when conjoined with scrophula, two or three months will pass over before this takes place. The pain, instead of being smart, as happens in buboes, is more of a dull obtuse nature. The swel- ling at first, instead of being firm, as we have describ- ed it to be in buboes, is somewhat soft and compressi- ble, like dough; and even when matter is fully formed init, the firmness and tension attending it is less. Nei- ther is the redness of the teguments, which takes place as the swelling comes forward, of such a bright hue as in buboes. This kind of connection between Lues Venerea and scrophula, may, in some instances too be discovered by the size of these tumours. The true venereal bu- bo is no doubt very variable in point of bulk, but it never becomes so large as tumours of this mixed na- ture commonly do. Few of the former ever surpass the size of a pullet's egor, but the latter very common- ly become two or three times larger than this. I have at present two instances of this kind of swelling stretch- ing from the root of the penis, nearly to the spine of the ileum. 2. Venereal buboes are very apt, in the course of their progress, to be attacked with erysipelas. When this does not take place till towards the latter stage of the swelling no cause for doubt occurs from it, as the real nature of the primary affection is previously ren- dered obvious. But when it occurs at first, as some- times happens, the practitioner, as well as the patient is thereby apt to be deceived. Tumours of this kindj. SeC. II. OF LUES VENEREA, 33 instead of being circumscribed, with their limits dis- tinctly marked, as happens in buboes, are commonly diffused, and terminate in a more imperceptible man- ner in the contiguous pails Instead of the vivid com- plexion of common inflammation, they are of a more deep copper colour, and the inflammation which takes place occurs suddenly, instead of approaching in a more gradual manner. I may also remark, that the pain in these swellings accompanied with erysipelas, gives more distress from the sensation which it communicates of a burning de- gree of heat than w/e ever meet with from these lanci- nating pains which take place in the latter stages of the true venereal bubo. 3. Lumbar abscesses have in some instances been mistaken for buboes. This, however, may at all times be easily avoided, and can never occur but from igno- rance or inattention. Any person of experience will easily distinguish by examination with his fingers, the difference between the one and the other. In the one the swelling is seated in the cellular substance, while it is in the body of a gland in the other. Whoever has once handled these different parts in a tumefied state will be at no loss to distinguish between them ; and to those who have not had this opportunity it is perhaps impossible to mark the difference by any description that can be given of it. I may remark, however, that these two swellings are for the most part sufficiently distinguished by the symptoms which precede and at- tend them. If buboes be not always preceded by chancres, lumbar abscesses are universally attended with pain about the small of the back and in the loins, Tiiis symptom indeed very commonly occurs as a fore- runner to the appearance of the tumour in the groin, and almost in every instance, before the tumour ap- pears, the patient is much debilitated by the fever with which he is attacked from the first formation of the disease, and which never in any considerable degree happens in bubo. 4. In some cases, both inguinal and femoral herniae have been mistaken for buboes. Of this I have known VOL. II, 5 34 OF THE SYMPTOMS Cll. 1\\ different instances with patients ; nor is it surprising that it should be so, for both kinds of swelling appear nearly in the same part; they are neither of them at- tended with any alteration in the colour of the skin* when they first appear, and they are both, for the most part, accompanied with some pain : but still the difference between them is so obviously marked that one can scarcely suppose it possible for any practition- er, however ignorant he might be, to fall into any dif- ficulty upon this point, did we not know that indif- ferent instances it had happened. Hernice have not only been mistaken for buboes, but buboes have been treated as hernia?. Besides the very marked distinction which occurs between buboes and hernia, in the appearances and other circumstances immediately connected with the tumours, and with which every practitioner ought to be acquainted, hernia is for the most part sufficiently distinguished from the other by the sickness, obstruc- tion of the bowels, and other symptoms with which H is accompanied, and which ought also to be so gener- ally known that to enumerate them more particularly would be altogether unnecessary. 5. Ulcers in the feet and legs, from whatever cause they may arise, occasionally produce swellings in the glands of the thighs : These, in some instances, have been mistaken for buboes. The chief means of dis- tinction are these ; our knowledge of the existence of such a sore as we have found by experience to be pro- ductive of tumours of this kind ; the seat of the tu- mours, these swellings being commonly on the fore part of the thigh, and somewhat lower than the ordina- ry seat of buboes; and lastly, their being attended with little or no pain, and very seldom proceeding to sup purate, but rather continuing indolent, and nearly of the same degree of hardness from the first. Even; when they do contain matter the skin seldom loses its colour; a circumstance which never happens with bu- boes in a state of suppuration. Women labouring under the venereal disease are equally liable to buboes with men ; and the disease is so exactly similar in both that a description of it m Sec. IL OF LUES VENEREA. 35 the one sex renders it almost unnecessary to speak of it in the other. The only circumstance in which they are different is the situation of the tumours. From the course of the lymphatics not being exact- ly the same in women the site of buboes in them must necessarily be different. I met with one instance of the swelling exactly upon the middle of the mons ve- neris ; for the most part, however, they are situated on the course of the round ligaments, near to where they enter the abdomen, or higher in the groin, some- what nearer the pudendum, than in men. These last become equally large with buboes in men ; but the others, it has been remarked, remain small, and still more circumscribed than buboes in their ordinary situation. The symptoms we have hitherto been describing, vi?.. chancre and bubo, are at first always local ; that is, they are never produced by, although they are ve- ry commonly productive of, what may be called the constitutional state of the venereal disease. This has induced some to treat of these symptoms as distinct and unconnected with the constitutional affection; and there would be much propriety in their doing so, were it possible to determine when the matter of chancre or of bubo has entered the system or not. But so far as I know this has never been done ; and there is much cause to imagine that no attempt towards it will ever prove successful. Some ingenuity has been shewn in endeavouring to ascertain the time which must elapse between the appearance of chancre and absorption by the lymphatics; and even during this period, the dis- ease, it is said, should be considered as local. To me, however, all such attempts appear to be both futile and dangerous. The point in question can never, in my opinion, be ascertained ; and while the contrary idea prevails, the constitution would in many instances be injured, as it would be very apt to lead, as with some it lias already done, to a very hazardous practice, a dependence in the treatment of these symptoms upon local remedies, Chancres and buboes may both re- main in a local state for a great length of time. Naw 36 OF THE SYMPTOMS Ch. IV. it is possible that their cure might sometimes be ac- complished without any of the matter arising from them entering the constitution ; but as this is mere conjecture, as we have no method of knowing when this might be the case, and as we know from daily ob- servation that in almost every instance the constitu- tion is injured even by the slightest degree of these symptoms, I judge it in every respect better to treat of them as constitutional affections. The next symptom we have to describe is univer- sally allowed to originate from the virus when it has entered the system. On the subject of buboes as a primary symptom, there are a vari- ety of "pinions; many respectable writers, agree with our author that true venereal bubo is sometimes met with when no chancre has preceded, from the direct absorption of the virus Mr. How- arc: observes, " When it arises alone, without any precedent or at- tendant symptom, and without any apparent ulceration on the parts, which are usually in the first instance affected, the same general affection of the system, the same venereal pains, eruption and at- tack on the periosteum, and other internal surfaces, may follow from tnis as from chancre j even though the latter should nerer ap- pear." Dr. Adams in his observations on morbid fioisons, maintains the Opposite opinion and says, " If bubo is the only symptom when our patient is first introduced to us, it becomes an important object, to learn the exact history of its first appearance, of every attendant crcumstance, and of every remedy which has been applied. If the tumour is. all that has appeared, to say the least, the chances are that it is not venereal. Such a disease was well known to Celsus ? and even in the milder climate of Italy was often found extremely troublesome. It is contrary to general analogy, that the glands shouid ever be affected by any contagion without the appearance of primary local action, if the law of the poison is to produce a prima- ry local action where it is first applied : I know of no instance on record, in which the constitution has been affected by a bubo, with- out a previous chancre, or Gonorrnoea. Lastly, as I am aware, that many nonest and ingenious men maintain a different opinion, I shall only add, that I have never seen reason to repent, the not having treated such buboes as venereal." If (continues Dr. Adams) a bubo has been the consequence of an ulcer on the penis, which healed spontaneously, we may be certain that it is not venereal. It may be the effect of morbid poison, as probably many of Ceisus's were : It may be assisted by, and may SeC. II. OF LUES VENEREA. 37 even heal under the use of mercury : but this will be no proof of Its venereal origin. If the bubo has not appeared till after the chancre has healed, it will often prove venereal, and must be treated as such. If the first view we have of the bubo is in its open state, the same enquiries, and the same cautions, are necessary as before. The first and most important of all these is, whether mercury has been used for it, to what degree of constitutional irritation and with what effect on the part. The knowledge of all this is absolutely requisite before we commence our treatment, and an attention to it, is equally im- portant, during the whole progress of cure." (Vide Howard and Adams.) Ed. % § 4. Of the Venereal Sore Throat. From whatever part of the body the matter of sy- philis may have enleied^the lymphatics, we find that it is more apt to attack the throat than any other part. This does not happen, however, at any certain peri- od. I have known it fix upon the throat in the course of ten days from the first appearance of a chancre^ while in some instances it remains perfectly sound till several months after every external mark of the dis- ease has disappeared. In addition to what has already been said upon this point I may observe, that the throat, as well as other parts of the body, are most apt to be soon affected when no buboes take place. When the matter passes directly into the system, along the absorbents, the in- fection shews itself more early than where it is first stopped by buboes, and afterwards taken up by the lymphatics on these swellings becoming ulcerated. In the venereal sore throat the patient is usually distressed with some degree of uneasiness in swallow- ing for some days before his attention is much excited towards it. He feels a sensation of fulness and ten- derness, but not much pain. In some cases this pre- vails over the whole throat, but for the most part on one side only. Unless there has been some recent cause for suspicion the disease is attributed to cold ; but the symptoms continuing, and an inspection being- made, an ulcer is in most instances discovered on the part of which he complained in swallowing. 38 OF THE SYMPTOMS Cll. IV. These ulcers in some cases make their first appear- ance upon the uvula, but they are much more frequent upon one of the amygdalae. On first inspection they are commonly small, but always foul, and accompa- nied wilh some degree of fulness or swelling, and with an erysipelatous redness of the contiguous parts. In most instances the ulcer remains stationary for a considerable time, not going deeper than the thickness of a shilling, nor spreading to any greater extent than it occupied at first ; but in others, unless the^wost ef- fectual remedies are immediately employed, tnfe ulcer not only becomes deeper, but spreads to a grFat ex- tent, and in some cases with such rapidity, that I have known the uvula and all the contiguous parts affected in the course of a few days. »In some the. ulcer, in its course, gives only the appearance ^o^foulness to the contiguous parts, which become covered with a yel- low coloured slough, somewhat resembling the huffy coat of inflammatory blood, while in others it spreads in the form of a corroding sore, and destroys all the parts as it goes along. It sometimes destroys a great part of the tonsil before leaving it, but it more fre- quently spreads along the arch reaching from the ton- sil, on which it is seated, to the uvula, and which, to- gether with the contiguous parts of the velum pendu- lum palati, are commonly destroyed before the other tonsil becomes affected. Even in this advanced state of these ulcers the pa- tient seldom complains of much pain, if it be not du- ring the action of swallowing. A general uneasiness is felt over the throat, but the pain is never so acute as the extent and appearances of the sores would give cause to expect. Wherever much pain takes place, we find that it proceeds not from the sores but from that kind of erysipelatous redness with which the contiguous parts are very apt to be affected, and by which such a distressful burning sensation is sometimes induced over the whole throat as renders the patient at all times very uneasy. Tn some cases of the venereal sore throat this in- flammatory redness takes place without any ulcera- Sec. II. OF LUES VENEREAr 39 tinn. If not prevented by mercury, ulcers would no doubt form at last ; but I have known the parts re- main swelled, and accompanied with that deep copper- coloured complexion which is very characteristic of these affections, for several weeks together, and with- out any degree of ulceration being perceptible. The disease in this state, although it is commonly fixed on §one side of the throat at first, is very apt to leave it suddenly and go to the other; and this we find will happen again and again, till the one side becomes ul- cerated, by which it is kept fixed to a particular spot. Where the throat is affected in this manner, that is, where it is attacked both with the venereal virus and erysipelas, a very distressful symptom commonly takes place, a constant heat and irritation over the whole fauces, by which the patient is kept under a perpetual df sire of clearing his throat, of an acrid, viscid mucus, with which it becomes so much stuffed from time to time as to render a great deal of exertion for this pur- pose necessary ; and it prevails equallfcat all tin even during meals, and when the patrenTshould rest. That it is chiefly by the irritability which takes place here that this acrid mucus is produced I conclude .to be the case, from finding ^at aothiwg ' ta^ i fw.) tmxfo~my to remove it as soothing anodyne applications, conjoin- ed with the internal use of opiates. It is commonly too in this- inflammatory state,ofsore throat that patients in Lues Venerea are seized with deafness. Deafness may happen from other causes, as we shall afterwards have occasion to mention, but ira this case I believe it to proceed from the inflammation spreading to the tuba eustachiana, so as to render it impervious. Inflammation may act in producing deaf- ness, either by stuffing this passage with mucus, or by exciting adhesion between the sides of the duct. In the one case the deafness may only be temporary, but in the other it must neeessarilv, to a certain decree, remain permanent. In most instances the venereal sore throat does not go deeper than the soft parts ; producing sores, such 3 pi**- 40 OF THE SYMPTOMS Ch. IV, as I have described, of various degrees of magnitude ; but where the disease has either been too long neglect- ed, or where mercury and other remedies employed do not prove successful, the bones themselves come in some cases to sufFer. I have known the body of the upper vertebrae of the neck affected in this manner, and it not unfrequently attacks the bones of the pal- ate and back part of the nose. 9, One of the most distressful circumstances which practitioners meet with in diseases of the 'hroat is, the uncertainty of distinguishing between venereal affec- tions of these parts and others which resemble them, by which a good deal of time is either altogether lost, or employed with much doubt and undecision. From this cause alone ulcers are sometimes .allowed to spread, where it might easily have been prevented by a timeous use of mercury ; and in other instances pa- tients are put upon the use of this remedy where it ought by no means to be employed. ^The complaints most apt to be mistaken for venereal Wcctions of vSlse parts are, those ulceis which occa- sionally succeed to long continued cases of catarrhal inflammation, and such as sometimts take place as the consequence of too much mercury having been used, or of the jn^ient being e^osed to cold while under a course of mercury. The chief means of distinction between venereal ulcers of the throat and such as succeed to inflamma- tion are these ; ulcers from inflammation very common- ly supervene upon abscesses; they are usually clear], and of a florid red appearance, and accompanied with a good deal of pain. The venereal ulcer again sel- dom or never produces abscess, and in the first place it always forms upon the surface. It is never clean till remedies have been employed for rendering it so y and although it is always accompanied with some un- easiness, the pain attending it is never so severe as in the other. I may also remark, that in the common in- flammatory sore throat the contiguous parts do not usually assume that erysipelatous colour which very universally takes place in venereal ulcers, nor are ScC. II. OF LUES VENEREA, 41 they apt to induce that plentiful secretion of acrid mu- cus* and the symptoms which ensue from it, which we have shewn to be frequent consequences of the other. We shall hereafter have occasion to speak more par- ticularly of that variety of sore throat arising from the effects of cold when under mercury, as well as from an over-quantity of mercury, having been employed. At present I may remark, that this is distinguished from the venereal sore throat by a very considerable fulness or swelling, not only in both amygdalae of the throat, but over tie whole fauces, together with some degree of tumefaction of the parotid gland, as well as of all the salivary glands; circumstances by no means connected with venereal affections of these parts. The parts are not so apt to ulcerate as in the venereal disease, and any sloughy appearance which takes place upon them, instead of being of a buffy colour, as happens in the other, is white and milky, somewhat resembling those apthous crusts so fre- quently met with in the* mouths of new-born infants. These sloughs too are more extensive than they ever are in venereal sore throats. In the latter they are. always confined to such parts as are inflamed, while, in the other, they commonly extend a considerable way over the contiguous parts. The natural unequal 'ties on the surface of the amygdalae have, in some instances, when in a state of inflammation, been mistaken for venereal ulcers; this, however, may always be avoided, and never can hap- pen but from ignorance or inattention. Mr. Hunter describes the true venereal ulcer in the throat as a fair loss of substance ; part being dug out, as it were, from the body of the tonsil. He further adds, that it has a determinate edge, and is commonly very foul, having thick white matter, like a slough, adhering to it, and not admitting of being washed away. Ulcers in such situations are always kept in a moist state, and the matter cannot dry and form scabs, as it does on sores upon the skin. The ulcer is also much more rapid in its progress and generally has thickened edges. (Hunter on the Venereal, Philadelphia Ed. p. 295.) Dr. Adams observes that although the edges of a venereal ulcev YOL. If» 6 4& OF THE SYMPTOMS Ch. IV. in the throat are defined, yet its surface is always ragged and une- ven, and of a complexion which can never be mistaken for a clean or healthy sore, that is, for a sore disposed to heal. The pus is of various colours, from the ash colour to the dusky brown. It is rare- ly attended with pain. In other respects, Dr. Adams' description agrees with Mr. Hunter. (Adams on Morbid Poisons, 2nd Edc p. 167,) Mr. Howard has remarked that during the progress of the ulcer- ation, the other parts of the gland seem often to be but little affect- ed, but they are sometimes enlarged, indurated and even horny. The ulcers at first are not unlike the aphthae of children, but soon increase in depth and width. The appearance of the true venereal ulceration of the throat is compared by Mr. H. to laid or musty, bacon half melted. (Howard on the Venereal, Vol. 1. p. 76.) It is of the highest importance, as our author observes, to form a correct opinion whether an affection of the throat be venereal, or not. In addition to the marks put down to distinguish it from a sore throat induced by mercury, may be added, a factor of the breath, and an increased secretion from the salivary glands ; symptoms which are never met with in the pure venereal ulceration. The venereal sore throat is distinguished, from the putrid sore throat, by the symptoms of general indisposition, quick febrile pulse, depression of strength, 8cc. which accompany the latter and never attend the former — from common inflammation of the ton- sils by the symptoms mentioned by Mr. Bell— from those cases in "Which coagulable lymph is thrown out on the surface, occasioning appearances, like ulcers, or sloughs, by the greater degree of swel- ling in the last and by removing the lymph, when the surface of the tonsil will be found free from ulceration — from an ulcerous ex- coriation of these parts by the latter being superficial and more ex- tensive. (Hunter.) In all cases of Ulcers of the Throat, many of which are often scrophulous, a minute attention to the progress of the symptoms is necessary to enable the practitioner to ascertain the cause of disease. In those instances where any doubt exists as to their being venereal, no injury can result from delaying the exhibi- tion of mercury. By steadily watching the progress of the ulcer, noticing whether it increases regularly, but slowly, and not healing duiine this period in any part, the real truth may soon be determin- ed, if it should proceed in the course we have described, for a few days, its syphilitic character may be considered as well estab- lished. (Adams.) Ed. § 5. Of Venereal Ulcers in the Nose and Mouth. Chancres, or primary venereal ulcers, rise occasion- ally, as we Lave already had occasion to remark, both in the nose and mouth; but sores of this description, wherever they are seated, having been already de- scribed in $ 2. of this section, we are now to treat of See. ii. of lues venerea. 43 those only which originate from the system being in- fected. Next to the throat the matter of this disease fUes most frequently upon the nose, which, so far as I have had opportunities of observing, is more apt to be at- tacked with it than the month. I need scarcely observe, however, that some variety occurs in this- In a few cases the mouth is attacked before either the nose or throat. In others the disease appears first in the nose ; but in a great proportion of cases it follows the pro- gress I am now describing; after having for some time fixed upon the throat it goes to the nose, if the dis- ease is not stopped in its course by a proper use of mercury. We may also remark, that although the ulcers in the throat should be cured by mercury, if a sufficient quantity of the medicine be not employed for eradicating the virus, the disease, when it again breaks out, will appear most readily upon the nose, in the same manner as if no mercury had been made use of. This, however, is not universally the case ; for in many instances we find it most apt to return to the parts where it was last seated, and after again fix- ing upon the throat it proceeds to the nose, as it would have done at first if no interruption had been given to it. It does not however attack every part of the nose indiscriminately. Soma have remarked that the mat- ter ot this disease has a particular tendency to fix upon the external parts of the body, that this always happens in the first instance, and when it proceeds from these to such as are more deeply seated that it does so with some regularity, by attacking such parts first as are most thuily covered. This, however, does not hap- pen with any kind of regularity, and seems only to have been noticed for the purpose of supporting an opinion. Instead of going first to the skin, which it would do were this opinion well founded, the throat, as we have just seen, is most apt to be affected ; and when it afterwards attacks the nose and mouth, it k not even the most external parts of these that are first apt to suffer. 44 OF THE SYMPTOMS (ill. IV. In a few instances the disease no doubt appears first upon the outward parts of the nose, but in by much the greatest number the more internal parts are previ- ously affected. The patient at first complains of a troublesome stoppage in one of his nostrils, accom^ panied with some degree of tenderness and pain at a particular point. This is often so deeply seated in the nostril that it cannot be seen, being most frequent- ly upon some part of one of the ossa spongiosa ; but when the under part of the passage is affected, togeth- er with a fulness of the membrane of the nose, a small foul ulcer is perceived, which is either covered with a white slough, or a firm brown crust, and on this be- in removed, although the parts beneath may appear dean and red, they soon become equally foul and sloughy as before. I»? the commencement of these affections, the dis- ci arge is commonly inconsiderable ; but on a longer, continuance, the matter forms in greater quantities, when it usually becomes thin and very foetid. Jf the ulcer is seated upon any part of the ossa spongiosa, tht bone soon becomes diseased, and the matter ac- quires a black dirty color; it becomes larger in quan- tity, and the fcetor still more considerable than at first. In this stage of the disease large portions of these bones are apt to separate and come away ; but before coming to this length, other symptoms have common- ly made their appearance. A weeping eye, as it is termed, or a constant flow of tears over the cheek, frequently occurs in this stage of the disease, owing to the under end of the lachrymal duct, which termi- nates behind the os spongiosum inferius, being apt to be stopped by the disease of this bone. The sense of smelling becomes impaired, and in some is entirely de- stroyed ; and the figure of the nose is at last affected, in the first place becoming swelled, red, and painful, upon the parts immediately above those that are ul- cerated, and afterwards losing its prominency by the bones of which it is formed coming away. This does not happen while the disease is confbed to the spongy bones of the nose, but the septum itself becomes af- SeC. II. OF LUES VENEREA. 45 fected, in which case there is always much hazard of the face being disfigured by this bone giving way, when the nose is apt to fall nearly or entirely flat. This is the usual course of ulcers in the nose ; but instead of attacking the internal parts in the first in- stance, we meet with them occasionally upon the car- tilaginous parts of the nose, in which case they com- monly begin with some degree of inflammation of the skin. After the skin has remained red and tender for some time, small ulcerations appear upon it, and these at last running together, a sore of more or less extent is formed by the whole. Like all other venereal sores, ulcers in this situation are always foul ; the matter they discharge is thin and offensive, and the skin for some way round their edges is of an erysipelatous red co- lour. When the cartilaginous substance of the nose becomes affected, they often put on a cancerous ap- pearance ; nor has mercury the effect of* stopping their progress so readily here, as in other parts of the body: This has in some instances been the cause of venereal ulcers in this part being treated as cancers, by which, even after being extirpated, the disease has again returned, when a cure might easily have been accomplished by the mercury having been continued for a due length of time at first. Every part of the mouth is occasionally the seat of venereal ulcers ; but although they appear from time to time on the inside of the cheeks and- on the gums, they are most frequent upon the palate and on the tongue. In other parts of the mouth the ulcers ap- pear without any previous warning, being for the most part fully T formed as soon as the part affected is exam- ined by the patient, and which is commonly done soon after it begins to excite any uneasiness ; but in the pa- late no ulceration takes place till the parts have been inflamed for some time. A deep copper-coloured spot is at first perceived somewhere between the uvula and middle of the palate. This at last becomes ulcerated ; and it is worthy of remark, that in no part of the bo- dy do venereal sores advance with such rapidity as they do here. In this respect they are different even 46 OF THE SYMPTOMS Cll. IV. from venereal sores in the throat. These last, as we have already had occasion to remark, seldom proceed to any great depth, nor do they advance with much quickness ; but here their progress is not only rapid but they go at once to the full depth of all the soft parts covering the bones, and in most instances soon do much injury to the bones themselves. I have known the bones of the palate become diseased in the course of a few days from the first appearance of ulceration; and it is by no means uncommon to find a great part of the velum pendulum palati destroyed in the space of a few days from the time that it was first perceived to be affected. Venereal ulcers of these parts have at times been mistaken for, and treated as ulcers of a very different kind, but with due attention this may perhaps in every instance be prevented. We are more apt to fall into the error of treating other sores as venereal. Both in the mouth and nose venereal ulcers have been mistaken for cancerous sores; and in the nose they sometimes bear a resemblance to herpetic affec- tions. From both of these we distinguish them not only by the history of each particular case, but by the different appearances which these affections actu- ally assume. Where a patient with herpetic eruptions on other parts of his body is attacked with sores of a similar nature upon his nose or lips, there will be rea- son to conclude that they originate from the same cause; but where this is not the case, and particularly when it is found that the patient either labours under Lues Venerea at the time, or that he was lately affect- ed with it, and not properly cured, this of itself will give ground to imagine that they are venereal. Her- petic sores seldom go to a greater depth than the skin ; whereas venereal ulcers, whether on the nose or lips, are apt to penetrate deep into the parts upon which they are seated. Cancerous sores are distinguished from these, as well as from every other variety of ulcer, by the schirrous hardness in the parts affected with which in every part of the body they are accompanied ; and they are par- Sec. ir. of lues venerea. 47 iicularly distinguished from venereal ulcers by the smart shooting pains which Ihey always excite; a symptom which does not usually occur in the others. The mouth is equally liable with the throat to sores from an over quantity of mercury, and from patients being exposed to cold when under the use of it. These are more difficult to distinguish than any others from the real venereal ulcer; for besides the resemblance which in some circumstances they bear to them, as they commonly occur while the patient is under cure of some symptom of syphilis, this of itself is apt to create suspicion concerning them. Independent of this, the very situation of the sores gives some cause to suppose that they may be venereal, so that we are readily induced to consider every ulcer on these parts as being of this nature. Sores arising from this effect of mercury, although somewhat resembling the true venereal ulcer, are read- ily enough distinguished from it by whoever has paid attention to this branch of business. Venereal ulcers are circumscribed, and in the mouth, whether upon the inside of the lips, cheeks, gums, or tongue, they are always of a corroding and somewhat of a cancerous appearance. There is seldom at first more than one sore, which does not, however, continue long station- ary, for in this situation venereal sores extend quickly. Now 7 sores arising from mercury are always diffused, and we commonly find them in different parts of the mouth at the same time. Like the first appearance of the venereal ulcer in these parts, they are always su- perficial, but they have not that corroding aspect which the other assumes; and although foul and sloughy, their colour is materially different from those that are venereal. The latter are commonly of a dirty brown cohmr, in some instances with a slight tinge of yellow : v bereas the other has always a whitish appearance, as if the patient had newly been drinking milk. The situation of the sores also affords some means of distinction. Those arising from mercury seem to be induced chiefly by the pressure of the teeth and gums Upon those parts that are more particularly acted upon iH OF THE SYMPTOMS Ch. IV„ by the medicine ; so that we always find them where the swelling is greatest, and the pressure most consid- erable : Hence they are most frequent on the sides of the tongue, near to the angles of the jaw; and on the insides of the cheeks; and when they take place in one of these situations, we usually find them prevail over the others. Now the true venereal ulcer attacks one part just as readily as another ; seldom at first more than one part at once, and we find it just as frequent upon the upper part of the tongue, and on the under part of the mouth between the tongue and the teeth, where pressure has little or no influence, as in any oth- er part. \\ ith due attention to these appearances, and to the history of the case, no practitioner of observation will ever remain long in doubt ; but where any uncertainty takes place, the best method of removing it is to desist entirely from the use of mercury. If the sores are venereal they will soon become worse, if not, they will soon disappear when the swelling and tenderness induced by the mercury are gone. I think it proper, however, to remark, that sores of this kind do not al- ways heal as soon as might be expected. In some in- stances, the swelling of the mouth, produced by mer- cury, continues for a great length of time. I have known it in a very obvious manner more than two months after any mercury had been exhibited. In such cases, the sores procc eding from this cause do not readily heal; and where due weight is not allowed to this circumstance, more mercury is in such a situation very often given, by which the constitution is not only apt to be injured but the very sores for which the med- icine was prescribed are rendered worse. In some ca- ses this no doubt proceeds from inattention or want of experience on the part of the practitioner: but it also criginaies from the fear and anxiety of patients, who, doubting of the real nature of the sores, and dreading their influence upon the constitution, are often so im- patient, that in a concealed manner they persevere in the use of mercury long after they have been desired to lay it aside. •SeC II. OF LUES VENEREA. 49 I have insisted the more upon this point from a very considerable number of cases having fallen within my own knowledge of the most distressful consequences being produced by measures of an opposite nature be- ing persevered in. Patients in general are so easilv alarmed with what- ever gives the least cause to suspect that the virus is not entirely removed, that even the most trifling cir- cumstances, when treated with inattention by practi- tioners, may be followed with very important conse- quences. A spoiled tooth with sharp ragged edges, is very apt to produce a sore upon that part of the cheek or tongue to which it is contiguous; and as it takes place in a slow imperceptible manner, without exciting pain, and produces a foul sore, somewhat resembling a venereal ulcer, if the real cause of it be not discov- ered and removed, very troublesome consequences are apt to ensue from it. From this cause alone I have known a patient put under a tedious course of mercu- ry, which, with very ordinary attention, might have been prevented ; for wherever an ulcer forms, either on the inside of the cheek, or on the tongue, the state of the contiguous teeth should be examined ; and where any spiculse, or inequalities are discovered, they should be completely removed, and due time allowed for the sores afterwards to heal, before any other meth- od of cure is recommended. The venereal oz&na or that ulceration and caries of the nose* which constitutes it, is sometimes so malignant in its nature and sq rapid in its progress, that the bones attacked are actually destroyed in some few instances as soon as the state of the case is clearly known, and in others* before the specific can be used with sufficient effect to check the disease. These therefore, of all cases require the most careful attention. Among the forerunners of this symptom, Mr. Howard mentions the following. When the os front.s, in consequence of a previous node, has become carious at its lower and middle part, just above the root of the nose and that caries is of considerable depth, through the outer table of the skull, the disease may insinuate itself thence* inwards, to the os ethmoides and bones of the nose, and precede an ozsena of the most alarming kind. Pains deep seated in the palate VOL. II. 7 .^0 OF THE SYMPTOMS Cb.1T* or bones of the nose, more especially if they are felt towards its root, either tvith or without a purulent and foetid discharge, be it ever so trifling or small in quantity, when not the effect of catarrh, scrophula, or scurvy, are also circumstances extremely suspicious. As ozsena very seldom occurs without previous well marked venereal symptoms, it is particularly proper to attend to the history of the case. It must be carefully distinguished from the effects of bad teeth, from scurvy, scrophula and from that kind of abscess which sometimes forms in the Antrum Highmorianum. — The disease is often not confined to the nose, but extends to the palate, velum pen- dulum palati, tonsils, and pharynx, and generally the tone of the voice is materially altered. (Howard on the Venereal, Vol. 1. p. 113.) It is worthy of remark in this place that Mr. Pearson considers the ozaenato occur frequently as a symptom of Cachexia syphiloidea, or Pseudo syphilis. (See the Note on Diseases resembling Syphilis.) The posterior part of the oesophagus, the tongue, the cheeks, and the velum pendulum palati, are sometimes attacked with venereal ulceration, and they sometimes appear singly, without any other symptom of lues, but most frequently in combination. When lues venerea attacks the tongue, Mr. Hunter remarks that it will some- times produce a thickening and hardening of the part, but when there are sores they are generally more painful than those in the throat, and oblige the patient to speak thick. It is often difficult to discriminate a venereal ulceration of the tongue from a cancerous one. In this case Mr. Howard recommends a careful examination pf symptoms for years past, and a resort to mercury in al) cases, as a cancerous affection is incurable, and if the specific cause only aii amendment, the practitioner may in general be assured that the case is venereal. Em $ 6. Venereal Blotches. Nex^to the parts which we have mentioned, the mat- ter of Lues Venerea is most apt to fix upon the surface of the body in the form of eruptions, or what are com- monly termed blotches. In a few cases the skin is af- fected before either the throat, nose, or mouth ; but this is by no means frequent. Every part of the body is liable to these blotches, but they appear more frequently on some parts than on others. The cause of this is difficult to explain, for when the whole system is affected we cannot a priori say why one part should more readily be attacked than another, but there is no doubt of the fact. In account- ing for this disease fixing most frequently upon the throat, nose, and mouth/ some have ingeniously sug- SeC. II. OF LUES VENEREA, 51 gested that there is probably some particular attraction between mucus and the matter of this disease, from t\ :ese parts being plentifully supplied with mucous glands: and mercury being particularly apt to affect these parts, while we know that mercury in every form very readily combines with mucus, a theory has been built upon this to account for the action of mercury in the cure of the disease. Admitting the opinion to be well founded, but which dots not appear to be the case, still it would not account for the matter of this disease heing particularly apt to fix upon the skin, pe- riosteum, and bones, parts which are less plentifully supplied with mucous glands than any others of the body. Neither does the idea hoid good here which we have already had occasion to notice, and which some have endeavoured to support, of the matter of this disease having a particular attraction for parts that are most exposed to the atmosphere. In the rise and progress of the venereal eruption the reverse of this a, pears to be the case. I have observed above, that every part of the body is liable to be attacked with these blotches; but »ve find from daily observation, that they appear both more frequently and more early in the disease, on such, parts as are kept well covered than on those that are not covered at all. We no doubt meet with them both on the face and hands ; but for one instance of this we have eight or ten of their appearing upon the breast and arms; and next to these, they attack in succession and with some regularity, the shoulders, thighs, legs, feet, and hands. Of these last the extremities of the toes are often the parts first affected, particularly the parts lying beneath and round the nails. Eruptions of this kind excite no pain : a slight de- gree of itchy uneasiness is the first sensation which they produce. When examined in this state, they are found to consist of a number of small distinct blotch- es, scarcely rising above the surface of the surround- ing parts, and seldom exceeding the size of a sixpence. They are of a pale red colour, and when smartly rub- bed the cuticle falls off in the form of fine bran, leav- 52 OF THE SYMPTOMS Ch. IV. ing the skin beneath somewhat more deeply tinged with red. The skin, however, does not appear to be otherwise injured ; and when the blotches are allowed to disappear of themselves, as they commonly do, the skin is, for a considerable time, found to be perfectly sound, and not even altered in colour. But although eruptions of this kind disappear from time to time, no advantage is gained by this ; they ei- ther proceed from one part to another, or they attack the same parts with more violence. In returning upon parts where they have been before, the cuticle is more elevated from the skin beneath ; and on being remov- ed, the skin itself is found to be either somewhat in- flamed or in a state of tenderness approaching to. ulce- ration. The skin not being in a state fit for producing cuticle, a scab or crust now forms upon these tender parts. In the course of a few days matter forms be- neath, which for some time oozes out at the sides, till the crust separating and falling off, the foundation is thus formed of the true venereal ulcer, of which a description will afterwards be given. In some cases these red, or rather mottled blotches, instead of proceeding to a state of ulcer in the man- ner I have just described, are all covered over with an infinite number of very small pimples, each of which contains matter ; and from these running together, a crust is formed, which likewise falls off at last, and leaves the parts in a state of ulceration. When blotches take place among the hair, which they frequently do, as they do not in their first stage rise much above the level of the surrounding parts, and as they never in this state create much uneasiness, they are seldom perceived till a scab or crust begins to form, and as the matter on oozing out gets matted into flakes with the hair, we are longer in this situation than in other parts of the body, of getting a view of the parts beneath, which, on the crust falling off, are always in a state of ulceration, forming what is com- monly termed the corona veneris. In tue palms of the hands and soles of the feet the firmness of the skin prevents these blotches from ap? SeC. II. OF LUES VENEREA* 53 pearing so obviously as in other parts. The cuticle is here either separated in broad flakes, early in the disease, or if it is so firm as to confine the matter for a considerable time, it at last bursts out, when the parts beneath are found to be ulcera* ^d. It is chiefly in this eruptive state of the disease that it attacks the nails of the fingers and toes. The cu- ticle which surrounds them is perceived to be red and tender; the parts below the nails also become red, and the nails at last become loose, and fall off*. The complaints most similar to venereal blotches, and with which they have frequently been confound- ed, are all the variety of herpetic eruptions, particu- larly such as are dry, and do not yield matter. There is one remarkable difference between them in the na- ture of the matter which they afford. The matter of the true venereal eruption is so tough and viscid that it does not crack, and commonly remains upon the parts perfectly entire, till it separates and comes away; whereas in herpes, although the matter is in one va- riety of the disease of a viscid glutinous nature, it does not form into flakes, as it very universally does in Lues Venerea. It sometimes forms into crusts, but these break and come away in small pieces. In herpes the eruption appears most frequently in the form of a circle and the pails which it surrounds appear to be sound : Hence by the common people it is usually termed ring-worm. These circles or rings are of every variety of size, but they are seldom less than a half-crown piece. Now the venereal blotch is not often larger than a sixpence, and never exceeds the size of a shilling ; and the whole skin of the parts affected appears to be nearly in an equal degree of disease. The mottled appearance which they assume gives cause indeed to suppose that some parts of the skin remain sound ; but on examination with a magni- fying glass, the whole is found to be more or /less dis- eased. Whereas in the herpes, the parts surrounded with the ring are equally sound with any part of the body. 54 OF THE SYMPTOMS Ch. IV. In judging of this point we derive no small assist- ance from attending to the situation of the eruption, as well as from the history of its rise and progress. We have had occasion to observe that the venereal eruption appears most frequently at first upon the breast and arms. Indeed this very commonly hap- pens ; whereas in herpes it is most frequent upon the under part of the abdomen, and about the hands and wrists. When to all these circumstances we add, that in the venereal eruption there is commonly much cause for suspicion, from the patient's course of life, and perhaps even from the existence at the time of some other symptoms of the disease, and that in herpes we often find that the patient has either at some for- mer period been liable to eruptions of a similar na- ture, or that they have prevailed in his family, scarce- ly any cause for doubt will remain. Herpetic eruptions and venereal blotches sometimes occur in the same person at the same time. In this case it may be difficult, or perhaps impossible to dis- tinguish them ; but no great inconvenience can arise from this, for the existence of the venereal affection being ascertained, this, as being the most important of the two, must have the specific remedy employed for removing it, and if the other eruption continues after the venereal blotches are carried off, proper remedies must afterwards be employed for it. I know no other eruption that may not be easily distinguished from venereal blotches. In this symptom, there is commonly great variety. The venere- al blotches are sometimes copper coloured, and as they advance in age, contain diseased mucus or matter. On breaking, they assume the crusty honeycomb appearance described by Sydenham. Others are red and florid. Venereal Eruptions are generally preceded by pains and as there is a consent between the skin and the internal sur- faces of the body, if the eruption be small, the inclination to an af- fection of the periosteum will be great. (Howard on the Venereai.) Dr. Willan in his splendid work on Diseases of the skin, mentions a number of eruptive complaints which are venereal in their nature. They resemble the following genera, Lichen Lividus, Lepra Ni- Sec. II. OF LUES VENEREA. 5& gricans, Psoriasis Guttata, P. diffusa, P. Gyrata and Erythema pa- pu latum. For the diagnostick marks between the common and syphi- litic forms of these diseases, we refer to the above cited work. Most of the latter, it must be observed, will run into ulceration, if not prevented bv the administration of mercury. Ed. § 7. Of Venereal Ulcers. In $ 2. of this section I have already given a de- scription of chancres, or ulcers produced by the local application of the venereal virus. It is those ulcers we are now to consider which take place, in more ad- vanced stages of the disease, and which evidently proceed from the virus having entered the system. In § 4. and 5. venereal ulcers of the throat, nose, and mouth, have been described, but ulcers from the same cause appear occasionally in almost every part of the body. But although no part of the body is perhaps entirely exempted from these ulcers, I mean no external part of it, yet some parts are much more liable to be at- tacked with them than others; and it is a fact worthy of remark, that there is no part of the surface of the body on which they do not occur more frequently than on the genitals. Indeed venereal ulcers of these parts, from infection of the constitution, is an occur- rence which seldom falls within our observation. Al- most every ulcer on the genitals may be traced to a local application of the virus. We have already had occasion to observe that ve- nereal blotches are apt to terminate in ulcers. Hence the venereal ulcer is most frequent on these parts that are attacked with these eruptions, particularly the breast, shoulders, and arms. We often meet with them among the hair, and between the fingers and toes. In the latter stages of the disease indeed, I have met with them more frequently upon the sides of the toes than on any other part. For the most part the venereal ulcer is preceded either by blotches, such as we have just described, or by a number of very small pimples ; but I have met 56 OF THE SYMPTOMS Ch> IV* with some instances of a part becoming ulcerated without either of these appearances going before it* A slight degree of itchiness prevails for some days, and the part is scarcely observed to be discoloured be- fore an ulcer is perceived. In whatever manner a venereal ulcer may form, the appearances which it afterwards exhibits are nearly the same. A considerable destruction of parts soon takes place; more quickly indeed than usually hap- pens from any other cause except mortification. In- stead of proceeding gradually from the surface down- wards, as other ulcers do, a certain portion of the soft parts between the affected spot of the skin and bone beneath seem to be contaminated at once ; for almost as soon as the skin becomes evidently ulcerated, the corresponding parts beneath not only appear to be diseased, but are soon thrown so entirely out that scarcely any thing but the periosteum is left to cover the bone. The sides and bottom of venereal ulcers of every description are at first always foul; but while chancres and all recent ulcers are usually white and sloughy, sores proceeding from diseases of the constitution are of a dirty brown appearance. The matter which they discharge is sometimes thin, and so acrid as to destroy the contiguous parts, but for the most part it is more tough and adhesive than good pus. It has often a sin- gularly green colour, particularly in ulcers on that part of the head covered with hair, and it is always of a very disagreeable foetid smell. These ulcers are seldom accompanied with much pain ; for although the skin which surrounds them has always a tender appearance, being in almost every in- stance of an erysipelatous red colour, they can bear to he handled more easily than sores of any other kind of equal extent. The parts, in some cases indeed, seem to be deprived of their natural sensibility; and I have in such instances found that one of the first ef* fects of the mercury prescribed for the cure has been to render them more irritable. SeC. it. OF LUES VENEREA. >W Venereal ulcers arising from disease in the constitu- tion differ from all such as are local in our not being able to render them clean or bring them to a healing state by any external application that we can employ. Where any doubt exists of the cause, they are often treated with local remedies ; but no advantage is de- rived from them. Even the most powerful detergents have no influence. The parts still remain foul. The matter continues to increase in acrimony; and if a course of mercury is not prescribed, or if not given in sufficient quantity, the sores not only become more extensive, but more numerous, by parts taking on a disposition to ulcerate which did not previously bear any mark of disease. The description which I have given of the venereal ulcer comprehends all the ordinary appearances of these sores; but some difference is produced in them by a variety of causes; by the nature of the parts in which they are seated ; by the constitution being sound or affected with other diseases ; and by the effects of such remedies as may have been employed without being sufficiently powerful to accomplish a cure. In a great proportion of cases the venereal ulcer is seated in the skin and cellular membrane. In the first instance, indeed, these are the only parts that are af- fected; but in more advanced periods of the disease, we find the virus fixing upon the tendons, fasciae of the muscles, periosteum, and bones. The parts least liable to be attacked with it are the glands, particular- ly those of the lymphatic system, but occasionally even they are affected with it. JNow we may easily suppose, that the ordinary appearance of the disease, that which it exhibits when seated in the cellular sub- stance, will be materially different from that which takes place from it in the tendons, fasciae, glands, or bones. It is difficult, however, and perhaps impossi- ble, to give any adequate description of the different appearances which occur in these ulcers thus different- ly situated. It is from experience alone that a know- ledge of this can be obtained* The appearances of venereal ulcers are more or less VOL. II, 8 58 OF THE SYMPTOMS Ch. TV. affected by 'every disease which the system may at the time labour under. Some indeed have contended that no two diseases can exist in the constitution at the same time. This remark, however, is certainly ill-founded, From daily observation, we find, not only that the system may be affected with different diseases at the same time, but that two diseases may at the same time fix upon the same part. Of the first we have instan- ces without end. It happens in the combination of fever with every variety of general cachexy, such as dropsy, jaundice, &c. of small-pox with scrophula, and scrophula with scurvy ; all of which are often met with, existing, and making progress in the same per- son at the same time, and of local complaints combin- ing in the same part, a variety of instances might also be mentioned. I have at present a person who had long been liable to piles, who some time ago was at- tacked with condylomatous excrescences about the anus from a venereal taint ; to these succeeded a com- mon abscess from inflammation, and last of all the parts have become cancerous. As all of these are ob- viously in existence at this moment upon the same parts, and as instances of other combinations of local diseases are occurring daily, it is with surprise and as- tonishment that I find much labour and ingenuity em- ployed to prove that this connection of diseases never takes place, and in a work too which does the highest credit to the author. The opinion which the author of that work endeav- ours to establish, is indeed so contrary to the observa- tion of all who have paid attention to the subject, that I should not have judged it necessary to take notice of it, were it not with a view of preventing the unexpe- rienced from being misled by it ; for were it to be re- ceived as a general principle, it would in a variety of circumstances have no small influence on practice, and would often, lam afraid, be productive of distress and disappointment, both to patients and practitioners.^ * The publication to \thich I allude is Mr. Hunter's Treatise on the Vene- real Disease. Sec. II. OF LUES VENEREA. 59 If this opinion was well founded, every ulcer of the venereal kind arising from disease of the constitution should yield to mercury alone: Instead x>f which, do we not daily meet with sores of this kind, in which mercury by itself fails entirely, and in which, from ihe constitution being at the same time infected with scrophula, or some oiher disease, bark and other re- medies must be employed before any progress towards a cure can be obtained ? This combination of Lues Venerea with other diseases, particularly with scro- phula and scurvy, is indeed, I apprehend, the most frequent obstacle which we meet with in the cure of almost every symptom of this disease. Buboes, as well as ulcers, are always particularly obstinate where scrophula prevails; and the slightest tendency to scur- vy puts it out of our power to employ mercury in such quantities as the cure of venereal ulcers often requires. The effects of this are chiefly perceived at sea, where a patient with Lues Venerea is sure to have all the symptoms aggravated, particularly such ulcers as may prevail, on his being attacked v\ith scurvy. The ulcers not only put on a worse appearance, but till the scorbutic affection is removed, the farther use of mercury is for the most part laid aside. The description of the venereal ulcer which I have given above relates to the disease in its more early sta- ges, and where no mercury has been employed. When mercury is prescribed, and has entered the system, sores of this description soon put on a healing appear- ance '; and if the medicine be continued, the cure usu- ally goes on without interruption. But if, instead of being long enough persisted in, the mercury is laid aside before the virus is eradicated, an effect results from it which could not a priori be expected. This partial effect of mercury not only gives a different ap- pearance to venereal sores, but commonly renders them more obstinate. If the sores have healed, and again break out, although they will not go to such a depth as they did in the first process of ulceration, they will spread farther, and become more numerous, J3y this imperfect application of mercury, a disposi- 60 OF THE SYMPTOMS Cll. IV, lion seems to be formed, not only in the parts contigu- ous to the old sores, but in almost all the soft parts of the body, to go readily into a state of ulceration ; and although the new sores which take place do not go deeper than the cellular membrane, they daily be- come more numerous, insomuch that the parts in which they are chiefly seated are apt to acquire a honey- comb appearance. But although these newly-formed ulcers seldom pen- etrate to such a depth as those to which they succeed- ed, they assume every other appearance of the true venereal ulcer. They are foul and somewhat spongy : They are not attended with much pain, and the sur- rounding skin has an erysipelatous, or copper-colour complexion. In the course of my experience, how- ever, they have always proved to be of more difficult management than the others; nor does mercury act with such certainty in removing them. The same sores either continue obstinately to resist the effect of this remedy, or, if these heal, others break out, and thus spread over a very considerable extent of sur- face, giving all the appearances of the phagedsenic or depascent ulcer of different authors. Hitherto I have been supposing that the disease is confined to the soft parts of the body ; but where the ulcers as now described, have been neglected, or where the remedies employed for removing them have not proved effectual, they are apt to affect both the bones and tendons; and where sores take place upon any of these parts, their appearances are materially different from the common venereal ulcer. The parts affected, instead of being corroded, and hollowed out in the form or a cup, as they usually are in the venereal ul- cer, are filled with a soft fungous substance, of an un- healthy complexion, which bleeds freely on being in- jured, and which always returns soon on being destroy- ed with escharotics. The discharge of these ulcers, "when seated upon carious bones, is thin and of a brown colour, and still more foetid than the ordinary discharge of venereal ulcers in the softer parts of the body. When the surface of a tendon becomes ulcerated the See. IT, OF LUES VENEREA. 61 parts are not only soft and spongy, but more foul or sloughy than sores of almost any other kind. There is another variety of venereal ulcer of which it is proper to take notice, I mean that which succeeds to the bursting of a bubo. Seated in the body of a gland, this kind of sore has a very different appear- ance from the common venereal ulcer, which attacks, as we have just seen, the skin and cellular substance only. Buboes are always accompanied with pain and inflammation : Hence when matter forms in them, it is of the purulent kind. But although the common ve- nereal sore is always attended with some degree of red- ness, as this is not of the true inflammatory kind, be- ing evidently erysipelatous, and which we find from experience never produces purulent matter, the dis- charge accordingly is different. But although the matter of buboes is always more or less purulent at first, it usually becomes thin and acrid at last, owing to sores of this description, on the farther continuance of the disease, being apt to become erysipelatous. Besides this change which takes place in the nature of the matter, the parts in which it was collected, al- though at first they have all the appearances of a com- mon abscess, at last become foul and spongy ; the edges of the sore become callous; and a much greater degree of pain takes place than almost ever accompa- nies the ordinary form of the true venereal ulcer. But although the sore which succeeds to a bubo is necessarily at first always in the body of a gland, we find at last that it is apt to spread and affect the contig- uous parts. The matter pervading the cellular sub- stance, sinuses form ; and the skin becoming inflamed, the foundation is thus laid for the formation of other sores. In this manner the ulcers which succeed buboes frequently spread to a great extent, one part either breaking out as another heals, or perhaps the whole continuing open, so as to leave all the upper part of the thigh, and in some cases, the under part of the ab- domen, covered with small sores. No part of the treatment of Lues Venerea gives more distress to patients, or more perplexity to prac- 62 OF THE SYMPTOMS 6h. IT. titioners, than the management of this ulcerated state of buboes, which, besides being accompanied with much pain, is often one of the most obstinate symp- toms of the disease. Instead of yielding to the use of mercury, sores of this description become often more obstinate after mercury has been employed ; fever is apt to take place ; and where the constitution is not very robust, they even sometimes end in the death of the patient. This great degree of inveteracy in these sores may originate from different causes; but I have commonly found that it takes place in scrophulous constitutions, and in such as are particularly delicate. It may also be remarked, that among our common people sores of this kind are still more particularly obstinate in such as are under the necessity of living in damp situations, as is usually the case with weavers. Venereal Ulcers are distinguished by their spreading irregularly, by sioughiness, and by the appearance of their edges, and when the true skin is affected, by their exquisite tenderness. (Howard.) In some cases it has occurred, that the ulcers are of a round shape, and M. Richerand mentions instances of this nature, which com- menced healing from the centre. It is problematical however whether these were really syphilitic. (Rees' Cyclopedia, Art. Lues Venerea.) Ed. J 8. O/ Nodes, and other Swellings of the Periosteum, Bones, and Tendons. A node is a hard circumscribed tumour, proceed- ing from a bone becoming affected with a venereal vi- rus. The periosteum, tendons, ligaments, and even fasciae of the muscles, are also liable to be attacked with the matter of this disease. The venereal virus, however, does not readily at- tack these harder parts of the body. In a great pro- portion of cases it remains long in the habit be tore tl ey become affected, and when tumours appear upon them, it is often at such a distant period from the ex- istence of any other symptom of Lues Venerea, that SeC. II. OF LUES VENEREA. 63 both the patient and practitioner are apt to be deceiv- ed, and to conclude that they proceed from some other cause ; Hence pains and swellings occurring in this dis- ease are often treated as rheumatic affections, in con- sequence of which remedies are prescribed from which no advantage is derived ; while mercury, from which alone relief could be obtained, is entirely overlooked. But although the true venereal node never takes place early in the disease, I mean such swellings as are of an osseous nature, and originate from the bones, yet the periosteum and tendons, as well as the fasciae of muscles, are in some instances very early affected, This I have known to happen almost as soon as there was cause to suspect that the virus had entered the sys- tem. In such cases, however, some obvious reason could alwavs be given for this variation in the course of the disease, by which the virus was made to fix up- on these parts in preference to others, which usually are first affected. In all of them the patients were found to have been much exposed to the effects of cold and dampness, which I have had many opportunities of observing to have an evident influence in exciting the virus of this disease to fix early upon these parts. Soldiers infected with Lues Venerea, when exposed to the cold and dampness to which they are usually liable during encampments, are particularly apt to suffer with swellings of this kind. Although it is of much importance to distinguish be- tween such of these affections as arise from the bone, and those which proceed from the periosteum, tendons, and muscular fasciae, yet this has not commonly been done with sufficient accuracy. They have all been considered as nodes, and blended under one general description, by which a good deal of perplexity has been introduced in the method of cure. Nodes may appear upon every bone of the body, but they are most frequent where the bones are thinly covered with muscles: Hence they are most common- ly met with upon the forehead, upon the forepart of the tibia, and on some parts of the radius and ulna. We also meet with them on the bones of the hands and 64 OF THE SYMPTOMS Gh. I\% feet. I never, however, saw them on the fingers of toes, but I have observed them upon the sternum and ribs. In two instances, where the patients died of oth- er diseases after being cured of Lues Venerea, and in whom severe pains had occurred in the middle of the thighs, nodes or exostoses upon the femur were dis- covered. In one there were two small knobs or pro- tuberances, in the other there were upwards of twen- ty, and all of them upon the anterior part of the bone. These osseous tumours do not produce any altera- tion in the colour of the skin, unless they arrive at a much larger size than is usual. Their first approach is distinguished by a slight degree of uneasiness in the parts affected. This excites the patient's attention, when on examination a small hard tubercle or protu- berance is discovered. This in a gradual manner be- comes larger ; and, while it increases in size, it also becomes more painful. By the time that it has acquir- ed the bulk of half an ordinary walnut, and few nodes I believe are ever larger than this, the skin has com- monly become red and tender: and ulceration at last, taking place, the bone on being thus denuded, is not only found to be swelled but completely carious. This is perhaps one of the most painful symptoms of Lues Venerea; for although the pain is at first al- ways moderate, it never fails to become severe on the tumour advancing in size. This does not. depend so much, however, on any alteration produced in the bone itself, as on the distension of the periosteum, •which the tumour of the bone necessarily occasions; a circumstance of which we are rendered certain by t he- pain ceasing entirely on the protuberance of the bone being laid bare, either by an incision, or by the soft parts which cover it being destroyed by ulceration. This description of a node, it is proper to remark, comprehends the full progress of this kind of tumour to its last and ultimate stage; a termination we seldom meet with, if it be not among the poor and destitute. Mercury is commonly prescribed as soon as the nature of the tumour becomes obvious, and as this puts a stop lo its farther increase, it is by great inattention or mis^ SeC. ife OF LUES VENEREA. 65 management only that the surrounding soft parts are ever allowed to ulcerate. When ulceration does take place, the parts soon assume all the appearances of the true venereal ulcer of which we have already given a description. The same bones upon which nodes most frequently take place are liable to tumours of a different kind, which, from their bearing a resemblance to nodes, have improperly been distinguished by the same ap- pellation. By some, indeed, all tumours upon these parts, as well as such as occur in this disease upon the tendons, ligaments, and fasciae of the muscles, are con- sidered as nodes. This proceeds -from the confused manner in which these symptoms were described by the first authors who wrote upon this subject, by which others who have not paid particular attention to it have uniformly been misled. It requires, however, no nice discrimination to perceive that the tumours to which these parts are liable from Lues Venerea are material- ly different in their formation, and requiring also a difference of treatment, it becomes an object of no small importance to have this pointed out. The tumours which most resemble nod aie produ- ced by an effusion of a small quantity of matter be^ tween the periosteum and bone. This seems to pro- ceed from the internal surface of the periosteum be- coming slightly inflamed, by which a few drops of a colourless fluid are poured out upon the surface of the bone. If not prevented by an early exhibition of mercury, the tumour, which was at first so small as to be with difficulty perceived, becomes gradually larger, and from being hard and colourless, it becomes soft and inflamed. Even when of the greatest bulk, however, at which it commonly arrives, this tumour does not exceed the size of the real node ; for the pe- riosteum not being capable of much distension, it either soon bursts, or the tumour becoming very painful, relief is obtained by making an incision in- to it. These tumours, although at first always hard, are by no means so firm as nodes. This, even in their VOL. IIv 9 &X OF THE SYMPTOMS Cll. IT. commencement, serves as a sufficient mark of dis- tinction between them ; and where matter is formed, as the tumour is thinly covered, a fluctuation is soon perceived, by which in the progress of the complaint, It is clearly and evidently distinguished from nodes, which always remain hard to the last. When tumours of this description either burst ov are laid open, all hough the bone may be found to be rough and carious, no swelling is discovered ; and on the ulcer healing by the means to be hereafter men- tioned, the parts appear to be reduced to the level of the surrounding skin ; whereas in real nodes, the tu- mour of the bone remains nearly, or perhaps entirely of the same size during the life of the patient, nor has mercury or any external application, any effect in re- ducing it. Some indeed entertain a different opinion, but where venereal tumours upon the bones have been removed by mercury, I have much reason to think that they have not been real nodes, but merely those small tumours produced by effusion which we have just been considering. At least this happened in different cases in which I have been concerned, where tumours, which at first were supposed to be formed of bone, appeared afterwards to proceed en- tirely from effusion ; and I have not met with a single Instance of a tumour evidently osseous being ever car- ried off by mercury, or any other medicine. Besides the tumours we have described, there is still another, by some also improperly termed a node, with which the parts covering the hard bones are not un fre- quently attacked in Lues Venerea. This variety of tumour occurs more early in the disease than nodes, and proceeds most frequently as I have observed above* from exposure to cold and dampness. It is also distinguished from nodes from its taking place in various parts of the body at once. The patient at first complains of pains over the whole affected limbs ; but he soon finds that one part of each limb is more severely affected than the resi- le the legs this happens about the middle of the tibia and fibula. In the thighs it occurs at the middle of Sec. II. OF LUES VENEREA. 67 the femur, and in the arms along the whole course of the radius and ulna. For the most part these pains are considered by the patient as rheumatic ; and I have known many instan- ces, even of practitioners being deceived with them. No advantage, however, is obtained from those medi- cines which usually give relief in rheumatism ; and at last the parts from whence the pains chiefly proceed are found to be swelled. But this swelling is very dif- ferent from that fulness of parts which occurs in rheu- matism ; and it differs materially from the latter in the parts which it attacks. The rheumatic swelling is chiefly confined to the joints. In verv severe cases it no doubt stretches over every part of a limb, but it very commonly originates in the joints : Whereas those venereal swellings, although they sometimes stretch towards the joints, very universally fix up- on those parts of the limb that lie between one joint and another. In rheumatism the whole circumference of the limb becomes swelled in nearly an equal de- gree, while in the other the tumour is circumscribed, being most frequently confined to less than one half of the circumference of the limb ; or when one limb is affected in different parts, as often happens in the fore-arm between the elbow and wrist, the seat of each tumour can be very distinctly traced. In the venereal svselling of these parts the tumour is firm, and so deep- ly seated that on a slight examination it is often sup- posed to proceed from the* bone itself while that swel- ling which takes place in rheumatism is of a more compressible nature, and appears even on the slight- est examination to be altogether free from the bone beneath. By attention to these circumstances, as well as from the history of the case, we need never be under much difficulty in judging of the nature of these swellings, nor in determining when they are venereal and when of a rheumatic nature. It is a prevailing opinion, that the difference between them is sufficiently marked by the pain in all venereal affections of this kind being particularly severe when the patient is warm in bed,, 68 OF THE SYMPTOMS Ch, IV. while the contrary is supposed to happen in rheuma- tism. I have not found, however, that any depend- ence can be placed upon this ; for both are apt to be very differently affected by the same cause in differ- ent patients, and even in the same patients at different times. This variety of swelling seems always to originate in the periosteum, and to proceed from some degree of inflammation, which first begins in that membrane and proceeds from it to the surrounding parts. Like every inflammatory affection of membranous parts, it- does not readily terminate in suppuration. I have never known an instance of matter forming in it : Nor do those serous effusions take place here which are so frequent in rheumatism; a circumstance which consti- tutes another characteristic distinction between the two diseases ; for rheumatism seldom arrives at a great height without swellings taking place in the parts chiefly affected, and they seem all to be of the serous kind. Almost every author who has written upon Lues Venerea describes affections of the ligaments, tendons, and fasciae of muscles, as frequent symptoms : This however, is far from being consistent with my expe- rience ; nor do I suppose that they often take place but in the most advanced stages of the disease. My own observation having led to this conclusion, I was induced to converse and correspond upon the subject with others, who from having much employ- ment in this branch of practice I had reason to sup- pose would be able to give me the best account of it. The prepossession which they had received from books had prevented them from entertaining a doubt of the frequency of this symptom, but none of them bad seen it so often as to be able from his own observation to give a distinct or well-marked account of it. Venereal ulcers often penetrate to ligaments, ten- dons, and other deep seated parts. In this manner every practitioner must have seen those parts affected with the virus of this disease; but in these the disease ■uniformly begins in the skin, and proceeds to the parts SeC. II. -OF LUES VENEREA. 69 beneath. Of swellings in the ligaments, tendons, or fasciae of muscles from this cause, I have met with very few instances ; and even of these some were of a doubtful nature, as they occurred in scrophulous con- stitutions. Those swellings, so far as I have had opportunities of observing, are not so painful as tumours of the pe- riosteum and bones. They are small and circumscri- bed: At first hard and colourless, and afterwards on the skin becoming red, they turn soft, and soon burst. The matter which they discharge perhaps nev- er partakes of purulency : It is thin, and either nearly colourless or somewhat tinged with blood. The sores which ensue are foul, and usually more difficult of cure than any other that we meet with in this dis- ease. I have seen different cases of tumours of a consid- erable size, seated upon tendons as well as upon apo- neurotic expansions, and which were suspected to be venereal. These have commonly been hard, and where they have come to create much uneasiness I have had occasion, in some instances, to remove them with the scalpel. Two of these were upon the tendinous part of the biceps ; and although in both they had been suspected to be venereal, a very decisive proof was obtained of the contrary, for the}' were both extirpa- ted, and the sores healed easily without any mercury being given. The soft tumours of which Mr. Bell speaks, commence with pain throughout the whole extent of cylindrical bones, bounded only by the epiphysis, and are succeeded by great tenderness, and unless mercury be speedily given, by a puffiness of the periosteum, re- taining the impression of the finger. This variety of node is called gummatous or soft in distinction of the other stiled tophaceous or hard. The latter is most common. That elevation of the bone which not unfrequently follows a venereal affection of the perioste- um, is named Exostosis, and the tumours which arise on muscles and aponeurotic expansions are often stiled Gummata, (Howard on the Venereal. En. 70 OF THE SYMPTOMS 6h. IV. $ 9. Of Venereal Excrescences about the Anus. The parts of generation in both sexes are liable lo be attacked with warty excrescences in Gonorrhoea, most frequently towards the end of the disease, when the running is nearly gone. In some cases they spiead over all the contiguous parts, and even reach to the anus; but however extensively this may happen, ex- crescences of this warty nature which occur from Go- norrhoea are always local, as we judge from mercury having no influence in removing them, and from find- ing that topical remedies are alone to be depended up- on for a cure.* But besides these, the parts about the anus are occa- sionally attacked with excrescences truly venereal, which appear in the latter stages of syphilis only, and of which we cannot accomplish a cure by any remedy that is not conjoined with a complete course of mercu- ry. They are easily removed, either with the scalpel or escharotics; but if mercury is not administered they soon return with more virulence than at first. In some cases they appear at the same time with ve- nereal blotches in other parts of the body, which in many instances they resemble, being raised or elevated above the contiguous surface. Till of late I had not seen them but as a symptom of sibbens, and I did not suppose that they took place in the ordinary form of Lues Venerea. I have now, however, met with a suf- ficient number of instances to convince me that in this I was mistaken, and which shew that they not only oc- cur along with eruptions in other parts of the body, but that altogether independent of these they appear as a distinct symptom in still more advanced periods of the disease. They are not so hard as those warts which succeed to Gonorrhoea ; they are more of a fleshy nature, more tender, and therefore more apt to bleed. They have a more uniform surface ; and instead of being formed of a number of small warts connected together, a^ * See Vol. I. chapter II. Section 13. Sec. 21. OF LUES VENEREA. 71 these tumours about the anus produced l>y Gonorrhoea usually are, we find them composed of one uniform mass. They do not approach so near to the verge of the anus as warty excrescences commonly do, being for the most part of the greatest extent and most elevated near to the tuberosity of the ischium. In some cases they become ulcerated, and discharge a great deal of very offensive matter; and when this happens in wo- men they appear sometimes to be productive of bu- boes; at least in different cases where buboes occurred in women, no other source of infection could be per- ceived. Why they should not be the cause of buboes in men may be difficult to explain; but although I have often met with them in men in a state of obvious ulceration, I never knew buboes to be the consequence of them. Perhaps in men the lymphatic vessels of these parts do not pass through any external conglo- bate glands, and if this is the case they cannot produce buboes; for in the history of buboes we have seen that tire matter of Lues Venerea does not excite swelling or obstruction in any of the internal glands. For the most part any ulceration which takes place in these excrescences is very superficial, and does not reach beneath the surface. In some instances, howev- er, sinuses form in them. In this manner I once knew a fistula in ano produced, for which it was necessary to perform the usual operation after the patient was cured of Lues Venerea. Like other symptoms of syphilis these excrescences eitl er" continue nearly in the same state, or become gradually worse, as long as no remedy is employed for the cure of the disease in the constitution. They never disappear either entirely or in part by any effort of the system; but if by a partial course of mercury their progress is interrupted, although the virus of the disease is not completely extinguished, they soon be- come less active than they were before ; in course of time they disappear altogether, and with whatever vio- lence the disease may break out in other parts of the body, it does not again excite a recurrence of excres- 72 OF THE SYMPTOMS Cb. IV. cences. In the latter stages of Lues Venerea, when by a long continuance of the disease the whole system may be supposed to be contaminated, we find a varie- ty of symptoms existing at the same time; otherwise this, as we have already had occasion to observe, does not readily happen; nor do we commonly find early in the disease more than one or two of the symptoms subsisting at once. The warty excrescences mentioned above, may originate, ac-* cording to Dr. Adams from a secondary ulcer seated in those parts, and which having no power to heal itself, will assume this character from the nature of the parts. Mr. Hunter and Dr. Adams do not consider this symptom as really syphilitic, except in the instance stated above. Verrucae or warts on the parts of generation are not an uncommon appearance during the progress of the disease, particularly when chancres have been imperfectly cured. They are stated to be vene- real, when large, irregular in figure and numerous. It is doubted however by many, whether any description are really venereal ; if so they will yield to the general remedy. Ed. i 10. Of Swellings of the Testes. Inflammation communicated along the urethra in Go- norrhoea is the most frequent cause of swelling of the testes. This has induced many to suppose, and some to assert, that this symptom is never induced by Lues Venerea ; that it is always a local affection, and never produced by any disease of the constitution. That this is very generally the case I will readily ad- mit ; for in a great proportion of cases we can clearly trace the disease to a local cause, and it is most easily removed by local applications ; but this is not always the case, for I have met with various well-marked in- stances of the testes swelling from disease of the sys- tem alone. Those who doubt the fact will ask, In what manner can this be ascertained ? By the swelling com- ing on without any external injury ; by no Gonorrhoea having preceded ; by the patient being known to be infected with Lues Venerea at the time ; and by the SeC. II. OF LUES VENEREA. 73 swelling being with ease and certainty removed by mercury, while it had daily become worse as long as those remedies were employed which usually prove effectual in swelling of the testes arising from Gonor- rhoea. With m^ these circumstances afford complete con- viction, and as I have repeatedly met with them I judge the fact to be clearly established. The very first approach of this swelling exhibits a difference between it and that which proceeds from Gonorrhoea. In this last a considerable degree of pain prevails from the first, and the disease begins in the epidydimis ; but in the swelling from Lues Venerea the patient for a considerable time feels only a slight uneasiness, and even on the farther progress of the dis- ease any pain that takes place is not acute, but dull and obtuse, such as might be supposed to proceed chiefly from the additional bulk and weight of the testes. The body of the testicle is always first affect- ed ; and it is only where the disease is neglected, or where the nature of it is mistaken, and mercury judg- ed to be improper, that the swelling proceeds to the epidydimis. These circumstances of themselves might sufficient- ly distinguish the one variety of swelling from the oth- er ; but we also observe that in the swelling from Go- norrhoea the scrotum becomes red and painful very early in the disease, by the inflammation spreading from the testicle ; whereas in the other the scrotum is very seldom affected, and in no instance till the swel- ling has been of long duration. Hence in the one the patient can scarcely admit of the parts being touched, while in the other little or no pain is produced, even when handled with freedom. In the hernia humoralis, as it is termed, the whole contiguous parts seem often to sympathise with the disease in the testis, by the pain spreading along the groins, and over all the upper part of the thighs and abdomen ; while in the other any uneasiness which occurs is either confined entirely to the testicle or to the course of the spermatic cord. In this the swelling comes slowly and gradually to «| VOL. II, 10 74 OP THE SYMPTOMS gll. IV. larger size, insomuch that some weeks will pass before it arrives near to its height ; while in the other the tumour is often as large in the course of forty-eight hours as it ever becomes. Those who doubt of the existence of the swelled testes from Lues Venerea assert, that where the testi- cle becomes hard and enlarged, where no external vio- lence has been applied to it, and without being prece- ded by Gonorrhoea, that, the disease is always to be considered as of the true scirrhous kind, forming what in general is called sarcocele. This, however, is by no means the case, and the means of distinguishing between sarcocele and the true venereal swelling of the testicle are numerous and obvious. In the former the testicle has a considerable degree of hardness from the first. The patient is from the first commencement of the disease, distressed with sharp stinging pains through the body of the tumour, and by degrees these become as severe as they usually are in any case of cancer. The swelling, although at first smooth, soon becomes knotty and unequal, and at last it very con- stantly attacks the spermatic cord, which also becomes hard, knotty, and painful. Now, in a swelled testis from Lues Venerea, although a considerable degree of firmness takes place, it is by no means of that hard nature which always accompanies the scirrhous. We meet with no stinging pains, not even in the most ad T vanced stages of the disease. The swelling never be- comes hard and knotty, but retains a smooth, equal surface, and we meet with few instances of its proceed- ing to the spermatic cord. Tn addition to the description which I have given of the disease I may remark, that in its more advanced stages this swelling sometimes suppurates, and dis- charges purulent matter ; while in sarcocele, whenever the tumour bursts, it yields nothing but a thin, bloody sanies, as commonly happens in all cases of cancen The sores which ensue to the bursting of these tu- mours are fully as different in their appearances as the tumours are different by which they were produced* In the sarcocele the edges of the sore are hard and re- torted, accompanied with every other circumstance Sec. ir. of lues venerea. 7s that usually takes place in cancer; whereas in the ve- nereal swelled testicle, although the edges of the sore are hard, they are neither raised nor retorted, and the sore, while it is foul and sloughy, as venereal sores al- ways are, exhibits no appearances of cancer. In very advanced slates of this disease we sometimes find it accompanied with effusions into the tunica vagi- nal is testis, producing what may be termed a compli- cated hydrocele. This, however, is a circumstance equally common to every tumour of the same magni- tude and duration to which the testicle is liable. It even sometimes succeeds to the hernia humoralis, but not so frequently as to swellings of greater perma- nency. If this affection of the testes is neither uncommon nor difficult to distinguish, it may be said that the particular description which is here given of it is un- necessary ; and I should have judged it to be so, if in some late publications a contrary opinion had not been strongly inculcated. Even this would not have been a sufficient reason for dwelling long upon any point of little importance, but in the subject we are now con- sidering many circumstances are involved. Any theo- ry we can establish of the nature of the venereal poi- son, and of the means employed for removing it from the constitution, is in some measure connected with it; while, at the same time, it is obviously a point of real importance in practice. The symptom noticed above, is mentioned both by Pott and How- ard under the name of Venereal Sarcocele. The former surgeon however expressly remarks that it has neither the inequality nor the darting pains of the scirrhus, and both observe that the exhibit tion of mercury is the surest mode of discovering its nature. It is usually accompanied with other secondary symptoms. Er. § 11. Of Alopecia. The disease termed Alopecia by Nosologisfs, or falling off of the hair, may be produced by different 76 OF THE SYMPTOMS Ch. IV. causes ; but it is most frequently met with as a symp- tom of Lues Venerea in the more advanced stages of the disease. The hair of the head first separates in greater quan- tities than usual on being combed. The eye-brows become more thinly covered, and if a stop be not put to the disease of the constitution, all the hair of the bead, as well as of the other parts of the body, soon falls off. Before the hair begins to separate, a scurf is usual- ly perceived among the roots of it, which comes away in great quantities on the head being combed, com- monly in the form of fine bran. On this scurf being removed, the skin beneath has a red complexion ; but the patient does not complain either of pain or tender- ness, and the same kind of brany powder forms re* peatediv on the same parts, although carefully remov- ed from day to day. In some instances the hair is renewed in as great quantity as at first ; but this is not a frequent occur- rence : It only happens during youth, and where the vims of the disease is quickly and completely eradi- cated. In more advanced periods of life it always re- mains thin, not only upon the head, but on the eye- brows; and when the eye-lashes fall out from this cause they very seldom return. As mercury has commonly been given before the hair begins to separate, and often in considerable quan- tities, this symptom has by some been supposed to be more the effect of the medicine than of the disease,, This, however, has not been the result of my observa- tion. I have seen different instances of the hair drop- ping off in Lues Venerea, where no mercury had been employed ; and were it to be produced by mercury, it would necessarily occur more frequently, and it would happen with equal readiness in every disease for which mercury should be prescribed. 1 consider it to be in almost every instance the effect of that scurf which in Lues Venerea sometimes forms among the roots of the hair. The matier by which the scurf is produced getting access to the roots, soon cuts off their connection with the surrounding parts, S-eC. II, OF LUES VENEREA, 77 $ 12. Of Blindness as a Symptom of Lues Venerea. In the first chapter of this work some account is given of blindness produced by the retropulsion of the r. the number of articles em? Sec. IV. IN LUES VENEREA. 99 ployed in modern practice for the cure of this disease is very few; and it is these only which I now mean to mention. The others, having been found either alto- gether inefficacious, or comparatively of weak pow- ers to those which are retained, have necessarily fal- len into disuse, so that now it would be considered as superfluous to speak of them. The only antisiphilitic medicines now in general use, are mercury, guiacum, sarsaparilla, mezereon, and opium ; Of each of which I shall speak sepa- rately. $2. Of Mereury. I. General Observations upon Mercury. Mercury having been long employed for the cure of a great variety of herpetic affections, we are not surprised at finding it early introduced in the treat- ment of Lues Venerea, in which the most obvious of the symptoms chiefly affects the integuments of the body. Besides, as it was universally known to be one of the most active medicines that had ever been made use of we can easily suppose that practitioners would soon be induced to employ it for the removal of a disease which resisted the effects of every other Remedy. Mercury in its crude state is found to be nearly inert, or not capable of producing any active effect, insomuch that it may be taken into the stomach in very considerable quantities. It has been swallowed to the extent of several pounds weight, and repeated daily for two or three weeks together with scarcely any effect being perceived from it ; so that wherever it has proved active when used in this state as in a few instances has happened, it must probably have been in consequence of its meeting with some unusual degree of acidity in the stomach or intestines. This inactivity of mercury in a crude state seems to depend entirely upon its insolubility in the fluids which it usually meets with in the human body. In, 1U0 OF THE REMEDIES USED Ch. IV. this state it either is not absorbed, or if absorbed, by not being soluble it remains inert. I shall afterwards point out the different means em- ployed for rendering mercury active, and for introdu- cing it into the system, but previous to this it will be proper to offer a few observations upon the ordinary effects of mercury, and upon the different opinions which have prevailed respecting its mode of action in curing the venereal disease. On the first appearance of the Venereal Disease, correctives of the blood, evacuant medicines, venesection and similar means were used. As early as Vhe year 1497, mercury was externally exhib- ited in syphilis, but was not administered very freely. About 1517, Guaiac was recommended as a specific, and supplanted the use of mercury, until Paracelsus again introduced the latter s*nd demonstrated its superior efficacy. (Cabinis* Sketch of the Revolutions of Medical Science. See a Note by Dr. Henderson, the Translator, p. 416.) Mr. Howard observes, that to Bercngarius Carpensis or his dis- ciple Vigo, we must attribute the promulgation of the important fact that mercury would cure by making the mouth sore. Ed. II. Of the Effects of Mercury upon the Human Body. One of the most certain effects of mercury is, that it acts as a cure for the venereal disease. It so sel- dom fails indeed, that when it happens not to succeed, as occasionally is the case, we are apt to suppose that this proceeds either from the medicine not having been properly administered; from its not having been giv- en in sufficient quantity ; or from the complaints for which it is used not being altogether venerea!. Besides this, mercury is perhaps one of the most universal stimulants with which we are acquainted. Even in small quantities it often excites heat over the whole body, quickness of pulse, and other symptoms of fever. It is also a very powerful evacuant. Other medi- cines act with equal certainty upon particular organs, of which we have examples in the effect of ipecacuan Upon the stomach, and of jalap, aloes, and other pur- SeC. IV. IN LUES VENEREA, 101 gatives upon the intestines; but we know of none which so generally affects all the secretions. Almost all preparations of mercury will act as purgatives. They also produce sickness, nausea, and vomiting. They often excite an increased discharge of urine ; and fesv medicines operate with more certainty upon the skin, for they can scarcely be employed without being productive of some degree of diaphoresis. The most remarkable effect, however, which we perceive from mercury is an increased discharge of saliva ; and it is perhaps the only medicine which from internal exhibition is known to act with any cer- tainty upon this secretion. It first excites some de- gree of fcelor in the breath, which is often accompani- ed with a gentle nausea, and very commonly with the taste of copper. The gums become red, full, and somewhat tender. The salivary glands become hard and turgid, and at last an increased flow of saliva takes place, accompanied with a good deal of pain in chew- ing, and with a loose vacillating state of the teeth. For the most part this increased quantity of saliva bears some proportion to the quantity of mercury that has been exhibited ; but this does not always happen, for occasionally we meet with cases in which a very great and long continued discharge of saliva is excited by the smallest dose of mercury that is usually given. In such instances, if the farther exhibition of the medicine be not managed with much caution, besides a great flow of saliva, and swelling of the salivary glands, a very distressful tumefaction takes place over all the contiguous parts, and particularly of the tongue and fauces. This also happens wherever mercury is given in too great quantities, and especially if the pa- tient is suddenly and unexpectedly exposed to cold or dampness. Where this takes place to any consid- erable degree the whole surface of the mouth over all the inside of the cheeks, the tongue, uvula, and gums, are apt to ulcerate, and the matter which ensues from mixing with the saliva gives it both an additional fcetor and an ugly, sanious appearance. Besides the usual symptoms of fever mercury is apt J 02 OF THE REME3HES USED Ch. IT. to excite restlessness, anxiety, general debility, and a very distressful irritable state of the whole system. These are the ordinary effects of mercury, and we shall presently have occasion to see that in the treat- ment of Lues Venerea one of the greatest difficulties we meet with is the management of this medicine; for while the cure of the disease often requires it to be given in considerable quantities, the constitution is apt to be materially injured if it be not exhibited with the greatest care and attention. III. Of the Operation of Mercury in the Cure of Lues Venerea. Various opinions have been offered of the action of mercury in the cure of this disease. It would be for- eign to our purpose, however, to enter minutely into the consideration of any of them. I mean therefore to make only a few observations upon such as have been most generally received, and chiefly upon that which in my opinion ought to be adopted. 1. Some have imagined that mercury acts chiefly in the cure of Lues Venerea by exciting a dissolved or putrid state of the fluids, which they conceive to be a state favourable for the peccant or morbid matter of the disease being thrown off from ihe system. The chief foundation of this opinion is the fcetor which we commonly perceive in the breath of patients under a course of mercury, and the increase with which it is usually attended of almost all the secretions. When we find, however, that whatever excites a quickened state of the circulation is commonly pro- ductive of "an increase to all the secretions, and know- ing that a quickness of pulse is a very common effect of mercury, we conclude, that upon this principle this effect of the medicine is more clearly explained than by any other opinion that has yet been suggested. Besides, we know from actual observation that the blood, during a considerable part of a course of mer- cury, instead of being thin and dissolved, is of a more firm texture than it usually is in health. Mercury, Sec. IV. IN LUES VENEREA. 103 when Ions; continued indeed, never fails to excite much languor and debility, with many of the corresponding symptoms of a putrescent or scorbutic diathesis ; but as many of the symptoms of syphilis are daily cured without this taking place, there is reason to suppose that this effect of mercury upon the system is in no way necessary for the cure of the disease. In confirmation of this we may remark, that all the slighter degrees of Lues Venerea are often removed, and in some instances cured, without even the saliva being increased in quantity or affected with fcetor: nay, a peculiarity of constitution sometimes occurs in which we cannot induce either salivation or fcetor of breath by all the mercury that we dare venture to give, and still the cure of the disease goes on, although not so speedily, yet with equal certainty as if these or- dinary effects of the remedy had been regularly in duced. 2. The symptoms of Lues Venerea being consider ed by some as the effect of a peculiar irritation exci- ted by the presence of the poison in the system, they have also ventured to say that mercury cures the ve- nereal irritation, as they term it, by producing an ir- ritation of a different kind.* The reasoning, however, which has been employed in support of this opinion seems to be altogether hy- pothetical, and directly contrary to many facts which fall daily within our observation in the treatment of this disease. Local pains may for a time be suspended, or they may even be removed altogether, by irritation of a different kind being excited either in the contiguous or some more distant parts of the body ; but we know of no constitutional disease that has hitherto been cur- ed by such means. This affords, therefore, much cause to suppose that the opinion is ill-founded when applied to the action of mercury in the cure of Lues Venerea ; for when no such effect is found to take place in other diseases, we cannot, without the strong- * Vide Mr. Hunter's Treatise on the Venereal Disease. 104 OF THE REMEDIES USED Ch. It. est proofs were given of it, be led to imagine that any thing so very unusual should take place here. Mr. Hunter indeed gives as the chief reason which he sug- gest in support of his opinion, that " the disease can in many cases be cured by raising a violent stimulus of another kind."* I must say, however, that I nev- er met with an instance of this, nor have I been able to hear of any who have done so; neither has Mr. Hunter, in treating of the method of cure, mention- ed any article for the purpose of curing the disease in this manner. The opinion seems to have arisen from mercury be- ing known to act as a very powerful stimulant ; but al though this will be very generally admitted, yet it is also well known that this stimulating effect is not only unnecessary for the cure of Lues Venerea, but that it is one of the most distressful occurrences that we meet with in the treatment of this disease, and that the more; we can counteract it, consistently with the quantity of the medicine to be given, the more certainly do we succeed. So evidently is this the case that it may be considered as one of the principal desiderata in this branch of practice, a means of throwing mercury in an active state into the system, and in sufficient quan- tity for the speedy cure of the disease without produ- cing these stimulating effects. Were we possessed of this the cure of Lues Venerea would be accomplished with ease, and probably in one half of the time that is now found necessary. With the assistance of ano^ dynes we in some degree counteract the stimulating property of mercury, but the most powerful we can employ, even opium itself, is not altogether sufficient; so that we succeed only by exhibiting the medicine in small quantities, and interrupting the use of it alto gether whenever it excites much fever, or proves oth- erwise so powerfully stimulating as to be productive of much uneasiness. Another obvious proof may be mentioned of thi?" stimulating property of mercury being in no degree Sec, IV. IN LUES VENEREA. 105 necessary for the cure of Lues Venerea. From time to time we meet with constitutions in which none of the usual effects of mercury are ever produced, and yet even in these it does not fail of curing the disease. VVe have already had occasion to remark, that in some neither salivation nor fcetor of breath takes place from mercury ; but I have also met. with many in whom it acts with perfect certainty in the cure of Lues Vene- rea, although it neither tends to quicken the circula- tion nor to increase any of the secretions. In all such cases too the cure is accomplished with more ease than where mercury operates in the usual way; and it is worthy of remark, that although all the more acrid preparations of mercury will cure the disease, yet their stimulating properties are found to be so hurtful and unnecessary, that almost by the universal consent of practitioners they are now generally laid aside. We may farther remark, that if mercury acted in the cure of Lues Venerea by the irritation which it ex- cites, other stimulants ought also to do so ; but we have not one authenticated instance, either of a single stimulant or of any combination of medicines of this class having ever accomplished a cure, and which we cannot suppose would have been the case were the opinion which we are now considering well founded. 3. Mercury being specifically mach heavier than any of the fluids of the human body, it was a prevailing idea with many that it operated chiefly in the cure of Lues Venerea by its weight. This opinion, however, seems to be equally ill-founded with the one we have just been considering. It has not been found that other ar- ticles of equal or greater ponderosity cure this disease. It is difficult, or even impossible, to conceive that any medicine can prove useful merely from its weight ; and we have no instance properly authenticated of mercury having ever been discovered in any of our fluids in a metallic form. I may also observe, that the real weight of mercury that enters the system in any case of Lues Venerea must, for the most part, be very inconsiderable. Where the more active preparations of it are employ- VOL. II. 14 106 OF THE REMEDIES USED CI). IV. ed this is particularly the case; but even where tritu- rated mercury is used internally, the form now in com- mon practice, we seldom find it necessary to exceed three or four drachms, and this requiring the space of six, eight, or ten weeks, the quantity in the constitu- tion at any one time must at all times be trifling. 4. The most prevalent opinion upon this question at present is, that mercury cures the disease by the evacuations which it excites. This has been support- ed by much ingenious argument; and as it is known that mercury seldom exists in the system without pro- ducing an increase of one or more of the secretions, we need not wonder at the preference which on a cur- sory view was given to it. I think, however, that it may be easily shewn that it is not in this manner that mercury acts in the cure of syphilis. If this opinion were well founded mercury ought to prove useful or otherwise in proportion to the evacua- tion which it excites. At one period this was general- ly believed to be the case, and accordingly the great- est degree of salivation that a patient could bear was commonly advised ; but now that the treatment of sy- philis is better understood, it is universally known that this is not necessary, nay, in many instances that it tends evidently to retard the cure. It happens indeed, as we shall hereafter endeavour to shew, that some of the more inveterate symptoms of Lues Venerea can- not always be cured but with such quantities of mer- cury as necessarily, in a great proportion of cases, pro- duce salivation to a considerable height. But we judge that this is merely an accidental property of the medicine, and not necessarily connected with the cure of the disease, from our being able to remove all the slighter degrees of it without exciting salivation, and from cures being in some constitutions obtained even of the most inveterate symptoms, without either the teeth, gums, or breath being affected. Neither does it appear that the power of mercury in promoting any of the other secretions is in any degree iiseful in the cure of Lues Venerea; at least instances frequently occur in which cures are accomplished with- SeC. IV. IN LUES VENEREA. 107 out any sensible evacuation 'taking place. Nay, I have bad evident proofs of a cure being retarded by mercury going too freely off by perspiration ; and we daily meet with instances of this where it affects the bowels so as to excite diarrhoea. If mercury acted in the cure of syphilis by increas- ing the secretions other evacuants ought occasionally to cure it. But no instance of this has happened, while vtp cannot doubt but that it must have been fre- quently perceived if any advantage had ever been de- rived from them. The necessity of promoting one or other of the secretions for the cure of other diseases is so frequent, and Lues Venerea so often takes place along with other complaints, that every doubt would long ago have been removed. If the opinion which we are now considering had been well founded every practitioner must have observed instances of the dis- ease being cured by diaphoretics, diuretics, &c. but none will probably assert that they have done so. We might, a priori, suppose, that syphilis cannot be cured by evacuants, but we knosv from experience that it is so, and that they do not even afford relief in any of the symptoms. We can easily conceive how those diseases that originate from affections of the so- lids, particularly such as are produced by spasm, or stricture upon the surface, may be much alleviated, or even altogether removed, by the operation of diapho- retics. By removing the cause the effect will com- monly soon cease. But where the symptoms are in- duced by contagion in the general mass of blood, and where this contagion has a power of propagating itself, as we have shewn to be the case in Lues Venerea, it does not appear how they are to be removed by any evacuations. By the use of diaphoretics and other evacuants the quantity of fluids in the system will no doubt be lessened, but this will not alter the nature of those that remain: If they were diseased before, they will still continue so; for it is not alledged that medi- cines of this nature have the power of discharging those parts of the blood that are diseased and leaving such only as are sound, and yet this would necessarily' iG8 OF THE REMEDIES USED (jh. iy c be the case if the venereal disease could be cured by evacuants. 5. Of all the opinions that have yet been advanced concerning the operation of mercury in the cure of Lues Venerea, that which supposes it to act as an an- tidote is liable to the least difficulty. This was long ago very universally admitted, nor was much doubt ever entertained of it, till attempts were made by the- oretical writers to account for every disease, and for the operation of every medicine, upon such general principles as are not often applicable in practice. Where principles of this kind are clear and evident they ought certainly to be adopted, but the surest method of having them overlooked in every case is to attempt to introduce them in all. By doing so absur- dities must often be admitted which tend to invalidate the whole, and by which many are led to throw aside reasoning in all cases, who willingly would go into it if our systems of theory were confined to such ques- tions as it is in our power to explain. Writers of this class deny the antidotal power of every medicine merely from their not being able to account for the manner in which they act. They do not consider that many of the most common opera- tions in chemistry are equally inexplicable. Thus no person can say why or in what manner the properties of an alkali should instantly be destroyed by an acid brought into contact with it. I do not say that the operation of mercury in the cure of syphilis is analo- gous to this ; but the one I think is equally incompre- hensible with the other, and that mercury acts in this disease consistently with the idea which we affix to an antidote is at least highly probable. What I conceive to be the property of an antidote, is, that when it comes in contact with the poison for which it is appro- priated, it either renders it altogether inert or so far changes its nature that no deleterious effects are produ- ced by it. How it so happens that we can bring more decisive proofs of this being the effect of mercury in the cure of Lues Venerea, than we might at first im- agine would be in our power in accounting for the Sec. IV. IN LUES VENEREA. 109 action of any medicine in the cure of any disease. Among other circumstances which tend to establish this the following may be enumerated, 1st, We know by experiment that the matter of Lues Venerea on being mixed with the triturated mer- cury is rendered inert, and will not produce the dis- ease. The fact is recorded by the best authority, the late Doctor Cullen, who having supported more ably perhaps than any other person an opposite opinion, we are not to suppose that he would have given room to what militated so strongly against it if he had not been convinced of the fact being well founded. His w r ords are, "A physician took a quantity of matter from a venereal chancre, and mixing it with a quanti- ty of Plenck's gummy solution of mercury, he ap- plied this mixture to a sound person, but could not find that it produced either chancre or any other syph- ilitic symptom/** This fact of itself might be judg- ed to be decisive, but more complete conviction is ob- tained of its being so from every view that we can take of the chief phenomena observed to occur from the operation of mercury in the cure of this disease. 2dly, We have daily evidence of mercury curing venereal sores not merely by acting upon the disease in the constitution, but on being locally applied to chancres and other ulcers. In answer to this it is said that these sores may be cured by other articles besides mercury. Allowing this to be the case, it is sufficient for our purpose that they are more certainly and more speedily cured by mercurial applications than by any others ; a fact so notorious, that mercury in one form or other is now the chief dressing for chancres all over Europe. Cop- per has been much extolled for this purpose, but al- though I have used it in every variety of form, it has never proved equal to the different preparations of mercury. * Vide a Treatise on the Materia Me&ica bv the late Doctor William Cullen. Vol. II. p. 110 OF THE REMEDIES USED Ch. IV. It is also said that mercury does not always cure venereal ulcers, which it ought we are told, to do, if it acted as an antidote. This kind of cavil, however, requires no serious answer. We may regret that our medicines will not cure every disease, but all will al- low that we are more certain of curing Lues Venerea with mercury than of removing any other disease by any remedy whatever. 3dly, Besides these local effects of mercury upon the matter of Lues Venerea we have the clearest proofs that can be wished for its acting as an antidote to the virus through the whole progress of the disease. Nay, the very practice of those who combat this opinion tends to evince it, although they do not seem to be sensible of its doing so. The first symptom of the disease that commonly succeeds to chancre is bubo, produced, as is now universally known, by the vene- real virus being absorbed and lodged in a lymphatic gland. Now it is acknowledged by all who have paid attention to the subject, that our best practice here is to bring the mercury we mean to employ as quickly as possible into contact with the virus lodged in the obstructed gland. Nay, of so much importance is it that this should be done, that although we may pre- vent the system from sufferings by throwing the medi- cine in a different manner, yet no other practice will prevent the virus from continuing to irritate the ob- structed gland till it is at last thrown out by a complete formation of matter. Now in what manner does the mercury act here? It cannot be by dissolving the tex- ture of the blood, for we have already shewn that this does not happen if it be not from a course of mer- cury being long continued, while buboes are often re- moved by a very short application of it. It cannot be by it& weight, for a few grains of it often prove sufficient ; and besides, it would have in most instan- ces to act contrary to its own gravity. It is not by ex- citing irritation, under any kind of modification, for when mercury succeeds in resolving these tumours, the pain produced by the first formation of them vpry quickly subsides, while no irritation of any other kind SeC. IV. IN LUES VENEREA. Ill ever succeeds to it. Neither does it act by exciting evacuation ; nor could evacuations of any kind be of any avail. The disease is here in a local state : In the formation of bubo the matter does not necessarily enter the system, so that there is nothing to carry off. I therefore think we may fairly conclude that as the action of mercury in the cure of buboes canuot be ac- counted for in any other manner, and as we find from the testimony of all practitioners that it has no influ- ence in resolving them, but when brought into direct contact with the venereal virus, that it proves effectu- al only by acting as an antidote to the virus. In my opinion this affords the clearest proof of its doing sa that can possibly be given. It even removes the ob- jection that has been stated to the antidotal power which we suppose mercury to exert in the cure of chancres, where it is said that these sores can be cured by other applications ; for in the treatment of buboes no practitioner has ever ventured to suppose that they can be resolved by the absorption of any other remedy but mercury. 4thly, In tracing the effect of mercury upon the venereal virus still farther we have all along the clear- est evidence of its acting as an antidote. In the treat- ment of many of the symptoms of syphilis, almost as soon as we can suppose the mercury to have entered the svstem, the same kind of relief is obtained which we experience from this remedy when it proves suc- cessful in resolving buboes. This is particularly the case in the venereal sore throat, where a good deal of uneasiness generally prevails till mercury is given, and in which much relief is commonly obtained soon after it is employed, without any other irritation being ex- cited, and often before the medicine has produced any evacuation whatever. 5thly, We conclude that the relief experienced from the internal use of mercury in the treatment of local venereal symptoms proceeds from the medicine com- ing in contact with the virus, in the first place, from our finding, as I have just observed, that it is analo- gous to what happens in the cure of buboes, where 11" OF THE KEMEDIES USED Cll. IVc we know that the mercury is directly applied to the vi- rus ; and secondly, from our having convincing proofs of the medicine entering the circulation almost in every case in which it proves successful, and therefore that it must be applied to every part that is diseased.. Some indeed have alleged that mercury never enters the circulation. In a metallic form this may perhaps be the case, but that the essential parts of it pass into the system is obvious, not merely from its influence in curing diseases, but from the taste which it gives to the saliva, although it be absorbed at a distant part of the* body ; and from the effect produced by the exhalation of a person under mercury upon gold and silver car- ried in the pocket, which is exactly similar to that which occurs from mercury being rubbed upon these metals. 6thly, It has been stated as an objection to this opinion, that the quantity of mercury employed for the cure of Lues Venerea is so small that it is difficult to conceive how it can have any influence upon the general mass of blood, to which it bears such a small proportion. To obviate this difficulty an ingenious opinion lias been offered. As we perceive the venereal virus to produce effects chiefly upon particular parts, it is supposed that all that exists of it in the mass of blood may be thrown out upon or be attracted by these parts, and therefore that the mercury employed in the cure, instead of acting upon the general mass of blood, may be supposed to exert all its influence upon the diseased pails only;* I think it more probable, however, from many of the phenomena of the disease, and it must undoubted- ly be so if the opinion I have endeavoured to support be well founded, that the whole mass of blood is taint- ed in an equal degree while any part of the contagion remain in the constitution, and that the mercury em- ployed in the cure acts equally upon every part of it We know that the disease itself may be produced by a very small particle of matter. We may just as read- ily suppose therefore that it may be cured by a small * Vide Observations on Mercury, by Dr. Andrew Duncan, professor of med- icine in the University of Edinburgh. SeC. IV- IN LUES VENEREA. 113 quantity of any remedy that acts as its antidote; and it is perhaps equally difficult to explain the manner in which such ,a small portion of matter acts in assimila- ting quickly to its own nature such a large proportion of our fluids, as it is to account for the manner in which the mercury operates which we employ for cur- ing the symptoms produced by it. Upon the whole, therefore, as the action of mercu- ry in the cure of Lues Venerea is not accounted for by any other opinion that has yet been offered ; as we have complete evidence of this disease being at all times the effect of contagious matter entering the blood ; as the local effects of this matter are cured by mercu- ry, whether they appear in the form of ulcers or by- obstructing the lymphatic glands ; as no other remedy hitherto employed operates with any certainty, either in removing the matter from the blood, or in obvia- ting the effects of it; as mercury seldom or never fails in curing syphilis, when it can be made to enter the blood, if it be not in the most advanced stages of the disease, or when Lues Venerea is connected with oth- er diseases, or with such peculiarities of constitution as will not bear a sufficient quantity of mercury ; and as no instance perhaps can be adduced of a cure being accomplished where the presence of mercury in the blood was not rendered obvious either by the usual effects of it upon the mouth or upon gold and silver carried in the pocket, we have no reason to doubt of this remedy operating perhaps entirely as an antidote ; that is, by rendering the matter of contagion inert or incapable either of exciting the disease, or continuing the symptoms even after the disease has been produced. The following observations on the modus operandi of mercury. by Dr. Francis, professor of the Materia Medica in the College of Physicians and Surgeons in the State of New-York, contain a com- pressed view of the several theories on the subject, as well as anew one suggested by Dr. Hosack, and ably illustrated by Dr. F.-—* These observations we consider of so much importance, that we would not sin against the author by an abridgment, any more than we would deprive our readers of a feast they will enjoy from perus- ing them in the words of the author. We feel a confidence that the VOL. II. 15 114 OP THE REMEDIES USED Ch. IV. intrinsic value of the extract will constitute a sufficient apology for its length. (Vid : Med : & Philosoph. Register, Vol. IV. p. 476.) " Numerous and discordant are the opinions which have been main- tained by professional men on the curative action of mercury in the treatment of disease ; and upon an examination into the history of this medicine, the most superficial observer will perceive that these different opinions have a relation more or less corresponding with the prevailing theories and physiological knowledge of the times. Upon the first introduction of mercury as an article of medicine, when it was administered in its metallic state, it was supposed to overcome all obstructions by its specific gravity. Upon its more general and successful employment by Paracelsus and others, its action, it was presumed, was readily explained according to the crude and absurd notions of the chemists. After this period its op- eration, in common with other remedies, was successively elucida- ted agreeably to the opinions of the humoral pathologists, and the corpuscularian doctrines of the mechanical physicians. Its peculiar action, however, in the treatment of lues venerea, has been more es ecially the subject of consideration among the most distinguish- ed authors who have written on that disease, as well as of those who have treated of the materia medica In not a few instances, it has given birth to the most fanciful and erroneous ideas, relative to the pathology and functions of the human system. Even the great Boerhaave, who acquired and appropriated to his own use the know- ledge of all preceding ages, " who examined systems by experi- ments, and formed experiments into systems,*'* believing the vene- real disease to be seated in the cellular and adipose membrane, con- ceived its cure was to be effected by melting down the adipose sub- stance by salivation.f And at the present day, after the more recent and popular theories of Mr. John Hunter and of Mr. Benjamin Boil, the modus operandi of this medicine remains a question far from being decided. Aware of the many difficulties which occur in accounting for the curative action of mercury in the treatment of disease, the writer does not' presume to suppose he can remove the obscurity in which this subject is involved: but as the theory of its operation will be the more readily understood in connexion with its effects upon the body, it seems necessary that they should first be briefly mentioned. Passing over the still more recent and more fanciful opinions en- tertained on this subject, by Doctors Girtanner, Beddoes, Thornton, Blair, and others, a few remarks may first be offered, perhaps with some advantage, upon the respective productions of Mr. Hunter and of Mr. Bell ; without the least view, however, to disparage the intellectual labours and numerous scientific discoveries of the for- mer, or the great practical sagacity and eminent professional servi- ces of the latter. Mr. Hunter, entertaining the opinion that no two morbid actions * Johnson's Life of Boerhaave, Works, vol. xii. ■j- Prselectiones Acad, de Lue Venerea, Prefatio ad Lusini Aphrodisiacum, fol Lug. Bat. 1728. Sec. IV. IN LUES VENEREA. 1 1 5 can exist in the system at the same time, maintained that the saluta- ry effects of mercury depended upon its producing an action incom- patible with that which already existed ; counteracting- the venereal irritation by producing another of a different kind. This opinion of Mr. Hunter may, at first sight, appear to derive considerable sup- port from the method of cure which is generally had recourse to in the treatment of some diseases ; as, for instance, the removal of glandular obstruction by the influence of calomel on the salivary- glands, and the transfer and diminution of a partial inflammation by the operation of epispastics. The general law, however, which he first devised and employed for the explanation of pathology, that two actions cannot be carried on at the same time in the same part, or in the same constitution, remains yet to be established, notwith- standing the great plausibility with which it has been enforced. It is scarcely necessary to remark, that so far as it regards inani- mate matter, this principle is altogether inadmissible, as is abund- antly proved by the doctrines of projectiles. The history of disea- ses also demonstrates that this law is unfounded, and particularly of those arising from a specific material. That the human body is susceptible of the operation of two distinct contagions at the same time has been satisfactorily shown by the facts recorded by Dr. Pa- trick Russell, of the small pox and measles which prevailed at Al- leppo, in 1765.* On the authority of Bergius and Tandon, men- tion is made of several cases in which the measles and small pox appeared together in the same individual.! Dr. Willan witnessed the occurrence of hooping-cough (a disease of acknowledged spe- cific contagion) during the eruption of the small pox in the same person ; the formfer disorder remained a long time after the latter xvitnoutany material alteration.} Cases of small pox combined with measies came under the notice of Dr. Waiker.§ Desessarts men- tions the complication of small pox with scarlatina.jj Mr. Leese inoculated an infant while labouring under measles, and both diseas- es went through their ordinary course.^ Two cases which exhibi- ted unequivocal evidence of the possibility of two distinct diseases, small pox. and measles, arising at the same period in the human constitution, and each preserving its ordinary course as when sepa- rately existing, attended with ail their usual characteristic symptoms, are recorded by Dr. Tracy.** A number of cases of small pox co- existing wita measles, and the two diseases going through their reg- ujar stages in the same individuals, occurred at tne Foundiing Hos- pital, at Dublin, as appears from extracts from the memoirs ot tne * rransl of the Society for the Improv. of Med. and Chirurg". Knowledge, vol. 2. •[ Ring's Ob serv. on Inoculation; London Med. and Phys. Journal, vol. 14 p 142. t Reports on the Diseases of London, p. 38. § Inquiry m<-o cue Small Fox. See also London Philos. Trans. No. 429> U Jo .a- ui de Med. L 49 : London Med. Rev. vol. i. p. 313. •f Lond. Med. and Phys. Journ. vol. 4. p. 18. ** Mitchell and Miller's Med. Bepos. vol. 3. p. 105, ll(i OF THE REMEDIES USED Ol. IV, Medical Society of that city, communicated by Dr. Rainey.* All these instances of the continued operation of measles with other dis- orders of specific contagion, it will be proper to bear in recollection, are cited from modern authors : the opinions of the more ancient writers on this point being disregarded on account of the errors into which they were led from adopting the principles of the Arabian physicians, and considering and generally treating these different specific disorders, small pox, measles, and scarlatina, as modifica- tions of the same disease.f Mr. Maurice vaccinated two persons who had been previously exposed to measles. The vaccine infection and the measles went through their usual course at the same time.}: It appears from the observations of Dr. Woodville, Dr. Willan, and other writers on the cow pox, that if the constitution be submitted simultaneously to the action of the small pox and vaccine diseases, that these dis- orders go through their course at the same time without influencing each other.§ Many cases of this kind might be mentioned. In the report of the New-York City Dispensary, published July, 1809, the physician of the cow pox department, recorded the case of a child who, on the eighth day after it was vaccinated, had the vaccine disease with all its characteristics, and, at the same time, laboured under a" plentiful eruption of small pox," to which dis- order it had been exposed by an imprudent visit some days previaus, Tne two diseases appeared entirely distinct and independent of each other. The physician vaccinated six children from the fluid of the vesicle, who all had the regular cow pox, and were afterwards test- ed by the small pox inoculation without effect. Several children %vere inoculated with the matter from the small pox eruption who took the disease in its usual form.|| Dr. Adams himself, the un- qualified and indiscriminate panegy ist of the doctrines of Mr. Hunter, asserts, that small pox and cow pox " will proceed togeth- er in the same person without the smallest interruption to each oth- er's course."! Instead, however, of admitting the validity of the fact, in opposition to the universal law of Mr. Hunter, Dr. Adams declares tnat this circumstance only proves the identity of the two morbid poisons. Admirable dexterity of reasoning ! If the constitution, imbued with the peculiar matter of any of the diseases of specific contagion, or under the action of the vene- real virus, were on this account, during the presence of such pe- culiar specific matter, not susceptible of the influence of other * Duncan's Med. Commentaries, vol. 3. p. 444 ; Macbride's Practice of Physic, p. 376. f Vide, Sennertus, Med. Pract, vol. 4. cap. xii. Diemerbroeck, Tract, de "Varjol. et Morbil. cap. xiv. $ Lond. Med. and Phy. Journ. iv. p. 38. § Reports on the Diseases of London, p. 313. Woodville's Reports for a series of Inoculations for Variola Vaccinae, p. 145, &c. || Gillespie's Report on the Cow Pox, in Mitchell and Miller's Med. Repos ▼ol. 13. p. 87. 1 Observations on Morbid Poisons., 4-to. p. 398. See also his Popular View qf Vaccine Inoculation, p. 41. SeC. IV- IN LUES VENEREA. 117 diseases of a specific origin, who would not have observed the in- stances of exemption from the operation of contagious and infec- tious diseases, and have ascertained and made known so singular and specific a cause ? Who is prepared to say, that the individual labouring under lues venerea is, on that account, exempt from the influence of small pox ; or that he who is infected with small pox is. secured from the attacks of plague or yellow fever ? The hypothesis of Mr. Hunter, however, whether it be correct or not, is irreconcilable with another principle which he himself has elsewhere adopted, that the venereal disease often becomes the im- mediate cause of other disorders, by calling forth latent tendencies into action, as he here admits the concurrence of two distinct ac- tions. " I have seen in many cases," says he, " the tendency so ve- ry strong, that it has taken place before the -venereal has been entire- ly subdued."* But enough has been said to prove the co-existence, in the same individual, of diseases essentially different in their pe- culiar character, and arising from the operation of distinct specific causes. Agreeably to the law which Mr. Hunter laid down, the method of treatment in the venereal disease is by counter irritation, and to excite an irritation greater than that of the venereal. Let this prin- ciple be granted as well founded, and it need not here be stated how extensive would be the class of anti-venereal remedies. If the sal- utary effects of mercury depended upon its producing irritation, then other medicines acting as irritants would occasion similar hap- py effects. Even fever itself, the effect of irritation, might be of the number of anti-syphilitic remedies ; yet, in the treatment of lues venerea, it is one of the most common objects of the physician's attention to subdue and guard against fever, as well as other sources of irritation. But the premises on which this ingenious author pro- ceeds cannot be granted. " The removal of venereal action by mer- curial action (to quote the language of an able critic) is gradual and progressive ; the mercurial must, therefore, exist along with, the venereal, until the latter is entirely overcome ; and if these ac= tions were not at certain periods co-existent, the cure must be ac- complished in a moment, or it could not be accomplished at all. ft The theory supported by Mr. Bell, that mercury acts as an anti= dote in the cure of the venereal disease, is no less untenable than that of Mr. Hunter. The experiment, which he has considered as decisive, of the matter of lues venerea on being mixed with tritu rated mercury (Plenck's solution) becoming inert, and, consequent- ly} incapable of producing disease, can be admitted only as a spe- cies of chemical agency upon inorganized materials, and will by no means apply to the organized animate body. The assumption that such an operation takes place in the human system is altogether gratuitous. If, again, the principle just stated were true, that mer- cury possesses a peculiar " antidotal" or neutralizing power, simU lar to the operation of an alkali upon an acidj the particular activity * Hunter on the Venereal, p. 26. \ London Med, Review, vol. 1. p. 202 11H OF THE REMEDIES USED Ch. IV. and the advantages which certain preparations of this metal possess, might be regarded as of no practical importance, and corrosive sub- limate and the crude mineral be employed without distinction: the successful treatment of this disease would uniformly depend upon the quantity of mercury administered. But this would lead to the adoption of a practice at variance with the experience of several very eminent writers, and one which Mr. Bell himself thinks pro- per to guard against:* and, indeed, the very small quantity of cor- rosive sublimate which is necessary to effect a cure, renders it al- most certain, as remarked by Dr. Cullen,f that mercury does not cure the disease by being an antidote to the poison. The arguments in support of this theory, derived from the operation of mercury when locally applied, are not to be considered as of any importance ; local disease may frequently be changed and effectually cured by the application of local remedies. The venereal disease can be re- moved by such remedies only as produce a general action upon the whole constitution, the medium through which the morbid matter is diffused, and upon which it exerts its destructive influence. Firstly, In what manner does the poison of specific diseases ope- rate upon the human constitution ? and, Secondly, What are the changes effected in the system by the in- fluence of mercury? Little, indeed, is known concerning the peculiar nature of the vi- rus of specific diseases: the action which takes place upon the ap- plication of the smallest particle of morbific matter to the human body, and the process by which it generates disease, converting a lo- cal into a general disorder, and thus producing an altered and vi- tiated state of the whole system, it must also be admitted, are nei- ther very obvious to the senses, nor very clear to the reasoning powers of man. The e fleets themselves, however, have been long and familiarly known; and from duly considering these, a rational theory may, perhaps, be formed of the manner in which they are produced. That the poison of specific diseases, as that of lues venerea, small pox, &c. diffuses itself through the whole constitution, and assim- ilates unto its own nature the general mass of circulating fluids, seems to be most consonant to all that is understood of their pecu- liar character. Upon the introduction of a particle of variolous matter into the system, an inflammatory action of the part, into which it is inserted, is excited ; by which action new morbific mat- ter of the same nature is generated. This process may be carried on to a greater or less extent, in a longer or shorter time, in differ- ent persons, before the specific material enters the absorbents ; and lence local inflammation is, in some cases, considerably advanced before the system becomes affected ; while* in others, the eruptive symptoms supervene when it appears to have made very little pro- gress.! The morbid poison, modified in its action by its degree of * Bell on Conor. Will, and Lues Ven. vol. 2. p. 259 r Cullen's Mat. Med. vol. 2. p. 254. t Woodville's Reports on Cow Tox, p. 15. SeC. IT. IN LUES VENEREA. 1 1 9 acrimony, the condition of the part, and habit of body, is taken up by the absorbents and enters the blood-vessels ; whence it is receiv- ed into the general circulation, and produces its peculiar effects upon the constitution. The fluids, therefore, are thus necessarily first affected, and, as a consequence of their morbid condition, the solids themselves next become vitiated. Hence the multiplication of the matter of variolous contagion in inoculated small pox ; and. hence, on the same principle, the generation of morbific matter, from a similar action, arising from the introduction of other specific contagions. By the introduction of a specific morbid matter into the body its condition is changed from a healthy to a diseased state, the local is converted into a general disorder ; the fluids, and ultimately the solids, become affected ; and, according to the particular virus in- troduced, the whole constitution partakes, in a greater or less de- gree, of its peculiar nature, whether it be small pox, lues venerea, measles, &c. The most satisfactory idea, perhaps, that can be formed of the action of morbific poisons on the body, is that of a ferment, or rath- er an assimilating- process. That such a process does, in certain diseases, take place in the living system has been maintained by many of the most distinguished writers. " It is evident," says Dr. Cullen, " that the contagion of the small pox is a ferment with re- spect to the human fluids, and assimilates a great part of them to its own nature/'* " Fermentation," remarks the celebrated Mr. Cruickshank, " has been chiefly observed in dead matter, but may also take place, and I believe certainly does take place, in living matter."! In his observations on the action of variolous contagion upon the blood, the most apt idea we can form of it, observes Dr. Walker, " is that of a ferment."^ See also the experiments of Sir John Pringle,§ and of Dr. Alexander. || Mr. Benjamin Bell, though he readily admits that the matter of all contagious diseases, and more especially that of lues venerea* has a power of assimilating to its own nature a " certain portion, and ultimately, perhaps, the whole fluids of the body,"*! canned easily suppose how such a process can take place in fluids in mo- tion, rest being essentially necessary for promoting fermentation* That the matter of certain specific diseases is conveyed through the circulating fluids, is abundantly evident from the condition of the axillary and other glands in different parts of the body, in small pox, lues venerea, Sec. The rapidity with which deleterious and other substances are absorbed and taken into the sanguineous circu- lation, has been long known, and, lately, satisfactorily shown by the interesting experiments, of Deiiie and Magendie.** * First Lines, vol. 2. Chap, on the Small Pox, ■{• Anatomy of the Absorbing Vessels. ± Liquny into the Small Pox, p. 49. § Diseases of the Army, appendix. I! Expenmental Essays, p. 15, &c. % Treatise or. Gonor. Viral. .jidLnes Ven. vol. 2. p. 164r " Amer. Med and Phil, Kesv?ter. vol. 1. p. 426. 120 OF THE REMEDIES USED Cb. IY r « Were the assimilating or fermentative action confined merely to a particular point in the cellular texture, where the specific cause was first applied, how would it be practicable to account for the generation of new and similar matter in other and distant parts of the body, as for the occurrence of confluent small pox after inocu- lation. The morbific poison enters the blood, and necessarily com- bines with some of its constituent parts ; if so, it must accompany, and operate upon, this fluid in its general circulation through the system. That this opinion is not hypothetical, but founded on ac- curate observation, many established facts might be adduced to prove. The effects of the variolous infection on the mother and foetus in utero, are capable of explanation upon no other principle than that the blood itself is in a morbid state, and assimilated more or less unto the nature of the variolous disease. The free and di- rect* communication which exists between the mother and child, while in the fetal state, will readily be the medium through which the matter of specific diseases exerts its operation upon the impreg- nated uterus. Dr. George Pearson has recorded many well-authen- ticated cases, in which the infection of small pox was communica- ted to the unborn infant, and the matter taken from the pustules on the foetus, by inoculation infected others.f Two instances of the effects of the variolous contagion upon the pregnant mother and child occurred in the practice of Dr. Hosack, in 17914 Two strik- ing cases of the small pox virus affecting the foetus in utero were lately published by Dr. Jenner.§ In the first case the infant sicken- ed on the fifth day after birth, and on the seventh well-formed pus- tules of small pox appeared : the virus was communicated to oth- ers by inoculation. In the second case the child upon birth had ma- ny eruptions on it, bearing much the appearance of small pox in the early stage of the disease. On the fourth day after birth, « I found,'' says Dr. Jenncr, " the eruptions had increased to some thousands, perfectly distinct, and their character well marked." " To put the matter beyond all doubt," continues Dr. J. " I armed some lancets with the virus and produced the small pox by inoculations with it." Other facts of a similar nature may be found recorded by Mead, jj Ludwigf, Burserius,** Baron Diinsdale,ft Mr. Hunter,|f Hay garth,§§ and other distinguished authorities. In like manner the circulating fluids may become vitiated and as* similated in their nature to the virus of lues venerea. The local effects of the disease will appear at different periods in different parts of the body, according to their peculiar susceptibility. The * MS. Notes on Hosack's Lectures on Pract. of Physic, and on Midwifery. i Duncan's Medical Commentaries, vol. 19. p. 213. &c. ± Duncan's Med. Commen. vol. 19. p. 249. § Med. and Chirurg. Trans, vol. 1. See also Eclectic Repertory, vol. l.p.4. || Discourse on the Small Pox, chap. iv. if Adver. Med. Pract. ** Institutions of the Pract. of Med, vol. 3. jj- Treatise on Inoculation ±+ Philos. Trans, vol. 70. §§ On the Small -Pox. SeC. IV. IN LUES VENEREA. 121 foetus in utero may also become affected with the poison of the dis- ease, and exhibit symptoms simiiar to those which arise from the same cause at other periods of life. The general experience of the most eminent practical authors, (with the exception of Mr. Hunter,) has so well established the fact that little further need be said at present concerning it.* The venereal disease may be communi- cated to the foetus in utero, and the healthy child after birth may be- come affected with the same disorder by sucking an infected nurse. Two remarkable cases, in confirmation of the fact last mentioned, occurred in the practice of Dr. Hosack, in the spring of 1S07. A healthy infant, born of respectable parents, was placed under the care of a wet nurse, and in about four weeks after, eruptions ap- peared in different parts of its body. The ordinary alteratives were had recourse to without effect : the child became worse ; ulcers on the throat and other symptoms strongly resembling those of lues venerea were observed. Mercury was now administered in the form of the solutio oxymur. hydrargy. by which the disease was com j pletely removed: Suspicions being thus confirmed as to the nature of the disorder, the infected nurse was dismissed, with an injunc- tion to undergo a mercurial course. Shortly after, and regardless of advice, she entered into another family in which she again com^ municated to a healthy sucking infant the venereal disease, which yielded only to the operation of mercury. These two cases render it no longer problematical, but unequivocally prove that an infected nurse may, merely by her milk, communicate a specific disease to her nursling. They also, still further, render valid the opinion, that not only the blood but the secretions may, to a certain degree, be assimilated in their nature to the virus of certain morbific pois- ons. It is asserted by the advocates of vascular spasm, that assimila- tion is founded on an erroneous and vulgar analogy between a mere- ly chemical action and the operation of the animated body ; and it has been urged with much force as an objection to the doctrine of a fermentative or assimilating process taking place in the living sys- tem, that such process is always accompanied with ebullition and the extrication of air, phenomena incompatible with the due perform- ance of the functions essential to animal existence. Surely those who have considered this objection of importance have not attended to the ordinary changes which wine undergoes during its secret fer- mentation, as it has lately very properly been denominated ; for in these changes neither ebullition nor motion is necessary to the fer- menting process by which the wine is matured. " Ebullition, or any evident motion," observes Mr. Cruickshank, « is not necessa- ry to constitute fermentation ; after wine has undergone what is cal- led its open fermentation, it continues, after it is bottled, to go through its secret fermentation, where no motion is evident, and every body knows requires time to ripen." f Even granting that the extrication of a portion of air is necessarily, at all times connected * Vide Mahon on the Ven. Infect, in Pregnant Women. Lend, Med. Rev, ol. 2. p. 44. f Anatomy of the Absorbing Vessels. VOL. II. 16 122 ©P THE REMEDIES USED Ch. IV. with the assimilating or fermentative process, it forms no argument against the principle here advanced : air conveyed slowly into the blood vessels is not destructive to animal life, a fact, which the ex- periments of Redi, of Florence, and other eminent naturalists have fully established.* There are two or three other objections urged against the doctrine of assimilation which shall be considered rather on account of the high authority of their author, than of any weight in themselves. In his valuable paper on the origin of contagious and new diseases, Dr. Ferriar asks, " docs contagion assimilate all the fluids to its own na- ture ?"t The objections which he considers of great force against this doctrine arc, that many phenomena in the symptoms and cure of fevers point out a spasmodic affection, or diseased action of the ex- treme blood vessels as the real cause of fever. In answer to this it :may be observed, that the existence of spasm, as essential to the character of fever, rests upon the hypothetical views of those who •considered diseases as exclusively affecting the solids, a theory, the absurdity of which has long ago been pointed out. li This affection fa spasmodic affection] is supported," adds Dr. F. " by the action of contagion, and, perhaps, is strengthened as more contagion is pro- duced/' According to this principle, spasm must be the prominent symptom the physician has to subdue in the treatment of contagious diseases, and this spasmodic effect will be the more violent in pro- portion to the virulence of the particular poison by which it is pro- duced. But where arc the facts which warrant conclusions of this nature ? Does not the history of contagion uniformly prove its ope- ration on the human constitution to be powerfully debilitating and depressing, and establish a pathological principle directly the re- verse of the one maintained by Dr. Ferriar ? Were the fluids infected, observes Dr. F. a patient would not cease to infect others till the whole mass was changed. f It is cer- tainly matter of surprise that this argument should have been offer- ed by a writer who has so long been practically conversant with the operation of febrile infection* and who is so fully aware how nume- rous are the circumstances which modify the communication of contagious disorders. Why the infected body does not, in all sta- ges of disease, infect the bodies of others, is a problem, the solu- tion of which is no less difficult than why contagious diseases them- selves do not uniformly operate upon the constitution of all who come within the sphere of their influence. Of the various diseases of specific contagion, small pox is justly considered the most viru- lent in its nature and the most universal in its operation: yet the many cases of exemption from the action of variolous contagion, particularly of those recorded by Dr. Lind,§ will assuredly not lead to the absurdity of denying the specific character of the disease, and that it is propagated by contagion. * Redi, vol. 4. p. 223. as quoted by Sir John Pringle ; Diseases of the Army. Appendix, paper vii. | Med. Hist, and Reflect, vol. 1. p. 280. 2d. ed. ± Med. Hist, and Reflect, loc. tit. p. 281. § Papers on Contagion and Infection , 8eC IV. IN LUES VENEREA* 123 Judging from the following passage, which occurs in the essay* from which the preceding quotations have been made, it would seem that Dr. Ferriar is by no means convinced of the soundness of his own reasoning. He here appears the decided advocate of the very principle which he elsewhere opposes. " It is peculiar to the animal poisons," says he, •" that they not only give rise to a disease similar to their original, but that, however small the quantity ap- plied, they convert a large portion of the Jluids to their oivn na* ture"* Analogical proof in support of the doctrine of assimilation might be adduced from considering the changes which the different articles of food uncleigo when converted into chyle; but the facts already- advanced render, in the opinion of the writer, the existence of such a process no longer controvertible. It appears, therefore, from the changes which take place in the healthy constitution upon the introduction of the peculiar virus of lues venerea, small pox, measles, and other diseases of specific contagion, and from the nature of the alteration which is thereby effected; from the conversion of a local affection into a general dis- order, and the multiplication of the particular morbific matter throughout the system ; from the communication in all cases of the same specific disease, by inoculation, through the medium of the> general circulation, and by the secretions, and from other phenom- ena which characterise these disorders, that the fluids of the human body are susceptible of material alteration even in the living states that this alteration uniformly partakes of the nature of the morbific matter introduced; that the materies morbi thus generated is alone capable of propagating a disease in another constitution, in all re- spects of the same character, and none other ; in fine, that the circu- lating mass of the system does become assimilated in its nature to the virus of specific or contagious diseases, and, as a consequence, that the solids themselves also become affected. For such is th© general law of the animal economy, modified by the living principle, that the action of one part is subservient to that of the other ; while they regularly harmonize in health, they all are acted upon by dis- ease. It has justly been observed, ki an exclusive theory, either of solidism or humorism, is a solecism in pathology." As this alteration in the healthy state of the system, which fol- lows upon the operation of the virus of diseases of specific conta- gion, is characterized by a regular and peculiar train of phenomena, from observing these effects thus constantly produced, many at- tempts have been made to ascertain the particular cause. The ex^ planation which has just been offered, seems to convey the most ac- curate idea of the kind of action which takes place ; that the spe- cific matter of these diseases acts as ^ferment, and by the process consequent thereon, assimilates the system to their own peculiar nature. Doubtless this process is more or -less governed by the liv- ing principle ; and as chemical writers have observed different spe- cies of fermentation in inanimate materials, so also pathologists will * Med, Hist, and Reflect- ioa, cit. p. 278. 32 i OF THE REMEDIES USED Ch. IT admit a modification of the same action when occurring in living or- ganized matter. " All that is necessary in fermentation," says an able philosopher already referred to, " is, that the elementary par- ticles be separated and recombined, so that the matter be converted into something different from what it was before."* From the re- futation that has been given of the chief objections to this theory, the reader will have already understood the principles upon which it rests. Secondly. With regard to the changes effected in the system by the influence of mercury. Mercury in the state of an oxide, is one of the most universal stimulants. Its action, though primarily on the nervous system, is communicated to every fibre of the body, and produces a degree of restlessness, anxiety, and debility. When taken into the system, it manifests itself by a quickened circulation, gives the blood the dis- position to take on the buffy coat when drawn, renders the pulse frequent and harder, increases respiration, excites the temperature of the body, occasions a whitish fur on the tongue, and other symp- toms of general inflammatory action. Its effects upon the secre- tions are still more apparent, producing a preternatural flow of sal- iva, an increased action of the mucous vessels of the trachea, lungs, digestive organs, chylopoietic viscera, and whole intestinal canal. It excites a copious discharge of urine, and in the smallest quantity operates with great certainty on the skin. In its thus extensive in- fluence on the body, it produces a consequently increased action of the absorbent vessels. These may be considered the more ordinary sensible effects of mercury when its action is not particularly mod- ified by the morbid condition of the constitution. From the very general and stimulant operation of mercury in pro- moting the excretions of the whole system depends its curative ac- tion. This theory of the manner in which mercury produces its salutary effects, was suggested in the lectures on the materia medi- ca formerly delivered by the present professor of the theory and practice of physic in the University of New-York.f It appears to be deduced from the nature of the changes which this powerful remedy uniformly effects, when its action is not interrupted or changed by adventitious circumstances; and believing it calculated to lead to material improvement in practice, in addition to the facts and reasonings with which it was originally enforced, the writer now offers such others as seem still stronger to confirm its correctness. It may be asserted as a fact fully confirmed by modern observation and experience, notwithstanding the general opinion of the older writers to the contrary, that the curative operation of mercury, in lues venerea, depends upon the action which it produces through- out the general system : that its sanative powers are in proportion to its uniform effects upon all the secretions, and that the advanta- ges which certain preparations of this mineral possess over those of others, are ascribable chiefly to their action not being confined * Cruickshank's Anatomy of the Absorbing- Vessels, f Doctor David Hosack. SeC. 1Y. IN LUES VENEREA. 3 25 to the increase of the salivary discharge. In proportion also as the action of mercury is general throughout the system, its tendency to run off by any particular secretion is diminished ; and, vice versa, the excitement and consequent increase given to any one secretion almost uniformly produces a diminution of every other. Admitting these principles to be well founded, it follows that the same salutary effects will not be experienced when the operation of mercury is exclusively directed to the salivary glands, or when it exerts its influence on the intestinal canal alone. Hence, in the ad- ministration of this remedy, in lues venerea, in order most effectu- ally to obtain its full operation, it must be introduced into the sys- tem in a gradual manner : as it is equally the physician's care to guard against an undue augmentation of the salivary discharge, as well as a preternatural increase of the evacuation by the bowels : for, in the former case, by promoting a salivation, the important functions of the skin and other secretions are lessened or suppres- sed ; and, in the latter case, the remedy is prevented from entering into the general system in proper quantity. That the medical vir- tues of mercury depend principally upon its operation on the exha- lent vessels of the general surface, at the same time that it operates upon the other emunctories of the body, is still farther evinced by the superior benefit which is derived from certain preparations cf this metal which are known to act almost exclusively in producing diaphoresis ; as the combinations of it with the marine acid in the form of the corrosive sublimate. Proofs of a like nature may be drawn from the action cf those remedies which are often united with mercury, for the more advantageous treatment of the venereal dis- ease, as antimony, gv.aicum, sarsaparilla, opium, Sec. Again ; ex- perience has uniformly shown, that if the action of mercury in cau- sing diaphoresis be aided by a proper regard to temperature, food ? and regimen, and such means as operate upon the skin, its salutary effects are greatly increased : and if its operation be prevented or suppressed by irregularities in diet, or from exposure to cold, they are greatly diminished. This view of the operation of mercury appears still more clear and satisfactory from considering the inlluence of climate in the re- moval of lues venerea. How mild and tractable even the most ob- stinate and confirmed cases of syphilis become upon the patient's removal to a temperate latitude is familiarly known. Not that the air of Montpelier, of Italy, or of Portugal, possesses, in itself, any peculiar balsamic influence, but that the effect of a tempera- ture, such as these places boast, is calculated to insure the full operation of mercury upon all the emunctories of the body, and to prevent its partial influence on any particular part. In temperate climates salivation is at all times studiously guarded against, not less than the pernicious effects which would arise from the inordi- nate action of the medicine upon the intestinal canal ; and if, while in the employment of mercurial remedies, the least symptom of such effects appears, the use of those remedies is immediately sus- pended. To restore the tonic powers of the system, if impaired, previous to entering upon the use of mercury, and to support them 126 OF THE REMEDIES USED Clj. IV, while under its action, are the principal indications of cure ; by these means the constitution is enabled to undergo the necessary al- teration, mercury exerts its natural operation, the venereal poison is eliminated, and a radical cure is effected. Those disposed to en« ter more fully into a consideration of the salutary effects of a tem- perate climate, Sec. in aiding the general operation of mercury, as an anti-venereal, will find the opinions of Mr. Hunter,* on this sub- ject, completely overthrown by the facts recorded in Harris,! Don Uiloa4 CJark,§ Moseley,|j Swediaur,^[ and Vage.** Availing him- self of a knowledge of the importance of a warm climate in mitiga- ting the severity of venereal affections, the practical physician, as Dr. Swediaur has justly observed, " will be able to put his patient, in any country whatever, in a situation which he finds necessary for curing this complaint." By keeping him in a mild and uniform temperature, by the occasional use of warm bathing, by enjoining the wearing of flannel, and proper attention to regimen and diet, a substitute not less efficacious than " climate" is obtained, which eminently contributes to the operation of mercury 'in eradicating the virus of the disease from the system. It is not at all contended for in this place, that mercury induces a peculiar morbid state of the fluids, such as some of the other au- thors denominated dissolved, and which a late writer of the same school, Mr Howard, terms a " putridity sui generis,"f f and that in this manner it throws out offensive matter and effects its salutary ends; but inasmuch as it produces a quickened action of the blood vessels, and a consequent increase of all the secretions, it may justly be considered a most powerful alterative ; and as it possesses in a special degree the property of exciting the excretory vessels of the skin, intestinal canal, and kidneys, it arrests the progress of that peculiar operation which, it has been maintained, takes place, Upon the absorption of a specific matter into the system, and which, as has already been observed, has significantly been termed by sev- eral practical writers the assimilating process. In the treatment of the diseases universally acknowledged to arise From s/ieci/ic contagion, mercury has at length become an active constituent in almost all the various articles employed for that pur- pose, and there is every reason to believe that the evils resulting from such practice have greatly counterbalanced the advantages, But the consideration of one only of the diseases belonging to this class can here be attempted. Notwithstanding all that has been written, so ill defined are the diagnostic signs of lues venerea, whe- ther it assumes the form of a local affection, or operates more im- mediately on the whole system ; so various and complicated are its * Treatise on the Venereal Disease, 4to. p. 348 — 9. f Collection of Voyages and Travels, fol. vol. 2. p- 5M t Voyages to South America, vol. 1. p. 280. § Diseases of Long Voyages, vol. 2. p. 440. !| Treatise on Tropical Diseases, p. 76, 4th ed ^1 Pract. Observ. on Ven. Complaints, p. 167 ** London Med. and Phys. Journal. H" See hi but this seldom happens where the mercury has been sufficiently triturated. Wherever much more than this has been given the mercury either has not been properly triturated or we may conclude that much of it has passed through the intestines without being ab- sorbed, or that the constitution of the patient resists this effect of mercury, 140 OF THE REMEDIES USED Cll. IV, Mercurius alkalisatus, and Plenck's solution of mer- cury in mucilage of gum arabic, are nearly of the same nature with the blue pill, but they are both more apt to purge, particularly the latter, notwithstanding of all that Plenck the inventor has said to the contrary. When properly prepared no more mercury should be given in either of these formulae than in the mercurial pill ; and as a much greater quantity is commonly di- rected, this can only proceed from neither of the pre- parations being made with sufficient exactness, and from much of the mercury which they contain being- left altogether inert by not being duly triturated, Many will be surprised at the small doses of these articles which I have mentioned here, as more than double of this is commonly given. It is not uncom- mon to advise six, seven, or eight of the blue pills daily ; and twenty grains of mercurius alkalisatus is recommended for a dose.^ Now I know from daily experience that the blue pill when properly prepared cannot be given in this quantity. I seldom give more than tw r o pills a day, and very rarely above three ; and in each pill, as I have observed, there is exactly one grain of mercury. But the mass from which these are formed is prepared with much attention : they are tri- turated six or seven hours daily for thirty or forty days ; and when the mercurius alkalisatus is properly prepared it proves equally powerful ; but it is difficult to separate the particles of mercury when rubbed with a dry powder, that this preparation is now very gen erally laid aside. It requires to be rubbed for at least one hundred days, in order to bring all the mercurv into a state of activity. Some are of opinion that mercurius calcinatus is equal in its effects to any of these preparations.! The dose is a grain or two evening and morning, either in the form of a pill or powder. It will certainly cure tie disease, and it puts a stop to the symptoms perhaps as soon as any other form of mercury ; but I have * Vide Mr. Hunter's Treatise oh the Venereal Disease, f Vide Appendix, No. 7 Sec. IT. 1$ LUES VENEREA, 141 sometimes thought that its influence is not so perma- nent ; that is, the symptoms have been more apt to re- cur after a sufficient quantity of this medicine was sup- posed to be given. But so many facts are requisite to ascertain this that I cannot speak decisively about it. From all that I know of it, however, it does not ap- pear to be equal to the blue mercurial pill. The ease with which it is prepared seems to be the only circum- stance in which it has a preference ; but this is a point of little moment when put in competition with utility. A tendency which it has to act upon the stomach and bowels may for the most part be checked by the ad- dition of a small quantity of opium. Hydrargyrus muriatus corrosivus, commonly term- ed corrosive sublimate, when it does not affect the stomach, proves frequently a very useful medicine. It was never generally employed for internal use till the celebrated Van Swieten brought it into repute. It has since been much used in almost every part of Europe ; and being easily disguised, and not so apt to salivate as other preparations of mercury, it has form- ed the basis of almost all the quack medicines that has of late been employed for the cure of this disease. The form of using this medicine by Van Swieten is, however, the most nauseous of any. He advises it to be dissolved in spirits, and one or two spoonfuls, containing from a quarter to half a grain of mercury, or even more, is commonly given evening and morn- ing ; and this is directed to be continued till a cure is accomplished.* Few can bear it in this manner; for it not only affects the stomach, but in this quantity it is apt to excite diarrhoea. Neither can it be with safe- ty given in powder, as it is not easily levigated so fine- ly as to prevent it from acting mechanically upon the stomach. The best form of using it seems to be in a watery solution, and this may either be given in a mu- cilaginous mixture or mixed with broths, or the solu- tion may be made into a mass with crumbs of bread, wheat-flour, or flour of liquorice, and divided into * Vide Appendix, No. 10 242 OF THE REMEDIES USED (Jh. IV, pills.^ Instead of giving it in larger doses evening and morning, it answers better to give the same quan- tity divided into four or five doses. A grain of mer- cury may in this manner be given daily ; that is, a quar- ter of a grain four times a day. Some have advised more, but this is the largest dose that I have ever been able to continue for more than two or three days to- gether. Opiates have not the same influence in preventing corrosive sublimate from acting upon the stomach and bowels which they commonly have with other prepar- ations of mercury. I have found nothing so effectual for this purpose as decoction of guaicum and mesere- on, or plentiful dilution with mucilaginous drinks and broths. These may act in the first place by sheathing the stomach and bowels directly from the effect of the medicine ; and they may also prove useful by promot- ing the natural tendency which this form of mercury seems to have to pass off' by the skin. Mercurius dulcis, or calomel, is given by some in large doses for the cure of syphilis, even to the extent of ten grains daily .f I have not found, however, that this is necessary, and it very commonly proves inju- rious both to the stomach and bowels. It answers bet- ter in doses of a grain repeated three times a day, by which it more readily enters the blood than when giv- en in larger quantities, and is less apt to be carried off' by stool. This form of mercury has long been in general use, and there cannot be a greater proof of its safety and utility than its being still preferred by many of our best practitioners. When as completely deprived as possible of its acid, I believe it to be one of our best saline preparations of mercury. In this state it com- monly operates mildly, and is equally powerful with any other form of the medicine in curing the venereal disease. Mercury in this form is best given in a bolus, in piiis, or in powder, for it is scarcely in any deg * Vide Appendix, No. ll. f Vide No. 9, SeC. IV. IN LUES VENEREA. 143 soluble in water, and it is so heavy that watery flu do not suspend it, so that it cannot easily ue given a mixture. The pulvis mercurius cinereus is another very use- ful preparation of mercury.* It also requires to be given in a solid form. The dose is two, three, or four grains evening and morning. Some have advised more, but I have not found that in common practice more can with safety be given. Hydrargyria vitriolatus flavus, or turpethum mine- rale/ is particularly apt, as I have already observed, to act upon the stomach ; but even this form of mercu- ry may be so given as to cure the venereal disease and yet prove sufficiently mild in its operation.f In doses of five, six, or seven grains it acts as a violent emetic, but it may with safety be given to tne extent of a grain, two or three times a day, particularly if each dose be conjoined with half a grain of opium. Hydrargyrus acetatus, or mercury combined with the acid of vinegar, is certainly more mild in its ope- ration than any of the other saline calces of mercury; nay, it does not derange the stomach and bowels so much as triturated mercury is frequently found to do; but from all the trials that I have made of it, I do not consider it as equally certain in curing the venereal disease. The symptoms abate while the patient is un- der it ; but if some other preparation of mercury is not employed either along with it or continued after- wards, they are very apt to appear again soon after it is laid aside. I have judged it proper to take this particular notice of all the preparations of mercury now generally em- ployed for internal use ; and from what 1 have said, it will be obvious that some of them are for ordinary pur- poses preferable to others. In common practice, the preparations of mercury obtained by trituie, and par- ticularly the blue mercurial pill, will be found to be the best. But as cases sometimes occur which do not readily yield to any one form of medicine, we are un- * Vide Appendix, No. 15. f Vide No. 16. J 44 OF THE REMEDIES USED Cll. IV. der the necessity of having recourse to others; and from what we have already had occasion to remark, the choice may be readily determined. We shall be- sides have farther opportunities of speaking upon this point when we come to treat of the cure of the differ- ent symptoms of the disease. But although we may in a great proportion of cases be able to cure the disease by one or other of these forms of mercury, and in most instances without any injury to the constitution, yet we find that even the mildest preparation we can employ, and under what- ever caution it may be given, is occasionally apt to af- fect both the stomach and bowels in such a manner that we are under the necessity either of giving it in too small quantities for the purpose of curing the dis- ease, or of laying it aside perhaps entirely, in order to make trial of the medicine in some other form. Our surest method of obviating this effect of mer- cury is to apply it to the surface of the body only, a practice which ought as much as possible to be adopt- ed, and to which the chief objection is, the trouble of applying it. The advantages, however, whici attend it are so great that every objection of this kind should as much as possible be made to give way to it. A pa- tient may be so situated that he cannot use the medi- cine in this way ; and instances occur occasionally in which the mercury is not readily taken up by the ab- sorbents on the surface of the body. In both of these cases we are under the necessity of giving it inwardly ; but scarcely any other good cause can occur for it. Nor would either of these be frequent if the advanta- ges of the practice were sufficiently explained to our patients, and due attention given to the proper appli- cation of the mercury. It sometimes indeed happens that mercury does not easily enter the system in any form, and does not in the usual time affect either the salivary or other excretory organs. In such cases, where the symptoms of (he disease are urgent, we should not be confined to any one method of cure, and the medicine should be given in every form in which it is likely to prove useful : but it is proper to ♦Sec. rv. in lues venerea. 145 remark, that failures of this kind are much more fre- quent from the internal exhibition of mercury than from the outward application of it, and which is an- other important advantage that we derive from using it in this manner. Different reasons indeed may be mentioned for this being the case ; the readiness with which mercury given by the mouth is carried off by stool ; the great quantity of food with which it is often mixed in the stomach, and by which we may suppose that a considerable part of the small quantity that we dare ever venture to give in this manner is prevented from coming into contact with the absorbents of the intestines ; and lastly, the great extent of surface to which we can apply it externally. By some it is alleged as an objection to this mode of using mercury, that we cannot exactly ascertain the quantity that enters the system. This, however, holds equally strong against every way in which we can give it, nor is it a point of any importance. It is not so much by the quantity we employ, as by the effects which ret lit from it, that we ought to be directed. The usual efft zts of mercury upon the mouth, and in the cure of the different symptoms of the disease, will, with some patients, take place from half the quantity of medicine required by others ; but were it an object of much more importance than it appears to be, I do not see how the quantity of active mercury entering the system, in any way we may use it, can be ascer- tained. It is also mentioned as an objection to the external use of mercury, that it is more apt to excite salivation than when given by the mouth. This, however, is not so much an objection to the practice as to the mode of conducting it. Mercury used in this manner enters the system for the most part so readily, that those who have not been accustomed to prescribe it, are no doubt apt to be deceived with it. It proceeds quickly to the salivary glands, and is thus more apt to excite sud- den salivation than when taken into the stomach ; but this proceeds altogether from inattention, and may al- ways be prevented by applying the mercury in small vol, ir, 19 146\ OF THE REMEDIES USED Oh. IV. quantity at first, and increasing it according to its ef- fects. Our being able to affect the system more speed- ily by the external application of mercury should be considered as another advantage of this mode of ex- hibition ; for the symptoms of syphilis in some instan- ces advance, so rapidly that it is an object of import- ance to check them as quickly as possible. Salivation appears to be the effect of a certain quantity of mer- cury in the system, in whatever way it is introduced. Some of the more acrid preparations pass off indeed more readily by other emunctories, but the milder forms of the medicine, and which I have endeavoured to shew, ought in most instances to be preferred, are equally ready to excite salivation. It is true that more time is required to throw the quantity into the system that is necessary for this purpose by one mode than by another, but when this quantity is introduced the ef- fect of the mercury upon the glands of the mouth is uniformly the same in whatever way it is accomplished. Upon the whole, therefore, all the objections that have been made to this method of exhibiting mercury are trifling when compared with the advantages it pos- sesses over every other mode of using it, so that for general practice it ought to be preferred. 1 own indeed that at one period I was of a very dif- ferent opinion upon this point ; but this proceeded from my not being so well acquainted with the supe- rior advantages of using mercury in the form of unc- tion as I now am, and which I now therefore very generally prefer. Mercury will pass into the system in various forms from the surface of the body. Lues Venerea has been cured by frequent immersions of the feet and legs in a solution of corrosive sublimate. The application of a mercurial plaister to the surface of the body, if of any considerable extent, will also cure the disease ; and we are indebted to Mr. Clare of London for a third meth- od of throwing mercury into the system from the sur- face.* By rubbing calomel into the inside of the * Vide an Essay on the Cure of Abscesses by Caustic, &c. also a New Method of introducing mercury into the Circulation, by P. Clare, Surgeon. BeC. IV. IN LUES VENEREA. 147 cheeks Mr. Clare found, and his observations have in some degree been confirmed by experience, that we can not onlv excite salivation bv this means, but cure every symptom of syphilis. Nay, the rubbing of a few grains of calomel upon the inside of the preputi- um or labia pudendi soon affects the system and ex- cites the mercurial fcetor in the breath and soreness of the gums. But although I have found 1 bis in some in- stances to be true, the practice has also in several of the trials I made of it failed entirely ; that is, it did not cure the symptoms for which it was employed, and which were afterwards removed by other preparations of mercury. I must own, however, that the experi- ence I have yet had of this method of using mercury does not entitle me to speak decisively concerning it ; but I conclude either that similar failures, or some other objections of importance, have occurred to it in the practice of others, for we do not now hear that it is employed, although Mr. Clare's book has been pub- lished upwards of twelve years. One obvious cause of this, and of the other modes I have mentioned of applying mercury externally fal- ling into disuse is, that all of them seem to be much inferior to the method of introducing it in the form of an ointment, and which was the fir=st, I may observe, that was employed for the cure of Lues Venerea. It is commonly termed the method of cure by unction, or inunction. An ointment for this purpose may be made with dif- ferent proportions of mercury ; but the best I have tried is that in which there are two parts of the unguent to one of crude mercury. In the form commonly used the ointment and mercury are in equal parts ; but the other, while it proves equally powerful, if it be applied over a greater surface, has the advantage of not being so apt to irritate the skin. In order to promote the absorption of the mercury- it has been the practice with many to advise the body to be immersed in a warm bath, once and again, be- fore the course is commenced, and to repeat it once or twice a week during the whole continuance of it. Thev 148 OF THE REMEDIES USED Cfa. IV, likewise think that the bathing proves useful by giving the mercury a particular determination to the skin, and thus preventing it from producing salivation. I have not found, however, that a frequent use of the warm bath is necessary. It cannot in every situation be obtained but with much difficulty, and if not very properly conducted it is apt, during a course of mer- cury, to expose the patient to suffer from the effects of cold. Before the commencement of the course, where t lie skin is particularly dry, I have sometimes thought it right to advise the use of a warm bath, but as in other instances of a similar nature the remedy has answered equally well where this precaution was not taken, I do not conceive that it is of much importance, and I now r seldom employ it. Where the remedy is chiefly employed for the re- moval of a local affection, such as bubo, we endeavour to make it pass through the lymphatic vessels of the part, and in such cases this determines the place to which the ointment should be applied ; but where no local symptom of this kind takes place it may be ap- plied with equal safety and propriety to any part of the body, and the place of application should be changed from day to day. By this means we obviate the irritation of the skin, which is apt to happen from applying it repeatedly to the same place, at the same time that we promote the absorption of the mercury I may also reomrk, that although, for the reasons I have given above, it does not appear to be necessary to immerse the whole body in a warm bath during a course of mercury, yet that some advantage is occa- sionally derived from causing the parts upon which the ointment has been rubbed to be well bathed with soap and water before repeating it upon the same place, It may therefore be proper to advise this to be general- ly done. In applying the ointment some have imagined that we need only Jay it upon the skin, and that it will enter the absorbents with equal certainty whether fric- tion is used or not, This, however, is bv no means SeC. IV. IN LUES VENEREA. 14& the case. I have repeatedly put it to the test of ex- periment, and it evidently appears that absorption is promoted by gentle friction. This indeed is so con- sonant to general experience, that some may be sur- prised at my taking notice of it, nor would I have judged it necessary if the contrary opinion had not of late been supported by authority of some weight. When the patient is able, the friction should be ap- plied with his own hands : Otherwise it must be done by an assistant, his hands being covered with a thin bladder. For want of this precaution, the assistant is apt to be salivated while the patient is deprived of a portion of the mercury. According to the nature of the case, from a drachm and a half to two drachms of the ointment should be rubbed in daily, and it answers bet- ter to apply it at two different times than all at once. For the purpose of applying properly this quantity of ointment, that is from forty-five grains to a drachm, twenty or twenty-five minutes of gentle friction is neces- sary, the patient while under it being exposed to the heat of a moderate fire. Fumigation with Cinnabar was introduced at an early date, but from the injurious consequences which frequently ensued, it grad- ually lost its reputation. In the year 1736, says Mr. Pearson, an empiric, of the name of Charbonnier, appeared at Paris, profess- ing to use mercurial fumigations, after a new mode, safe and suc- cessful. Several of his patients, whom he was permitted to select from different hospitals, were undoubtedly cured, yet he often fail ed and what was more important, a greater proportion of persons died under this mode of treatment, than when mercury was admin- istered in the usual manner. After this time, the practice was nearly abandoned, until the year 1776, when the Chevalier Lalon- ette, a Physician in Paris, published an account of a new method of curing the venereal disease by fumigations. His preparations were free from the inconvenience of sulphureous vapours during their combustion, and he stated that in the space of thirty-five years, he had successfully treated more than 4000 cases, that had resisted all the ordinary methods of cure. The following account of his method we extract from Mr. Abernethy. " It consisted in inclosing the patient previously undressed, in a kind of box resembling a sedan chair, with an opening at the top to let out the head and an, other at the bottom, to which was fitted a small grate, or furnace, having in it a heated iron to convert the mercurial remedy into fume, The preparation he made use of was a kind of calomel, which bv 150 OF THE REMEDIES USED Ch. IV. repeated sublimation from iron filings, was so far deprived of its muriatic acid, as to be in part reduced to running quicksilver; and while it possessed considerable volatility, was perfectly irritating. Some oi this powder being strewed upon the hot iron placed below, was immediately converted into smoke, which surrounded the pa- tient's body, and after some time settled on his skin in the form of a white and very fine calx of quicksilver : a complete dress, having its inside fumigated with the same powder, was then put on. The remedy being thus applied to the mouths of the cutaneous absorb ents, soon got admission into the circulating fluids and the constitu- tion became more speedily affected than by any other process known before." (Abernethy's Surgical and Physiological Essays. Part 2. London. 1793) This method of introducing mercury into the system was adopted by Mr. Abernethy in several instances with complete success, and from his experience, he draws two conclusions in favour of it, first, that it affects the constitution when other means have failed, and second, that its effects are produced in a much shorter time, than any other mode requires. Mr. Abernethy adds, that the feelings of the patient during the operation are not unpleasant, provided the heat is properly regulated. Finding M. Lalonette's fumigating powder very operose and expensive, Mr. Abernethy employed the follow ing, in which the muriatic acid is abstracted by the volatile alkali - Two drachms of Aqua Ammonise are added to six ounces of dis- iiiled water, and four ounces of Calomel are thrown into this liquor, and shaken up with it; the powder is afterwards separated by a fil- ter and dried. The powder thus obtained, is of a grey colour and contains a good deal of quicksilver in its metalic state, which of '•curse is extremely volatile, but become oxydated when raised in - to fume, and afterwards condenses into a white and very fine dust This method, Mr. Abernethy found extremely useful in healing extensive venereal ulcerations, and indeed considers it adequate to the cure of any variety of the disease. (Abernethy ut Sufira.) Mr. Pearson procured Mr. Lalonette's fumigating machine in 1786, and instituted a number of experiments to ascertain the com- parative advantage of this method and the practice of unction, lie found that the gums became more speedily turgid and tender, and the local appearances were sooner removed, but to counterbalance this, debility and ptyalism was induced in a short time and a rapid manner. Mr. Pearson concludes by observing, that where it is ne- cessary to check the disease suddenly, where the body is covered with venereal ulcers, or where the eruptions are so numerous, as not to allow the use of mercurial ointment, the application of the vapour of mercury will be advantageous. This method is however hardly sufficient to secure the patient from relapse. Applied to Venereal Ulcers, Fungi, and Excrescences, Mr. Pearson found fumigation very efficacious, but he observes, that an equal quanti- ty oi mercury must still be introduced into the circulation, as if the local application were not a mercurial one. (Pearson on the effect- of various articles in the cure of Lues Venerea, 1st Edit. 1800.) If it is judged proper to fumigate venereal sores about the geni SeC. IV. IN LUES VENEREA. 151 tals, it will be most convenient to place a red hot heater at the bot- tom of anight stool-pan, and after sprinkling a few grains of Cin- nabar on it, seat the patient on the stool. (Cooper's Surgical Dic- tionary.) The Blue Pills, or Pilula Hydrargyri is a very common prepara- tion, and much used in conjunction with mercurial friction. Should they purge, opium may be combined with them. This preparation is a favourite one with Mr. Pearson. The Hydrar gyrus cum Creta, or Mercurius Alkalisatus of Mr. Bell, is not at present in much repute. The Red Oxyd of Quicksilver was much used by Mr. Hunter, and is considered by many as a more certain remedy in curing the disease, and preventing secondary symptoms, than any other mode of exhibiting mercury. The difficulty and expense attending its preparation, has in many instances, prevented its general use. From our own observation however, we venture to recommend it as a high- ly valuable medicine. The Corrosive Sublimate after the testimony of Van Swieten, was very generally introduced, and the reports in favor of it, says Mr. Pearson, would fill a volume of considerable magnitude. Among its advocates may be found the names of De Haen, Pringle, Cleg- horn, Russel, Stoll and Lewis. Dr. Locher, of Vienna, who had the care of a hospital for venereal patients, states that he has treat- ed near 5000 cases with success. Mr. Pearson has not however found it equal in the cure of primary symptoms to simple Mercury, Calomel or Calcined Mercury, and although useful in secondary symptoms, has not observed any permanent benefit from it, new symptoms appearing during the use of it, He does not consider it safe to confide in this preparation alone for the cure of any truly vene- real symptom. (Pearson on the effects of various articles in the cure of Lues Venerea, 1st Edit.) In exhibiting the corrosive sublimate, we would at all times re- commend the giving it in pills ? in preference to the nauseous mode of solution. It will be proper to acid a small quantity of opium to the prescription given by our author, (Appendix No. 11.) and in this form, the bowels are not so liable to be affected as many imagine. In combination with the decoction of the woods, it is a highly valu- able preparation. (See Francis' Observations on Mercury, in Amer, Med. and P. Register, vol. 4. p. 476.) Calomel is at present but little given by British Surgeons for the cure of Lues Venerea. If it is intended to excite salivation, it should always be combined with opium. As an alterative, it will be found useful to combine it with antimony, in the form of the Plummer's Pills. R. Sulphur of Antimony. Calomel aa 3 U J- Extract of Gentian. Castile Soap aa ^i. Mix. Make a mass and divide it into ISO Pills. 152 * OF THE REMEDIKS USED Cil. JV V The remaining preparations of mercury for internal use, enume- rated by Mr. Bell, are at present in but little repute. The Hydrar gyrus Phosfihoratus has within a short time attained some celebrity on the continent, as an anti-venereal, particularly in inveterate secondary symptoms, such as exostosis, and chronic com- plaints of the skin. It is given, in the quantity of 1-4 of a grain a day, which may be increased, if the patient can bear it. (Cooper's Surgical Dictionary.) In the note to the next section, we shall continue our remarks on these preparations of mercury, which we have found most useful in the cure of this disease. Ed. VI. Of the Duration of a Mercurial Course, and the Quantity of Mercury to be exhibited. In the preceding parts of this section I have enume- rated the different preparations of mercury which chiefly merit attention, with the doses of each, which may with safety be employed. I am now to offer a few observations upon the quantity of mercury to be given, and the length of time to which a course of this, medicine should extend ; questions of the first impor- tance in the treatment of the venereal disease. As salivation is one of the most obvious effects of mercury, practitioners began very early to imagine that the morbid matter of Lues Venerea was carried off in this manner; and at last it was generally be- lieved that a cure could not be obtained if a very considerable discharge of saliva did not take place. In consequence of this every patient labouring under Lues Venerea was made to salivate; and as it was thought to be of importance to have this quickly accomplished mercury was immediately applied in the most effectual manner for this purpose. It was either prescribed in large doses, and these frequently repeat- ed by the mouth or frictions with strong mercurial ointment were applied over the legs and arms, and in some instances even over the whole body. In this manner the system was very quickly charged with as much mercury as it could bear, and for the most part a cure of all the symptoms was no doubt ef- fected : But the sudden manner in which this great quantity of mercury was introduced, and the violent gee. IV. IN LUES VENEREA. 353 evacuations which it excited, together with the low regimen with which it was commonly accompanied, reduced even the strongest constitutions to a degree of debility from which they seldom entirely recovered ; so that a great proportion of all delicate people sunk under it. A course of mercury, conducted in this manner, be- came therefore nearly as formidable as the disease for which it was prescribed, and no other remedies being discovered the same practice was still pursued, till a considerable time after the commencement of the pre- sent century. About this period some abatement of this rigorous course was introduced ; but it was not till of late years that any material innovation took place in it. This ma}' be considered as one advantage among others that might be mentioned which we have derived from rational theory. Some practitioners suspecting that the salivary discharge produced by mercury could not probably be the means by which the cure of Lues Venerea was accomplished, and some trials which fa- voured this supposition being made, they soon came to think that all the symptoms of the disease might be removed with much less mercury than had commonly been employed. If the change of practice, which occurred as a consequence of this opinion, had rested here, much advantage would have been derived from it. But this was not the case. In every attempt to introduce an alteration, while we endeavour to avoid one extreme we are apt to fall into another. The in- conveniencies and distress induced by mercury in the way in which it had formerly been given being so great that every patient was much afraid of being put un- der it, any alteration that was proposed for lessening their sufferings was most readily adopted, and practi- tioners persuading themselves that it might be done with safety, and wishing to adopt the treatment of the disease to the feelings of their patients, they unfortu- nately allowed this to carry them too great a length. So far as the ease, and comfort of a patient is consist- ent with his safety he is certainly entitled to it, but vol. it. 20 154 OF THE REMEDIES USED Cll. IV. more than this be should not be indulged in. There is much cause, however, to think that this has hap- pened in the change of practice which has taken place in Lues Venerea. Instead of the full salivation that patients were formerly put under, and the strict con- finement with which this was accompanied, a course, commonly termed alterative, was judged sufficient, In this, if the mercury is allowed merely to be felt in 1he breath, or by the slightest soreness of the gums, it is never permitted to go farther, and the patient, in a great proportion of cases, is allowed during the whole time that he is taking it to go abroad. That this will prove sufficient in many slight infections, and that it will even answer in many cases of a worse nature, if the course is carried to a proper length, I know from experience is true; but I also know that it ultimately fails in a great proportion of cases that are more invet- erate and of long duration. Even in these it soon gives a check to all the symptoms, and will often make them disappear entirely ; but wherever the system is deeply injured particularly if the disease has attacked the bones, although a cure may in some instances be completed by such a course, and in all of them may be apparently obtained, yet in many the disease will afterwards break out again, and in all even the first re- moval of the symptoms will be protracted to a much greater length than if more mercury had been given. When I first engaged in practice the treatment of Lues Venerea upon this plan was by many adopted in its fullest extent, and I must own that few went more freely into it than I did. The opinion of salivation being unnecessary, and that an alterative course was sufficient, had not only been taught in the schools of medicine, but the practice had been adopted by many of our best physicians and surgeons. Beginners there- fore went readily into it; but if others from farther experience have been led to form the same opinion of it which I have done it will soon, except in the slight- est cases, be generally laid aside. The result of all my experience is, that I am now fully satisfied that to render general practice in the venereal disease safe ; See. IV. IN LUES VENEREA. 155 - that is, to guard as much as possible against a return of the disease, a middle course must be observed be- tween the severe degrees of salivation which our fore- fathers judged necessary, and the opposite extreme in- to which the moderns have fallen. In cases of a slight nature, that is, in the incipient state of mild chancres, what is commonly termed an alterative course will be found sufficient. If the mouth be rendered gently sore, and kept in this state for eight or ten days after the chancres are cured,' no more will be necessary. But even in the treatment of chancres only, if they have been of long duration, or not of the mildest kind, and in every other symp- tom of the disease, the mercury should in a gradual manner be given so as either to induce a very consid- erable degree of soreness in the mouth, and which in most instances will be attended with an increased dis- charge from the salivary glands, or when from pecu- liarity of constitution this cannot be induced, we should persist in the use of mercury till the febrile symptoms which it usually excites are brought to as great a height as the patient can easily bear. It will generally indeed be perceived that those symptoms of the disease to which I allude cannot be cured but with such a quantity of mercury as perhaps in every in- stance excites heat, quickness of pulse, anxiety, and restlessness, and in proportion as the patient is able to bear these in a greater or lesser degree the sooner and more effectually will he get free of the disease. I have already observed that I give a general prefe- rence to the method of cure by unction ; but whatev- er preparation of mercury we make use of, it ought, in ordinary cases, to be pushed in a gradual manner to the extent I have mentioned ; and when as much of it is employed as is sufficient for this effect it ought to be continued so as to keep the system in an equal degree under its influence, not only till all the symptoms of the disease are removed, but for some time thereafter. This will in different cases happen at different periods of a course, and with very different quantities of mer- cury. It is therefore obvious 4hat nothing decisive can 156 OF THE REMEDIES USED CI). IV. be mentioned, ether of the length of time to which a mer- curial course should extend or of the quantity of the medicine that should be given. Our surest, and per- haps only guide that should be trusted, is the result of experience in similar cases; and as the certainty of guarding against a relapse is a point of the first im- portance nothing should ever be left in doubt that may be required for this purpose. In all primary affec- tions, that is, in chancres and buboes only, and where no other symptom of the disease has appeared, I have found that a course of mercury conducted in the man- ner I have mentioned, and continued for a fortnight after the symptoms have disappeared, has at all time? proved sufficient ; but wherever the skin, throat, or bones have been affected, I now always advise the remedy to be persisted in for the space of a month af- ter the cure is apparently completed. I cannot posi- tively say that less than this would not do, but in a matter of such moment, where the health and happiness not only of the patient but of his progeny are at stake, it is better to exceed by giving occasionally somewhat more than might be necessary than incur the smallest risk of the poison being ever to appear at any future period. I have said that in ordinary practice the mercury should be pushed in a gradual manner to the extent to which we mean to carry it; that is, a small quantity should be employed at first, and gradually increased till the effects expected from it are excited, by which we not only avoid the inconveniences which always occur from a salivation being suddenly induced but are thereby enabled to throw in a much greater quantity, and to keep the system more completely under its in- fluence during the whole course than we ever can do when much mercury is given at once ; and this, I may observe, is a point of the first importance in the treat- ment of syphilis, for whoever has paid attention to the subject must have perceived that our success depends in a great measure upon the effects of the medicine being fully and regularly kept up during the whole duration of the course, and which can seldom be done SeC. IV. IN LUES VENEREA. 157 where it is not given in a gradual manner at first. When the fever, salivation, and other symptoms be- come severe, and which they are very apt to do when the mercury is given in large quantities at first, an interruption must necessarily take place, and it is the effect of every interruption to protract the continu- ance of the course and often to deceive both the prac- titioner and patient. My opinion, in short, upon this point is, that our certainty of obtaining a speedy and permanent cure of any symptom of Lues Venerea is not merely in proportion to the quantity of mercury we employ, but to the quantity which in an active state can be thrown into the system in a given space ef time. But while with a view to this I have advised that in common practice mercury should be given at first in a gradual or slow manner, it is proper to remark that cases are sometimes met with in which it is necessary to adopt a different practice. Wherever the symptoms of the disease are particularly urgent, from their being deeply seated in parts of much importance* and from the progress which they are making being rapid, we are justified in deviating from this general rule, and in applying the mercury in such a manner as will most speedily get it in a very ample quantity thrown into the system. In this way a check will soon be given to the farther progress of the disease, when the medicine, during the rest of the course, may be given in the gradual manner which I have just pointed out. The time to be employed in a course of mercury, and the quantity to be given, are circumstances, as I have already observed, that cannot with any exact- ness be ascertained. They depend in a great measure, as we have had occasion to remark, upon the effects with which they are attended, but I may observe in general, that few cases are so bad as to require the medicine, when properly conducted, to be continued longer than nine or ten weeks. In recent cases four or five weeks are for the most part sufficient ; while in some obstinate old affections, where the bones have 158 OF TriE REMEDIES LSED Cll. IV. either been diseased, or the ulcers very foul and ex- tensive, I have known it necessary to go on to the twelfth or thirteenth week. During these periods ointment of the strength I have mentioned may be rubbed in from the quantity of three ounces to eight or ten. When the blue mercurial pill is employed and properly prepared the quantity may vary from four or five drachms to two ounces, or even to two and a half or three ounces. Whenever these quantities are exceeded there is much cause to sup- pose that a great proportion of the medicine has not entered the system, either from the improper method of applying it or some other cause. The opinion which I have thus ventured to suggest of the effects of mercury depending chiefly upon the quantity which in an active state can be thrown into the system in a given space of time, will, at first, be doubted by many. Being contrary to the practice which now generally prevails, few may be inclined to follow it, but those who do will have the satisfaction to find that by means of it they render their patients much more secure than can possibly be done in any other manner. By giving as large a quantity of mer- cury as the patient can with safety bear, they will find that the most inveterate symptoms of the disease may be cured in much less time, and with much more cer- tainty than they usually are by an alterative course, which, however well it may be adapted for the cure of the slighter symptoms of syphilis, is by no means suf- ficient for the removal of the more advanced stages of 1he disease. Many practitioners think that the same quantity of mercury must prove equally useful in whatever time it may be given, provided the mouth be kept mode- rately sore during the whole period. This, however, is not the case. I have met with various instances of venereal sores, as well as other symptoms, which had either obstinately resisted a very long continued course of this kind, or which had recurred from time to time after a cure had been supposed to be obtained, and ivbich at last were entireJv removed by a much less Sec. IT. IN LUES VENEREA. J 59 quantity of the medicine being given in a shorter pe- riod. What I wish to inculcate is, that the more in- veterate symptoms of the disease will seldom yield to an alterative course of mercury, however long it may be protracted, while the same quantity of the medi- cine will seldom fail, when given so as to keep the sys- tem for a shorter period more completely under its influence. I have now the history of more than fifty cases in which this actually happened; where venere- al sores, from resisting mercury under an alterative course, were judged to be incurable, and where com- plete cures were afterwards obtained merely by carry- ing the use of mercury to a greater length than had previously been done. We cannot do better than add the observations of Dr. Francis on this subject, as they contain a summary of our own practice, and the reasons on which it is founded. " If the view which has been taken of the nature and seat of the venereal disease be well founded, and the circumstances which mod- ify its character and method of treatment be correctly stated, much also depends upon a judicious choice of the different mercurial pre- parations. Those combinations of mercury must possess a decided advantage which are least calculated to excite the salivary discharge, and whose operation is general throughout the system. Of the va- rious preparations of this mineral, now in most general use, the oxygenated muriate of mercury, or, as it is commonly called, the corrosive sublimate, (the oxynnirias hydrargyria l. p. jnurias hy- drargyria e. p. murias kydrargyri corrosivu?n, d. p.) is particularly recommended for this purpose. This form of mercury, like every other, has had many opponents and adherents. It is thought by- some to have been first employed as an anti-venereal by Basil Valen- tine ;* but, upon the authority of the celebrated Van Swieten, it came into general use only in 1754, and the favourable reports of its efficacy " would fill," says Mr. Pearson, " a volume of consid- erable magnitude." In the number of its most decided advocates may be found the distinguished names of Locher, De Haen, Pringle, Cleghorn, Gorden, Russell, Stoll, Lewis, Dease, and Seile. Among the principal advantages which the corrosive sublimate possesses over that of every other preparation of mercury are, that, judiciously administered, it is particularly mild and safe'in its ope- ration, will admit of a more extensive use in all the various forms of lues venerea, and subject the patient to fewer inconveniences : that it readily enters into the general circulation, becomes miscible with the several fluids of the body, the soonest arrests the progress Peai arson on the Effects of Various Articles, &c. p. 100, 160 OF THE REMEDIES USED Ch* IV. of the complaint, and eliminates the morbid matter through those emunctories best calculated for that purpose : that it supersedes the necessity of salivation, by its action on all the secretions, and by promoting especially the cuticular discharges, and the evacuations from the kidneys : that it is the only preparation to be depended on in those peculiar habits of body so susceptible to become salivated by every other form of mercury now in use : that in its ultimate ef- fects upon the constitution, it is attended with comparatively no in- jury. These facts are indeed truly important, and many of them are granted by those who altogether reject the use of this prepara- tion. It is not a little unfortunate for the advocates of other combina- tions of mercury, that the objections which have been brought against the corrosive sublimate are so dissimilar. It has been as- signed as a reason against the preparation itself, that it has failed o'. its salutary effects by being given in too small doses. By some its anti-venereal properties are said to be lost on account of its too readily exciting the cuticular discharge ; by others it is owing to its defective action on the secretions of the skin and mouth. By some it is admitted to be beneficial in the primary stage of the disease, and by others it is contended that it is calculated to remove only se- condary symptoms. It is also declared that it is violent and uncer- tain in its operation, and that it does not render the cure permanent.* Some of these objections are, indeed, weighty, and, were they well founded, would fully justify the abandonment of this peculiar com- bination of mercury ; but if the least reliance is to be placed upon the experience and observation of those who have employed the corrosive sublimate with the most disinterested and honourable views, and solely to determine upon its anti-venereal powers, evi- dence sufficient to prove the fallacy of these objections, and derived from indubitable sources, might be adduced. The testimony of Dr. Locher, of the Vienna hospital, is so full and explicit, that it were an omission not to insert it. Having witnessed the " horrid calamities" arising from salivation and other abuses which existed in that institution in the management of venereal patients, upon the recommendation of Van Swieten, he made trial of the corrosive sublimate. From the year 1754 to 1762, he cured by it no less than four thousand eight hundred and eighty persons, without inducing salivation ; and testifies, that " no persons died, or experienced the least painful and dangerous symptoms, in consequence of this rem- edy."! In the cases in which the same preparation was recommend- ed by Pringle,! the cures that were effected were permanent, and from the repeated experience of many other distinguished practi- tioners, the - same result ensued. Muita nobis exempla visa sint luis venerese, murcurio sublimato corrosivo perfecte sanat2e.§ * Hunter, Howard, Pearson, Mathias, and others. j Locher s Observat. Pract. as quoted by Van Swieten, Commentaries, vol. 17. p. 294. * Gorden, Lond. Med. Obs. and Inq. vol. 1. p. 365. vol. 2. p. 73. § Ratio Medendi, pars secunda, p. 229. See also Medica Clinica, bv Chris- tian Gottlieb Selle. Berlin, 1802. Sec. IV. IN LUES VENEREA. lit To enter into a consideration of the treatment of the various symptoms which characterize lues venerea in its simple and in its •more confirmed state, is not deemed necessary, nor will it here be attempted. Fully convinced, as the writer is, of the decided advan- tages which the corrosive sublimate, as an anti-venereal remedy, possesses, in most cases, over other mercurial preparations, he cannot forbear adding a few further observations for the purpose o£ recommending- to more general use this combination of mercury. A very forcible reason why a preference ought to be given to the corrosive sublimate as an anti-venereal remedy, is the mildness of its operation when compared with most other mercurial prepara- tions. In the mind of the judicious practitioner, there need exist no apprehensions of the severity of its action ; few articles of the materia medica can be more readily accommodated to the peculiar condition of the patient and the nature and stage of the disease. The evidence of its mildness may be adduced from the salutary ef- fects which it produces in the constitution of delicate children, and even of infants. In not a single instance, within the recollection of Dr. Hcsack, has it ever been followed by pernicious consequences, though long employed by him in many cases in which the patient laboured under some hereditary taint, obstinate cutaneous eruption, or ether symptoms indicating an alterative course of remedies. The destructive effects which have been mentioned as attending its ad- ministration, such as excessive pain and irritation of the stomach and bowels, headach, fever, &cc. may, in certain cases, arise from some peculiarity of constitution obnoxious to mercurial remedies, but are doubtless, in general, to be attributed either to the impro- per preparation of the corrosive sublimate, or to its having been given in undue quantity. It has been asserted that this mercurial salt is particularly injurious to those labouring under pulmonary af- fections. That this objection is ideal, or rather that, of all mercu- rial preparations, it applies with least force against the corrosive sublimate, must be evident upon considering the general operation of this form of mercury. Every combination of this mineral may prove more or less injurious in the forming stage of consumption, on account of the active inflammation which is then present, and the additional irritation attendant upon mercurial action. For it may be laid down as a general principle, that mercury is in itself in* jurious when administered to any considerable extent during the existence of inflammation and febrile excitement, and before the employment of blood letting or other evacuants. From the mild operation of the corrosive sublimate, properly prepared, may be inferred the utility of its employment in persons of delicate habit, and in those cases especially where the constitu^ tion is materially impaired. In cases of this kind its exhibition is followed with the best effects. That the tonic powers of the system may, however, in certain instances, be so far weakened as to render the employment of every form of mercury not only inefficacious in the removal of syphilitic complaints, but productive of the most distressing symptoms, and, consequently, that the use of the oxy- genated muriate "will at times be the cause of much inconvenience VOL.11. 2] 162 OP THE REMEDIES USE© Ch. IV. and real suffering, there is left no room to doubt. In irregular ca- ses of this nature, the remedy necessarily fails of producing its or- dinary beneficial effects ; and as it becomes an additional source of irritation, it greatly increases the debility which already prevails. These effects, as has just been remarked, do not result from the exclusive employment of any particular form of mercury ; they seem to arise less frequently from the corrosive sublimate, but are common to all mercurial preparations. For if the constitution has not the power to support the action of mercury, vain is the attempt to eliminate from the system the virus of lues venerea. Hence, in the treatment of certain diseases of hot climates, especially in un- healthy situations, it is not an uncommon practice to administer the bark daily during the whole course, for the purpose of enabling the constitution to bear a sufficient quantity of mercury to subdue the complaint.* Upon the same principle that learned physician and distinguished writer, Dr. Chisholm, maintains, that in the manage- ment of disease a reduction of plethora at the commencement, and the augmentation of the vis vitss in the advancement, are to be par- ticularly attended to, in order to ensure the successful administra- tion of mercury .f Dr. Ferriar has observed instances in which the venereal disease itself assumed a peculiar character owing to debili- ty ; where the debility so far prevailed that the constitution had not power to form a genuine syphilis. When this happens, mercury will not effect a cure. " Under these circumstances," adds Dr. Ferriar, " I have advised with success a course of tonics without mercury, to raise up the constitution to a higher level. Mercury may then be expected to cure.*^ It was deemed proper to make these few remarks on the condi- tion of the system necessary to ensure the successful operation of mercury, not only from the circumstance of its being too geneially overlooked, but because it strengthens the belief that the pernicious effects which have been so hastily attributed to the corrosive subli- mate, might have been more satisfactorily accounted for by advert- ing rather to the debilitated state of the constitution than to the acrid nature of the preparation itself. Difficult as it is to establish any diagnostic signs by which the de- predations of Venus and of Mercury on the human constitution may be accurately distinguished, enough is known concerning the nature of mercurial affections to lead to the abandonment of that indiscrim- inate recourse to the external application of this mineral, which has now become so general. Mr. John Pearson states that the mercurial oezena, or erythema, as it is also called, may arise after the employment by friction of a single drachm of mercurial cint« ment, and after the internal use of a dose of calomel : and were it necessary to say any thing in corroboration of this fact, the writer might detail the particulars of a case of vesicular eruption tnat lately came under his notice, which occurred in an adult patient to whom had been administered eight grains of calomel. The vesicles * Vide Clark on the Diseases of Long Voyages. f Essay on the Malignant Pestilential Fever, yoI. X-. f Med, Hist, and Reflect, vol. 3. p. m Sec. IV. IN LUES VENEREA. 163 first appeared, and were confined, chiefly about the anterior and su- perior part of the chest and on the chin ; they were of the size of an ordinary split pea, of a pale or rather light gray colour, unaccom- panied with inflammation or fever, and strongly resembled the erup- tion described by Dr. Willan, in his fourth ordei of Cutaneous Dis- eases.* The serous fluid they contained was discharged on the se- cond or third day, and the excoriated surface readily healed. But notwithstanding that the internal as well as external use of mercu- ry, even in small quantity, will, in certain habits, give origin to the mercurial erythema, yet a careful examination of what has been written on the subject seems to warrant the conclusion that this form of disease arises, in a great majority of instances, from mercury externally applied. If this opinion be well founded, it presents strong additional arguments in favour of the internal use of the cor- rosive sublimate as an anti-venereal remedy. That the corrosive sublimate, of all mercurial preparations, soon- est affects the system and arrests the action of the venereal virus> is a truth grounded upon the concurring experience of the most distinguished practitioners. It is but proper to state, that the preparation of mercury now re- commended, has been employed for the last twenty years in the pri- vate practice of Doctor Hosack, and during his attendance at the New-York State Prison, New-York Hospital, and the Alms-house of this city, as physician of those institutions. It has invariably been found to be the remedy best calculated for the removal of lues venerea, both in its primary and secondary stages; and not a single case is recollected in which the cure has not been permanent. Those injurious effects upon the stomach and bowels, which are so much apprehended, were avoided by a cautious employment of the medi- cine, and by a due consideration of the peculiarities in the constitu- tion and state of the patient. From this form of mercury, saliva- tion scarcely ever was induced ; and while under its influence, the employment of the decoct, guaiac. et sarsaparil. was found to be an excellent auxiliary in recent cases ; and in the secondary stage of the disease, where the patient had been neglected, or when impro- prieties in the cure had been committed, it was almost indispensable, Though satisfied that the oxy muriate of mercury possessed full claims to the title of a powerful anti-venereal remedy, from a peru- sal of the testimony published in its favour, and from a personal knowledge of the result of several cases in which it had been em- ployed ; with the view of more fully determining so important a matter, and to ascertain, as far as practicable, whether the objec- tions which have been stated against it, particularly those of the distinguished Mr. John Pearson, were founded in reality, at the sug- gestion of the writer, the use of the corrosive muriate of mercury was adopted in the spring of the year 1811, in the New-York Hos- pital, by Dr. John C. Cheesman, the tnen house surgeon. From the extensive charity which this excellent institution afforded, ther« * Vide Cutsm. Diseases ; order Bullje, IIL Genus, sp, i ; . 164 OF THE REMEDIES USED Cl). IV. was abundant opportunity of seeing almost every form of this dis- ease, from the more mild to the most aggravated ; cases of recent infection and those of long standing. After a careful eywarnination of the histories of a great variety of cases, a selection was made of several of those patients who were affected with the primary, and of others labouring under the secondary stages of this disease. The corrosive sublimate was given in some instances in the form of the spirituous solution, and in other instances made into pilis; the de- coction of guaiacum and sarsaparilla was employed as an auxiliary, and occasional recourse was had to the application of the lunar caus- tic; but the external use of every preparation of mercury was omit- ted. In no one instance were unpleasant effects produced by the action of this mercurial salt; and, contrary to the opinion enter- tained by Mr. Pearson, of the efficacy of this remedy, the result of these several cases was attended with complete success. To multiply further arguments, or offer additional proofs in fa- vour of the oxygenated muriate of mercury does not seem neces- sary. It may be confidently pronounced a safe, convenient, and ef- ficacious remedy in lues venerea. How far a too ready acquies- cence in the force of authority may be assigned as the cause of that want of confidence in the virtues of the corrosive sublimate, and of that apprehension of its pernicious qualities which at present pre- vail among many practitioners, it is impossible to ascertain. It is evident that the opinions of Mr. Pearson are those chiefly which have been adopted and reiterated by every subsequent writer who has opposed the use of this mercurial combination. But the suc- cess attendant upon the administration of the oxymuriate of mercu- ry furnishes the most satisfactory answer that can be given to those who have denied its efficacy. Upon the successful result of the ca- ses of lues venerea which existed in the New-York Hospital in 1811, the corrosive sublimate again became the principal anti-vcncreal remedy in that extensive establishment. This form of mercury* since that period, has also been in general use in the New- York Alms-house, in the treatment of syphilis in its different stages ; and in most instances it is now employed for the same purpose by the physicians of the City Dispensary. The observation and experi- ence of the writer during the last three years, in a number of un- equivocal cases of lues venerea, have tended to corroborate the fa- vourable opinion he formerly expressed,* and induce him to recom- mend with increased confidence a more extended application of this preparation of mercury. Various are the forms in which the corrosive sublimate has been used in the different stages of lues venerea, and in other disorders indicating an alterative course of remedies. Its external applica- tion in the form of ointment, has been recommended by some ; but * Vide An Inaugural Dissertation on Mercury: embracing its Medical His- tory, Curative Action, and Abuse in Certain Diseases. Neno-Yorifc 1811. The. present communication, and a former one on the same subject, which appear- ed in the Register for April, 1813, may be considered a constituting the col- legiate exercise just mentioned, though now m some parts enlarged and per- haps, somewhat improved. Sec. IV. IN LUES VENEREA. lOo against this practice many forcible objections might ue brought. Tin- internal use of the spirituous solution of Turner, in which the proportion of ardent spirits to the mercurial salt was remarkably small, has justly been accused as the source of much mischief. The formula of Van Swieten deserves a decided preference ; for the muriated quicksilver dissolved in spirits and exhibited in doses lim- ited to the quantity of one eighth cf a grain, two, or, at most, three times in twenty-four hours, seldom produces the least nausea, or any derangement of the stomach or bowels. The corrosive sublimate, dissolved in common brandy, in the proportion of two grains of the salt to one ounce of the liquid, is a valuable and convenient preparation for delicate children. It may be given with the greatest safety, in a little sweetened water, to the amount of three or four drops to a child of one year, and repeated three times a day ; and to a child of two or three years old six or eight drops three times a day. After its employment two or three days the dose may be increased to ten or twelve drops. A solution of the oxymuriate of mercury in common distilled water, with the addition of a little muriated ammonia, (sal ammo mac) is also a judicious and safe pharmaceutical combination. But the best form of administering the corrosive, sublimate is that in which this mercurial salt, united by solution with the muriate of ammonia, is made into amass with the crumb of wheat bread, and then divided into pills. R. Oxymuriat. Hydrarg 1 . Muriat. Ammon. aa gr. xv. Aq. distillat. vel. font. Xiss. Solutioni addatiu Funis medul. sic. q. s. Ut fiat massa, in pil. cxx. dividends. Every pill in this prescription contains, if the materials be uni- formly combined, the eighth of a grain of the corrosive sublimate;. The dose can therefore easily be regulated with the greatest accu- racy. Of these pills one is to be taken every night and mbrni though, in some aggravated cases, another pill may be taken at the middle ot" the day with additional advantage. In this manner a quar- ter of a grain of this preparation of mercury will, in ordinary cases, be taken in twenty-four hours ; and in the more severe form of lues venerea the additional eighth of a grain. Instances may occur in which it may be advisable to administer half a grain daily. Mr. Beil has given a grain of the corrosive sublimate divided in four or five doses, but has not been able to continue this quantity ior more than two or three days together. The corrosive sublimate to the amount of one quarter of a grain a day, and, in some cases, an additional eighth of a grain, in pills, may be continued for a long time without producing the least incon- venience in the stomach and bowels, and with greater certainty and more beneficial effect than the same quantity of this salt in the form of tne spirituous solution. The use of the corrosive sublimate ought to be continued two or three weeks after the disappearance of the disease, in order more effectually to accomplish a radical cure.- 166 OF THE REMEDIES USED Gh. IV, It has already been observed, that the oxygenated muriate of mer- cury operates more readily on the constitution than any other form of this mineral, and that even in very small quantity it soonest ar- rests the progress of venereal symptoms, and, by its general ac- tion, eliminates the poison of the disease. It deserves to be stated that during the use of this preparation, all those precautionary measures with regard to diet and regimen, which are generally re- commended by writers, need not be regarded with the same scru- pulous attention, while in the use of the corrosive sublimate, as during the employment of other mercurial medicines. For as the corrosive sublimate rarely affects, to any considerable degree, the salivary glands, those subjected to its use are not rendered so sus- ceptible to the influence of cold, and the physician is seldom under the necessity of devising means for the purpose of obviating the pernicious consequences of salivation. Instances of peculiarity of constitution may occur which require much management and dis- cretion in the use of this remedy. Mr. Bell has observed, that opi- ates have not the same influence in preventing an undue action of the oxymuriate of mercury upon the stomach and intestinal canal which they commonly have with other mercurial preparations.* The limited experience of the writer has not in any case corrobora- ted this opinion: on the contrary, he has found an occasional re- course to small quantities of opium highly serviceable. As some one or more articles of the vegetable kingdom are in general employed in those cases in which the corrosive sublimate is administered, it perhaps would not be irrelevant to examine how far they are entitled to particular confidence. It may be proper to re- mark, that of the many substances which have been employed as auxiliary remedies, or are now in use, the lignum guaiaci and the radix sarsafiarilltz unquestionably claim the first notice. They are acknowledged to be useful during the administration of the oxymu- riate of mercury, in cases of recent affection ; and in the secondary symptoms ot the disease, for the removal of the evils which have taken place from the injudicious employment of mercury. Sec. their salutary operation has been uniformly evinced The compound decoction of guaiacum and sarsaparilla may read- ily be prepared in the following manner : R. Rasur. lig-ni guaiac. Rad. sarsapar. fissse aa. 5i. Coq. in aq. font, lbiij. ad. lbij. Of this decoction the above quantity, taken warm, ought to be drunk within the twenty -four hours. Of its effects as a powerful alterative for the removal of some of the most painful symptoms of lues venerea and obstinate cutaneous affections, indubitable eudence exists in the pages of the old and in those of the most eminent mod- ern authors.! During a period of more than foit -five years its vir- tues for these purposes have been tested in the practice of that * Treatise on Gonor. and Lues Ven. vol. 2. p. 248. t Vide Aphrodisiacus, Ed. Bogxhaavii, Also., Hunter, Bell., &c< SeC. IV. IN LUES VENEREA. 167 learned and distinguished physician, Dr. Samuel Bard, and for more than twenty years in the practice of Dr. David Hosack. Its saluta- ry properties appear to be owing chiefly to the general excitement which it produces and to its action as a diaphoretic. When had re- course to, while in the use of mercury, particularly in the treat- ment of those cases where the disease is of long continuance, it proves eminently useful by promoting the natural tendency which the corrosive sublimate possesses to increase the cuticular dis- charge. The compound decoction of the guaiacum may be taken with success for the removal of many of the morbid effects produced by the improper employment of the different preparations of mercury, and for restoring the constitution to its wonted vigour. The advan- tages arising from the use of the Rob Anti-syfihilitiquei* for which so enormous a consideration is demanded, may with confidence be attributed principally to the sarsaparilia which enters into its compo- sition. As the local effects which arise from the venereal virus depend upon constitutional irritation, or the action of lues venerea upon the constitution, these effects in most cases are to be permanently re- moved by those remedies only which operate through the medium of the whole system. But the consideration of the local applica- tions best calculated as efficient auxiliaries for the removal of these consequences is at present purposely omitted/' * Vide M'Neven's Account of the Rob of Laffacteur, in New- York Med. and Phil, Journal, vol. 3. p. 23. VII. Of the Regimen to he observed during a Course of Mercury. It was formerly the practice and still is in some parts of Europe, to put every patient while taking mercury upon a low diet, and previous to the commencement of the course blood-letting and purgatives were pre- scribed. When it is necessary in a full habit of body to throw in any considerable quantity of mercury very quick- ly, and especially when it is known that the patient has been liable to inflammatory complaints, some pre- vious evacuation is proper, and the patient during the first part of the course, should be kept upon a low al- lowance. But in general there is no cause for this, and the cure proceeds with least difficulty when the patient is kept upon his usual diet. It is the effect indeed of mercury to produce weakness in such a degree, that if i 60 OF THE REMEDIES USED Cfa. IV. not counteracted by nourishing diet, it is apt to injure the constitution materially. Of this I have met with so many instances that unless where some strong ob- jection occurs to it, I always desire patients under mercury to live as well as a person in health ought to do. A full allowance of animal food would in most instances be improper, but I have never observed any harm occur from a plentiful use of any other article that did not disagree with the stomach and bowels. When mercury is taken by the mouth acid vegetables are apt to do harm ; but there is no cause for avoiding them when the cure is conducted by unction. Patients under mercury are commonly desired to avoid wine and even malt liquor. A great quantity of either ought never to be given ; but in moderate quantities they may be used with safety. .Different opinions have also been entertained respecting the propriety of patients going abroad while under mer- cury. So far as my observation enables me to decide, I think there should be but one opinion upon the sub- ject. We are often obliged to allow venereal patients when usin£ mercurv to go abroad, and to manage their ordinary business, but I have never done so but with regret. Exposure to the irregularities of the ex- ternal atmosphere always does harm in a course of mercury. It is apt to produce distress at stomach, pains in the bowels, and purging. This necessarily impedes the operation of the medicine, by which the cure is not only protracted but rendered more uncertain. I am clearly of opinion therefore, that this kind of expo- sure should at all times be avoided. At the same time I do not think it necessary that patients under mercury should be kept in a great degree of heat. On the con- trary, much advantage is derived from their living in a large well aired apartment, and in a degree of heat that is most agreeable to their own feelings. Nay, e\- ?ej)t in the cold weather of winter and spring, there is no necessity for confinement to one apartment; and any unusual quantity of cloathing, whether in bed or : ring the day, is altogether unnecessary* In short, Se€. IV. IN LUES VENEREA. l6§ much exposure appears obviously to prove hurtful, while no advantage is derived from the patient being- kept in an unusual degree of heat. I think it proper, however, to observe with respect to cloatbing, that linen should never be worn next the skin during the use of mercury ; whether the patient sweats much or not it keeps the surface of his body colder than it ought to be ; and if he is liable to plen- tiful perspiration he is even apt to be hurt by it. Flan- nel should be wore during the cold of winter and spring, and cotton when the weather is more temperate* We hare not found it necessary, except in very peculiar cases, or from the great inclemency of the weather, under our mode of treatment, to confine the patient to his apartment ; nor have we at any time seen any ill effects from this license, Ed. VIIL Of Profuse Salivation and some other Effects of Mercury. We have already had occasion to see that in the cure of Lues Venerea there is no advantage to be derived from any increase that may be made to any of the secretions. But we have also seen that the advanced •stages of the disease cannot be with certainty cured without such a quantity of mercury being thrown into the system as very commonly excites an increased dis- charge of all the secretions, and particularly of the saliva. When this continues moderate no harm ensues from it, but occasionally they come to such a height as to produce much inconveniency and distress. In- deed the readiness with which mercury in some cases runs to the mouth is such that it is with difficulty a suf- fix ient quantity for curing the disease can be given * and it produces, I may observe, one of the most dis- tressful circumstances that we rneet with in practice. The most certain method of preventing severe sal- ivation k the gradual exhibition of mercury in the manner we have already pointed out. Occasionally we succeed in preventing it by guarding against exter- nal cold, by confinement to the house and the use of VOL. IK 22 J 70 OF THE REMEDIES USED Ch. IV. warm cloathing of flannel or cotton. But while in this manner we support a gentle and equal flow of the matter of perspiration, severe sweating is to be avoid- ed, which always proves hurtful, and even sometimes, as I have thought, more so than profuse salivation. But in some cases, even with all the attention that can be given, the mouth becomes quickly sore, and a grad- ual discharge of saliva takes place much sooner than is expected. Purgatives are the remedies most frequently em- ployed for removing salivation: I have not found, h >wever, that they prove useful, and when persisted in they never fail to do harm, for they weaken the pa- t ent, while they seldom have any effect in lessening the salivary discharge. Blisters have also been advised. The sense of suf- focation, which the swelling of the salivary glands sometimes gives, .would appear to indicate the use of blisters. We do not perceive, however, that they have much influence upon the discharge, while by the irritation which they excite they very commonly do harm. As sulphur when combined with mercury renders it so inert that it scarcely acts upon the human body, many have imagined that it ought to have some influ- ence in lessening or removing the ordinary effects of mercury upon the system. We do not find in prac- tice, however, that these views which theory suggest- ed are in any degree realized. It has often been em- ployed for" lessening the violence of salivation, but few instances have occurred of any advantage being derived from it. To me i< appears that this effect of mercury is en- tirely local, and to be cured therefore with most cer- tainty by local remedies. It is obviously the conse- quence of irritation produced by mercury upon the salivary glands: The dread, therefore, which some have entertained of applying local remedies seems to have no good foundation; and accordingly I have found that they may be employed with freedom. As a wash for this purpose lime-water proves useful, bul SeC. FV. IN LUES VENEREA. 171 it requires to be diluted. A strong infusion of red- rose leaves, of galls, oak-bark, and other astringents 3 prove also serviceable ; but the most effectual appli- cation I have ever employed is a strong solution of bo- rax.* A little of it being kept in the mouth from time to time proves exceedingly pleasant and sooth- ing, and at last has often an obvious effect upon the quantity of the discharge. It may prove in some de- gree useful as an astringent, but it seems to act chiefly as a sedative by lessening the irritable state of the sa- livary glands. It is evidently in this manner that opium proves use- ful in removing salivation ; for although some advan- tage is derived from applying it directly to the parts affected in the form of a gargle it proves always much more useful when given internally. A dose of lauda- anum, sufficient to allay the irritation and pain which always accompany a profuse salivation, and to pro* cure sleep during the night, not only gives temporary relief but is the most powerful remedy we can employ for removing the discharge. When the uneasiness is severe the opiate should also be repeated in the morning. Where salivation comes suddenly to a greater height than the quantity of mercury we have employed should give us cause to expect we are apt to be at a loss, and afraid of giving more lest distressful consequences ensue from it. In such circumstances, however, I have often found that although the usual quantity of mer- cury Was continued daily, the salivation was not in- creased, and that in this manner it might be persisted in till the cure was completed. This will not indeed be always the case ; but it succeeds so frequently, that in every instance a trial should be made of it, for a cure may thus be effected in a few weeks which otherwise might be protracted for several months. It has also been remarked, if salivation excited in this manner be allowed to subside entirely, that the same, or even a greater quantity of mercury, may * Yide Appendix No, 20. 112 OF THE REMEDIES USED Ch. If. afterwards be exhibited without any risk of the dis- charge coming again to a similar height. Of this I have met with several instances, so that the prac lice may always be adopted when it is found that a prop- er quantity of the medicine cannot be continued w ith safety from the first. One of the most distressful occurrences which we meet with in this disease proceeds from a peculiarity inherent in some constitutions, by which even the smallest quantity of mercury that we employ is apt to rush with violence to the mouth. This is particularly apt to happen where the patient at the same time la- bours under the sea scurvy. In this case our only remedy is the removal of the scorbutic diathesis b\ a plentiful use of acid vegetables and other antiscorbu- tics} but w ere it does not proceed from this cause all that we can do is to give those preparations of mercu- ry that are least apt to affect the mouth, and to pre- scribe them in the smallest doses. In this view corro- sive sublimate in small quantities is particularly indi- cated ; and in such constitutions I have sometimes found that Plummer's pill, a combination of calomel and sulphur, and which in common practice no great dependence can be placed upon, has proved complete- ly successful.* It luckily happens, however, where salivation is thu£ easily excited that the symptoms of syphilis in general yield to a small quantity of mercury. Some of the worst symptoms of the disease will give way to a sali- vation induced by a very few grains of mercury. Even the uneasiness produced by nodes subsides at once on the salivation being fully excited. But it is proper to remark that this first effect of the mercury will not prove permanent if it be not followed out with farther quantities, given at such intervals as the state of the salivation will admit. I have repeatedly found, however, that this um\ be done with safety, even where a severe degree of salivation has previous- ly taken place. In one case of this kind, where there * Vide Appendix,. No. 21'. SeC. IT. JI\ LUES VENEREA. 1 73 were deep venereal ulcers on the shoulder and on the head, as well as a node upon one of the bones of the fore arm, a violent salivation was excited by the ex- hibition of five mercurial pills, each of which con- jtained only one grain of mercury. This gave an en- tire check to the pain which accompanied the node T and to the progress of the ulcers, and although other five pills only were given the salivation was kept up for eight weeks, w r hen the sores healed and the cure was complete, no venereal symptoms having yet ap~ j peared, although several years have elapsed. In the progi ess of a long continued salivation tooth- ach and pains in the jaws and gums are apt to occur, and they add much to the distress of the patient. There is one advantage that we derive from giving mercury in a gradual manner ; by beginning with small quantities arid increasing them slowly the glande of these parts do not swell so suddenly, nor is the pain which ensues so severe as when too large doses are made use of at once. We also derive some advan- tage from keeping the parts moderately covered with thin flannel. There is no necessity for the head being so warmly covered as is eommonlv done, nor is it at all necessary where these pains do not take place; but when once they have occurred nothing proves more useful than moderate warmth. Indeed flannel seem? here to be equally useful as it is in the ordinary form of rheumatism ; from which, and from the resemblance which these pains to which patients taking mercury are liable in their jaws and head bear to rheumatic af- fections, I conclude that they are of the same nature. Before a patient enters upon a course of mercury, if there is cause to imagine that he will be long kept under it, and that a large quantity of the medicine will be necessary, w 7 e may save him a good deal of distress by inspecting his mouth and removing any teeth that are either very loose or much spoiled ; for teeth in this state never fail to give much pain when the full effect of ihe mercury upon the mouth has taken place. The points of teeth that are ragged ought also to be re- moved, as they are apt to produce painful and trouble 174 OF THE REMEDIES USED Ch. IV. some ulcers on the contiguous parts as soon as they become much swelled. Ulceration of the inside of the cheeks and other parts of the mouth occurs also, and often in a very distress- ful manner from the mercury alone, where no teeth in this state can be discovered. The most effectual me- thod of preventing this is, to cause the patient, from the very first effect of mercury upon these parts, or even be lore this takes place, to wash his mouth several times a day, perhaps every two hours, with port wine and water, an infusion of red-rose leaves, or any other astringent. In this manner we strengthen the parts against the usual action of the medicine, and it also proves useful by preventing that foulness of the mouth which in every course of mercury is apt to take place. Fig tea and other emollients are commonly ^employed for this purpose, but I have not found that they an- swer so well as astringents. In speaking of the different preparations of mercu- ry we had occasion to iemark, that almost all of them, when given internally, are apt to injure the stomach and bowels. It is chiefly the bowels, however, which suffer from mercury, and they do so in some instances in a very alarming degree. The purging which takes place proves not only painful and debilitating, but of- ten exceedingly obstinate. At first the discharge consists chiefly of fceces, but afterwards these are mix- ed with slime, and often with considerable quanti- ties of blood. The patient is also apt to sutler from a very frequent tenesmus. From the similarity of symptoms we should be apt to imagine that purgatives might be equally servicea- ble here as in common cases of dysentery and diar- rhoea ; but we do not find this to be the case. We de- rive some advantage, however, from sheathing the intestines with a plentiful use of the farinaceous ve- getables, and animal jellies prepared with calves feet ? and shavings of heartshorn. Milk boiled to the consis- tence of a jelly with wheaten flour, or flour of rice, proves likewise an useful remedy. i SeC. IV. IN LUES VENEREA. 175 Tn preventing this effect of mercury upon the intes- tines we derive most advantage from the patient being kept in a moderate and equable heat, and from his skin being preserved in a perspirable state, and so re- markable is the influence of this, that the slightest check to the discharge by the skin seldom fails of in- ducing purging. The fact indeed is so generally ad- mitted that I would not have taken this particular no- tice of it, if a contrary opinion had not lately been advanced, and from which much mischief might en- sue, were the practice to be adopted which it tends to inculcate.* Camphor proves sometimes useful in correcting this symptom. It may be given for this purpose to the ex- tent of eight or ten grains, three times a-day. Some of the absorbent earths, and kino, are occasionally used with advantage ; but opiates, particularly when thrown up by the rectum, are the remedies upon which we chiefly depend for removing the pain, and this is very commonly attended with a diminution of the dis- charge. When a clyster of thin starch and fifty or sixty drops of laudanum can be retained it seldom fails to give immediate relief, but where the tenesmus is severe whatever is injected by the anus is very apt to be instantly returned. In this case opium conjoin- ed with kino, in the form of pills, seems to be the best form of the remedy, It is here proper to remark, that although purging and gripes are frequent consequences of the internal use of mercury they are seldom observed during the longest mercurial course where unction only is em- ployed. When the course is conducted- in this man- ner loose stools may occasionally occur, but they may be generally traced to the effects of cold and damp- * Mr. John Hunter, whose ingenuity and abilities are only to be eqalled by his singular opinions, does not imagine that the operation of mercury can be affected by cold, not even by the patient being allowed to walk " in frost and snow." Mr. Hunter does not say that he has practised this method, and I cannot avoid observing that nothing should have warranted the publication of such an opinion but very ample experience of its being well founded. Vide Mr. Hunter's Treatise on the Venereal Disease, p. 349. 176 OF THE REMEDIES USED Cll. IV, ness. I have seldom observed an instance of severe or obstinate diarrhoea from the external application of mercury, where the commencement of the purging could not be traced to some other cause. \\ hen none of the means employed for removing purging induced by this cause prove effectual, we are under the necessity of advising a temporary suspen- sion of the mercury, without which, indeed, all our remedies will frequently fail. Profuse sweating, I have already noticed as an ef- fect that sometimes ensues from mercury, and it ought to be guarded against with much attention. Nothing tends more to induce debility and injure the constitu- tion than a long continuance of this symptom. The most effectual method of preventing sweating is to avoid much warmth, so that patients are seldom hurt with it who pay due attention to the heat of their apartments. It was formerly the practice to con- fine patients under mercury to small apartments ; to prevent as much as possible all kind of access to the external air ; and to have the bed placed by the side of a large fire. These measures prove detrimental in different ways, and they seldom fail to excite a con- stant and profuse perspiration. The most effectual method of preventing this is, to keep the patient in an equal moderate temperature, in a large apartment, and even to admit of his going from one apartment to another, which, in most instances, may be done with safety. A nourishing diet, a moderate allowance of wine, the free use of Peruvian bark, and of the vi- triolic acid, are the most effectual remedies against this effect of mercury. But nothing proves successful where the apartment is kept too much heated. In some cases the kidneys are particularly acted up- on by mercury; but the discharge of urine which it excites is seldom so great as to injure the patient. Were it ever to do so, the remedies commonly em- ployed in diabetes would be advised, and of these the' most effectual perhaps that we could give, would be such as operate by promoting a diaphoresis. SeC. IV, IN LUES VENEREA, J 77 It is not an uncommon effect of mercury to excite an eruption upon the surface of the body. In some this appears as a miliary rash, somewhat resembling measles ; while in others it is considerably elevated and seems to be produced by a serous effusion between the cutis and scarf skin. In some the eruption is partial, being confined to particular spots, while in others it prevails generally over the whole body. This eruption or efflorescence is not attended with pain, but the heat and itchiness which accompany it are in some instances so distressful that it keeps the pa- tient at all times very uneasy, and deprives him en- tirely of rest. The remedies which I have found to answer best are the internal use of opiates, conjoined with the ap- plication of flour, or starch-powder to the parts affect- ed. The skin is kept sufficiently cool and easy by one or other of these powders being from time to time freely applied to the eruption; and by a proper exhi- bition of opiates we secure rest during night. In some instances, however, we are obliged to avoid the use of opiates ; for although they may answer the pur- pose of procuring sleep they tend evidently to in- crease the heat and itchiness of the eruption. We find, indeed, that in some constitutions opium excites an uneasy itchy sensation over the whole body, even where no irruption has previously taken place; and it is perhaps with such patients only that it cannot be employed in the treatment of this eruption. The eruption to which I allude appears to arise en- tirely from the effect of the mercury upon the system; but it does not seem to depend on any particular pre- paration of the remedy. It takes place indiscrimi- nately from all of them, and not more readily from unction than from these preparations that are used internally. But there is a kind of eruption of a local nature, produced entirely by the friction employed in the application of unction. This appears in the form of distinct pustules, which in some are accompa- nied with a good deal of uneasiness, while in others vol. ir, 23 17& OF THE REMEDIES USED Cll. IV. they produce no kind of distress. No remedy proves of any avail while the application of the oinhii'-nfc is continued, but the eruption may always be pre- vented by the precaution we have formerly ^iven, of not applying the friction in daily succession to the same part. Mr. Pearson does not place much confidence in the efficacy of the articles mentioned by our author, (Lime Water, 8tc.) for the remo- val of salivation, but recommends a discontinuance of the mercury for a time, a free exposure to cool dry air, the occasional use of cathartics; the Peruvian bark and mineral acids, with the assiduous application of astringent gargles. The only danger to be appre- hended from this course is a sudden suppression of Ptyalism, which is often productive of serious consequences. In a case related by Dr. Silvester, the patient was unable to retain hardly any food in her stomach for the space of three months, and Mr. Pearson has ob- served not only violent pains, but general convulsions produced from this cause. This however cannot be attributed to a cool and dry air, since it has occurred in patients confined to a warm temperature, but rather originates from exposure to cold and moisture. The remedy for this suppression is a quick introduction of mercury into the body, so as to produce a soreness of the gums, with the occasional use oi the hot bath. When the ptyalism is accompanied with ulceration of the tongue, of the cheeks, or of the tonsils, Mr Pearson has found that by sus- pending the use of mercury, and exhibiting the sulphuric acid dilu- ted three or four times a day? a very speedy amendment was produ eed. Mortification is sometimes a consequence of this complaint, and in this case we would recommend the application of blisters,, as pointed out by Dr. Physick : That sudden and violent rushing to the mouth of which Mr. Bell speaks, when even the smallest quan- tity of mercury is exhibited, is often relieved by the application oi pounded ice to the jaw, and the use of cold acidulated gargles, ca- thartics and blisters, are also sometimes advantageous. In cases of diarrhoea or dysentery originating from the use of rncr cury, the exhibition of opium, not only in the form of clysters, but by the mouth, is the most efficacious remedy. Mr. Pearson states that in the course of two or three years after his appointment at the Lock Hospital, he observed almost ever) year, one or two cases of sudden death among the patients, without any assigned cause, and the subjects were commonly persons who had nearly and sometimes entirely finished their mercurial course. On enquiring of his colleagues Messrs., Bromfield and Williams, they. acknowledged themselves ignorant of the cause, mode of pre- vention* or treatment of the disease, and remarked that they had never discovered any morbid appearances in the bodies of those who had died thus unexpectedly. Mr. Pearson alter diligent attention See. IV. IN LUES VENEREA. %7§ ascertained that these effects were owing to mercury acting as a pois- on on the system, quite unconnected with its agency as a remedy, ^nd its deleterious qualities, were neither in proportion to the in- flammation of the mouth, nor to the actual quantity of that mineral absorbed into the body. This morbid condition of the system he has denominated Mercurial Erethismus, and Observes that it is charac- terized by great depression of strength, a sense of anxiety about the prascordia, frequent sighing, trembling partial or universal, a small quick putee, sometimes vomiting, a pale contracted countenance* a sense of coldness, but the tongue is seldom furred, nor are the vi- tal or natural functions much disordered. A sudden or violent exer- tion of the animal power has, when these symptoms are present,- generally preceded the sudden death of the patient. To prevent its dangerous consequences it is necessary immediately to discontinue the use of mercury, whatever may be the state of the venerea! symptoms. The patient must be exposed to a dry cool air, in such a manner as shall be attended with the least fatigue. He ought to be taken into a garden or field and live as much as possible in the open air. This mode of treatment will often relieve him in the space of from ten to fourteen days, and Mr. Pearson observes that he nas ficarcely lost a patient since he first adopted it. What may appear remarkable, lie adds, is that the persons amicted with it can very soften employ mercury efficiently afterwards, without suffering any inconvenience. (Pearson on the effects of various articles in thft cure of Lues Venerea, 1st Edit. 1800. P. 130 — 3.) In the early stage* of the Erethismus, its further progress ac cording to Mr. Pearson, may be frequently prevented by exhibiting the Camphor mixture, with large doses of the volatile alkali, sus- pending at the same time the use of mercury. Also when the stomach is not oppressed by sarsaparilla, this medicine is produc- tive of infinite benefit. (Rees' Cyclopedia, Art. Erethismus, in which the writer quotes the second edition of Mr. Pearson's work.) In the concluding paragraphs of this section, Mr. Bell has given the first printed account of a disease which of late years has excited great attention among medical men. This honour is universally al- io- sd lam, although Mr. Pearson asserts that he has been in the hi it of describing it, since the year 1783, in his Lectures on Sur- gery, and that he became ..cquainted with it in 1781. Cases have also been observed as early as the year 1798, in the Royal Infirmary of Edinburgh. It was however far from being familiar to practition- ers until the year 1804, when it was described by Dr. Thomas Spens of Edinburgh, under the name of Erythema Mercuriale in the Edinburgh Med. and Surg. Journal, vol 1. p. 7. by Dr. Moriar- tv. of Dublin, under the name of the Mercurial Lepra, and by Dr. Aiiey, his countryman, in u an Essay on a peculiar eruptive diseasej arising from the exhibition of mercury." The latter gentleman, in 1804, assigned to this complaint the appellation of the Mercurial- Jjisease, but in 1810, gave it in a new edition the name of Hydrar- gyria. The term used by Dr. Spens was adopted by Dr. McMullin 5 in his Essay on this disease in the Edinburgh Med. and Surg. Journ= ■al for January, 1806, and in 180f, Mr. Pearson published an ao I BO OF THE REMEDIES USES) Ch. IV. count of it under the appellation of Eczema Mercurials, in the se- cond Edition of his work on the effects of various articles in the cure of Lues Venerea. — The above, is we believe, a complete list of writers on this subject, particularly as Mr. Mathias* work on the Mercurial Disease more properly relates to that class of com- plaints which of late years has been described under the name of Diseases resembling Syphilis. Dr. McMullin commences his Essay by observing that eruptions of various kinds are very common symptoms of syphilis, but a very unusual effect of mercury. In consequence, until the real nature of the erythema was discovered, it was considered an anom- alous form of lues venerea, and mercury was given to a greater ex- tent than before, thus applying the cause of the disease for its re- moval, and aggravating all its symptoms. The observation of this fact, together with another of less frequent occurrence, namely, a similar eruption appearing inpatients using mercury for other com- plaints, and in whom no suspicion of syphilis could be entertained 5 at last led to the important discovery) that the eruption was entire- ly caused by the mercury, and not at all connected with the origin- al disease.' The following account of the symptoms of Erythema Mercuriale, we extract from Dr. McMullin's valuable Essay. " The different appearances," he observes, " which this disease assumes, accord- ing to its severity and duration, will be best understood by describ- ing it ys consisting of three distinct stages. Tue first stag j commences with languor, lassitude, and cold shiv- crings ; tnese symptoms are succeeded by increased temperature of the oody, quick pulse, nausea, head-ach, and thirst. The patient is troubled with a dry cough, and complains of difficult respiration, anxiety, and sense of stricture about the praecordia. The tongue is usually moist, and covered with a white glutinous slime ; it some- times appears clean and bright red in the centre, whilst the margins remain foul. Tne skinfeeis unusually Hot and itchy, with a sense of ^rickiing, not unlike the sensation experienced from the appli- cation of nettles. Tne belly is generally costive, but a diarrhoea is often produced by very slight causes. On tne first or second day an eruption most commonly shows it- sell, the colour of which is either dark or bright red : thepapu.ae are at first distinct and elevated, resembling very much those in ru- beola. Sometimes, but rarely, the eruption appears like urticaria, and in such instances the disease is observed to be very mild. The papulae very speedily run together in such a manner as to form a sutfused redness, which disappears on pressure. In most cases it begins first on tne scrotum, inside of the thighs, fore arm, or where mercurial friction had been applied, and the integuments of the parts affected become much swoin. There have also been observ- ed instances where an eruption of a purplish colour, and unaccom- panied by papulae, has diffused itself suddenly over the entire body. This, however, may be considered as uncommon. In every instance winch came under my observer on, it was confined at first to a few places, and from thence gradually extended, untU the different poi- Sec. IV. IN LUES VENEREA, 181 tions of the eruption had united, and the papulse were also rough to the feel. But in those cases which resemble urticaria, a number of minute vesicles, which contain a serous fluid, appear, from the commencement, interspersed among the papulae. Contrary to what happens in most diseases accompanied with cutaneous affections, the febrile symptoms are much aggravated, and continue to increase after the eruption has been completed. The pulse in general beats from 120 to 130 in a minute, the thirst continues urgent, and the pa- tient, extremely restless, seldom enjoys quiet sleep. When the eruption has continued in this manner for a certain period, the cuti- cle begins to peel off in thin, whitish, scurfy exfoliations, not un- like those observed in rubeola. This- desquamation has not been attended to by Dr. Moriarty or Mr. Alley, if they have not, by giv- ing the same name to the decrustation which occurs in the last stage* confounded both together. It commences in those places where the eruption first made its appearance, and in this order spreads to other parts. About this period the fauces become sore, the tongue swells, and the eyes appear somewhat inflamed. The duration of this stage is very various ; sometimes it contin- ues from ten to fourteen days, and in other cases it terminates in half that time. When the disease has appeared in its mildest form, the patient recovers immediately after this desquamation, a new cu- licle having formed underneath ; but, if severe, he has only experi- enced the smallest part of his sufferings, and the skin now assumes a new appearance, which I have considered as the second stage. The skin at this period appears as if studded with innumerable minute vesicles, which are filled with a pellucid fluid. These vesi- cles maybe expected, if the patient, at the close of the first stage, complains of increased itching, and sense of burning heat, in those parts from whence the cuticular exfoliations have fallen. They re- main sometimes for a day or two, but are most commonly burst, im- mediately after their formation, by the patient rubbing them, in or- der to relieve the troublesome itchiness with which these parts are affected. They discharge a serous, acrimonious fluid, which pos- sesses such a very disagreeable odour as to induce nausea in the pa- tient himself, and those who approach near his bed-side. The odour is so peculiar, that it can easily be recognised by any person *vho has once experienced it. This fluid is poured out most copiously from the scrotum, groin, inside of the thighs, or wherever the skin forms folds, and sebace- ous glands are most numerous. The serous discharge from these minute vesicles form, with the cuticle, an incrustation, which may be considered as the third or last stage. These crusts are generally very large, and, when detached, retain the figuie of the parts from which they have fallen. Their colour is yellowish, but sometimes appears dark and dirty. This period of the disease might be termed, I think, with much propriety, the* stage of decrustation, in order to distinguish it more fully from the desquamation which has been already noticed. From the use of the two last terms indiscriminately, those who have described the dis- ease have introduced into their descriptions a degree of confusion, 182 OF THE REMEDIES USED Ch. IV. •which has caused its progress not to be well understood. When this stage appears, the fauces become more affected, the eyes intole- rant of light, and the tarsi tender, inflamed, and sometimes invert- ed. The crusts formed on the face, as in other parts of the body, before falling off, divide asunder, so as to leave cracks and fissures, which produce an hideous expression of countenance; and the eye- lids are also, from the general swelling of the face, completely clo- sed. The back and hairy scalp are last affected, and, even in very severe cases, these parts are sometimes observed to escape entirely. The patient, whilst in this state, is compelled to desist from every kind of motion, on account of the pain which he experiences on the slightest exertion, and which he describes as if his flesh were crack- ing. The crusts also fall off in such abundance, that the bed ap- pears as if strewed with the cones of hops. Whilst the eruption is only making its appearance in one place, another part may have ar- rived at its most advanced form; so that all the different stages of the disease may be present at one time in the same individual. It is attended with typhus through its entire course ; but it is very cu- rious to observe, that the appetite for food, in most cases, remains unimpaired, and sometimes is even voracious. This circumstance was particularly remarkable in a patient who laboured under the dis- ease, in its worst form, for the space of three months, in the Royal Infirmary of Edinburgh ; for double the usual hospital allowance of food was scarcely sufficient to satisfy his hunger. When the catarrh- al symptoms have continued during the progress of the compiaint, they are, at this advanced period, particularly aggravated: the anx- iety and pain of breast are also very severe, attended with cough, and bloody expectoration, and the patient always feels languid and dejected. The pulse becomes frequent, feeble, and irregular, the tongue black and parched, and at length diarrhoea, delirium, con- vulsions, gangrene of the surface of the body, and death, super- vene. In its mild form, it only goes through the first stage, and terminates, as we have already stated, in a few days, by a slight de- squamation. But, when severe, it is often protracted more than two months, every stage of the eruption continuing proportionably longer; and when, in this manner, it has run its course, it repeated- ly Wreaks out on the new surface, and passes through the same stages.' 5 To the above we add an abstract of Dr. Alley's work, taken from >hc New-England Journal of Medicine and Surgery, for April, 1814. " The Hydrargyria," as Dr. Alley states it, *« is characterised by an eruption, which is very variable in its appearance. These va- rieties in the appearance of the eruption being usually accompanied with corresponding symptoms indicative of the medicines or pecu- liarity of the disease, justify the division of it into three species. 1 . Hydrargyria mitis vel sine febrc ; 2. hydrargyria simplex febri- lis ; 3. hydrargyria maligna. 1. Hydrargyria mitis. This species has at a first view nothing to characterize it further than a light rose coloured efflorescence ; an nttentive observer, however, by holding the affected parts between feim and the light, and keeping his eye on a level witfi them, may Scc.it. in lues venerea. J 83 perceive the surface to be studded over with innumerable, minute, and transparent wrinkles ; but to the naked eye the vesicular ap- pearance is sometimes with difficulty perceptible, Heat and itching attend the striking out of the eruption, and slight headach and nau- sea, in some cases, exists for a few hours. At times the smarting itching which attends the striking out of the eruption is not contin- ual, sometimes attended with accelerated pulse, and Hushing of the face. The efflorescence though not close at first, is gradually diffused over the parts affected, viz. upper part of the thighs, groins, scro- tum, lower part of the abdomen, &c. and it usually is confined to these parts. If, however, mercury be used after its appearance, it does not long remain local, the colour of the eruption in this is sometimes as dark as in the second species ; the spots are minute and distinct however, unless the use of mercury be persisted in af- ter their appearance. In this as in the other species, the colour of the eruption recedes on pressing, and suddenly returns, when the pressure is removed, and the finger will readily detect an inequality of the surface. At times the efflorescence fades away without any desquamation, when however the vesicular appearance is very man- ifest, a slight scurfiness may be observed after a few days, and the natural colour in some instances is net regained for some time after the desquamation has commenced. This species by an incautious use of mercury while it exists may degenerate into the second, and even third, or be produced in an aggravated form by a too early re- moval of the mineral. This is however, contrary to Mr. Pearson's experience who states that u it has even occurred where the patient has been sent out of the hospital that he might enjoy the benefit of a pure atmosphere." 2. Hydrargyria simplex-febrilis. The eruption in this species is preceded by fever, it is accompanied with itching of the skin, audis considerably more rough to the touch than the efflorescence in the same species. From being distinct the spots soon become crowded together, and after the third day the natural colour of the skin can- not be discerned. This eruption may be distinguished from measles by the spots being larger in the former, and not appearing in the annular form which is the case with measles. Mr. Crampton, however, thinks it very difficult for the first two days to distinguish them, the eruption is of a dusky reddish hue, and if mercury be laid aside it is seldom darker than on the second day. The parts attacked are various, in males sometimes the scro- tum, thighs, sometimes however, the backs of the arms and hands,, or the back and abdomen are first affected, contrary to what occurs however, in the first variety, it gradually spreads over the entire surface of the body. In this species at times the vesicular appear- ance of the first, may be noticed, especially on the first striking out of the eruption. When on the decline the eruption may be mista- ken for the last of scarlatina anginosa, at a similar period : the dusk- iness of colour which it always preserves will- enable a careful ob- erver to distinguish them. This species maybe distinguished from the first, by a greater sep- 184 OF THE REMEDIES USED Cll. IV* aration of the cuticle. This is usually preceded by soreness of the throat and fauces. This latter symptom is of short duration. De- squamation generally commences on the fourth day of the eruption* and the earlier it occurs the milder in general the disease. It has been observed, that successive desquamations at times take place, and that this is chiefly observable incases in which mercury has been Used after the formation of the disease. The febrile symptoms mentioned as the precursors of the erup- tion are followed by a considerable degree of oppression about the prsecordia, a hard cough and difficult respiration. The skin is usu- ally very dry. heat very great; from 102° to 106° and is in no dis- ease perhaps more steady or permanent. Sometimes, indeed, in this species, a very foetid perspiration takes place, where there is much attrition of surface, as in the axilla, Sec. The pulse, though full, is not in general hard and varies from 100° to 130° in the minute. The febrile symptoms, except the headach and nausea, increase as the disease proceeds, and does but seldom abate with the desquamation. The eleventh clay has hither- to been considered critical. 3. Hydrargyria maligna. This species is ushered in with the same symptoms as the last. But Mr. A. considers the following as almost certain indications of the distressing nature of its termina- tion. 1. The sense of burning on the surface is experienced to a very painful degree. 2. The actual heat of the skin becomes- in= tense. 3. The soreness of the throat and fauces is extreme. 4 The colour of the eruption is darker, rising sometimes even to purple, and there is considerable tumefaction of the surface. 5. Vesicles of a larger size than in the former species precede desquamation. It must be remembered, that the other species may degenerate into this, by continued use of mercury, and even by continuing the patient in the venereal ward of a Hospital. A most painful burning sensation accompanies the tumefaction, and immediately preceding desquamation the heat has risen to 108°. Blisters are now formed and discharge an acrimonous lymph. So numerous are the vesi- cles that the whole cuticle desquamates from the tumefied parts, as in that species of Roseola attendant or small pox. As the disease advances, the discharge acquires a most offensive odour, one which will be readily recognized, after having been once experienced. The discharge also becomes more acrid and viscid. Desquamation is later in this than in the other species, not occuring in some cases till the tenth day. The separation commences with cracking of the scarf skin, scabs form on the surface. The eyelids partaking of the general tumefaction are sometimes closed ; and so irritable at times is the surface, that blood instead of lymph attends the desquama- tion. The cuticle sometimes separates in large pieces, thus, that of the hand will come off, so entire as to resemble a glove. The desquamations which succeed,' discover a surface less red, and exposed, and the discharge ceasing the epidermis is renewed. Painful tumours sometimes occur in different parts of the body, they suppurate and heal kindly;. While desquamation is only commen- SeC. IV. IN LUES VENEREA^ 183 cing in some parts, a thin acrid matter often exudes in others. The cuticle also when regenerated at times cracks, and separates again ; and in some cases, after the disease has disappeared in every other part of the body, one particular place remains discoloured and ex- tremely sore. The cuticle, in some severe cases of this species, is not the only part separated ; but so deep does the desquamation extend, that in one patient who was very much pitted with the small pox, no pits were discoverable after his recovery. In other instan- ces the hair from the chin, axilla, Sec. has been completely removed by the desquamation. Dr. Alley observes, that the febrile irritation is, in general, proportionate to the severity of the external symp- tom. The affection of the lungs is among the first and most dis- tressing symptom. In some cases great sense of weight and op- pression about the pragcordra and difficult respiration are the most distressing ; in others hard and incessant cough, and a fixed pain in the chest are superadded. The pulse is hard as in pneumonia ; and during fits of coughing, severe headach is experienced. Delirium has not been observed. The soreness of the throat is very distress- ing in some cases for many days, sometimes hoarseness and hae- morrhage from sloughing of the lining membrane of the fauces has occurred. At first the tongue is white, it becomes however parch- ed, and black in the centre, towards the conclusion. The pulse continues quick, but loses its fulness ; it becomes weak and fre- quently irregular. The secondary fever is the most dangerous, and is so in proportion to the extent of the disease and the depths of the desquamation. True hectic at times occurs in these cases, andfre- q lentiy diarrhoea supervenes, constituting the most formidable ■symptom of the disease. Convulsions sometimes occur, andatoth- eis the fasces and urine are discharged involuntarily. As tne hydrargyria has been mistaken for other diseases, Dr. A. subjoins the following brief recapitulation of its most leading feat- ures. 1. The eruption is, for the most part, at first vesicular. 2. The fever and eruption are generally synchronous in their ap- pearance. 3. Exfoliations of the cuticle usually take place, about four days after the appearance of the eruption, and is commonly preceded by soreness of the throat and fauces. 4. In several cases, blisters, sometimes large vesications pre- cede desquamation. The cuticle, in such case's, cracks and forms fissures ; and the odour of the exudation from the surface, is strong- ly characteristic of the disease. 5. The presence of the delirium ferox has never been witnessed, however considerable the inflammation a^d tumefaction of the ex- ternal parts of the head ; nor has the head appeared engaged, ex- cepting where the debility was extreme and the exudation from the surface profuse. 6. When the cuticle desquamates, the parts underneath appear red, as before that occurrence. 7. The disease is »eyer fatal unless secondary fever supervene VOL. IT, 24 186 OF THE REMEDIES USED Cll. fV. Dr. Alley gives the following table of the results of all the cases that he has witnessed during- the last ten years. Hydrargyii Mitis. H Simplex f'ebrilis. H. Malig- na. Total. Cured. Died. Male. 6 12 10 28 22 6 Female 4 7 4 15 13 ■ 2 Total. 10 19 14 43 35 8 Mr. Pearson however, has never seen it fatal, nor has he seen it in subjects above 50, and says, that its occurrence is more common about eight or ten days after beginning a mercurial course. The remote cause of this disease, is the employment of mercury and this without reference to the quantity or manner in which it is used. " I have seen the eruption'* says Mr. Pearson, " take place after the friction of a single drachm of mercurial ointment and af- ter one dose of calomel. I have known a slight degree of the ecze-* una mercuriale, induced in young children from the administration of a single grain of calomel, the touching any part of the human body with mercurial ointment will sometimes produce it and I have seen the accidental falling of a few grains of the hydrargyrus nitra- tus ruber upon the skin, succeeded by a similar effect, but under these circumstances, the eruption will be confined to the parts with which the mercurial preparation comes in contact." (London Med- ical Review, vol. 3. p. 315.) Practitioners however appear to differ on the point whether the application of cold to the body, when un- der the influence of mercury, is necessary for the production of the disease. This is the opinion of Dr. Gregory and Dr. McMullen inclines to this belief, in consequence of the constant combination of catarrhal symptoms. Dr. Spens remarks that in all his cases, the patients had been exposed to cold, but adds that something more is necessary for the production of the disease, since its occur- rence is too rare to be the necessary consequence of a cause so com- mon. Mi". Pearson however considers the irritation of mercury to be the exciting cause, independent of the action of cold, which he denies having any effect in bringing on the complaint. For the removal of this disease Dr. McMullen recommends the Immediate discontinuance of mercury, the removal of the patient irom wards, where this mineral is in use ; the frequent use of tepid bathing; emetics and diaphoretics, but on account of the irritable state of the bowels, he prefers theacetite of ammoniac or citrate of potash to antimoniais ; and purgatives of tne mildest kind, such as oleum recini, magnesia vitrioiata, Sec. To aliay the cough and sore- ness of the fauces, he advises mucilaginous drinks with opium. He recommends great attention to cleanliness and is opposed to lo- cal applications of an astringent kind to the eruption and also to the use of blisters. In the second stage, when the lever assumes more of a typhoid type, the cola infusion of bark with opium maybe tri- ed, but it generally disagrees with the stomach. Wine and porter SeC. IV, IN LUES VENEREA. 1 8*7 are very useful, as are large quantities of diluents and tenid ablu- tion. To relieve the ophthalmia tarsi, the uuguentum oxidi zinci will in general prove sufficient, and to. appease the painful sensation of the skin cracking, the linimentum aquse calcis, which should be applied as soon as crusts appear. The method of cure adopted by Dr. Spens is in general similar to the above. He observes that the external applications which he found most useful were lime water and flour. Mr. Pearson seems doubtful whether any mode of treatment has the power of interrupting the regular course of the disease, or abridging its duration. Believing however in the benefit of reme- dies to mitigate it, he recommends in the early stage, small doses of antimonial powder, with saline draughts or the ammonia acetata. A gentle purgative should be given every three or four days and opium to procure sleep, and the latter article may be advantageous- ly combined with camphor. Sarsaparilla with bark may be given, when the discharge is no longer ichorous and the tumefaction is sub- siding. He has also found the sulphuric acid to prove grateful and refreshing. The diet should be light and nourishing, but no fer- menting liquors should be allowed until the desquamation has some- what advanced. Frequent use of the warm bath and often changing the linen and sheets of the patient are indispensable'. Mr. Pearson also covers every part from which the cuticle is detached, with a. mild cerate of litharge plaster* . yellow wax and olive oil, spread thickly on rollers, and renewed twice a day. This mode of treat- ment, he has, during twenty years experience, found successful, (Rees' Cyclopedia, Art. Erythema Mercuriaie.) Dr. Alley agrees with Mr. Pearson in the opirikhi, that medicines have no effect in cutting short the disease, but objects most decided- ly to the remark of the latter gentleman, that in some cases, the continuance of mercury is proper. Dr. Alley advises the imme- diate discontinuance of mercury, tepid ablution in the eruptive stage and some gentle purgatives, for the removal of the pectoral symp- toms. This plan he considers proper during the eruptive stagje of each of his species. He recommends the culd affusion, but does not appear to have used it in any of his patients, blood-ietting where the inflammatory symptoms are severe; and diuretics especially digitalis, after evacuations. Emetics do not appear to be indicated, and the mineral acids although useful in the primary stages ought to be laid aside in the secondary one, unless combined with opium, as diarrhoea is generally present. The same objection occurs to the use of bark, which also aggravates the pectoral symptoms and Dr. Alley has found wine an excellent substitute in the latter stages of the disease. As to external applications the author speaks well of the liniment : aq : caic : and also of finely levigated carbon ; zinc: pp. or meal, separate or in a combined form. He deprecates the external use of lead a^d considers it highly prejudicial. (Lon- don Med. Review, vol. 3. p. 317. Eclectic Repertory for October, 1813, and New-England Journal for April, 1814.) With respect to the controversy an the name which ought to be given to this disease, we refer our readers to the works quoted 388 OF TH~E REMEDIES USED Cb. IV. above. It is proper however to observe that Dr. Rutter of Liver- pool, has published a case of erythema not occasioned by mercury, in the Edin. Med. and Surg. Journal for A> Hi, 1809, aid Dr. Mar- cet of London, another in the Medico Ghirnrgital Transactions, vol. '2. (New-England Journal, vol. 1. p. 304) Tbe latter gentleman suggests the term Erythema ichorosum as more suitable than that of Erythema mercuriale. It appears that this disease is not confined to Europe, since in a letter from a surgeon in Madras (Edin. M and S. Journal, for Oct. 1806) it is stated that among the natives, who never can be made to clothe themselves sufficiency, when under the use and influence of mercury, the disease occurs frequently and of- ten proves destructive. Dr. Wilian in his work on the Diseases of the skin, mentions a complaint under the name of Erythema jiafiulatum, which he is in- clined to refer to the use of mercury. It occurs lie observes, at an advanced period of the Lues Venerea on the upper and inner part of the thighs, on the scrotum and between tne nates. It is attended with heat, pain and itching, and an acrimonious viscid discharge, which partially excoriates, but which at length forms a smooth whi- tish incrustation, ovei all the affected surface. The best remedies arc washing the parts with warm soap and water, and applying soft- astringent ointments. Dr. Wilian has also known the Pomfiholy& berdgnus induced by the use of a few grains of mercury. (Wilian on Cutaneous Diseases, vol. 1st. London, 18 8.) Madness is not a very uncommon consequence from the exhibition of mercury, largely and injudiciously administered. Mr. Hasiam in his work on Insanity, sates tnis among other causi s, and Baron Larrey in his Relation Chirurgicale cie PArmee D 'Orient observes, that although syphilis was very easily cured in Egypt by the internal use of mercury, diaphoretics and valour baths, yet mercurial fric- tions were not only insufficient, but produced violent frenzy in some patients, and spasms, convulsions and profuse salivation in others. (Edin. M. and S. Journal for April, 1806.) It is a fact, indeed, well attested, that in warm climates, a smaller quantii) of mercury and a shorter period of time are sufficient to cure the disease. Tnis, %ve have observed is the case in Egypt, and Mr. Pearson states the same to occur in Italy, Spain and the Southern parts of France. Ed IX. JDocs Mercury ever fail in the Cure of Lues Venerea ? This is a question of the highest importance, and therefore merits our attention. 1 am disposed lift an the result ol my own experience to say, that menu- ry under proper management may be considered as a certain remed) for syphilis, when not combined* wi.r.h other diseases, or where it does not ahect patients SCO. IV, IN LUES VENEREA. 189 whose constitutions are so reduced and debilitated as to prevent the quantity of the medicine that is neces- sary to destroy tie virus from being employed. I know that some are of a different opinion ; but I con- clude that they are wrong; from my never having met with an instance of mercury having failed when it was properly given, but where some obvious rea- son, such as i have mentioned, could be assigned for it, Lues Venerea as we have already had occasion to see, is often combined with diseases in which mercu- ry commonly does harm. This is particularly the case in scurvy, and in some degree with scrophula. In the higher degrees of scurvy mercury cannot be giv- en but with great danger ; and even where it prevails in a slight manner only, mercury cannot be employ- ed in such quantities as are sufficient for eradicating any of the more formidable symptoms of Lues Vene- rea. When the two diseases therefore are conjoined we cannot expect that mercury will have much influ- ence in the cure of any venereal symptoms that may take place ; and I believe that we are often disappoint- ed in the treatment of the disease by the patient at the same time labouring under a certain degree of scur- vy, which although not so obviously marked as to in- dicate the propriety of advising an antiscorbutic regi- men, may yet be sufficient to prevent him from receiving the full advantage of a course of mer- cury. I conclude this to be the case from the frequent in- stances of the failure of mercury in the cuie of many of the symptoms of syphilis, in which it afterwards proves successful when the constitution of the patient has been restored from a weak debilitated state to strength and firmness, and which we usually accom- plish by a milk and vegetable diet, country air 9 and such other articles of regimen as generally contribute to remove even the high degrees of scurvy. Nay, I believe that a mercurial course when long protracted, is apt to irduce a certain degree of that very state of the sysiem which I now allude to, and 190 OF THE REMEDIES USED Gil. VI. which T conceive to be the cause of the remedy being often found to fail where in this manner it has been long continued. Every practitioner is acquainted with tills circumstance, that a variety of venereal symptoms, and more especially extensive ulcers, will to a certain length do well under mercury, when af- ter a great deal of the medicine has been exhibited they will begin to remain stationary, and make no progress whatever, although the mercury should be given in larger quantities than at first. Nay, in some instances they become worse. The discharge from the ulcers, instead of being mild and purulent, as for some time it may have been, will become thin, sharp, and, corrosive, and the sores themselves more exten- sive. In this situation a farther continuance of mer- cury very commonly does harm, whilst the most ob- vious advantages are derived from it after the consti- tution of the patient has been restored by the influ- ence of a proper regimen. We even sometimes find that a cure is accomplished by regimen alone, and that no more mercury is required, but this can only hap- pen where a sufficient quantity of the medicine has been previously given for the destroying the virus of the disease, and where the ulcers which remained were kept up by a state of the system, which mercu- ry, instead of removing, seems evidently to promote. In the commencement of a mercurial course, and for some time thereafter, it is a certain effect of mercury to excite inflammation, and to produce that state of the system which we conceive to be the very reverse of what takes place in scurvy. The pulse becomes full and frequent, and the blood is firm and sizy ; but all who have paid attention to the subject will have perceived that the contrary happens where mercury has been, long continued. The patient, however full he may have been, is for the most part much emaciated: his pulse is feeble, and any febrile symptoms to which he may be liable are of the low or putrid kind. The particular state of the blood in this situation we have few opportunities of observing, as for the most part the discharge even of a small quantity would in such SeC. IV. OF LUES VENEREA. 191 circumstance prove hurtful, and therefore is not advi- sed : We have reason, however, to conclude, that it is the reverse of what takes place from inflammation, as the most effectual remedies we employ here, are a generous diet, wine, and bark. This opinion of the effects of mercury upon the system receives some confirmation, I may remark, from the putrescency which it evidently excites in the mouth; and from the peculiar tendency both of mer- cury and scurvy to excite a tender st te of the gums, and a very foetid state of the breath, we. have reason to suppose that the effects of both are in some degree the same. This might be farther elucidated by various argu- ments which the extent of this publication will not ad- mit. Enough, however, has been said for the purpose of explaining the chief part of the treatment I have ven- tuied to propose ; particularly that which relates to di- et and other articles o( regimen during a course of mercury. In speaking of scrophula as an impediment to the action of mercury in the cure of Lues Venerea I do not mean to say that the disease cannot be cured in scrophulous constitutions. We daily meet with the contrary of this : But we also find, when the same sore partakes both of scrophula and Lues Venerea, that we do not derive the same advantages from mer- cury as in sores purely venereal. In such circumstan- ces, after as much mercury has been given as is pro- ductive of any beneficial effect, and of which we judge by the sores or other symptoms making no progress towards farther amendment, our best chance of effecting a cure is to omit the mercury, and not have recourse to it again till by the use of bark, cold bathing, cicuta, and other remedies employed for scrophula, the dis- position is corrected or removed by which the opera- tion of the mercury upon the syphilitic symptoms was rendered ineffectual. But the most frequent cause of our failure w 7 ith mncury in the cure of this disease is that which I have already had occasion to insist upon, our giving it in 192 OF THE REMEDIES USED Cll. IV. such small quantities as are not sufficient in the more advanced stages of the disease for eradicating the virus ; by which, although the symptoms may all be render- ed much milder, or even apparently removed, they either do not entirely disappear, or if they do, are af- terwards very apt to recur. This, however, is not the fault of the remedy, but of the method of giving it, and of which all who adopt the practice of giving it in sufficient quantities will be convinced, Since I went into this practice, besides having had many in- stances of the medicine proving effectual when exhi- bited in these quantities, where it had previously fail- ed, T have not as yet, and several years have elapsed, bad a single instance of its failure, except in such combinations as I have mentioned, or where the con- stitution was in such a state of debility that a sufficient quantity of mercury could not be employed. But even of these very few cases have occurred. I have no hesitation, therefore, in saying that mercury un- der proper management may, with very few limita- tions, be considered as a certain remedy for syphilis, We are not acquainted with any cases in which the use of Mer- cury (as formerly prescribed,) has not been amply sufficient to erad- icate the venereal poison, except those which the author has no- ticed ; and we are inclined to say with him that under judicious management, mercury seldom or ever fails, in the cure of Lues Venerea. Ed. 6 3. Of Guiacum Guiacum has long been employed as a remedy in Lues Venerea. It was used indeed very generally over Europe soon after this disease came to attract the attention of practitioners. Being for some time the only remedy upon which any dependence could be placed, it was at first greatly extolled by all who wrote upon it ; and from the testimony given of it by authors of the first reputation, not only of these times, but of later periods, there was no reason to doubt of its be- ing possessed of the power of mitigating, and perhaps See. if; IN LUES VENEREA; 193* of curing some of the symptoms of syphili3. The powers of mercury, however, were found to be so pre- eminent that guiacum came at last to be seldom used by itself, but by many it was, and still is continued as an assistant to mercury. Being seldom given bv itself many came at last to doubt whether any advantage was obtained from it or not i and some went so far as to say that it posses- sed no power whatever over any symptom of this dis- ease. This is one, which among other effects, might be mentioned that result from habit and prejudice, t own too, that from the same cause I was at one period of this opinion, till I found by experiment that guiac- um in different forms could even bv itself remove ma- ny of the symptoms of syphilis. Venereal ulcers and blotches upon the skin are the symptoms in the remo- val of which its effects are most conspicuous. In three cases of ulcers, and one of blotches upon the breast and arms, all clearl\ marked, and in which mer cury had never been employed, the symptoms were- completely removed by the internal use of guiacum alone. In the patient with blotches, however, the dis- ease returned in the space of a month, but not in the same form. In one of the others the ulcers appeared again at the end of six weeks. In a third they con- tinued well after three months had elapsed, but what became of this patient afterwards, and of the fourth, I do not know 7 . The two first were afterwards cured with mercury. Although the result of these trials did not induce me ever to trust to guiacum alone, they gave suffi- cient ground to consider it as a remedy from which, some advantage may be occasionally derived when conjoined with mercury ; accordingly I have been led to continue, or rather to recommence the use of this remedy in many cases of syphilis, for at one period, from the cause I have mentioned, I had laid it entire ]y aside. I believe, indeed, that I would have been induced to place more dependence upon it, or at least to have prosecuted my experiments with regard to it farther vol, m 25 194 OF THE REMEDIES USED Gil. IV. than what I had done, if I had not been prevented by the result of some trials which Mr. Hunter also had made with it, and which he published about the same period. By these it evidently appeared that guiaeum has a considerable influence upon the venereal virus. I never made trial of it as a local application ; but Mr. Hunter found that in this manner it cured venere- al ulcers, first in one part of the body, and afterwards in others, where sarsaparilla employed in a similar manner had failed. He found too that very numerous venereal ulcers were removed by the internal use of it, but after both trials the disease soon returned. Mr. Hunter's experiments were made with the gum, mine with an extract and strong decoction of the wood. The extract seemed to be equally effectual with the decoction, but as it has a strong tendency to affect the bowels I soon left it off. and employed the latter only. In these cases to which I allude, as well as in some others, a very strong decoction was employed, three ounces of the wood to an English quart of water, that is, this quantity w 7 as boiled in two quarts of water into one, and this was taken in the course of a day, either by itself or mixed with milk; but as it is apt to purge when of this strength, and is likewise disagreeably acrid, and as I never now depend upon it alone for the cure, I seldom put more than an ounce to this quanti- ty of decoction.^ That mercury might not cure every symptom of sy- philis equally well whether guiaeum was employed along with it or not I will not positively say ; but I am disposed to think, and not without much attention \q the subject, that the cure commonly goes on more easily when the two are conjoined than when mercury is given to any great extent by itself. I am therefore in the frequent habit of using guiaeum, particularly where the disease is of long duration and has appeared upon the surface, either in the form of ulcers or erup- tion. It has also been much recommended for its effi- cacy in nodes, and for the removal of those pains re- * Vide Appendix, No. 22 Sec. IV. IN LUES VENEREA. 195 sembling rheumatism, which frequently proceed from syphilis. 1 have not found, however, that it proves so useful in nodes as in other symptoms of the disease; and where pains only take place we ci.n never with such certainty determine from what cause they pro- ceed, as they are undoubtedly one of the most equiv- ocal symptoms of syphilis, and there is no cause to doubt of guiacum being a very useful remedy incases merely rheumatic. I have in different instances found a strong decoction of £uiacum prove particularly useful in the cure of those extensive ulcers which sometimes succeed to bu- boes. In some the guiacum answers by itself, but it proves more frequently successful, as we shall here- after have occasion to mention, when conjoined with mezereon and sarsaparilla. The Lignum Guaiaci or Guiacum Wood was first employed by the natives of St. Domingo as an antidote against the Lues Vene- rea ; the Spaniards soon acquired a knowledge of its virtues, and introduced it into Spain in the year 1508, and in a short space 01 time it acquired great celebrity Its reputation as an an ti- venereal con- tinued high for two centuries, although repeated instances occurred, in which it was given in vain. Mr. Pearson observes that when he was first entrusted with the care of the Lock Hospital in 178', it was a favourite remedy with his colleagues. The patients for whom the guiacum was directed were those who had previously used the usual quantity of mercury, but who complained of nocturnal pains, who had gummata, nodes, ozccna, and such other effects of the ve- nereal virus, connected with secondary symptoms, as did not yield to a course of mercurial frictions. The diet of these patients con- sisted of raisins and hard biscuit; they drank from two to four pints of the guiacum every day, they were ordered to use the hot bath twice in the week ; and they commonly took a dose of antimo. iai Wine and Laudanum, or of Dover's powder, every evening. Con- stant confinement to bed was not deemed necessary ; and they were seldom exposed to the vapour of burning spirit to excite perspira- tion, as only a moist state of the skin was required. This treat- ment was sometimes of singular advantage to those whose health had sustained injury from the complicated operation of the disease, combined with confinement and a long course of mercury. The strength increased, untractable ulcers were frequently healed, cari- ous bones exoliated, and those anomalous symptoms which would have been exasperated by mercury, yielded readily to the decoction of Guiacum. Mr. Pearson observes that this Medicine was also 196 OF THE REMEDIES USED Ch. IV. formerly given on the first attack of the venereal disease, and from the benefit derived, a radical cure was considered to be accomplish- ed. Frequent relapses however followed, and Mr. Pearson re- marks that although it may operate like a true antidote, in sus- pending for a time, the progress of certain venereal symptoms and removing other'appearances altogether, yet experience has evinced that the unsubdued virus yet remains active in the constitution. In exhibiting the decoction of Quiacum for pains in the bones, Mr. Pearson rarely found any benefit, except where it acted as a sudorific, and in this respect he considers it inferior to antimony or volatile alkali. When the constitution has been impaired by a suc- cessful course of mercury and long confinement, and a thickened state of the ligaments, or periosteum, or foul ulcers still remain, these sores will heal and the enlarged membranes subside, during the administration of the decoction. It will also suspend for a time, the progress of certain secondary venereal symptoms^ such as, ul- cers of the tonsils, venereal eruptions, and even nodes, but Mr. Pearson never saw an instance, in which the venereal virus was erad- icated by the powers of this medicine, nor does he consider a com- bination of it with mercury, as increasing the virtues of the mine- ral, nor lessening the necessity of giving a certain quantity of it., He has however administered the guiacum with good effect in Cu- taneous Diseases, and in the ozoena. (Pearson on the effects of va- rious articles in the cure of Lues Venerea.) Ed. & 4. Of Sarsaparilla, Sarsaparilla has been long employed in (be cure of Lues Venerea, and from the result of some trials which I made wilh it I am disposed to think that some advantage may be derived from it. The trials which I have made with it along with mercury have been nu- merous, but it is not upon these that any judgment can he formed of its real efficacy. Neither have I given it often where mercury had not been previously used ; but I have had many opportunities of using it in cases where mercury had not proved altogether successful, whether from being given in too small quantities, or from being exhibited without that attention to regimen which it requires, and in a great proportion of these it has been productive of evident good effects. I have found it particularly useful in those symptoms which chiefly affect the skin, such as blotches and the remains of old venereal ulcers. When mercury from either of the causes which I have mentioned has failed of com^t beC. IV, M LUES VENEREA. 197 pleting the cure, I have in various instances known it accomplished by sarsaparilla, where otherwise there was much reason to think that mercury in a larger quantity, or given in a different manner, would have been necessary. I have given sarsaparilla in powder, in extract, and in decoction, but the latter has always appeared to an- swer best. Not unfrequently I conjoin it with guia- cum, and it answers the purpose of blunting the acri- mony of the latter.^ Sarsaparilla and guiacum have both a tendency to promote perspiration. Besides any power which they may possess of acting directly upon the venereal vi- rus, they seem also to prove serviceable where mercu- ry goes too readily to the mouth, in diverting it from that outlet* * Vide Appendix, No. 23. The Radix Sarsaparilla "was introduced into Europe from the West Indies as a remedy of great efficacy in venereal cases, about the year 1530, but afterwards lost its fame. It was again brought into notice by the late Dr. William Hunter, who advised Dr. Chap= man to use it in a bad case of phagedenic bubo, and from the bene-* fit derived, Dr. Hunter was induced to recommend it to other prac- titioners. Sir William Fordyce in a memoir contained in the " Med- ical Observations and Inquiries, vol. 1st." speaks highly of its vir- tues and considers it effectual in curing many of the secondary symp- toms, without the aid of mercury. He also observes that in chan- cres it will be of little service, but thinks it probable that sarsaparil- la will always cure what resists the powers of mercury. Mr. Pear- son in opposition to the above writer, contends that this medicine has not the power of curing any one form of the disease, and cites in favour of this opinion the observations of Cuilen and Brornricld. He allows however, that it may suspend for a time the ravages of the disease, — that it will alleviate symptoms, derived from the joint action of mercury and the venereal poison on certain constitutions? or such as are often the sequelee of a full course of mercury, such as nocturnal pains, membranous nodes, cutaneous ulcerations, &.c. ; but adds that the combined exhibition of sarsaparilla with mercury does in no case diminish the necessity of giving a certain quantity of the latter. (Pearson on the effects of certain articles in the cure of Lues Venerea, 1st Edit. 1800.) Sarsaparilla is an important ingredient in several French prescrip- tions of high reputation. The AntUstjfihilitic Rob of Laffacteurh 198 OF THE REMEDIES USED Cb. IV one of these, and we are indebted to Dr. M'Nevin for the following receipt for preparing it. Take of Sarsaparilla 5xxx. Marsh reed grass, (Arundo phragmatis) 5xxx. Flowers of Borage, 5viij. Senna and Roses, aa ?ij. Boil these for one hour in nine pounds of water, then strain the liquor ; put an equal quantity of water on the residuum, and boil it again for nearly two hours, strain this, and to both decoctions, add six pounds of sugar, as many of honey, and boil down the whole to the consistence of a rob. The dose for men is six table spoonfulis, and for women, four. For further directions, we refer the reader to Dr. M'Nevin's Paper on this subject. He observes that the effica- cy of this medicine is confined to those venereal cases which have been aggravated by the abuse of mercury, and that it is seldom ser- viceable in the primary stages. Another Medicine much in use in the French Hospitals is the Syrup, of Cusinier f which is prepared as follows : Take of Sarsaparilla Jj^x. Senna, 5x. Flo\rers of Borage, 5iij. Flower of Roses, 5nj. Boil and strain and add sugar and honey each forty pounds, and reduce the whole to the consistence of a syrup. Dr. M'Nevin adds that he has found a saturated decoction of sar- saparilla and guiacum answer as well as either of the above, taking care at the same time, to confine the patient to a warm room, and to prevent costiveness. (New-York Med. and Phil. Journal and Re- view, Vol. 3d. P. 23.) E». $ 5. Of Mezereon. The root of this plant has long been employed for the removal of schirrous tumours by whatever cause they may be produced, and many have thought that it lias proved particularly useful in venereal nodes, as well as in some other symptoms of this disease. As I have not made much use of it where mercury was not either employed along with it or before it was given, J cannot from my own observation determine whether It is possessed of the power of curing syphilis by it- self or not ; but from much experience of the effects of it when conjoined with mercury, I can say deci- sively that in this manner it often proves useful. I SeC. IV. IN LUES VENEREA. 199 have never known any advantage that was sufficiently clear and obvious derived from it in nodes, but it cer- tainly tends to heal those ulcers which sometimes re- main obstinate after the quantity of mercury is given that we judge to be necessary. I have already had occasion to mention that spread- ing ulcers of this kind are particularly apt to succeed to buboes, and that they often resist all the remedies that we employ for them. As this sometimes happens after a very full quantity of mercury has been given, and as the sores often heal at last from the effects of a change of regimen alone, I conclude that they are not kept up by any remains of Lues Venerea ; and as it is in this state of the disease that I have chiefly observed any advantage to accrue from mezereon, I conclude that it acts particularly by correcting that state of the system which long continued use of mercury is apt to induce, and which by experience we find to be very inimical to the cure of all such sores as the patient at the time may labour under. It seems to be in this manner that Kennedy's decoc- tion, and of which mezereon appears to form a consid- erable part, proves particularly useful. There is no reason to suppose that any quantity of mercury is con- tained in that decoction, and yet there is no cause to doubt of sores of this description having been often soon healed by it, which had previously resisted every aitempt that was made to cure them. Of this 1 could mention several histories which have fallen within my own knowledge, but they are too long to admit of in- sertion in this place. This decoction, I may remark, appears to be nearly, or perhaps entirely the same with the Lisbon decoction, for which a form is given in the Appendix.* In using this root it is proper to observe, that the ligneous parts of it are altogether inert. The bark of the root appears to be the only active part of it. An English quart, containing a drachm and a half of the bark, is a sufficient quantity to be taken in the course * Vide Vol. I. Nos. 46 and 47. 200 OP THE REMEDIES USED Cfr.lV,. of a day, and even this, when the root is in perfection renders the decoction so acrid that it is apt to affect the throat. With a view to lessen this acrimony we conjoin it with gum arabic, liquorice, althea, and of- ten with sarsaparilla.^ * Vide Vol. II. No. 24. The Mezereon Root was recommended by Dr. Alexander Ru'ssel in the " Medical Observations and Inquiries, vol. 3," as a cure for the venereal node, but he added that it was not found of service in ihe removal of any other symptoms. Mr. Pearson however asserts that it has not the power of curing the venereal disease, in any one stage, or under any one form, and considers its use unnecessary, since the good effects attributed to it are derived, without its dis- agreeable qualities, from the Guiacum, Sarsaparilla, 8cc. (Pearson.) As the Lisbon Diet Drink and the Decoction of the Woods are famous prescriptions in venereal cases, we give the following for- mulas in additition to those contained in our author's appendix When the disease is doubtful, or mercury disagrees, or has been given in sufficient quantity, such remedies may often be administer- ed with great benefit. R. Sarsaparilla concisae. Ligni santali rubri. Ligni santali citi-on. sing : ?iss>. Radicis Glycyrrhezse. Radicis mezerei sing : Zij, Ligni rhodii. Ligni guiaci officinalis. Ligni sassafras sing : ^iss. Antimonii ?i. Aquae distillate ffo v. These Ingredients are to be macerated for twenty-four hours, and aftcrvvaic ^ boiled till the fluid is reduced to half its original quantity. From one to four pints are given daily. The following decoction is said to be the genuine Lisbon Die- Drink. R. Sarsaparillee concisx. Radicis Chinse sing : 5i. Nucurn juglandis cortice siccp.ivr^m No "* Antimonii 5j. ., . ■. . *Ji . - . . — . Lapidis pumicis pulvensati ^; Aquse distillate jfex. The Powdered Antimony and Pumice Stone are to be tied in sep- . § 6. Of Opium. Opium bad long been employed for Ibe relief of that kind of irritation which some of the symptoms of Lues Venerea are apt to excite, but it was not till within these fourteen years that it was supposed to possess any power of destroying the venereal virus, or of curing this disease. It was first employed with this view in the British hospitals in America ; and Doctor Michaelis, physician to the Hessian troops was, I believe, the first who put it to the test of ex- periment. Since that period it has been used as an antisypmlitie medicine by various practitioners in almost every part of Europe ; and it has had the fate of almost every new remedy, or of every remedy employed with new motives. Some have spoken of it in the highest terms of panegyric, while others do not admit that it is ca- pable o( removing even the mildest symptom of the disease. In matters of doubt all that authors ought to attempt is to state clearly what they know to be matter of fact, as it is from the result of repeated tri- als properly authenticated that an adequate judgment on all such points is alone to be formed. As it ap- peared to be a matter of the first importance to have a new remedy for the cure of Lues Venerea, and which was reported to act with much more ease and certainty than mercury, I was one among many who gave it a very full trial. It was used in a variety of cases and in different stages of the disease; but in no instance did it accomplish a cure where there was cause to sup- pose that the virus was not previously destroyed by mercury. Sores originally produced by this virus, and kept up, as is sometimes the case, by irritation alone, and long after the venereal taint is d vol. ii. 20 cstroved. 202 OF THE REMEDIES USED Cll. l\ are more effectually cured by opium than any oilier remedy. Sores which from this cause have remained obstinate for a great length of time, are, by the use of opium, often brought to a healing state ; and when the constitution is not otherwise diseased, they are, for the most part, soon cicatrised. It is proper, however, to distinguish between these sores and such as are vene- rea L Sores in this state are not to be considered as venereal. The venereal virus, it is true, has acted a,s the exciting cause, but tills being destroyed by mer- cury, they no longer depend upon this, and in such circumstances are to be treated in the same manner with sores of a similar nature proceeding from any other cause. In whatever way sores may have taken place, if much irritation prevails, opium is perhaps the best remedy we can employ, but I have not found that it proves more effectual in sores that are the con- sequences of Lues Venerea than in such as are produ- ced by any other cause, provided the degree of pain and irritation with which they are accompanied be the same. I suspect much, therefore, that this distinction has not met with sufficient attention by many who consider opium as a remedy in the cure of syphilis. By acting as a very effectual remedy in the cure of many sores in which mercury had failed, they have been induced to attribute powers to opium, which I have much reason to think it does not possess, for I have never known it prove effectual where mercury had not previously been given. Antisyphilitic powers being once attributed to opi- um it was readily imagined that in proportion to the quantity exhibited it would prove more or less effect u- al. It was accordingly given in large doses, and these were more frequently repeated than had been usual in former, practice. Few, I believe, made more com- plete trials of it, or have pushed it farther than I have in various instances done : Beginning with two grains at bed-time, one in the morning, and another at mid- day, and adding a grain to eacii dose every third or fourth day, patients in this manner I have found could S€C. IV. IN LUES VENEREA. 203 bear very considerable quantities in the course of a short time. One of my patients who could not at first bear more than a grain at once, in the course of five weeks look three doses of fifteen- grains each, daily. I did not find, however, that any advantage was deriv- ed from giving it so largely, while it frequently did much barm. It was apt to excite sickness, head-ach, and giddiness, a total loss of appetite, in some an ob- stinate costiveness, and what was more surprising, it acted with many as a smart purgative. I never observ- ed this effect, however, till the dose came to the ex- tent of ten or twelve grains; but when this symptom did take place from it, no astringent medicine seemed to have any effect in removing it, and ii was only re- lieved by emetics and purgatives. I must indeed admit that opium was taken by many, even in large doses, without any inconvenience or dis- tress ; but being soon sensible that it had no effect in destroying the venereal virus; that it proved in no other way useful than by lessening or removing irrita- tion ; and that this resulted with equal certainty from moderate doses, I have of late desisted from giving it in larger quantities than two or three grains in the course of a day. Opium conjoined with an emetic has long been known as a very useful remedy in rheumatism; and I have found it prove particularly useful in those pains resembling rheumatism which occur in the venereal disease. But the relief which it procures is only tem- porary- if mercury be not employed along with it. For this purpose laudanum may be given along with tincture of antimony, or opium may be given with ipecacuan, in the form of Dover's powder!* Jn some cases opium proves useful as an external application, whether employed as a wash for painful phagedenic ulcers, or in a solid form as an ointment ; but it does not appear, even in this manner, to act in any other way than as an anodyne, Vide Appendix, No, "31 204 OF THE REMEDIES USED CI]. IV. Opium was first employed as a specific in the {Military Hospitals in the City of New-York, about the year 1779. In the opinion given by our author on its anti-syphilitic virtues, he is seconded by the unanimous voice of the profession. The utility of opium is confined to its preventing that irritable state of the bowels, or sys- tem, which mercury sometimes induces, and thus enabling the prac- titioner to administer the latter in sufficient quantity. Besides the articles enumerated in the preceding sections, as re- medies in the cure of Lues Venerea, we shall mention a few addi- tional ones, some indeed of no great reputation, while others are of considerable utility. The Cinchona or Peruvian Dark is considered by Mr. Pearson as a salutary medicine in several of the symptoms of lues venerea.— j He has observed incipient buboes reduced, although not cured by it ; venereal ulcers in the throat become clean and heal, although the disease recurred ; and a gangrenous appearance of chancres, togeth- er with a consequent mortification of the penis, occurring in pecu- liar constitutions, totally removed by its exhibition. There are ca- ses however he remarks, in which after the slough has separated and the ulcer assumed a clean and favourable aspect, it will become painful and foul and spread with thick and indurated edges. At this crisis, the bark is to be abandoned and mercury is to be exhibited. Mr. Pearson concludes by observing that where the tonic powers of the bark are not indispensably necessary, it ought not to be given, since the power it possesses of diminishing the several secretions may prove detrimental. Several other vegetable remedies have acquired a short lived re- putation. Among these are the Radix China whose consequence originated in the report of its having cured the Emperor Charles V.; the Cicuta, recommended by Dr. Storck, and useful in prevent- ing the spreading of irritable sores, whether connected with the venereal virus, or remaining after a mercurial course ; the Sassa- fras Junifierus, Lobelia syphilitica, Safionaria Dulcamara, Astra- galus Exscafius, and the green rind of the Walnut, which Mr. Pearson has used for many«years with advantage in cases where pains in the limbs and indurations of the membranes have remained after a full mercurial course. The Ammonia /irc/iarata, or Volatile Alkali, which was first in- troduced into notice as an Anti-Venereal by M. Peyrilhe, was found beneficial like other diaphoretic medicines in pains of the limbs and in venereal eruptions, and Mr. Pearson has also found the Muriate of Barytes, of which Mr. Bell speaks hereafter, (Chap. IV. SecL IV. § 2.) useful in painful and ill-conditioned sores derived from a venereal cause, and it has proved beneficial by improving the health in general. This medicine, along with the Muriatic and Vitriolic Acids appear from Mr. Pearson's experiments^ to have the power of suspending for a limited time, the progress of the disease, and are useful in phagedenic ulcers of the genitals, of the penis, andcf Sec. IV. IN LUES VENEREA. 205 the threat. The tonic power cf the acids will also be found advan- tageous. The remedies however which of late years have raised the highest expectations among practitioners, and have excited the sanguine hopes, as well as the deliberate examination of many, are the JVitric Acid and the Oxy -muriate of Gold. Valuable as these medicines are in several of the symptoms of Lues Venerea, the re- sult of the investigations concerning them has only added new proof for the opinion that mercury is the only specific. Of the Nitric and Nitrous Acids. The Nitrous Acid was first introduced into notice as a remedy for the Lues Venerea by Mr. Scott, Surgeon at Bombay, in April, 1796. On transmitting an ac- count of his success to England, it was immediately used by a num- ber of practitioners, several of whom have given the result of their experience to the public. Among these may be named Dr. Beddoes, Dr. Rollo, Dr. Ferriar, Mr. Pearson and Mr. Blair. Mr. Scott is said to have caught the idea from Dr. Girtanner, who suggested that the efficacy of the various preparations of quicksilver might arise from th'e oxygen which they contained. The success which he appears to have met with, in India, does not correspond with the result of Mr. Pearson's and Mr. Blair's experience in England The former gentleman found both the nitric and nitrous acid, com* pletely able to remove the primary and secondary symptoms in sev- eral cases, whilst in a vast majority, they were nevertheless, inade- quate. He observes however that where the constitution is so im- paired, as to render the introduction of mercury improper, the ni- trous acid will restrain the progress of the disease, and also im- prove the patient's health. Another advantage which Mr. Pearson has remarked is when given in conjunction with a course of mer- curial unction, it improves the appetite, determines powerfully to the kidnies, and counteracts in a considerable degree the action of mercury on the mouth and fauces. (Pearson, 1st Edit.) Di\ Fer- riar found the nitric acid useful in removing pains in the bones and also in ulcers remaining after a mercurial course, but does not con- sider a less quantity of mercury necessary to remove the disease, even when given in conjunction with it. (Ferriar's Med : Histories and Reflections, 1810. vol. 3rd.) In further experiments on this subject, the nitric acid ought to be used instead of the nitrous. It is given in the following manner. Mix 51 of the nitric acid with a pint of distilled water and sweeten the mixture with simple syrup. This quantity is to be drank at different times, in the course of twenty -four hours, through a small glass tube, which is used to pre- vent the teeth from being injured. If no inconvenience is felt, the dose may be increased to 5"ij or even 5 u j- It will be found most ad- vantageous in the primary symptoms. The Oxygenated Muriate of Potash, which contains an immense quantity of oxygen, is stated by Mr. Cruikshank, to be more effi- cacious than the nitric acid, in relieving venereal symptoms. Dr. Ferriar observes that he has perceived no remarkable advantage from its use. In an able article in Rees' Cyclopedia on Lues Venerea, it is sta- ted on the authority of Richerandjthat experiments have been .made 206 OF THE REMEDIES USED Ch. IV. at the Ecole de Medicine at Paris, with the oxygenated fat and ni- tric lemonade. The former is probably the Oxygenated Cerate of Mr. Alyon, which Mr. Pearson mentions (a composition of nitrous acid and hog's lard) and which he found useless. Mr. Richerand mentions that a few cures were effected by the above remedies, that some received temporary relief, whilst others suffered such relap- ses as to render a resort to mercury necessary. o Gold. In addition to the remedies already noticed in the cure of Lues Venerea, we may notice different preparations of Gold, some of which were at an early period prescribed in its treatment, and as speedily abandoned. Its use has however, of late been revived, both on the continent of Europe, in Great Britain, and subsequently in this country, and has been attended with various success. By some it is considered as a specific, by others as inert, while a third considers it injurious, producing troublesome ef- fects on the stomach and chylopoetic viscera. We confess on the first trials we made with this medicine (the triple muriate of gold and soda) we were incli- ned to regard it not only as a specific, but one which we fondly hoped would supersede, the more trouble- some and painful one then in use ; but experience soon taught us that this hope was delusive ; for though chancres and buboes, rapidly healed and disappeared under the use of it, and the disease appeared to be totally eradicated; yet in every case where we trusted to it alone, the patient returned in the course of a few weeks with ulcers in the throat; these how- ever easily yielded to a slight alterative course of mercury. From these cases we were led to the con- clusion, that though no confidence could be placed in it as a specific, it was nevertheless a most important auxiliary in the cure of Lues; and we have used it in all cases of chancre or bubo which have come un- der our care, for upwards of two years, and with the happiest effects. We commence with the gold and continue it till the chancre or bubo disappears ; when we immediately begin with a moderate alterative Sec. IV. IN LUES VENEREA, 207 course of mercury, which is continued for five, six or more weeks, making use at the same time of the De- coction of the Woods. This is a much less painful course for the patient, and infinitely less troublesome to the physician, than when mercury alone is given, and has proved equally effectual in every case in which we have given it, — so perfectly so, that in up- wards of two years we have not seen or heard of a single case of its failure. In secondary affections, we have not experienced the same good effects from this remedy ; though we have tried it in several cases, where the patient could not conveniently hear the ac- tion of mercury. We have given it to the extent of a grain in the twenty-four hours, in the form of Pills, The following is our ordinary prescription, viz. E. Miiriat : Aur : et Sod : Gr. i. . Pulv : Glycyrrhiz : Grs. x. Hue .lag- : G. Arab : q. s. M. ft. Mass : et divid : in pill : No. xij. Three of these pills to be taken, three or four times a day, and the chancres to be dressed with dry lint. The only sensible effects that we have observed the gold produce, are exeited on the kidneys, the quantity of urine being greatly increased; at least we have known but one exception to it: indeed so pow- erfully diuretic did it prove, that we were induced to give it a trial in a well marked case of Ascites, in which it was attended with more than the expected success. We have not in a single instance discovered any bad effects of the gold either on the stomach or any other organ. For some account of Gold as a remedy in Lues Venerea, Fide Medical Repository Vol. XIV. page 197. Eclectic Repertory Vol. III. page 281. 289. New-England Journal, Vol. I". page 171. Vol. II. page 5, Ed 208 OF THE CUR* Ch. IV, SECT. V. Of the Cure of Lues Venerea. $ 1. Of the Cure of Chancres. A DESCRIPTION of chancre is given in Section II. of ibis chapter, page 12. The first question to be determined in the treatment of chancre is, whether the cure should be trusted entirely to the internal ex- hibition of mercury ; to the use of local applications ; or to both of these combined. A considerable time ago I had occasion to mention my opinion on this subject, and hitherto I have seen no good cause for deserting it.* My opinion at that time was, as it still is, that chancres should be healed as speedily as possible, and that this may be done with safety by combining the advantages of local remedies with the internal use of mercury : Many practitioners think that chancres ought not to be healed but by the internal use of mercury alone, and they give as reasons for this, that when externa! applications are employed we can never be certain whether the constitution is rendered safe or not, while we can scarcely be deceived, they imagine, when chancres heal solely from the use of mercury. To this practice, however, there are different objections. The internal exhibition of mercury alone will not al ways cure chancres. I have known a person kept un- der the complete effect of mercury for many weeks. and the chancres for which it was prescribed remain nearly in the same state as at first. Nay, in differ- ent instances, where this practice was pursued, and in which ihe cure was trusted to mercury alone, although the remedy was continued in all of them for six or seven weeks, and under the best management, as the chancres did not heal the mercury was laid aside on the supposition of the constitution being rendered * Yide Treatise on the Theory ?nd JNlanagemcnt cf T : - SeC. V. OF LUES VENEREA . 209 safe; but although in all of them the sores were soon cured by the application of caustic, red precipitate, or some other escharotic, in several, symptoms of pox appeared in the course of a few weeks ; in some with ulcers in the throat, and in others with blotches upon the skin. From which I conclude that we cannot de- pend upon the internal use of mereuy alone for the cure of chancres ; nor have I observed that it acts with certainty, unless the sores are kept up by the vi- rus having entered the constitution. But the most important objection to the practice is, that being much more tedious in accomplishing a cure, it creates a greater risk of the virus entering the sys- tem than when the sores are more speedily healed by the use of external applications. The practice of heal- ing chancres by the internal use of mercury only, ori- ginated from an opinion that venereal sores of every description proceeded from the constitution being in- fected, and were this the case, there might be cause to consider it as well founded; but now that we know that chancres at first are always local, and that they are the source of whatever matter enters the system, it is obvious that the more speedily they can with pro- priety be healed, the less will be the risk of the consti- tution being injured. Chancres might frequently be cured by the use of external applications alone, and as we know from ex- perience that the matter is not always absorbed, the cure would in a few instances prove permanent ; but as we have no means of distinguishing when this is the case, while there is reason to think that in most instan- ces absorption takes place, we ought in no case to trust to it. In order to avoid the inconveniences of a course of mercury, it has been fashionable of late to trust the cure of recent chancres to local remedies, but I know from various instances in which I have been consulted, that the practice is exceedingly dangerous. The chancres may be easily healed ; but where mercu- ry is not employed the disease in a great proportion of cases soon shews itself in the system. The most certain, as well as the speediest cure of vol. ii. 27 '210 OF THE CUKt; Ch. IV. chancres is to be obtained from a clue attention to ex- ternal applications conjoined with a well regulated course of mercury. By -the former we are frequently enabled to complete the cure in a few days, which otherwise would require a great length of time, and by the latter the constitution is rendered perfectly se- cure. Chancres in an incipient state are most effectually cured by the application of caustic or eseharotics. If the diseased parts are completely destroyed with caustic they soon become clean, and heal as quickly as sores proceeding from any other cause and of the same magnitude usually do. This practice is now very- general ly adopted, and the effect of it is so remarka- ble that it has never probably bren laid aside by any who have given it a fair trial. Kone, I imagine, have pursued it more fully than I have done; but I find it necessary to remark, that in the usual way of con- ducting this practice it is liable to one very important objection : the chancres to which it is applied, if they are not of long duration, very commonly heal quick- ly ; but in a great proportion of cases the cure of the sores is succeeded by buboes in the contiguous glands. For a considerable time I was induced to suppose that the swellings of the glands which thus took place after the cure of chancres were more the effect of accident than of the method of treatment, and that they would have occurred under whatever management the sores might have been. The frequency, however, of their appearance made me at last suspect that I was mista- ken, and farther observation made it obvious that ihi - was the ease. As experiment alone could determine the question, I was resolved to employ this test. Of the first twen- ty patients who occurred with incipient chancres, in ten they were destroyed by an immediate and effectu- al application of lunar caustic, the remedy being em- ployed according to my usual custom at that time, in- stantly on my being; called. Of the other ten, five were dressed with blue mercurial ointment, and live with common wax ointment. The sores to which, caw- See. v. or lues venerea. 'Ill tic were applied healed much sooner (ban the others, and next to these the sores that were dressed with mer- curial ointment. Bui to the ien patienisto whom caus- tic was applied no less than eight had buboes, while only one bubo occurred in all the others, and it hap- pened in one of the patients whose chancres had been dressed with mercury. I thought also that buboes ap- peared to be less frequent from the application of caus- tic where mercury had been previously given. This fell within my observation from time to time with pa- tients who had taken mercury either of their own ac- I or by the advice of others, and appearing to be of importance I was resolved to bring it likewise to the test of experiment, and the result was as follows : Of forty-eight patients with chancres in an incipient state, and exactly as they occurred in practice, one half was treated in the manner I have .mentioned, by destroying the chancres with caustic, immediately on my being desired to see them, while all the others were put under mercury for eight or ten days before the application of caustic. In every other circum- stance the method of treatment was the same. The difference, however, surprised me exceedingly. Of ttie twenty-four treated with the immediate application of caustic twenty were seized with buboes, while only three buboes occurred in an equal number to whom mercury had been previously administered. These buboes did not indeed all terminate in suppu- ration, nor did many of them arrive at any considera- ble size. Being closely watched, mercury was imme- diately applied for the purpose of discussing them, and for the most part it proved successful; but there was no cause to doubt of their being venereal from their being equally difficult to manage, and from those which ended in suppuration being equally difficult to cure with buboes which occur in the ordinary course of bu- siness. At first I was induced to hope that swellings produced in this, manner were not venereal, but mere- ly the effect of irritation excited bv the caustic, but it soon became obvious that this was not the case, and that caustic does notdestrov the venereal virus so com- 212 OF THE CURE CI). IV. pletely as is commonly imagined, while, by the irrita- tion which it always in some degree excites, it tends often to produce buboes, which otherwise never would take place. This affords an additional proof to what has already been mentioned of the effect of irritation in exciting the action of the absorbents ; and the effect of mercury in this case, by preventing the formation of buboes, tends farther to support the opinion of this medicine acting as an antidote to the syphilitic virus. In most instances buboes produced in this manner begin to form in the course of a day or two after caus- tic has been applied ; in some cases even sooner. But I have known them take place where the glands had remained sound for a good many days after the chan- cres were completely cicatrised, and where there was no*reason therefore to suspect that any exciting cause of buboes could remain. In these instances I conclude that such a small- portion of the virus had been lodged in the lymphatics forming the gland, as required this length of time to excite that degree of irritation that is necessary for the production of bubo. The same effect appears to result from whatever caustic is employed ; at least this has been the case with such trials as I have made with lunar caustic, red precipitate, blue vitriol, and corrosive sublimate ; and as the caustic is more easily applied, while it common- ly acts with more certainty, and perhaps with less pain than any of the others, I commonly give it the preference. Where caustic is to be employed, my practice now is to put my patient previously under mercury for the space of six, eight, or ten days, till there is full evidence of the medicine having entered the system. At this time caustic is applied over the whole surface of the chancre, however extensive it may be, in such a manner as to destroy all the diseas- ed parts, and the application is renewed as often as the sores become foul or sloughy. In some it is not ne- cessary to use it above once or twice, while in others it must be repeated in every second or third day, dur- ing a great part of the cure. Even where the sores have become clean, caustic often proves useful, par- Sec. V. OF LUES VENEREA. 213 ticularly when they are stationary, and make no pro- gress towards a cure; in which case we may common- ly make them cicatrise more speedily by the reiterated application of caustic than by any other remedy. When chancres are brought into a clean healing state a cure will for the most, part be obtained by con- tinuing the use of mercury for a sufficient length of time, and by dressing with dry lint, or any simple ointment; but that fixed or stationary state to which I allude, and in which they often remain where caus- tic is not frequently applied, is very effectually pre- vented by dressing with precipitate or calomel oint- ment; and in some cases I have employed for the same purpose an ointment prepared with verdigris.* In ail cases of chancres the parts ought to be kept particularly clean, and the best ordinary wash for this purpose is a weak solution of corrosive sublimate, in the proportion of one grain to seven or eight ounces of water. Where the sores remain foul notwithstand- ing the application of caustic, but which does not of- ten happen where a sufficient quantity of mercury is given along with it, it becomes necessary to employ a solution with a greater proportion of sublimate. In this case one, or even two grains, may be added to an ounce of water; but this being too strong for applying to the contiguous parts, care must be taken to confine it as much as possible to those that are diseased. In this foul or sloughy state of chancres, among the vari- ety of dressings which we are occasionally obliged to employ, the blue ointment prepared with equal parts of mercury and hogs-lard sometimes answers well, as it does indeed in almost every state of chancre in which it is proper. that mercury should be used. For the purpose too of removing this foul appearance which chancres are very apt to assume, and under which they never heal, red precipitate finely levigated is of- ten employed in powder, and frequently with advan- tage. Calomel applied in this manner also proves use- ful ; and it is chiefly in this state of chancres that I * Formula: of these ointments are given in the Appendix, Nos. 26, 27, and 28- 214 OF THE CURE (Jh. IV. have perceived most advantage to be derived from mercurial fumigations. In all slight cases of chancres a free application of caustic very commonly proves successful ; but where the sores are deep, extensive, and very sloughy, together with the use of caustic we are obliged to employ one or other of the articles which I have mentioned ; and when precipitate, cal- omel, and even verdigris have failed, I have in various instances found that the parts have been rendered clean, and brought into a healing state, by fumigating once or twice with cinnabar. There are two states, however, of chancre which do not admit of this mode of treatment, viz. where the parts affected are either much inflamed, or show some tendency to mortification. In all other situations, whether the sores be upon the glans, prepuce, or free- num, or even within the mouth of the urethra, caus- tic may be applied with freedom. It may be proper here to remark, that when a chancre is seated upon the frasnum, or beneath it, if it is not altogether su- perficial, the freenum itself should be cut across. It is easily done, no inconvenience is experienced from if, and it tends always to forward the cure. When the parts upon which chancres are seated be- come much inflamed, such remedies should be em- ployed as prove most effectual in removing inflamma- tion. When the patient is plethoric, blood-letting in some instances is necessary, together with cooling laxa- tives, and a low diet. The parts should be dressed with any simple oint- ment, such as the common saturnine ointment and wax liniment mentioned in the Appendix.* In such cir- cumstances too, saturnine poultices prove sometimes useful ; but nothing ever gives more relief than the internal use of opiates. By allaying irritation they frequently tend more effectually than any other reme- dy to lessen or remove the inflammation. In some cases, however, notwithstanding all our at- tention, this inflammatory state of chancres terminates * Vide Nos. 29, and SO. Sec. V. OF LUES "VENEREA. 215 in gangrene, while in others gangrene takes place where no great degree of inflammation had been pre- viously observed. In these opposite circumstances the remedies to be employed ought evidently to be dif- ferent. Where much inflammation still prevails, blood- letting with other parts of an anti-phlogistic course ought to be pushed as far as the strength and age of the patient can with safety admit, while a plentiful use of bark is perhaps the best remedy where little or no in- flammation occurs. For th e removal of inflammation, besides general blood-letting, I have occasionally ventured upon the application of leeches to the diseased parts, and com- monly with much advantage. The bites of leeches may in some instances give rise to venereal ulcers, which otherwise would not have taken place, but little or no disadvantage ensues from this, as they heal by the use of the mercury that we must necessarily em- ploy for the cure of the disease, while nothing proves so effectual as local blood-letting, for carrying offthat great degree of inflammatory tension which in cases of this description we sometimes meet with. Whether inflammation takes place or not, gangrene, when it arises from chancres, proceeds with more rapidity than it usually does from any other cause. I have known a considerable part of the glans destroy- ed by it in the course of a day. For the most part, if not immediately checked, either by general or local blood-letting, or by a liberal use of bark, according to the nature of the case, it proceeds without our being able to put a stop to it till it comes to the urethra. In different instances I have known the urethra laid en- tirely bare for a considerable length on the mortified parts being removed ; and where it begins upon tire preputium, it proceeds in some cases not only through the loose skin and cellular substance of the penis, but even into the corpora cavernosa. The most distressful symptom which takes place from the mortification of these parts is the vent which it sometimes gives to the urine by penetrating the sub- stance of the uretl T *n some instances one opening: 216 OF THE CURE CI). IV, is formed ; in others we meet with two, three, or more, Besides the inconvenience and distress which this al- ways occasions it adds considerably to the hazard of the patient, for the urine in this manner finds access to the surrounding cellular substance, where it not only gives much additional pain, but the irritation which it excites seems to be of a nature particularly apt to cre- ate a disposition to gangrene, so that whenever it takes place the mortification extends more rapidly than it did before, nor has bark and the other remedies usually given much influence in putting a stop to it. We derive most advantage from opium. Whether opium acts here as an antiseptic may be difficult to as- certain : I rattier suppose that it proves chiefly useful by lessening or removing the irritation produced by the urine, for I have not perceived that its beneficial ef- fects are in proportion to the quantity that is given* Small doses, when they procure ease, seem to prove equally useful with the largest, which they would not probably do if they acted in any other manner. While by means of opiates we endeavour to lessen the pain, much care should be taken to prevent the urine from finding access to the contiguous parts. Where it hap- pens to lodge, the sac which receives it should be laid freely open, and the parts bathed with a decoction of bark, an infusion of rose leaves, or some other an- tiseptic after every time the patient voids urine, I have taken the more particular notice of this ef- fect of urine upon parts in this situation as I do not find that it has been mentioned by others, and as vari- ous cases have fallen under my care in which the most distressful consequences ensued from it. Chancres are particularly apt to become gangrenous when combined with paraphymosis, but they do so oc- casionally where no degree of this symptom has ever occurred. The most alarming symptom of this state of chancre is the hsemorrhagy which occurs when the mortification reaches the large arteries of the penis. No advantage is derived from tying these arteries with ligatures till the gangrene is completely stopped ; so thai in this Sec. V. OF LUES VENEBEA. 217 situation we are obliged to trust to the uncertain ef- fects of astringent applications conjoined with mode- rate pressure. Pressure in this case is most effectual- ly applied by means of a fillet of linen or cotton, passed round the penis, after a leaden or silver tube has been inserted into the urethra. The point of most importance in this state of the disorder is to determine the propriety of giving mer- cury, or delaying the use of it till the mortification is over. It is the common practice to continue the mer- cury that had previously been given for the chancres, and many even judge it necessary to give it in greater quantities. In every instance, however, where I have known this done, it has evidently proved hurtful ; and having found from various trials that the mercury may with safety be laid aside during the progress of the mortification, I now never employ it till .all the morti- fied parts are removed. The fear of the disease gain- ing ground from this, and an opinion of the mortifica- tion being of a venereal nature, and that mercury is therefore necessary to stop it, is the cause of its being in general persisted in; but the progress of mortifica- tion is so rapid, when compared with the usual syrup-' ioms of syphilis, and it is in every circumstance so different in appearance from these, that I do not con- ceive it to be venereal. It is indeed evidently induced by this disease ; but in this respect the syphilitic virus seems to act in no other manner than as the occasional cause ; 'and chancres, being at first always local, I be- lieve, that in most instances the sore which remains af- ter the mortification is gone is not venereal, and that it would heal whether mercury should be given or not, in the same manner as would happen with a great pro- portion of chancres where caustic has been freely ap- plied on their first appearance. But as we cannot in either case know with certainty whether the virus has entered the system or not, the safety of our patient requires in both instances that mercury should be giv- en in such quantities as may be necessary to effect this purpose. While mortification continues to advance, it should be treated in the ^ame manner with gangrene VOL. II, 28 218 OF THE CURE Ch. IV, i from any other cause, and without any regard to the venerea] disease: but as soon as the mortified parts are removed, the case should be considered as entirely venereal ; a course of mercury should be advised and continued from a fortnight to three weeks or a month, according to the virulence and obstinacy of the symp- toms after the sores are cicatrised. I have seldom, however, found it necessary to dis- continue mercury during the inflammatory state of chancres. Even where inflammation runs high, mercu- ry may be safely given. By lessening the venereal irritation, it tends for the most part to abate, and even to remove the inflammation, so that I commonly pre- scribe it immediately, and persist in the moderate use of it during the whole continuance of this symptom. After the inflammation produced by chancres 13 gone they fall to be treated in the same manner as if this symptom had not taken place. When they are clean, and with a surface disposed to granulate and heal, any common ointment will answer for dressing them, but when foul or sloughy the application of caustic, calomel, precipitate, and verdigris are equally proper as if the inflammation had not happened. Ver- digris may not only be applied to chancres in powder, and in the form of an ointment, but in solution; and it equally tends to remove that sloughy foulness to which I allude, and disposes the sores to heal when they become stationary. It may be used in various proportions, from two grains to a, scruple in the ounce of water. In this clean state of chancres, when the cure doe$ not advance, the application of spirit of lavender, ar- dent spirits, or even of alcohol, proves sometimes useful; and in some cases we derive advantage from bathing the parts with lime water, a solution of blue vitriol, traumatic balsam, or tincture of myrrh. One of the greatest impediments to the cure of chancres is their taking place whether on the inside of the prepuce or upon the glans along with phymosis ; for when they cannot be kept clean and dressings prop- erly applied, the cure proves always both tedious and See. V. 0F LUES VENEREA. 219 uncertain. In all slight cases of chancre in this situa- tion we endeavour to cure them by injecting from time to time, between the prepuce and glands, one or other of the articles I have just mentioned sufficiently di- luted; but when the sores are either deep or extensive the operation for the phymosis should always be advi- sed as the first part of the cute.* This being a meas- ure to which a patient does not readily assent it is commonly postponed, by which a great deal of time is lost, and chancres often allowed to proceed deep into the substance of the penis, which might easily have been healed without the hazard of this being in- cured. When an operation for this purpose becomes neces- sary the prepuce should be divided through its whole length. We are commonly desired to carry the incis- ion only the length of the chancres, but in different instances I have perceived bad consequences ensue from this. The undivided skin is apt to inflame and become tight, and the pain from the operation being nearly the same, the other as being more effectual and not productive of these inconveniences, should be preferred. When the cure, how T ever, is conducted without the prepuce being laid open, besides a very regular at- tention to cleanliness care should be taken to prevent adhesions between the preputium and gians ; a cir- cumstance particularly apt to happen when much in- flammation takes place, and fro n which a good deal of inconvenience is afterwards experienced. This is most effectually prevented by making such liquids as are injected pass freely round the whole substance of the gians, and inserting pledgits with proper dressings, and placing them between the prepuce and those parts of the glans that are affected. Chancres in the parts of generation of women re- quire the same method of treatment as in men. The parts do not appear to be so irritable, so that they more xeadiiy admit of the escharotic application? * Vide Chapter III Section XIJ 220 OP THE CURE Ch. IV which I have mentioned. In both sexes the cure is much promoted by confinement while nothing tends more to retard it than the fretting of the parts by mo- tion in walking or riding on horseback. Where venereal sores form upon the mons veneris and external parts of the labia pudendi, or when chan- cres spread to these parts, as they sometimes do from the nympha3 clitoris, where they often begin, they are commonly more foul and sloughy than venereal sores in any other situation: Neither are they so readily cleaned by the usual dressings. Besides a more fre- quent application of lunar caustic they require any escharotics that we employ to be used in powder in ^tead of being mixed with ointments. They even ad- mit of being covered from time to time with leviga- ted verdigris; nor have the milder articles of this class, such as calomel and red precipitate, the same influence in keeping them clean that we find them to have in venereal sores in almost every other part. It is proper, therefore, in the treatment of sores upon these parts, that this circumstance be kept in view. Lunar caustic is the best application for chancres upon the lips. In this situation ointments cannot be conveniently employed, we therefore trust almost en- tirely to the repeated application of caustic ; but in chancres upon the nipples the application of caustic creates so much pain that it ought never to be advis- ee}. We are therefore in these parts obliged to em- ploy the milder dressings, and nothing answers better than the common saturnine ointment, or wax oint- ment, with a fourth part of calomel. Some advan- tage is also derived from bathing the parts affected with a strong solution of opium in water. It lessens irritability, by which the sores are more readily dis- posed to heal. Our treatment of chancre has been already detailed at some length in the note on « the duration of a mercurial course, fee." page 159, extracted from Dr. Francis' paper on that subject, and the section on " Gold," as a remedy in lues venerea, page 206. Notwithstanding the reasons adduced for this practice and thq SeC. V. OF LUES VIKEREA. 221 success with which, (so far as our experience goes) it has been attended, there are some practitioners of great authority who ad- vocate strenuously the plan of cure " under confinement," or as it may be more emphatically called the "cure by salivation," For this mode of treatment Mr. Howard and Dr. Adams are the two most illustrious champions, and as they have offered some very spe- cious reasons for their practice, we shall endeavour to give a short abstract of it for those who may not have been favoured with a pe- rusal of the original works. Mr. Howard in what he terms the early or ajxh thous chancre, ad- vises confinement, frictions, till there be foetorof the breath, slight affection of the mouth, with or without mercurial griping, or much increase of the salivary secretion towards the close of the course, principally by the latter doses of the medicine. Every friction, from the beginning to the end of the course, must be fairly perform- ed, for the space of half an hour, by the patient himself, with his naked hands. The dose originally begun with may after a little time, be doubled, trebled, or quadrupled, as circumstances di- rect. The effects of this course, is frequently obvious in eight or ten days and often before the mouth is affected, which is known by the base and callous edges of the chancre becoming soft and clean. The medicine should be continued not only till the chancre be healed, but till it be perfectly cicatrised, without the smallest degree of hardness remaining, and for a few days after. In this species of chancre, he advises no topical applications, but water and dry lint. As to the quantity of mercury necessary for a com- plete cure, he thinks one half of what would be required for a chancre of an old date, or a secondary affection, will be sufficient, provided the general effects be fair and unequivocal. Care should be taken that the connection between the several doses be preserved entire, without the interruption of a single day till there be a con- siderable accumulation. In the use of the remedy we are invariably to go from a small to a large dose, for if this order be inverted the course is checked, and the effects expected from it greatly weakened. The external marks of the decisive internal change are tenderness of the gums, foe tor of the breath, increased secretion of saliva, languor, pros- tration of strength, sudden emaciation ; sometimes with, some- times without a dysenteric affection of the bowels arising after a preceding costiveness. " In some cases the sore immediately heals upon the coming on of these symptoms ; when I say im- mediately, I mean in the short period of a night's time ; but in oth- ers it may be three, four or more days." When a dysenteric affection of the bowels occurs in consequence of mercury it should never be treated with any kind of purgative not even the most gentle, but the local irritation should be quieted by a warm opiate, such as the opiate confection. This course under confinement generally takes from fourteen to twenty-one or more days. In the next species of chancre, which is the same as the forego- ing except being of an older date, the same rules are to be pbserv- edj double the quantity of the remedy employed, and for a much 2J2 OF THE CURE « Cll. IV. longer period, at all events till all the decisive effects of the remedy are visible. In what is termed irritable chancre, the same mode of treatment is applicable. If topics can be avoided, so much the bet- ter ; if the irritation be great, evacuations, cleanliness, opium, and rest, will generally give relief. Where phymosis takes place, rest is essentially necessary, and local treatment, as lotio ex calomel, et aq: rosar. employed. This lot'on should be injectedbe tween the glans and prepuce, while the specific is introduced in full doses. Opium is very useful in this stage. The last kind of chancre noti- ced by Mr. Howard is " the irritable, livid, spreading, moist kind of chancre." In this species he considers the use of topics indis- pensable, from the great irritability and uncommon acrimony of the discharge. In this case he makes use of the lotio ex calomel, and pushes the specific to the fullest extent, in order to prevent phy- mosis, and mortification of the glansand prepuce. The most pro- per time in every mercurial course for the application of a pow- erful topic to chancre seems to be only during the three or four days at the close of the course, when the medicine i« quickly producing its anti-venereal effects. In this case sedatives are useful. Doctor Adams prefers the method of cure by inunction, and if the patient will not submit to that, the crude mineral reduced by tritura- tion with some conserve, but objects strongly to all the mercurial salts. Should it affect the bowels, small doses of opium must be combined with it, and the pills taken shortly after a meal, avoiding every thing sour : The dose to be gradually increased, till the de- cisive effects are produced. This is known by the yielding of the callous edge and base of the chancre. As Dr. A. adopts the theory of Mr. Hunter, (counter irritation) he advises the excitement of the mercurial irritation, as expeditiously as the constitution of the patient will admit, for this purpose he directs the rubbing in of the ointment twice a day and the wearing of drawers, not wiping the ointment oft* in order that the absorption of it may continue. Sali- vation is the usual, but not a certain proof of mercurial irritation ; the first symptom of mercurial action is known by the starting of the gums before the angles of the teeth. In those constitutions, where the specific does not affect the mouth, the cure goes on nev- ertheless with the same regularity, as under the severest salivation. He thinks the chancre heals more readily by applying dry calomel to it during the frictions. When the frcenum has been the seat of chancre the patient should be careful not to indulge in venereal commerce for sometime after recovery, as the general consequence is a rupture of the part. But the best way is to divide the whole frsemlm at once. In phymosis, the penis should be kept in a perpendicular posture, parallel to the pubes, to prevent as much as possible the extravasa- ted lymph from subsiding and increasing the intermiscence. In the mean time the glans should be frequently washed, by means of a syringe, with a solution of oxymuriate of mercury in lime water, till the absorption of the extravasated juices, permits the denuda- tion of the glans and the treatment of the ulcers in the common way. Vide Howard on the Venereal, vol. 2, page 1.30. Adams on Poison?; quarto, page 116, 126* JEn. SeC. V. OF LUES VENEREA. 223 $ 2. Of /Ae Cure of Buboes. A history of the rise and progress of bubo has al ready been given in sect. II. of this chapter, p. 20. Our treatment of bubo has varied and been improv- ed by the more perfect knowledge which of late years has been obtained in the anatomy of the lymphatic system. Till thi§ was acquired buboes were consider- ed as an effort of the system to throw off the morbific matter of the disease, so that in every instance to pro- mote their suppuration was thought to be necessary ; but now that it is known that they are not produced by any disease of the constitution; that they originate from a stoppage of the syphilitic virus in its progress to the common course of the circulation ; that by bringing mercury into contact with the virus while in this situation we can render it totally inert ; and that sores the consequence of the suppuration of buboes are difficult of cure, we do not hesitate to say that it is the best practice to prevent the formation of matter, and by a proper application of mercury, combined with other means, to procure a discussion of every tumour of this kind. But although the advantages of this practice are ob- vious to all who have given it a proper trial, stiM there are many who have not adopted it, as thinking that they lessen the hazard of the patient by inducing sup- puration in t tie substance of the gland, and afterwards discharging the matter, the consequence of the inflam- mation induced by the obstruction. We must indeed acknowledge that this reasoning would have every appearance of being well founded, and that the practice of curing buboes by discussion ought certainly to be exploded, was it to be accom- plished by forcing the matter of infection into the sys- tem, but as we have it in our power by a proper use of mercury entirely to destroy the nature of the mat- ter lodged in the obstructed gland, and as we know from daily observation, that when accomplished in nanner the discussion of buboes can never be pro- ductive of danger, it ought in all cases to be ad- vised. 224 OF THE CURE Ch. IV, The discussion of these tumours might often be in our power by other means than the direct application of mercury to the matter of infection; but we act with more certainty of doing no harm to the consti- tution by first destroying the active property of the matter in the obstructed gland, and trusting after- wards to a proper course of mercury for obviating the effects of any part of the virus that may have passed into the system. On the first appearance of a bubo mercury should therefore be applied so as that it may with most cer- tainty pass into the obstructed gland. Hence it should be chiefly applied to those parts lying between the bu- bo and the spot at which the matter of infection was absorbed ; but in the ordinary seat of buboes the space lying between these points is not sufficient for the quantity of mercurial ointment that must be employ ed. Where buboes form in the arm pit, or in the fore part of the thigh from venereal sores in the hand or feet, this may at all times be done ; but when seated in the groin, besides rubbing the ointment on the parts lying between the chancres and the swellings, we also apply it along the inside of the thigh and leg- When the practice of discussing buboes with mercury was first introduced the ointment was chiefly rubbed upon the tumour, and in many instances a mercurial plaster was kept constantly applied to it ; we find; however, that the mercury passes with much more cer taint y into the gland by applying it to those parts from whence the lymphatic vessels forming the gland take their origin. But although a mercurial plaster applied upon the gland seems to do harm, by the heat and irritation which it excites, I am of opinion that a small portion of the ointment which we employ should be rub- bed upon it. Although none of it should by this route pass directly into the substance of the gland, still if will go into the system, and the discussion of the tu- mour is in many instances evidently promoted by gentle friction applied to it. Jn our application of mercury for the purpose of SeC. V, OF LUES VENEREA, 225 making it pass through a particular gland it is evident that a knowledge of the course of the lymphatic ves- sels is a matter of importance; but we cannot always apply it, as we have already observed, to those parts from which the greatest number of lymphatics of the contiguous glands originate. Thus in women, where the bubo is sometimes seated within an inch or so of the seat of infection, which is the case where the glands upon the round ligaments become obstructed, as the lymphatics forming these glands arise perhaps chiefly from the tender skin of the labia pupendi, we cannot with propriety apply the ointment to these parts ; nor can we in most instances in the treatment of buboes in men take the advantages of those \y mphatics which originate in the glans penis in the internal surface of the prepuce or scrotum : at least wherever I have at- tempted to do so, however gently the friction was ap- plied, so much irritation was induced by it that there was an evident necessity for desisting. In the scrotum it is very apt to excite a fretful itchy eruption, and a considerable degree of uneasiness. In all these situa- tions, therefore, we must apply the ointment to the more firm skin of the contiguous parts. When the full quantity of mercury to be employed can be rubbed upon the leg and thigh of that side in which a bubo is seated, it ought certainly to be done, but the cure of the disease often requires a greater quantity of the ointment than can be used in this manner. In such cases we commonly apply it to the other thigh, but it may with equal safety and advan- tage be rubbed upon the arms or any part of the body. From what has been said, it will appear that we de- pend chiefly upon a proper application of mercury for the discussion of buboes ; but we ought by no means to trust entirely to this. When the patient is plethoric he should immediately lose blood, in quanti- ty proportioned to his strength, and his bowels should be opened by a brisk purgative, It proves sometimes serviceable to repeat the purgative once and again : Cold saturnine poultices should be applied to the tu mour : The patient should be kept at perfect rest : His vol. ii. 29 226 OF THE CURE Ch. IV. diet should be moderate; and where much irritation prevails opiates should be given in such doses as are sufficient for removing it. I think it right indeed to observe, that in the treatment of buboes much advan- tage may be derived from the use of opiates, and that mercury will often fail if we do not at the same time lessen or remove the irritation and pain, for which no- thing answers with such certainty as the internal use of opiates combined with a frequent renewal of cold sat- urnine applications. In some instances I have made trial of local blood-letting by means of leeches for the discussion of venereal buboes, and in some cases with advantage. In others, however, it has not proved so serviceable as this remedy commonly does in swellings of these parts that proceed entirely from inflammation. On the contrary, the irritation excited by the oites of these animals has in some appeared to do harm. By a proper application of the remedies thai have been enumerated we endeavour to carry off any in- flammation that may have taken place in the tumour, while by a due continuation of mercury we secure the safety of the constitution. The length of time to which a course of mercnry should extend for this purpose can only be ascertained by the effects w hie h result from it. It ought always, however, to be continued till the swelled gland is nearly reduced to its natural size; and when chancres take place along with it, the mercury cannot with safety be laid aside till the sores have been cicatrised for two or three weeks. But in atten- ding to the discussion of the tumour we have no rea- son in any case to expect that it will be reduced alto- gether to its usual size ; for lymphatic glands when swel led from this cause commonly remain for a great length of time, and in some instances during the life of the patient, somewhat more full and prominent than they were before. All we have to expect there- fore is, that they should fall nearly to their natural size, and be entirely free of pain. This being accom- plished, if no chancres or other symptoms of the dis- ease exist, and if the full effect" of the mercury has SeC. V. OF LUES VENEREA. 227 been kept up, it may with safety be left off at the end of a fortnight. In buboes altogether venereal we commonly suc- ceed in removing them by discussion, where the pa- tient applies in due time and gives that attention which he ought to do to the application of the remedies ; but in various instances we fail, and notwithstanding all our endeavours, the tumour proceeds to suppuration. This may take place from various causes, but it hap- pens chiefly from patients delaying too long to ask for assistance; from their improper manner of living, and being allowed to walk about when they ought to be confined ; from their not applying the mercury with that care and attention which it requires; and in many instances from the patient being of a scrophulous con- stitution; by which although the syphilitic virus may be removed or destroyed by the mercury, still it is not sufficient for the purpose of carrying off that tenden- cy to the formation of matter in the gland which the "virus has produced. As soon as a bubo shews any tendency to suppurate, k is the practice with many to endeavour to promote the formation of matter as speedily as possible ; but I have not found that there is any good reason for this. By still proceeding with an attentive application of mercury, and with the use of cold applications, we frequently succeed in the discussions of these tumours after they have arrived at a considerable bulk, and in some instances even after some partial suppuration has taken place. Neither does any harm occur from the practice when it does not succeed ; for although complete suppuration should afterwards take place, we do not perceive that the process is retarded by the mercury having been continued, while the sores which ensue heal more kindly than they usually do where the mercury has been previously laid aside. By some we are told, that the use of mercury, during the for- mation of buboes, ought never to be advised; but al- though I have paid much attention to the subject I have never perceived that in any instance it has done harm, while, besides other advantages, it saves a good' 228 OF THE CURE Ch. IV. deal of time which otherwise would be lost. Even where the formation of matter has taken place to a considerable extent, and, where it is therefore proper io promote the complete suppuration of the tumour by the frequent renewal of warm emollient poultices and fomentations, still there is no necessity for desisting; from the use of mercurv, which ought to be corvtmu- ed without interruption till a sufficient quantity is em- ployed for the safety of the constitution. It does not prevent the suppuration from going forward; and the sores which ensue from the discharge of the matter heal mere readily, as we have already observed, when no interruption has been given to the exhibition of mercurv. When buboes have come to a state of suppuration it is a question with some whether they should be opened or not, for many have observed that they fre- quently heal easily when they are allowed to burst, by which the pain and terror of the operation is avoid- ed. The result of my observation has been, that when buboes do not arrive at any great size we should proceed with the use of mercury till they burst of themselves, unless where the teguments are unusually thick ; but when the substance of the gland is entirely suppurated, as the matter, if thickly covered, would be a long while in getting out, and as it might in the mean time insinuate among the surrounding parts, in order to prevent the inconveniencies which this would induce, we ought certainly to make an opening into it; and in all cases of large buboes we should not he- sitate in advising them to be opened. Our object in opening buboes should be nearly the same as in other purulent collections. Such an open- ing should be made as will afford a free vent to the mat- ter, but there is no necessity for making it larger. In very large buboes, indeed, the teguments are apt to be so loose and flabby, and the texture of the skin so much destroyed, that the cure would be rendered tedious was the skin allowed to remain. In such cases I some- times discharge the matter with caustic, applied in such a manner as to destroy an^ part of the teguments Sec. V. OF LUES VENEREA, 229 that appear to be superabundant. This, however, ig not often necessary; and for the most parti have found that an opening made from the centre of the tu- mour, where the matter commonly points down to the most depending part of it, is perfectly sufficient. Even a smaller opening than this would often answer ; but it is better to make it of a sufficient size at once than to be obliged to repeat a very painful operation perhaps once and again, as is often necessary where buboes of a large size are opened with small incisions. I need scarcely observe that the opening should in every in-* stance be continued down to the most depending point of the collection. From want of sufficient attention to this we meet with daily instances of the matter be- ing allowed to collect, and in this manner to find ac- cess to the contiguous parts, by which a great deal of distress is induced, which, with due care at first, might easily have been prevented. This I may observe is a point of the first importance in the treatment of buboes, but it does not often meet with that attention which it merits. Patients under mercury being for the most part highly irritable, they seldom submit easily to have buboes properly opened ; so that although the lancet may be entered at the most prominent part of the tumour, which it ought always to be, the practitioner, if not firm and resolute, is of- ten prevented from carrying it to the most depending part of it, by which some space is left for the lodge- ment of matter; and however small this at first may be, it seldom fails of becoming more extensive. This again gives rise to a great extent of ulcer, or to the formation of sinuses, which very constantly prove the source of much pain to the patient, and of distress and embarrassment to the surgeon. When sinuses in this situation are superficial, and run little deeper than the skin, they are easily managed. jNo risk is incurred in laying them open, by which, if the constitution is healthy, a cure will be obtained on a sufficient quantity of mercury being given ; but they sometimes run deep, and pass so near to the large blood-vessels of these parts., that no attempt of this 230 OF THE CURE Ch. IV. Jdnd can with safety be made. In such circumstances all that art can in general do is to preserve the exter- nal opening of the sinuses sufficiently large, and by regular and equal pressure at the different dressings, to prevent as much as possihle the matter from lodging. In some instances I have derived advantage from in- serting, from time to time, a piece of caustic to the bottom of a deep sinus, and applying it gently over the whole internal surface of the sore. In others, the insertion of a small portion of ointment impregnated with red precipitate has proved useful. By removing the sloughs with which the surface of these sinuses are commonly covered, they thus excite a disposition over the whole to granulate and unite. When buboes come forward to full maturation with- out much injury being done to the skin, I have in dif- ferent instances, discharged the matter by the intro- duction of a small cord or seton, and the practice has succeeded. This requires, however, the teguments to be firmer than they commonly are when a bubo is ready to be opened. It is universally admitted that it is of much import- ance to prevent the air from finding access to sores; and as we sometimes observe buboes ooze out the mat- ter which they contain by a number of small openings, and as these openings commonly heal easily, I con- clude that they do so from their being so small as. to exclude the air entirely. In different instances I have attempted to imitate nature, by making a number of small punctures with the point of a lancet over the whole extent of the bubo, and for the most part with success. The matter in this manner comes slowly off; the sides of the abscess contract gradually ; and when completely emptied, w>e find the whole parts that have been affected sufficiently firm without any sores or si- nuses remaining. When the patient has taken a sufficient quantity of mercury, if the constitution in other respects is sound, the sore in most instances heals easily, merely by dres- sing with common cerate, and by that attention to cleanliness which in the treatment of sores of every Sec. v. or lues venerea. 231 description is necessary. It often happens however that the cure of these sores proves tedious, notwith= standing all the attention that we can give to them, Their edges become hard, livid, and often retorted ; the matter thin, sharp, and foetid; and instead of heal- ing, the ulceration gradually extends, or, if it heals in some parts - it breaks out in others, giving a honey-comb appearance to all the contiguous parts. In some in- stances the tendency to this depascent kind of sore is so great that it soon spreads over all the under part of the abdomen, and upper parts of the thigh ; in some cases by the matter being so acrid as to corrode and destroy all the contiguous parts with which it comes in contact, and in others by spreading beneath the skin, and bursting out from time to time in a variety of small ulcers. The situation of patients with sores of this descrip- tion is often very deplorable. The pain with which they are attended is commonly severe ; the acrid mat- ter which they afford being absorbed, hectic fever is thereby induced ; the patient becomes hot and restless through the night; and almost a total want of appe- tite renders them soon much emaciated. In such circumstances cicuta has sometimes proved useful ; and in different instances the sores have been healed by it when no advantage was derived from a™ ny kind of ointment. In these cases it was applied in the form of poultices, commonly by mixing the juice of the fresh herb with emollient cataplasms. I have also observed that the recent expressed juice has, for internal use, proved more effectual than any other form of it. I have employed hyoscyamus and bella- dona fully, but seldom with any material advantage. Neither have I in these cases observed any obvious be- nefit from sarsaparilla ; but in different instances me- zereon, guiacum, and sarsaparilla combined have pro- ved useful, when exhibited in the manner I have a! ready mentioned. The most effectual course, however, which I have employed, is the application of caustic round all the edges and hardened parts of the sores, conjoined with 262 OP THE CURE Ch. IV. the internal use of opium. For a considerable time I trusted entirely to dressings of the emollient kind, be- ing afraid of irritating parts already highly sensible. In some cas^s a saturnine ointment has proved success- ful, and in others the common calamine cerate has an- swered ; but in most instances, on those days in which caustic is not applied I have found more advantage from dressing with ointments prepared with a consid- erable proportion of calomel, red precipitate, or ver- digris.* In some cases it is necessary to sprinkle these articles over the sores in the form of powder, but for the most part they are sufficiently powerful when mixed with ointments. Instead of exciting pain, as those not accustomed to use them are apt to suspect, they commonly remove it; and they seldom fail to al- ter the discharge from a thin acrid sanies, to a well digested pus. The application of lunar caustic indeed always ex- cites pain at first, but this soon subsides, especially when the internal exhibition of opium is advised a- long with it. Indeed opium of itself proves often use- ful in sores of this description, not by acting, as some have imagined, as an antisyphilitic remedy but by re- moving, as I have already had occasion to observe, that pain and irritation with which sores discharging acrid matter are usually accompanied. By removing this state of irritability it destroys the disposition in the vessels of the sore to form that kind of matter, which, by its own acrimony, serves to perpetuate the ulcera- tion ; and this being accomplished, when no other in- terruption takes place, nature alone seldom fails to complete the cure. In some instances I have known sores in this situa- tion which resisted every other remedy soon healed by being fumigated from time to time with cinnabar: In others warm salt-water bathing, and afterward the or- dinary form of sea-bathing has proved useful; while in some a cure has not been obtained but with an en- * Vide Appendix, Nos. 26, 37, 38 SeC. V. OF LUES VENEREA,. 233 tire change of regimen. Where the patient has pre- viously lived upon milk and vegetables a moderate al- lowance of wine and animal food has proved service= able, while those who have previously been accustom- ed to full living have derived much advantage from a diet consisting altogether of vegetables and milk. In all such cases country air proves particularly useful. Where mercurial fumigations are employed for the cure of these sores they should be conveyed to the parts affected by metallic tubes, and kept applied to them for the space of twenty-five minutes or half an hour at once, and this should be repeated every second or third day, for six or eight times. For some time past I have been making trial of the muriated barytes, a remedy lately brought into notice by the ingenious Dr. Crawford of London.* These trials have been chiefly confined to sores and tumours produced by scrophula, but I have also made use of it in some of those spreading ulcers which we are now considering, after there was no cause to doubt of the syphilitic virus being eradicated, and in some instances 1 think with advantage. I have not as yet, however, given it in a sufficient number of cases to be able to speak of it with precision. Besides this state of bubo there is another which in some instances proves very distressful, in which the tu- mour, after arriving at a considerable bulk, remains nearly stationary, and shews no tendency either to sup- purate or dissolve, notwithstanding of all the remedies we may employ. For the most part this indolent state of bubo depends upon the patient being of a scrophulous constitution ; but whatever may be the cause, our first object should be to employ that quantity of mercury which may ap- pear to be necessary for rendering the system safe. Unction affords here likewise the best form of using mercury ; by making it pass through the diseased parts discussion of the tumour is more readily accomplished * Vide Appendix, No. 32. VOL, XL 30 ■I 234 OF THE CURL Cb. IV, than when the medicine is given by the mouth. Even this, however, will in some instances be continued without any advantage for a great length of time. Tn such circumstances I have in various cases advised blis- ters to be repeatedly applied over the tumours. They never do harm, and in some cases they have proved evidently useful. In others electricity has proved ser- viceable, but it is necessary to continue it for several weeks in order to judge of its influence ; and it ought to be continued longer at each time of applying it than is usually done. In four cases of indolent tumours where electricity proved successful, and two of these were of the kind we are now considering, no advantage was derived from the common way of using it. In all of these it was applied for the space of half an hour at once; this was repeated three times a-day, and at each application sparks were not only taken from the surface of the tumours, but gentle shocks were passed through them. For the first two or three weeks scarce- ly any alteration was perceived in any of them, but they all decreased suddenly at last. One of them of considerable size, which had been of eight months du- ration, and in some parts of which matter seemed to have formed, was reduced to the fourth part of its bulk in the course of a few days from the period at which it began to diminish. In this state of these tumours a long continued use of cicuta proves sometimes service- able ; and I have seen evident advantages from sea- bathing, and from drinking as much salt water daily as the patient can bear without being much purged. Before entering upon the use of cold bathing I have in some cases advised warm salt water to be poured upon the swelling morning and evening, for the space of two or three weeks, and for the most part it has ap- peared to prove useful. In the course of time buboes in this state sometimes become soft, and shew a tendency to suppurate, al- though they may not have done so before. It is here that I have observed the warm gum plasters prove most useful. By stimulating the vessels of the diseased SeC. V, OF LUES VENEREA* 235 part? they seem to excite that kind of effusion which readily proceeds to a state of purulency. But the most alarming circumstance to patients with tumours in this indolent state, is, a suspicion which they are apt to entertain that they may some time or other end in cancer. This is, however, so rare an oc- currence, that it should scarcely give any cause of a- larm. The phagedenic sores which occasionally suc- ceed to buboes, and of which we have already taken notice, sometimes put on a cancerous appearance, but the real sehirrhus which terminates in cancer is rarely if ever the consequence of a venereal bubo. In dif ferent instances I have been consulted for indolent hi- m Sec. V. OF LUES VENEREA. 243 $ 4. Of the Cure of Venereal Blotehes. A description of this symptom is given in Section II. of this Chapter, p. 50. Almost the only remedy employed for the cure of venereal blotches is mercury, and when the course is well conducted it seldom fails. We never find it ne- cessary to have recourse to external applications unless the eruptions* become hot and uneasy, in which case relief is sometimes obtained from dusting the parts with (lour or starch powder, as is done in cases of ery- sipelas. Where the usual method of exhibiting mercury has failed in the cure of these eruptions, corrosive subli- mate has appeared to prove useful ; but as the medi- cine in this form cannot be given in large quantities, it requires to be continued for a great length of time. It should be regularly given for at least six weeks af?- ter the blotches have disappeared ; and it seems to op- erate with most, certainty when conjoined with the de- coction which I have just had occasion to mention. The Lisbon diet-drink is said to have proved particu- larly useful in the cure of this symptom.* Antimoni- als, from their well known property of exciting a de- termination to the skin, are frequently combined with mercury in the cure of venereal blotches. Upon this principle I conceive to be funned many of the quack remedies generally employed in cutaneous affections; and it is for the cure of this symptom of syphilis thai Phmimer's pill has been most Frequently used.f Crude antimony is, in cases of this kind a favourite medicine with some practitioners, and when conjoined with mercury I think I have observed it prove useful It may be given either in powder or pills, to the ex- tent of fifteen or twenty grains three times a-day ; and besides being given along with the mercury, it may be continued with advantage for two or three weeks aftei the mercurial course is over. * Vide Appendix, Vol. I. No. 4. f Vide Vol. IF, No, 21 244 OF THE CURE Ch. rv> } 5. Of the Cure of Nodes, Swellings of the Perioste- um, Sfc. A description of these swellings has already been given in Section II. page 62 ; and it is of importance in the method of cure to distinguish them accurately. In all the affections to which the periosteum and bones are liable from the syphilitic virus, mercury ought to be given immediately, for it is -upon this rem- edy that we chiefly depend. Where the bones are much swelled, that is, where tumours truly osseous have arrived at any great bulk, mercury alone will not prove sufficient ; for although it may destroy the con- stitutional infection, these tumours will remain, but when given immediately upon their first appearance, it will prevent their farther increase ; and as they are always small at first, although they may never disap- pear entirely, no inconvenience will be experienced from their remaining in this state, even during the life of the patient. The method of throwing mercury into the system by unction is the best adapted for this symptom, as it is perhaps with a very few exceptions for the cure of every symptom of the disease ; but it does not appear that any advantage is derived from rubbing the oint- ment upon the tumours. On the contrary, by tending to irritate and fret the skin, it renders them more pain- ful, so that it answers better to apply it to other parts. As the bones seldom become affected till the disease has been of long duration, it is perhaps for this reason that more mercury is in general required for the cure of this symptom than for any other syphilitic affection. 1 believe, however, that we are often deceived in this, and continue to give mercury for the cure of the local affection long alter the virus by which it was produc- ed is eradicated, and for which purpose alone it was prescribed. Next to the state of the system, which we render safe by a due continuation of the mercurial course, the pain excited by the tumour is the symp- tom which chiefly requires attention. When the mer- cury is employed immediately upon the swelling tak~ SeC. V. OF LUES VENEREA. 245 ing place the pain commonly subsides soon ; but if the tumour has previously arrived at any considerable bulk, the pain which it excites is apt to be severe, while it is not allayed or even lessened by all the mer- cury we can employ. Where the skin has become in- flamed and painful, some relief will be obtained from saturnine applications; but as the pain depends chiefly on the stretching of the periosteum by the tumour of the bone, whenever it becomes severe nothing will prove effectual but the division of this membrane. No practitioner would lay a bone bare for a moderate degree of pain, whatever the cause of it might be ; but whenever the pain produced by nodes becomes distress- ful, and is not allayed by a course of mercury, as I know of no other remedy that will give relief, I con- clude that we are fully justified in advising an incision to be made completely through the periosteum, along the whole course of the tumour. Where the bone is not so much increased in bulk, and not otherwise diseased, if a sufficient quantity of mercury has been given for the destruction of the vi rug, a cure may be obtained without any part of it ex- foliating. With which view the mildest dressings on- ly should be employed, while the sore is protected as effectually as possible from access to the air. But, when the tumour of the bone is considerable, and par- ticularly when caries has taken place, as it would be vain to expect a cure but with the exfoliation of the diseased parts of the bone, so all such means should be employed for effecting this as are known to be most powerful. Any of the soft parts covering the diseased part of the bone should be removed with escharotics. Small holes should be drilled through the carious part of the bone, and the sore should be dressed with pre- cipitate or verdigris ointments, of such a strength as to act gently as stimulants upon the contiguous parts. By due perseverance in this mode of treatment, and taking care at the same time to support the strength of the patient with a nourishing diet, the diseased parts of the bone will at last exfoliate, when the healing of 216 OF THE CURE Cll. IV. the sore not being impeded by any other cause, a cure will soon be obtained with common treatment. The next variety of tumour taken notice of in the description which I have given of nodes, proceeds, as we have had occasion to see, from the effusion of a thin fluid between the periosteum and surface of the bone. This also is apt to be accompanied wilh severe pain ;» but as the pain is induced by the distension of the pe- riosteum, inconsequence of a fluid being collected be- neath, and as this fluid is frequently absorbed on the mercury taking effect, we seldom find it necessary to lay this variety of tumour open. Absorption of the matter is sometimes promoted by the application of a blister to the part, or by rubbing it occasionally with stimulants, such as volatile liniment or tincture of can- tharides. But when the swelling has been of long du- ration, as the surface of the bone is in this case com- monly injured, as the absorption of the matter does not take place so readily, and as the tumour at the end of the mercurial course is commonly larger than before, an incision the whole length of the tumour should be made through the periosteum, and the wound dressed in the manner just now advised. I think it right, how- ever, to observe, that the opening of these tumours is very seldom necessary ; and that it would in no in- stance perhaps be so if mercury was given in sufficient quantity soon after their formation. Even where the quantity of effused fluid is considerable, the swelling, for the most part begins to lessen soon after the mercu- ry has fully entered the system ; and if the effect of the medicine is kept up for a sufficient length of time we seldom fail in removing it entirely. In those diffused swellings upon the bones which I have taken notice of in the description as a symptom of syphilis, and which also have improperly been term- ed nodes, mercury, when properly given, seldom fails to effect a cure ; but it requires to be given in as large quantities as the patient can bear, and to be continued for a considerable time, commonly for nine or ten weeks. The pain indeed soon subsides upon the mer- cury taking full effect; but when the swelling has been SeC. V. OF LUES VENEREA. 247 of long continuance, as often happens before mercury is given, from the disease being at first apt to be mis- taken for rheumatism, in order to remove it the mercu- ry must be employed for several weeks after the pain has ceased. In the treatment of this symptom blisters prove particularly useful, and they should be applied along the whole course of the swelling. Where the ligaments, tendons, and fasciae of mus- cles, become swelled, as sometimes happens from the matter of venereal ulcers spreading to those parts from the skin and cellular substance where they originate, we depend entirely upon a course of mercury, with proper attention to the external treatment of the ul- cers in the manner we have already pointed out. 5 6. Of the Cure of Venereal Excrescences about the Anus. In section second of this chapter, a very particular description has been given of these excrescences. A full mercurial course is the remedy for these ex- crescences, under which they gradually lessen, and at last very commonly disappear altogether ; but where we are disappointed in this, we must use the same ap- plications recommended for the removal of the warty excrescences which succeed to Gonorrhoea. 5 * The disease being now entirely local, no advantage can accrue from mercury being longer continued, while we seldom fail with a proper application of es- charotics. Where the surface of these excrescences becomes ulcerated, and yields matter, saturnine lotions and other astringents should be employed to heal them : for as the matter which they afford appears to be ve- nereal, and of which we judge from the real venereal bubo being in women sometimes produced by it, the longer that this secretion is allowed to continue the more of it will pass into the system, and the greater * Vide Chapter III. Section XIII. Vol. I. 248 or the gMe Ch. W& the risk will therefore be of some of the glands in its course towards the heart being obstructed. When local applications become necessary to venereal excres- cences, we would recommend the use of the Tincture of the Oxy- muriate of Iron, as stated in the note to Chap. III. Sect. XIII. — We have found it much preferable to the remedies mentioned by Mr Bell, or Mr. Hunter, or the Pulv : Sabin : so highly spoken of by Mr. Howard. The same remedy will be found useful in warts on the organs of generation. Ed. $ 7. Of the Cure of the Venereal Swelled Testicle. For the description of this affection of the testicle, and of the difference between it and other tumours to which the testis is liable, I must refer to section second of this chapter. One important difference between this tumefaction of the testicle and that which proceeds from Gonor- rhoea is, that in the latter mercury very frequently does harm, while in this it is the remedy upon which we chiefly place dependence. Unless the swelling has been allowed to advance to a great size, from an opin- ion which some have entertained that it is always of a local nature, and not connected with diseases of the constitution, mercury seldom fails to cure it. Were it not to add considerably to the extent of the present work, this, as well as many other points, of which I have had occasion to take particular notice, might be illustrated and proved by a variety of cases which have fallen under my observation, in which the swelling of the testis to which I allude, produced altogether by the syphilitic virus in the system, and in many instan- ces where Gonorrhoea never existed, after resisting ev- ery other remedy, has at last been completely cured by mercury. Besides other views of no small import- ance in the theory of the disease,, which this lends to establish, it may be looked upon as an additional argu- ment for considering the matter of Gonorrhoea and of pox as different. The swelling of the testis which oc- curs in Gonorrhoea vields entirely to the effects of an SeC. V. OF. LUES VENEREAo 249 antiphlogistic course and without doing an injury to the constitution, while the other in no instance has been known to do so, and gives way only to that re- medy which we know by experience is alone to be trusted for the cure of every other symptom of sy- philis. Mercury even proves effectual in removing those tumours in- which matter has formed. I have met with several cases in which a partial suppuration had taken place in the body of the testis before mercury was given, and the matter has been absorbed, and the swelling entirely removed soon after a sufficient quan- tity of the medicine has been thrown in. In some I have thought that mercury was assisted by a decoction of mezereon being given along with it ; but it is for the most part abundantly successful by itself. Where the use of mercury has been too long delay- ed the swelling commonly suppurates, and the sore which ensues from the bursting of the tumour assumes always a very ugly appearance. Even in this situa- tion, however, our chief advantage is derived from mercury ; nor do we often fail in curing the sore if due attention is given to regular dressings, and pro- curing a free discharge of the matter. The best dress- ings for this purpose are the saturnine and zinc oint- ments when the parts are clean, and the precipitate or verdigris ointments when they are foul or sloughy. But where matter is observed to lodge in any part of the swelling, nothing can be of advantage but mak- ing a free opening into it. This, however, is not al- ways done so completely as it ought to be. The tes- tes being organs of much delicacy, we are apt to be afraid of opening any abscesses that may form in them, in consequence of which the matter is apt to find ac- cess into the cellular substance of the scrotum, where it seldom fails to produce very troublesome sinuses. This however, may always be prevented, either by making a free incision into the most depending part of the abscess, without allowing it to burst, or taking care to en'arge the opening if it has previously made way for itself. Nor should we ever be afraid of doing vol. ii. 32 250 OF THE CURE Ch. IV. so, for the injury which this may do to the testicle can- not be equal to what it must suffer from matter being allowed to lodge in it. In all such circumstances I never hesitate to lay the testicle freely open, and no inconvenience ever ensues from it. As this affection of the testicle never occurs but in Tery advanced stages of syphilis, it requires a very con- siderable quantity of mercury to remove it, and at the same time to eradicate the virus from the system by which it has been produced. It ought to be continu- ed from ien to twelve weeks, and in as great quantities as the patient can bear. When the sores which ensue from the bursting or opening of these tumours do not heal after such a quan- tity of mercury is exhibited as we judge to be proper for the safety of the constitution, some advantages ifc occasionally derived from a plentiful use of hemlock, and from sea-bathing ; but in such circumstances no- thing proves for the most part so useful as dressing the parts in the manner I have mentioned with stimulat- ing ointments, and touching them occasionally with caustic. This we are also apt to be afraid of from the natural irritability of these parts ; but I have not found that there is cause for this. On the contrary, a free application of caustic to the surface of these sores renders them for the most part less painful. Where much irritation however prevails, and is not removed or much lessened by the use of caustic, opi- ates must be given in such quantities as are sufficient to allay it. The general remedy will remove this symptom, and the applica- tion of mercurial ointment to the part ought to be suspended until towards the end of the course, as it may possibly induce, a metasta sis, if applied at an earlier period. Ed. v 8. Of $he Treatment of Alopecia, Venereal Blindness ; and Deajness. A description of these symptoms wa3 given in See- lion II. of this chapter, § 11. 12. and 13, See. V. OF LUES VENEREA 3r5I . When alopecia, or the falling off of the hair takes place in any considerable degree before mercury is employed, particularly if the patient is advanced in y ars, it never grows again but in very small quanti- ties ; but during youth, and when mercury is given m the commencement of this symptom, we not only pre- vent it from advancing farther, but any hair that has been lost will very commonly be renewed. There is scarcely indeed any other remedy upon which we can depend but a full course of mercury ; for although many external applications are recommended to re- cover or renew hair lost in this manner, there is no reason to suppose that any advantage is derived from them. Where the falling away of the hair is connected with a scurf over the head, some benefit indeed is obtained from the application of external remedies ; by remov- ing the eruption we tend to prevent any farther loss of hair, and the internal use of mercury alone is not alto- gether sufficient for this. The most effectual applica- tions for the removal of this are the unguentum citri- num,* and a weak solution of corrosive sublimate in water. When the former is used the parts should be rubbed with it once a-day. The latter may be applied three or four times daily, in the proportion of half a grain of the mercury to an ounce of water ; and for the more effectual application of these remedies, the head should be shaved, and the hair not allowed to grow till the eruption or scurf is entirely removed. In the treatment of blindness as a symptom of Lues Venerea, we have scarcely any variety of practice. Mercury is perhaps the only remedy from which any advantage is to be expected ; nor does it prove of any avail if it be not given immediately, and in as great quantities as the patient can bear. Whether the eye is therefore affected with gutta serena, cataract, or effu- sions upon the cornea, where there is the least reason to suppose that the affection proceeds from Lues Ve~ nerea, the patient should be immediately put under a * Vide Appendix, No. 14. 252 OF THE CURE Ch. IV t complete course of mercury, and his mouth kept fully affected for the space of ten, eleven, or twelve weeks, according to the effects which may arise from it. In gutta serena it may be proper before mercury is given to premise a smart purgative or two, and during the course to conjoin the repeated application of blis- ters to the temples and head, with electricity, and err- hines for the purpose of exciting a discharge by the nose, although the effects of these remedies are so un- certain that in every instance our chief dependence must rest upon mercury. Where the blindness is found to proceed from cata- racts, if mercury does not succeed m removing the opacity, our only remedy must be the usual operation of depressing or extracting the chrystallines. This will not always succeed, but where the eye is other- wise sound, and only the local affection of the lens ap- pearing to be the < ause of blindness we ought in every instance to advise it. We sometimes find that mercury here proves so far ■useful as to lessen the opacity of the lens in a conside- rable degree, without removing it entirely ; and where this has happened I have found in more instances than one that a cure has been accomplished by electricity. I have never perceived, however, that electricity has produced any advantage where the opacity was not previously much diminished, and even in this situation it requires to be long continued in order to prove effec- tual. In blindness produced by the humours of the eye becoming confused or turbid, where it is known that this proceeds from the system being affected with sy- philis, the patient ought no doubt to be put under mercury ; but this cause of blindness is of a vtry hope- less nature, for I have never known an instance of its being removed. Neither do we prove very successful even with mercury, where vision is affected by the matter of syphilis fixing upon the coats of the eye. We may prevent the. disease from advancing much farther, but mercury does not appear to be sufficient for removing any considerable degree of opacity in the Sec. \. OF LUES VENEREA. 253 cornea that has already taken place. Nor does this cause of blindness admit of remedy by means of a sur- gical operation ; for it is not upon the surface, but in the very substance of the cornea that it is seated. When abscesses form in the coats of the eye, we have it in our power by discharging the matter which they contain to remove in some degree the deformity which they produce, as well as the pain with which they are accompanied ; but we are not to look for any farther advantage from this or any other remedy that can be proposed. Of all the symptoms of Lues Venerea, none prove more obstinate, nor are less acted upon by mercury than deafness. A certain degree of deafness, indeed, produced by venereal ulceration or swelling at the opening of the Eustachian tube in the throat is some- times relieved or even removed by a course of mercu- ry ; but no advantage is ever obtained from this or any other remedy where the disease has fixed upon the membrane or bones of the ear. In the description of this symptom, I had occasion to remark, that a tempo- rary deafness is sometimes produced in Lues Venerea by the meatus externus being filled up by a scurfy eruption ; and in some instances, by the membrane of the passage becoming thickened and even ulcerated. In this, as in some other symptoms of the disease, we depend entirely on the internal use of mercury for removing the virus from the constitution ; but the local affection may remain after the system is rendered safe, The best remedy I have employed for this is a cau- tious use of bougies. Care, however, must be taken that they be not pushed so deep into the passage as to injure the tympanum ; and they ought to be formed of the mildest materials, as they never fail to do harm when they excite much irritation. In venereal ophthalmia, the first object should be to reduce the in- creased circulation in the vessels of the part, and of the system al- so, if necessary. Bleeding general or local, blisters and brisk mercurial purgatives ought to be administered. The blister should be kept open and the specific daily given with all possible expedi- 254 OF THE CURE Cll. IV.. iion. The eye ought to be kept from the light until the inflamma- tion is gone, and the safest way will be to confine the patient in a st convenient way of employing mercury here is in the form of a w r atery solution of corrosive sublimate. It may be used of various degrees of strength, from the quantity of one grain to three grains of mercury in the ounce of water. More than this proves irritating and corrosive. As it is probable that the virus proves more adhesive than it otherwise would be by combining with the mu- cus of the parts to which it is applied, all such articles as prove solvents of mucus, or that in a more particu- lar manner destroy its tenacity, may with propriety be employed in the composition of an antisyphilitic wish. Upon this principle lime water may be used with ad- vantage ; also the caustic fixed alkali, and even the caustic volatile alkali so diluted with water as to ad- mit of their being applied with safety. No harm can ensue from the external use of any of these articles in the form of a wash, and more advan- tage, I have reason to think, may be derived fromttn-rn than is commonly obtained From the use of those secret specifics which the interest of individuals and credulity of our young people have occasionally brought into no- tice. I think it right, however, again to remark, that none of them'can with certainty be relied upon, and that in no instance ought any of them to be injected into the urethra, as preventives of Gonorrhoea. VYhen the disease has actually taken place, they may, when much diluted be used with freedom ; but they cannot be employed but with much risk of inducing inflam- mation when of such a strength as can have any influ- ence in dislodging the virus, by dissolving or destroy- ing the mucus with which it is combined. Whether these specifics to which I allude have any of the arti- cles which I have mentioned for their basis or not I cannot determine, but when used as injections they of- ten do much harm by exciting pain, and such a con- stant inclination to pass urine as proves exceedingly distressful. 234 OF LUES VENEREA Ch. IV, The best Prophylactic in Lues Venerea, is circumcision. " Jews and Mahometans/' observes Mr. Howard, " from the constant ex- posure of the glans and loss of the prepuce, have the cuticle of the balanus (glans penis') of much firmer texture than those who have not been circumcised, and they are from this circumstance, much less subject to gonorrhoea and chancre, than the rest of mankind." In proof of this, he quotes Fallopius, who states that even in his day, scarcely two out of a thousand persons were infected, whose prrputia were short and whose balanci were kept constantly uncov- ered. Patio est quoniam detects glandis durius corium redditur atCjiw. callodus. Persons who have short preputia and hence liable to abrasion in coitu, are very subject to be infected. Ep, SECT. IX. Of Lues Venerea as inducing other Diseases. AS the virus of syphilis is often difficult to eradi- cate, and the disease being frequently known to break out again long after a cure has been supposed to have been accomplished, the fears of patients have induced them to suspect that it cannot with any certainty be removed after having appeared as a general disease of the system, and even to consider it as the cause of ma- ny other diseases. Even practitioners have been divided in their opin- ions upon this. The result of my observation has al- ready t-een given on the power of mercury in curing the disease. In section fourth of this chapter I have endeavoured to show that where failures have happen- ed they must in a great measure have arisen either from the misconduct of patients when under mercury or from too small a quantity of the remedy being given* But while I am clearly of this opinion I at the same time think that Lues Venerea is often the cause of other diseases, which frequently prove fata) from want of a proper application of mercury, by which a cure of ail of them might be easily obtained. geC. IX. AS INDUCING OTHER DISEASES. 285 In the preceding parts of this work a description is given of all the ordinary symptoms of Lues Venerea, and of the method of treatment appropriated to each; but if the opinion which I am now endeavouring to support is well founded, this disease, it is evident, must occasionally appear under other forms. We have already had occasion to observe that Lues Venerea, when not interrupted in its course by the use of mercury, usually makes a certain progress, and that the symptoms make their appearance with some regu- larity : But when mercury is employed, and not given in quantities sufficient for eradicating the virus, al- though all the symptoms may thereby be suspended, the disease will certainly appear either in the same or some other form at some future period. In this case the disease generally shows itself by one or other of the symptoms that have been described, but occasion- ally we meet with it under a variety of other appear- ances; the virus, instead of producing the ordinary symptoms of Lues Venerea, tending rather to induce other diseases. This I know is denied by many, who alledge that syphilis is never productive of other diseases; but I have met with it in such a number of instances, and these so evidently marked, that I consider the fact as certain. The virus of syphilis will not produce any' disease that depends upon a specific contagion, such as small-pox, measles, itch, and some others, but I have much reason to think that a great variety of other dis- eases are induced by it. It may be asked in what manner can syphilis act in producing other diseases, and what evidence can be given of its ever having done so ?' In answer to this I may observe, that it is often difficult, and sometimes impossible, to explain the action of causes in producing diseases. We may easily, however, suppose, where the virus of syphilis exists in the system, but not in sufficient force to show itself by the usual and more obvious symptoms of the disease, that it may, however, in various instances be capable of exciting a great deal of derangement, and even many diseases which otherwise might not take 286 OF LUES VENEREA CI). IV* place, and that it will more especially be apt to pro- duce those diseases to which the constitution is predis- posed, or those to which the patient is rendered liable by exposure to particular occasional causes. If the virus can exist in the system for a considerable length of time without shewing any external mark of disease, and of this few I believe will doubt, it is difficult to conceive that it should not produce both general de- rangement and particular organic affections; and ac- cordingly I believe that it more frequently does so than we are usually led to imagine. The evidence which I could give of this would be exceedingly am- ple, as I could relate a very extensive collection of cases in a great variety of diseases in which it actually happened; but the extent of this publication renders it necessary to confine the proofs of it within narrow- er limits. The diseases induced by the venereal virus, of which I shall give instances, are phthisis, asthma, rheumatism, dropsy, head-ach, epilepsy, and mania. In the month of October 1783 I was desired to visit a gentleman at some distance from town, with an ex- tensive foul ulcer upon his left shoulder. This was mentioned as the most material part of his distress; but I also found that he had for several months labour- ed under all the most alarming symptoms of phthisis, such as severe cough, spitting of purulent matter, pains in the breast and sides, night sweats, quick pulse, and an emaciated state of the body. These symptoms, however, did not excite the attention of the patient iioj of his friends so much as the ulcer upon his shoul- der, which, from the great quantity of matter which it discharged, and the great length of time which it had en- dured, was considered as the cause of his weakness as well as of all the other symptoms. The appearance of the sore giving cause to think that it might be venereal, I mentioned this to the sur- geon in attendance, as well as to my patient, with a view to discover whether from the history of the case, and from his previous course of life there was any ground for suspicion. Tie answer which I received to this inquiry was. that soon after the Hist appearance of this SeC. IX. AS INDUCING OTHER DISEASES. 287 ulcer, about three years before the time of my being consulted, an ulcer had appeared in his throat, accom- panied with some other symptoms of syphilis. For the removal of these he had been put under a long course of mercury, which had proved successful ; and as he had not since that period run any risk of being infected he did not suppose it possible that the ulcer upon his shoulder, or any of his other symptoms could be venereal. Having found, however, that the mercu- ry, although long continued, had never been given in greater quantities than to render the mouth moderately sore, and that for a considerable time an eruption re- sembling venereal blotches had prevailed over his breast and arms, I did not hesitate to sav that the infection had not been eradicated, and that he ou^ht immedi- ately to enter upon a full course of mercury. The chief objection to this was the debilitated state of our patient, and the quickness of pulse, with other symptoms of fever, which prevailed in a very conside- rable degree, the pulse at this time beating upwards of 130 in a minute. Even these considerations, however, did not deter me from advising the use of mercury 5 having even at that time seen more than one case of a similar nature, where the lungs were evidently affected? and in which a cure was obtained by mercury; and judging from the whole history of the case that the phthisical symptoms might be kept up by the syphilitic virus, I observed to my patient, that if my conjecture was well founded, these symptoms, as well as the oth- ers, would gradually abate on the mercury taking ef- fect. I also said to his friends, that in such circum- stances the mercury could not add much to his hazard, however severely it might operate ; the nature and se- verity of his symptoms being such as gave no cause to imagine that he could live above a few weeks if some, unexpected alteration did not take place. The patient himself having readily acquiesced a course of mercury was immediately prescribed. At first he rubbed in a drachm of strong mercurial oint- ment every evening. This came to be repeated morn- ing and evening ; and as his cough and fever were not 28# OF LUES VENEREA Ch. tti increased by it, and the stale of his mouth enabling bim to bear it, the quantity at each application was increas- ed at the end of eight days to a drachm and a half. The ulcer was dressed with common wax ointment. About the end of a fortnight it became clean, which it had never before been, and any uneasiness with which if had previously been accompanied was now removed. The blotches upon his skin had begun to yield, and even the febrile symptoms, instead of being increased by the mercury, were somewhat abated. His mouth became exceedingly sore ; but although a- good deal of salivation was excited the same quantity of mercury was continued. This I was induced to insist upon from our having now very satisfactory evidence of alt bis symptoms being venereal, for even the cough and purulent expectoration became moderate in proportion to the quantity of mercury that was exhibited. By the end of the sixth week the cough was nearly gone ; the blotches were almost entirely removed ; the ulcer continued perfectly clean and much contracted, and bis pulse did not now beat above ninety strokes in a minute. In the course of a fortnight from this time, that is, after he had taken mercury for the space of eight weeks, scarcely any remains of the blotches could be perceived : The sore was reduced to the fourth part of its original extent ; but about this period it became nearly stationary, for which it was touched every se- cond or third day with lunar caustic. At the end of another fortnight it was completely cicatrised ; but the infection having been of long duration, I judged it proper to continue the mercury three, weeks longer, being thirteen v*eeks in all. He had now been many weeks entirely free of cough. His pulse was about its natural standard ; and as he had been allowed nour- ishing diet during the whole course, he was even con- siderably improved in appearance and strength. By the beginning of the ensuing summer he was equally strong as he had ever been at any period, and when I last saw him, about three years ago, he had continued entirely free both of Lues Venerea and phthisis, Sec. IX, AS INDUCING OTHER DISEASES. 28S In the beginning of January 1784 I was desired to visit a patient newly come to town, with sores on dif- ferent parts of his body and limbs, and he had also for a considerable time been distressed with asthma. It was chiefly however for the sores that he applied for advice, as he had been led to consider asthma as a dis- ease for which there was no remedy. There was one large ulcer immediately above the great trochanter of the right thigh ; one upon the middle and most promi- nent part of each leg, both of which penetrated to the tibia; one upon the breast, where the sternum appear- ed to be thickened, although not carious; one upon the right side, upon the seventh and eighth ribs ; and a small sinous ulcer upon the middle and outside of the right arm, which, upon probing, was found to run to the surface of the ulna, which was rough for the space of an inch. Besides these there were several small ulcers upon the toes of both feet. These, as well as the others, were all foul, and discharged a thin, foetid matter; and being accompanied with that erysipelatous kind of redness which frequently surrounds the mar- gins of venereal ulcers, I was thereby led to suspect them to be of a venereal nature. The patient men- tioned, as reasons for thinking that I wa3 mistaken, that these ulcers were now of seven years continuance, and on the suspicion of their being venereal that he had taken mercury to a considerable extent at three differ- ent times, each course having been continued for nine or ten weeks; and although he had from all the three derived benefit, that none of the sores had healed by the effects of any of them, and that some of them had even become worse soon after the last course of mer- cury was left off. The asthmatic symptoms were now of five years duration. They began without any ob- vious cause, and had gradually become more violent.* nor had any remedy that had been employed for them given him relief, excepting opium, and even this was* merely temporary. Besides a constant difficult breath- ing, he was liable to periodical attacks of a more se- vere nature, which occasionally came to such a height as to endanger suffocation. These occurred most fre- YOJL. II. 33 290 OF W7ES VERE1 E I CI). quently during sleep, and, for the most part, with much regularity, about three o'clock in the morning. The patient, who was now about forty-fife years of age, acknowledged that in hi? earlier years he had suf- fered much from Lues Venerea, but having been led to suppose that he tiad already taken more mercury than was necessary, it was with difficulty thai I per- suaded him to enter upon a farther course of it. The mure, however, that I beard of the rise and progress of his complaints the more I was convinced of their being venereal; for besides, the appearances of t tic sores which I have mentioned, 1 found upon enquiry that he tiad never taken a full course of mercury, for although it had always rendered his gums sore, he had never used it in such quantifies as to require confine- ment. Neither had any of the attempts which had been made- to cure the sores by external applications proved successful. A great variety had been employ- ed, but although some of these had rendered thera more clean than they tiad been before, and procured a discharge of better matter, no permanent advani had been derived from any of them. These considerations determined me to give a deci- sive opinion on the propriety of his taking mercury in larger quantities than lie had ever as yet done. This induced him to agree to it, and he entered upon the course on the 14th of January. At first he nibbed in a drachm of mercurial ointment every night, and took one of the blue piils evening and morning. In the course of eighl days he used two drachms of the oint- ment dally, and the same number of pills were con- tinued till his mouth became exceedingly sore, and a good deal of salivation induced which happened at the end of a fortnight. At this period the pills were left off, and only a drachm of the ointment employed dai- ly. The common wax ointment was applied to the sores and renewed morning and evening. Till he entered upon this course the sores had at all times given him much uneasiness. They had never produced acute pain, but they were accompanied with an uneasy, itchy sensation, which frequent!} deprived Sec. IX. AS INDUCING OTHER DISEASES. 291 him entirely of rest. Before the end of the third week this was completely removed ; the sores were become clean, and the discharge of a better consistence; at the same time that his asthmatic symptoms were by no means so severe. As by this he was convinced of the propriety of the course of mercury, he readily submit- ted to the distrcssand inconveniency which it produced, and kept his mouth fully affected during the whole time of it. By "the beginning of March, that is, after having taken mercury for nearly seven weeks, all the sores were entirely healed excepting that upon the outside of the thigh and those upon the legs. Even these were much diminished, and the cure in all the three seemed to be retarded only by the state of the bones beneath, which were found to be denuded of the peri- osteum, and even in some parts rough. These, as well as the others, had been dressed with mild wax ointment from the first, and excepting the laying open the sinus upon the fore arm, no farther attention had been given to any of them. Fie now breathed easily and had not experienced any severe fit of asthma from the time that his mouth became first fully affected with the mercury. The course was carried on in the same degree to the end of the thirteenth week, when judging from the quantity of mercury employed, and the regular man- ner in which it had been taken, that the virus by which his disease seemed to have been produced must be eradicated, 1 caused him to leave it off. The asthma was entirely gone, and ail the sores continued firm and well, excepting the three 1 have mentioned. I now supposed, however, that these were kept up entirely by the carious bones on which they were seated ; and as a cure could not be looked for till the diseased parts exfoliated, and as this might probably be tedious, I advised him, as soon as he could with safety venture upon a journey, to go home, and to do nothing with a view to the sores but dressing regularly with red pre- cipitate ointment in order to prevent the growth of a fungus, with which all the three were covered. This, with the occasional use of calcined alum, prevented the fungus from being considerable ; but it was not till 292 OF LUES VENEREA Cll. IV, a year bad elapsed that any of the sores healed. About this period an extensive exfoliation appeared to be coming away from the tibia of the right leg. He now came to town, and by cutting into it I got it easily out, and the sore healed in a fortnight. The sore on the other leg healed in a similar manner at the end of three or four months after a small spiculated portion of the tibia had come away, but the ulcer upon the trochanter has not healed. Several small pieces of bone have from time to time come away, but I conclude that more must be thrown out before a firm cicatrix will form ; for although now reduced to the appearance of a nar- row sinus, which frequently heals, it always bursts out again. It is not, however, productive of much incon- venience ; and on account of the situation of the bone, I think it better to trust to time alone than by means of any operation to attempt to promote the exfoliation of the diseased parts. No return of asthma has taken place, and he is now in good health. In the month of May 1789 I was desired to visit a pa- tient, by trade a brewer, aged forty, and very corpu- lent. For several years he has been liable to periodi- cal returns of asthma, and during all that period his "breathing had been difficult, insomuch that he had for the most part been obliged to sleep nearly in an erect posture. He had been liable to frequent and very dis- tressful palpitation of the heart, and his pulse was at all times frequent and irregular. Other practitioners had previously been called, and, as is usual in such cases, different opinions were formed of the cause of the disease. By some it was considered as gout ; others judged it to proceed from hydrops pectoris, while by some it was supposed to constitute what of late has been termed angina pectoris. The patient himself, however, was of opinion, that all his symptoms ori- ginated from what he termed an ill-cured pox. He informed me that in his earlier years he had suffered much from frequent attacks of syphilis, and not hav- ing taken mercury in a regular manner ; particularly from the last attack, and to which this affection of his SeC. IX. AS INDUCING OTHER DISEASES. 293 breathing had succeeded : From this he was convinced that the virus had not been eradicated. No evident symptoms of Lues Venerea, however, could be discovered; so that I could not venture to advise a course of mercury as my patient wished me to do. Purgatives, diuretics, and blisters, were re- peatedly employed, but with no advantage; and some relief being derived from opiates, he was at last induc- ed to trust entirely to a large dose of laudanum taken at bed-time, and a lesser dose in the morning. In this situation I left him in the month of September, nor had I again occasion to see him till the month of April 1790, when I was called on consultation with the sur- geon of the family for an ulcer which two months be- fore had appeared upon the right side of the nose. At first this ulceration was so inconsiderable as scarce- ly to excite his attention ; but, as it soon began to spread, various applications were employed, from the mildest to the strongest escharotics; but although these, with the occasional use of lunar caustic, had proved useful, by preventing the growth of fungus which had previously prevailed, still the sore continu- ed to extend, and at this time had spread to the oppo- site side of the nose. Upon inquiry I found that in the month of November, some days after exposure to infection, a chancre had appeared upon the glans pe- nis; but as it healed by being twice touched with caustic, and which he had done without the know ledge of his surgeon, he had not thought it necessary to enter upon the use of mercury. At this time the difficulty of breathing and distress- ful palpitation of the heart were more severe than ihey had ever been at any period ; but the account which I had received of this recent infection, the progress which the ulcer was daily making, and the inefficacy which had already been experienced of local applica- tions, determined me to advise an immediate and full course of mercury. Being informed that mercury did not readily affect him, both the internal and external use of it was advised ; so that in the course of ten da vs (his mouth was rendered as sore as he could possibly 294 OF LUES VENEREA Ch. IV. bear it, and he salivated to the quantity of between two and three English pints a day. The sore was dressed with common wax ointment. In the course of three weeks from his entering upon the use of mercury the sore was considerably dimin- ished, and at the end of six weeks it was entirely heal- ed; but to the surprise and satisfaction of all concern- ed all his other symptoms became better on the mer- cury taking effect. The difficulty of breathing was soon much relieved, the palpitation vanished entirely, and the pulse fell to its natural standard. It was seve- ral weeks before the asthmatic affection left him entire- ly, but this happened before the end of the course, which was continued to the end of the third month ; and he has not since that period experienced any re- turn of his disorder. In this last case it may be a question whether the patient laboured und^r syphilis at the time when I first saw him or not : He himself imagined that he did ; and on finding afterwards that the disease in his breast was completely removed by mercury, when rendered necessary by the presence of a more obvious symptom of the disease, I came also to be of the same opinion, and this induced me to give the mercury in large quan- tity, and to continue it longer than would have been necessary for the cure of a more recent infection. In March 1787 I was consulted by a gentleman of fortune in the south of England. His case was de- scribed to be a severe rheumatic affection, with which he had been afflicted for the space of eighteen months. After much exposure to cold and wet weather in the course of hunting, he was attacked with severe pains in all his joints, particularly in the shoulders, wrists, knees, and ancles. These continued in some degree from the first approach of the disease, but he had oc- casionally been distressed with severe pains in his back, loins, and hip-joints, to such a degree as not to be able to move for two or three weeks together but with an unsupportable increase of pain. His fingers and toes also became swelled and painful; and as the balls of the great toes had been particularly affected Sec. IX. AS INDUCING OTHER DISEASES. 295 his disorder by some had been considered as gout. At the time of my being consulted the joints of his fin- gers were so much swelled that he could not even sign his name, but the chief cause of his distress at that time was a swelling of his right knee. The swelling and pain in his other joints had at different periods pre- vailed in various degrees; they even at times left him entirely ; but the right knee had continued swelled and painful from the first, and at this period it was repre- sented as being nearly double the size of the other. There was accordingly much tension, and a very ex- tensive fluctuation had for seven or eight weeks been discovered in the superior part of the tumour. The skin, however, was no where discoloured. He was at this time thirty-two years of age. When first attacked with the disorder he was full and vigorous, but now much emaciated. His pulse, however, was good, for although for a considerable time a good deal of fever prevailed, it had now left him entirely, his skin was cool, and his pulse between seventy and eighty in a minute. The remedies he had employed were these : At first he was repeatedly blooded ; the pained parts had been rubbed with a variety of stimulating applications, such as volatile liniment and tincture of cantharides, and blisters had been frequently applied. He had taken James's powders, camphors, and opium ; but the lat- ter being the only remedy from which he derived re- lief, the others had long been disused. Sixty drops of laudanum taken at bed-time, and twenty-five in the morning kept him for the most part tolerably easy, but he experienced much distress whenever these were omitted. The following is the advice which I propos- ed to him : 1. That two drachms of a weak mercurial ointment containing only a fifth part of mercury, should be rub- bed upon the swelling of his knee evening and morn- ing for the space of twenty minutes each time, and continued five or six weeks if it did not excite saliva- tion, 2=96 OF LUES VENEREA Cll. IT. 2. That he should use a warm bath of sea-water ev- ery second night: The whole body to remain immers- ed for the space of twenty-five minutes, or half an hour, and a quantity of the warm water to be poured from the height of three or four feet upon the swelled knee at each time of using the bath. 3. Instead of laudanum at bed-time, that he should take fifteen or twenty grains of Dover's powder. 4. That he should wear flannel next his skin, not only upon the diseased knee, but over his whole body. 5. If by these means the swelling did not abate in the course of four or five weeks, that blisters should be applied to it ; the first to be applied upon that part of it in which the fluctuation was discovered, and the others alternately on each side of the joint. I heard again from him in the month of June, when he informed me that he had been prevented from using the mercury by a physician who had been con- suited on the receipt of my opinion. Being afraid that his debility might be increased by the mercury, be had desired that it might not be used, but all the other parts of the course which I had pointed out had been complied with. His general state of health was better, and by the use of the warm bath and Dover's powder his pains had been much relieved, but they always recurred on these remedies being laid aside 5 and the swelling of the knee was nearly in the same state as when he first applied to me. Besides this, he had been attacked with a painful swelling on the up- per part of his right shoulder, which, after becoming red and tender, had ended in an extensive foul ulcer This giving rise to much anxiety, for the sore was dai- ly becoming deeper, he was particularly anxious to have some remedy pointed out for it. In return to this, I desired that the mercury might still be employed with a view to remove or lessen the swelling of the knee, and I gave him formulae of dif- ferent ointments as dressings for the sore on the shoul- der. I said, however, that he must depend chiefly on the surgeon in attendance for the treatment of this -ore ; hut being within forty or fiftv miles of London, See. IX. AS INDUCING OTHER DISEASES'. 29? I advised him, if he did not soon get better, to go there for the advantage of a consultation. I did not hear of him again till the month of Sep- tember, when he arrived in Edinburgh. He now in- formed me that he had gone to London on the receipt of my second letter, and that he had been advised to the use of guiacum ; a deep-seated pea issue had been inserted on the inside of the swelled knee ; and differ- ent ointments had been given him to apply in succession to the sore on the shoulder. Having continued, how- ever, under the regular application of these for up- wards of two months, and no advantage accruing from them, he determined at last on coming here. The pains over his joints were still very universal, almost every joint being more or less swelled, but they were not any where so severe as they had at first been. The swelling on the knee was very considerable, and a fluc- tuation was perceived, reaching from the patella, be- neath the rectus muscle, nearly to the middle of the thigh. The skin, however, was not discoloured, and the joint was still in some degree capable both of flexion and extension. But the symptom which gave him most uneasiness was the ulcer upon his shoulder, which had now extended from the top of the shoulder over the clavicle, and down to the middle of the hu- merus. It had already destroyed some part of the del- toid muscle, by which the motion of the arm was much impeded, and a considerable portion of the cla- vicle was become carious. This ulcer he had lately been informed was of a scrophulous nature, but as to me it had many of the appearances of a venereal sore, I decidedly said so, and on inquiry I found that there was still farther cause of suspicion. About three months before he was first attacked with rheumatism two small chancres appear- ed upon the penis, which were removed in the course of eight or ten days by the application of caustic, and the use of a very small quantity of mercury. The quantity he could not exactly ascertain, but. he knew that he had not taken it for a week, and that his mouth had never been sore with it, I also fonnd, that nearly vol. i r* 38 298 OF LUES VENEREA Ch. IV. about the time at which his shoulder became sore an eruption had appeared upon different parts of his body, particularly among his hair and on his breast, but which till now he had not mentioned, as he had not supposed it to be of any importance. This, how ever, along with the other circumstances of his situa- tion, determined me to advise a full course of mercu- ry, and which he the more readily agreed to from eve* ry other remedy which had hitherto been tried having proved ineffectual. He entered upon this course on the sixth of Octo- ber. At first half a drachm of the blue ointment was rubbed in evening and morning, and one of the blue pills, with two grains of opium were given at bed- time. The opium was necessary not only for pre- venting purging, but from the patient having been in the habit of taking it. At the end of ten days, as the mouth was not affected, nor any other symptom pro- duced by the mercury, the quantity both of pills and ointment was doubled. This, in the course of a fort- night rendered the mouth exceedingly sore, and pro- duced some salivation ; but the uneasiness excited by this was amply compensated by the relief which he had obtained. Although the pains in his joints had abated they had still given him much distress. This was almost entirely removed in the course of a day or two after his mouth became evidently affected, and being anxious to avoid the habit of taking opium. I found at the end of another week that he had left it off, and that he slept better without it than he had done for two years before. Still the knee continued nearly of the same size, but the sore on the shoulder was much better. Under the same dressings which he had for some time been using the surface of the sore soon became clean, the discharge was of a better con sistence, and much less offensive, and in some parts new granulations had begun to appear. The mercury was continued in such quantities to the end of the third month as was necessary to keep the mouth completely sore during the whole period, and during the course of the last of these months he Sec. IX. AS INDUCING OTHER DISEASES. 299 drank daily an English quart of a strong decoction of sarsaparilia, guiacum, and mezereon.* At the end of six weeks all the swellings of the smaller joints, parti- cularly those of the fingers, were entirely removed, and even the fulness of the knee was considerably re- duced. The sore on the shoulder was already con- tracted to one half of its former size, and at the end of another fortnight the whole of it was cicatrised ex- cepting those parts seated upon the carious part of the clavicle. At this time too the knee had assumed a very different appearance. It was not only much lessened but the fluctuation above the patella was en- tirely gone. No application had been made to it but a portion of the mercurial ointment, wnich, morning and evening, was rubbed upon it. In the course of the tenth week a thin, long exfoliation took place from the clavicle, and the small sore which remained healed in a few days thereafter. He continued here for several weeks after the course was over, and on going away, although the knee was about an inch in circumference larger than the other, it gave him no uneasiness, not even in walking; but a very consider- able degree of stiffness remained in the joint of the right shoulder, and which I informed him might pro- bably continue for a great length of time, perhaps even for life, owing to a considerable portion of the deltoid muscle having been destroyed by the ulcer* In order to lessen this stiffness as much as possible, I desired, as soon as the skin was sufficiently firm to admit of it, that the whole shoulder and arm should be rubbed evening and morning with some emollient oil, and if no relief was obtained from this, that he should go to Bath, and have the warm waters of that place pump- ed upon it. I found, however, after two years had elapsed, although in every other respect he continued well, that his shoulder remained in nearly the same state. Many cases have fallen under my care of venereal pains which resembled rheumatism =o much that it w?. c Vide kppen&i:& Vol I "N'n. 46 300 OF LUES VENEREA Ch. IV. difficult to distinguish of what nature they were ; but in a great proportion of these, circumstances were dis- covered upon enquiry, by which the distinction was sufficiently well marked. In this, however, as well as in some others which I have met with, the symptoms were for a long while so evidently rheumatic that there was not the least cause to suspect them to be venereal. Venereal pains almost universally fix upon the middle parts of limbs ; very rarely upon the joints only. Now in this case the joints only were affected, as very com- monly happens in rheumatism, and the palient having been much exposed to the most frequent cause of that disease, while no symptom occurred that had any ap- pearance of being venereal till these pains had contin- ued upwards of twenty months. The ulcer on the shoulder was the first symptom that created suspicion ; for when I prescribed the mercurial ointment, it was not, I must acknowledge, from thinking that the patient was infected with Lues Venerea, but from experience of its utility in similar affections of the joints proceeding from other causes. An officer of the navy, who had been exposed to hard service both in the East and West Indies was seized with severe rheumatic pains in spring 1782. At first they were confined to the large joints, but after- wards a soreness prevailed over his whole body. He was about forty years of age, and till this time he had been strong and healthy. All the remedies usually employed in rheumatism were advised. Flannel was applied, and the pained parts were rubbed with a variety of stimulating appli- cations ; blisters were applied to the parts that were most painful ; sudorifies were used in various forms ; and in the course of the first three years he had used a great variety of baths. He bathed at first in warm salt- water, and afterwards went both to Buxton and Bath ; and he had last of all used the cold bath. JNo advan- tage, however, was obtained from any of these ; and at last the only remedy which he employed was a large ilose of laudanum at bed-time. He had frequently been liable to pain and some de- Sec. IX. AS INDUCING OTHER DISEASES. 301 gree of fulness in the region of the liver, which he at- tributed to his residence in India. This, however, never gave him much uneasiness, till the winter of 1785, when a soft diffused swelling, larger than it had ever been, and accompanied with some pain, was perceived exactly on the site of the liver. The tumour became larger, and at last a fluctuation of matter was perceived in it. In this situation I first saw him in the month of April ; and the chief reason of my being called was to judge of the propriety of discharging the matter by an operation. This, however, I found to be inadmissible. The matter lay so deep that it did not point any where, and the fluctuation was very obscurely felt. I there- fore in the mean time advised, that mercury, which he was then taking, should be given in greater quantities, so as to render his mouth completely sore, and, as he was much reduced in strength, that his constitution should be supported with light nourishing food. As he lived at a considerable distance I did not ex- pect to see him again, neither did I hear any thing of him till the month of February thereafter when I was again desired to visit him. A considerable change had taken place in the nature of his complaints, and the following is the account which I received of it. His mouth had been rendered moderately sore with mer- cury, and in this situation it was kept for three weeks ; but as it then gave him severe pains in his bowels, ac- companied with purging, he did not afterwards use it in such quantities, nor was it judged necessary to do so, as the swelling, for which it was prescribed, was almost entirely carried off by what had already been done. It was therefore given in such quantities, as his stomach and bowels could easily bear ; and this being continued for the space of a month longer, that is, for six or seven weeks in all, it was then left off. During this course of mercury the pains which had so long dis- tressed him were much less severe, and at one period they had left him almost entirely. While the weather continued mild in summer and harvest they did not re- cur ; but about the end of October they became more severe than they had ever before been. A few weeks, 30tf OF LUES VENEREA Oil. IV. however, previous to this, symptoms of a more hazard- pus nature had made their appearance. In the month of September he was attacked with anasarcous swell- ings of his legs, and soon thereafter with ascites, which, notwithstanding the usual remedies employed in sucli cases, increased so quickly, that in the course of seven or eight weeks from the first approach of the swelling, it became necessary to draw the water off from the legs by punctures ; and by the middle of December the distension of the abdomen was so considerable that the operation of tapping was judged adviseable. These operations, however, had procured only a temporary relief, for although the punctures had been frequently repeated, his legs, at the time of my being called to him, were much swelled, and his abdomen was more distended than at any period before the operation. The chief reason, however, of my advice being ta- ken at this time, was the appearance of some hard pain-, ful tumours upon his forehead, legs, and arms, one of which upon his right arm on the outside of the ulna, and another on the upper part of the os frontis, had burst some weeks before, and were now discharging a considerable quantity of a thin foetid matter. The others, viz. two upon his forehead, one upon his left arm, and one upon each leg were become very painful, and those on the head were discoloured, and contained such a quantity of matter as gave reason to think that they would also burst. The patient was at this time much emaciated, but he had no fever, and bis skin was softer and his discharge of urine more plentiful than they generally are in dropsical complaints. As the tumours resembled venereal nodes, and as the peculiar fetor of the discharge from the ulcers, to- gether with their sloughy appearance, gave farther cause of suspicion, I found, upon enquiry, that in Sep- tember 1731, about six months before he was attacked with rheumatism, chancres appeared upon his penis, and a bubo in each groin, but that these symptoms were easily removed by the use of a small quantity of mercury, and a short confinement of eight or ten days, and that he had not since that period run any risk of SeC. IX. AS INDUCING OTHER DISEASES. 303 being infected ; that no other symptoms of the disease had appeared upon him, and that the only mercury he had used was that which was prescribed for the affec* tion of his liver. I now began to suspect even that the rheumatism with which he had so long been distressed was of the syphilitic kind, and my reasons for doing so were ap- parently conclusive. There was full evidence of in- fection being communicated while it did not appear that he had taken half the quantity of mercury which the nature of the symptoms that ensued would have re- quired. These pains occurred at such a distance from the other symptoms as tended to confirm the suspicion. They had not been relieved by any of the remedies which in the ordinary form of rheumatism prove for the most part useful, while they were for some time almost entirely removed by the mercury employed for the diseased state of his liver. These considerations, connected with the present appearances of the tumours and ulcers, determined me to say that he was poxed* and that he should begin to the use of such a quantity of mercury as his present situation would admit imme- diately upon the water in his abdomen being taken off, and which was done that ver> 7 day. Being afraid in his present state of debility of irri- tating his bowels by the internal exhibition of mercu- ry, he was desired to use it in the form of unction on- ly; and his legs being still much swelled and tender, he was made to rub it upon his arms and abdomen. In the course of a few days his mouth became sore, and at the end of a fortnight he discharged three or four English pints of saliva daily. This was more than we wished for, and he Was desired to lessen the quantity of mercury ; but as his pains were soon almost entire- ly removed, and the distress which he had experienced from the tumours and ulcers being also much lessened, he was thereby so much convinced of the propriety of his present treatment that it was with some difficulty he was prevented from carrying the course of mercury too far. Care, however, being taken, to support him with a light nourishing diet, and with a liberal use of 304 OF LUES VENEREA Cil. IV wine, of which he took a bottle daily, he was enabled to bear the effects of mercury better than one in his state of health might otherwise have been expected to do. At the end of eight weeks, during which period his mouth had been kept constantly and fully affected, he had used twelve ounces of slrong mercurial oint- ment. His pains were now entirely gone; the ulcers were cicatrised ; and the tumours were so completely removed, that excepting those on the fore part of the legs, none of them had left any fulness by which their former situations could be discovered. The matter contained in those upon the foiehead, and which at one period was just ready to burst out, was entirely absorbed, and only a slight discolouring of the skin remained ; but what was still more remarkable, no swelling had as yet occurred in the abdomen, and the anasarcous fulness of his legs and thighs was almost entirely gone, although the punctures last made in them had been healed upwards of three weeks. The mercury was continued for five weeks longer, during which period four ounces of ointment was rubbed in, by .which the mouth was kept as sore as the patient could possibly bear it; and when at the end of the thirteenth week the mercury was left off no collection could be perceived in the abdomen ; and excepting a slight degree of oedema on the upper part of the feet, they were altogether free of swelling. Even this dis- appeared in the course of a few weeks ; and at the end of three years, when I had last an opportunity of hearing of him, he remained in good health. The circumstances of this case, while they give much cause to think that hydropic symptoms may be induced by the virus of Lues Venerea, tend also to shew that mercury given in sufficient quantity acts with equal certainty in removing them as in the cure of any symptom of the disease. They also evince the power of mercury in the cure of that affection of the liver to which many are liable who have resided in the East Indies; and that even the most advanced sta- ges of that disorder may be removed by a quantity of mercury that will not be sufficient for the cure of Sec. IX. AS INDUCING OTHER DISEASES. 305 Lues Venerea. It also appears, from the result of this case, that the matter which sometimes forms in venereal nodes may be collected in considerable quan- tity, and yet carried off by mercery. Tt may be pro- per, however, to remark, that where this takes place the tumours in which the matter is contained begin to diminish almost as soon as there is evidence of the mercury having entered the system ; and that when they do not diminish the? matter should be discharged by a proper opening, in order to prevent it from af- fecting the bone beneath. About two years ago I was desired by a gentleman to visit his wife, who I found had been liable for more than a year to what she considered as scorbutic spots upon different parts of her body, one of which, seat- ed on the sternum, had about three months before ended in an ulcer. At first the sore did not exceed the size of a sixpenny piece ; but at this time it was very extensive, reaching from one mamma to the other, and almost from the inferior point of the ster- num to the top of it. It was foul, and discharged a thin foetid sanies. For upwards of three years she had been distressed with almost a constant head-ach, which occasionally was so severe as to deprive her entirely of sleep for many days together, and on some occa- sions nearly of her reason. It did not, like the aguish bead-aeh, fix upon one spot, but affected every part of the head alike. She was now about thirty years of age, and her menstrual flux regular. Till attacked with these head-achs she was healthy and rather cor- pulent; but now she was much reduced, being almost entirely confined to bed with the violence of the pain, and she had scarcely any desire for food. Blood-letting, blisters, bark, cold-bathing, and a variety of nervous r:x dicines, had all been tried in vain. The eruption upon the skin, as well as the ulcer on the breast, having the true venereal aspect, I enquired of the husband whether he had of late been infected ormot: He said that he had not, but he candidly in- formed me, that soon after his marriage, which hap- pened more than four years before, and when he had vol. m 39 i306- q$ LUES VENEREA Ch. IV. no reason to think that he was infected, for he had no connection with any woman for a fortnight before* marriage, and after having remained well for a fort- night thereafter, a ehAncre had appeared upon the pre- putium. Immediately upon this being perceived he applied to a surgeon and was cured ; and he had eve- ry reason to think thai his wife had escaped; for al- though she had complained of a soreness in the puden- dum about the same period, it had gone so entirely off without any mercury being given, that the surgeon, "by whose advice he was directed, had assured him, it must have proceeded from some other cause. He also recollected that soon thereafter a painful tumour had formed in one of her groins; but as it also went off without coming to suppuration, and without the assist- ance of mercury, he had supposed even that this symptom could not be venereal, particularly as she con- tinued in perfect health till attacked with the head-ach ; and no symptom of pox had ever appeared upon her, unless the eruption and ulcer already described should be of tli at nature. From the whole of this history, the probability of the wife being infected with the venereal disease, and the necessity of a mercurial course were abundantly evident. Mercury was accordingly exhibited. Opi- um, which she had hitherto employed for lessening the violence of her head-ach was continued, while the sore was dressed with common wax ointment. Her mouth became sore in the course of a few days, and before the end of a fortnight she was under some de- gree of salivation. The eruption soon began to les- sen, and the sore from being exceedingly foul became dean and florid, at the same time that the head-aehs, for which no cure was expected, left her entirely ; the mouth was kept completely affected; the blotches dis- appeared altogether in the course of six or seven weeks, but the ulcer was not cicatrised till the end of the eleventh week. The mercury being continued three weeks longer was then laid aside, and neither the head-ach or other symptoms have since recurred. Sec. XX. AS INDUCING OTHER DISEASES. &07 In the month of July 1781 a young nian about seventeen years of age was put under my care in a very miserable situation. The account which I re- ceived from his parents was, that till his fourteenth year he was remarkably strong and healthy, and ex- ceedingly clever. About that period he became deli- cate, and was taken from school, in order to have full attention paid to his health. Worms, and a variety of other causes were suspected to give rise to this state of delicacy, and various remedies were employed without effect, when after two years had nearly elapsed sores appeared on different parts of his body ; his eyes be- came tender and inflamed, and at last he lost the use of one eye entirely, and about a year before I saw him he had been attacked with severe fits of epilepsy, which for the last two months had recurred several times a- day. He was now much emaciated, but his pulse w 7 as good, and the fits had not impaired his judgment. Till this time he had been under the management of a physician, a relation of his own, who considering the complaint to be scrophulous, had prescribed bark, steel, cicuta, and sea-bathing ; all of which; as well as differ- ent remedies for the epileptic fits, having been tried in vain, all hopes of a cure were lost, arid for a long while nothing had been employed. My opinion was asked on account of the ulcers, some of which had of late become so painful that large doses of laudanum were required to procure rest. Besides several small ulcerated spots, there wasat this time seven large foul ulcers on different parts of his body, none of which had given him much uneasiness while not deeper than the cellular substance ; but having in different parts penetrated into the substance of muscles, they began now to impede the motion of the parts on which they were seated, which added much to the distress which they excited. His left eye exhibited a very singular appearance. It was somewhat enlarged, and that part of the tunica conjunctiva, which in a state of health is white, was of a deep red colour, while all the promi- nent part of the cornea opposite to the pupil was much 303 OF LUES TO ERE A CI). IV, thickened, and white like paper. He still retained the sight of his right eye, which, however, was much in* flamed, and in a state of great irritability. As the ulcers had a venereal appearance, particu- larly one upon the right side of his nose, and another on one of his temples, where it had penetrated to the muscle, I said so to the young man himself, and he confessed that he had all along been afraid of his dis- ease being of that nature, but not being certain of this being the case, and afraid of incurring the displeasure of his parents, he had never till now, that inquiry was made concerning it, had the resolution to speak of it. The information he gave me was, that when he was about fourteen years of age he was infected by a wo- man with whom he had connection, and that his symp- toms had been sores upon the penis and a swelling in the groin. These, by the use of mercury, which he. received from a young man, at that time a student in the university, were removed ; but as he had not taken it in a regular manner, and only in small quantity, he had always entertained suspicions of the symptoms which ensued being the consequence of this infection. J now decidedly said that he ought immediately to take mercury, and he entered upon the use of it that very evening. It was employed in the form of unc- tion, and all the sores, excepting that upon his nose, were dressed with common cerate, the only applica- tion which he had hitherto made to them. As the ul- cer upon his nose had already begun to disfigure his fate, I advised it to be touched with caustic every se- cond or third day, in order to stop the progress of the disease as quickly as possible, and besides this it was dressed with basilicon and precipitate. As the mer- cury did not readily affect his gums 'he was desired to take two of the blue pills every night at bed-time, and to continue to rub in the same quantity of ointment which he had used from the first, viz. a drachm evening, and morning. In the space of three weeks from the commencement of the course a considerable salivation was induced, which was afterwards kept up by the unction alone till the end of the fifteenth week, The SeC. IX. AS INDUCING OTHER DISEASES, 309 ulcers bad become clean, and put on a healing appear- ance soon after the mouth became sore, and by the end of the ninth week they were all cicatrised ; but the infection having been of very long duration, and the symptoms more inveterate than usual, I did not think it proper to advise the use of mercury to be sooner left off. The most remarkable circumstance, however, in this case was, the cure which took place during the course of mercury of the fits of epilepsy. In less than three weeks they became less frequent, and not so violent as they had been before, and by the end of the sixth week they did not recur above once in three or four days. Long before the course was finished they van- ished entirely, nor was he ever distressed with them afterwards. His left eye still continued white and opake, but the inflammation of the other being remov- ed, he soon recovered the free power of vision of which he had long been entirely deprived. A married lady, twenty-six years of age, after being for some time distressed with severe head-achs, was attacked with epileptic fits, which at first were neither frequent nor severe, but recurred at last so often ti at she was commonly seized with three, four, or even more, daily. Preparations of copper and other reme- dies were employed without effect. In other respects her health was good, till at last, after the fits had been more than usually severe for eight or ten days, she became suddenly lunatic, from which time the epilepsy did not recur. In this situation she was kept at home for three or four months, but there being no prospect x>f her re- covering, she was at last put under the care of a fami- ly accustomed to take charge of lunatics. As her keepers were desired to apply to me in the event of her health requiring any particular attention, I was called to her after she had remained with them about two years, in order to give directions for the manage- ment of some sores which had appeared in different parts of her body a considerable time before. Besides several small foul ulcers upon her toes and feet, there 310 OF LUES VENEREA (Jil. J$* was a large one upon the wrist of her right arm; one upon her side, which had penetrated nearly to the ribs r and two upon the upper and back part of her head, where the cranium was found to be carious. These ulcers, they informed me, were preceded by an erup- tion, which the}' considered to be scorbutic, but which I found upon inspection to be venereal. On this being stated to her husband, he acknowledged that she might have been infected by him, but as she had never com plained of any of the symptoms of Lues Venerea, he bad hoped that she had escaped. A course of mercury was advised, but as her lunacy ■Was of the most unmanageable kind, she could not be made either to take the medicine inwardly, or to ad- mit of the external application by unction* The latter might have been done by force, but the trouble of se- curing her twice a-day for that purpose would have been considerable. Finding that she was fond of oatmeal porridge, she Was allowed to take them both to breakfast and sup- per, and with each meal her keeper was desired to mix a spoonful of a watry solution of corrosive subli- mate, in which was contained three quarters of a grain of this preparation. No obvious effect appeared from it till nearly the end of the third week, when her breath became affected, and her gums sore and spon- gy ; but although the same quantity of mercury was continued, no salivation took place. Simple dressings were applied to the sores. It became necessary, how- ever, to make an incision along a considerable part of the left parietal bone, in order to discharge a quantity of foetid matter which had lodged between the tegu- ments and a portion of that bone which was carious; All ttie rest oi the sores soon put on a healing appear- ance. In the course of nine weeks they were com- pletely healed, and during this period the maniacal symptoms also abated. In less than three weeks from the above period she became perfectly well, and no ap- pearance of lunacy has since taken place, although several years have elapsed. The sore upon the left side of the head continued open for eight or nine SeC. IX. AS INDUCING OTHER DISEASES. 311 months after the mercurial course was finished, owing to an extensive exfoliation from the parietal bone, which could not possibly be accomplished sooner. These, as I have already observed, are only a few of a considerable number of cases of a similar nature which I might relate; but as the evidence which these afford, of the opinions which I have suggested being well founded, may be considered as sufficient; any farther argument would be unnecessary. The histo- ries which I have given are in proof, that the syphili- tic virus may remain for a great length of time in the system, without producing any of the ordinary symp- toms of Lues Venerea: That other diseases altogether different from Lues Venerea in the form under which it usually appears, are, in some instances, induced by this virus. That the quantity of mercury commonly given in what is termed an alterative course may be sufficient for curing the existing symptoms of Lues Venerea, and yet altogether inadequate, however long continued, for removing the disposition, And lastly, although a course of the alterative kind may repeated- ly fail, that the syphilitic disposition, as well as the worst symptoms of the disease, may be removed by ■the proper exhibition of a full quantity of mercury. As a Supplement to this section, we intended to give an analysis of the works which of late years have been published on Diseases resembling syphilis, or more properly, on those complaints which originate either from an improper administration of the specific, from a failure in eradicating the virus of the disease, or from both combined. After however attentively perusing the writings of Aber- netlvy, Mathias, Sec. we have found the subject treated so exten- sively, and the opinions of surgeons so diversified, that it would be difficult to include a complete analysis within the compass of a few pages. The sterling merit of the above writers entitle them to a distinct perusal, and the reader will find much information both in the reasoning and cases of each. — The following works are among the most important. Abernethy's Surgical Observations on Diseases resembling Sy- philis. Philadelphia. 1811. Mathias on the Mercurial Disease. Hunter's Chapter on Diseases resembling Lues, 312 OF LtfES VENEREA, &C. Cll. IV. Pearson, 2nd Edit. This distinguished Surgeon styles the dis- ease Cachexia Syfihiloidea. Remarks on Diseases resembling Syphilis by Dr. Channing of Boston, in the New-England Journal, Vol. I. — together with Re- views of Abernethy and Mathias, in the London Medical Review? * r oL 3rd, Ep< APPENDIX THIS Appendix contains formulae of injections and other reme- dies for Gonorrhoea, enumerated in the preceding work. No. 1. R. Calomel, pptt. 5 ii. Mucilag. gum, arab, 5 ii' et adde. Aq. rosar. ? iv. No. 2. R. Calomel, pptt £ ii. Balsam, copaib. £ i. Vitell. ovi. 5 ss. M. et adde paulatim. Aq. rosar. 5 iv. No. 3. R. Hydrargyr. puris. £ ii- Mucilag-. arab. 5 ii. M, S. A. et adde. Aq. distillat. 5 iv. These formulae of mercurial injections seem to act, as I have else- where observed, altogether as astringents. They excite little or no irritation and when they prove successful they commonly do so in the space of a day or two. In all of them the mixture requires to be shaked when used ; for even with the assistance of mucilage the mercury subsides so quickly that scarcely any of it will enter the syringe, if this precaution be omitted. Instead of mucilage, prescribed in No. 3, I have sometimes em- ployed honey. This proves more expeditious for extinguishing the mercury, but the injection prepared with it excites more pain. Whether mucilage or honey be employed, the mercury should be very completely tritured. No. 4. R. Lap. calamin. pptt. 3 "* Balsam, copaib. £ i. Mucilag. arab. 5 ii. M. S. A. et adde- Aq. fontan. 5 iv. No. 5. R. Lap. tutije pptt. £ ii. Mucilag. arab. 5 ii- M. et adde Aq. fontan. 5 iv. No. 6. R. Lap. calam. pptt. 5 iv. Camphor, in pauxil. spirit, vin. rect. solut. ? i. Mucilag. arab. 5 iv. M. et adde aq. fontan, lb. vl, Ut fmt injectio, VOL. II. 40 314 APPENDIX. In No. 4,the quantity of the astringent earth is so small that it may- be well mixed with the liquid at the time of using it, but in Nos. 5 and 6, where there is a greater proportion of earth, after shaking the phial, it. should be allowed to subside for the space of a minute before filling the syringe. In this manner the finer particles only of the earth are thrown into the urethra; and it commcnly proves as effectual as when the whole of it is used. No. 7- R- Alumin, 2> iss. Solve in aq. distillat. 5 viii. No. 8. R. Cortic. quercus ? i- Coq. in aq. fontan. 5 xx. ad. 5 xvi. colatura: adde. Pulv. alumin. 5 ii- No. 9. R. Gall, quercus contus. 5 i- Coq. in aq. fontan. 5 xxx. ad. ± xx. cola et adde. Pulv. Alumin. ^ Ui- No. 10. R. Kin. pulv. 3 ii. Mucilag-. arab. 5 i. M. in mortario et adde aq. fontan. bul. "Z 1 No. 11. R. Kin. pulv. 5 ii. Pulv. alumin. 3 i- Opii. 9 ii. Mucilag". arab. 5 i- M. et adde. Aq. fontan. bul. 5 x. No. 12. R. Opii. J i. solve in aq. font. 5 vi. No. 13. R. Aq. rosar. $ vii. ss. Tinctur. thebaic. J ss. M In a great proportion of cases opium dissolved in water answers the purpose ; but in a few instances I have found the spirituous tine ture, in the proportions here mentioned, prove more effectual. No 14. R. Balsam, canadens- Vel. copaib. 3 i»- Vitell. ovi. 5 ss. M. et adde. Aq. rosar. 5 vi. When the balsam and yolk of an e^^ are previously well rubbed together, the water may be mixed with them so completely that no great degree of separation will afterwards take place ; but to pre- vent any inconvenience which might ensue from the balsam getting to the top of the mixture, it should always be well shaked imme- diately before the syringe is filled with it. JS T o. 15. R. Ceruss. 3 ii. Mucilag. arab. ? ii. M. et adde. Aq. fontan. distil. 5 vi APPENDIX. 3 1 5 No. 16. R. Sacch, saturni. 9 »» Solve ill aq. distil. jr viil No. 17. Aq. distil. 5 viii. Acet. lythargyr. gutt. xxiv. M. When saccharum saturni, or cerussa acetata, as it is now termed} can be obtained pure, it is perhaps preferable for every purpose to vinegar of litharge, as being of a more determined strength ; but it is frequently so much adulterated that it will not dissolve but in very small quantities, even in distilled water. Some of it indeed is so very insoluble, that an ounce of water will not dissolve above a grain of it. By the addition of vinegar this may, it is true, be part- ly remedied ; but vinegar, for many purposes, is not admissible in such quantities as would be necessary for rendering this article much more soluble than we usually find it. Two, three, or more drops of the vinegar of litharge may be used in every ounce of in- jection. Two drops often prove sufficient, but many can bear eight or ten. The following method of preparing vinegar of litharge is the best I have met with. It is not very different from the extract of lead of Goulard, but the strength of it is more certain, R. Lythargyri J-j^ iii. Acet. distillat. fe x. coq. leni igne ad. fe vi Cola. Besides boiling on a slow fire, during which time it ought to be well stirred with a wooden spatula, the whole should be allowed to cool, and the faeces to subside before straining. Lead dissolved in this manner is easily mixed with water, and it proves to be a very convenient, as well as a very effectual method of using it. No. 18. R. Zinci vitriolat. vul^o vitriol, alb, X ss. . "-' Solve in aq. font, distillat. ^ xvi. No. 19. R. Zinci vitriolat. ►) i. Solve in aq. distillat. *z x. et adde. Acet. lythargyri gutt. xx. ut. f. mjectio. In some cases, where these articles have excited pain when used in this manner, they have been rendered perfectly mild by the addi- tion of mucilage of gum arabic, and in others by camphor. Cam- phor does not dissolve completely in any watery fluid, but being previously well rubbed with a few drops of spirit of wine, as much of it may be mixed with the water as to render the other articles much less pungent than they otherwise would be. The camphor, however, separates in such quantities as renders it necessary to fil- ter the solution before using it. 316 APPENDIX. Although a precipitation necessarily takes place from a mixture of vitriol and saccharum saturni, the following combination of these two articles with opium gives a very useful form of injection. No. 20. R. Vitriol, alb. Sacchari saturni. afi ^ ss. Camphor, J *■ Opii. 9 ii. Solv. in aq. fontan. bul. ? x\ i Cola. Ko. 21. R. Fol. rosar. rub. ? ss. Alumin. pur. X ii. infund. in aq. bill. ± xvi. Cola. ut. f. in- jectio. No. 22. R. Balsam copaib. Vitell. ovi. aa 5 ss. M. et adde. Infus. rosar. rubr. 5 xvi. No. 23. R. Cap. papaver. alb. $ iv. Rad. altheac incis. 5 i- Infund. per noctem in aq. bul. fe ii Cola, No. 24. R. Hydrargyr. muriat. vplg. mercur. sublimai. corrosiv. gr. 1 Solve in aq. fontan. 5 x. No. 25. R. Mercur. sublim. corros. gr. 1. Acet. lythargyr. girtt. xvi. Aq. fontan. $ viii. M. S. A. No. 26. Mercur. sublimat. corros. gr. 1. Mucilag. arab. ± ii. Aq. fontan. ^ vi. M, Corrosive sublirnate dissolved in water proves to be the most cei^ tain, and perhaps in every respect the best form of a stimulating- injection. Some have advised a much stronger solution than any of these, even to the extent of a grain of mercury to three or four ounces of water. I suspect, however, that those who recommend it of this strength have never made use of it, at least I have never met with any who could bear it. When the mercury is combined with water alone, as in No. 24. one grain to ten ounces proves suffi- ciently strong; but when mixed with saccharum saturni, with ace- turn lythargyri, or with mucilage, as in Nos 25. and 26. a grain may be added to six or eight ounces of water. When mixed with either of the two first of these articles, some part of the mercury precipitates, and is therefore lost, and in the other the mucilage tends evidently to render it less active. No. 27, R. Sal. aramon. crud. gr. x. Solve in aq. font, g x, APPENDIX, 317 No. 23. R. Aq. fontan. ~ x. Spirit sal. aromat. gatt. lx. M. No. 29. R. Aq. fontan. 3 x. Spirit corn, cervi gutt. lx. M. No. 30. R. Formul. inject. No. 23. § viii. Lixiv. caustic, gutt. xx. M. I have frequently found both the volatile and caustic alkali prove useful where other injections had failed, but we cannot with any cer- tainty point out the strength for any individual. While one is able to bear ten drops to every ounce of water, others cannot bear above three or four: The strength I have advised in the three preceding formulae proves to be the best for general use, but patients are more easily affected with variety in the strength of these injections than of any other I have ever tried. The caustic alkali may be used in water alone ; but may be ventured upon in larger quantities, and with more safety, when combined with a mucilaginous infusion. No. 31. R. iErug. pptt. gr. viii. 01. oliv. Opt. I iv. M. No. 32. R. JErug. pptt. 5 i. Spirit, corn. eery. 5 iv. Digere et cola. R. Solut. supr. parat. gutt. xl. Aq. distillat. § x. M. Verdigris mixed with oil may be used with perfect safety of the strength mentioned in No. 31, but as injections prepared with oil prove dirty and disagreeable in the application, I commonly prefer the form of the remedy No. 32. A much larger proportion of verdigris is commonly advised, but when more is employed, it precipitates immediately on being adcied to the water. Even of this strength the precipitation cannot be pre- vented entirely but by adding about a half more of the volatile al Ka- li to the filtered solution of the verdigris. After filirating through paper, if two ounces of volatile alkaii be added to it, no precipita- tion will take place if distilled water is employed ; but in this case, a greater quantity of the solution may be added to the same quantity of water. Instead of forty drops, forty-eight or fifty may be added to ten ounces of water. No. 53. R. Aq. fontan. ~ x. Tinctur. caiuliarid. gutt. xx. ad xxx. M. The three following are prescriptions for bougies. No. 34. R. Emplast. diachyl. siffipl. 5 iv. Cer. punss. 5 iss. Ol, oliv. opt. Z iii, 318 APPENDIX. No. 35. R. Emplast. commun. Spermat. est. aa § iv. 01. oliv. opt. ^ ss. Minii. § ss. M No. 36. R. Emplast. commun. £ vi. Cerae flavae puriss. Spermat. cxt. aa § ii. 01. oliv. opt. § i. Antimon. crud. pptt. £ ss. M. S. A. Any of these prescriptions afford a good composition for bougies. They require to be slowly melted, and the different articles to be well mixed together. No. 34. is the simplest and perhaps the best, the red lead in No. 35. and antimony in No. 36. being added chiefly for the purpose of affording variety of colour. No. 37. is a com- position for bougies recommended by Mr. John Hunter,* and No. 38. by Mr. Sharp.f No. 37. Take oil of olives three pints, Bees wax one pound, Red lead a pound and a half. Let them be boiled together on a slow fire for six hours. No. 38. R. Diachyl. cum pice burgund. § ii. Argent, viv. § i. Antimon. crud. pptt. g ss. The quicksilver to be previously dissolved in balsam of sulphur, or in honey, and added to the plaster when melted in a moderate heat. Any of these compositions, when boiled to a proper consistence, will answer for the formation of bougies, which is done in the fol- lowing manner: While the liquid still continues warm, let a piece of fine old linen be dipped in it, taking care with a spatula to cover the whole of it. If the melted liquor be of a proper heat, no more of the plaster will adhere to the linen than is necessary; but as air bubbles are apt to rise and produce inequalities on the surface of the cloth, the spatula made use of should be somewhat warmer than the plaster, and by means of it the whole should be made as smooth tts possible. The plaster might indeed be spread entirely with the spatula ; but this is not only attended with more trouble, but it does not cover the cloth with sufficient equality. The cloth being sufficiently cold, may be immediately formed in- to bougies, and the whole should, in the first place, be cut into the number that is meant to be made. The most exact method of doing this is by means of a sharp pointed knife directed by a rule. The pieces should be eleven inches in length for bougies of a full size ; but they should likewise be kept of all the variety of lengths for strictures of different heights in the urethra. * See Treatise on the Venereal Disease, p. 137. f See Critical Enquiry by Samuel Sharp, F. R. S. &c. APPENDIX. 319 A variety of directions have been given for the form of bougies, Some advise them to be made nearly of an equal thickness to within an inch of their smallest end, and to taper from that to the point, while a great proportion of them are made to taper to within an inch or two of the point, and the rest of them are cylindrical. I once thought that this last form of bougie was the best ; but after a long course of experience in this branch of business, I am now con- vinced, that bougies, which taper equally from one end to the oth- er, are the best, and that this form answers equally well for every variety of size. They are introduced more easily, and with less pain than any of the others ; the linen should therefore be cut in such a manner as to give this form to the bougies. When rightly spread, and the linen sufficiently fine, a well shaped bougie will be formed of a slip of about five eighths of an inch broad at its largest end, and somewhat more than three eighths at the smallest end. This forms a bougie of a middle size ; for particular purposes they must be considerably larger, and for others not so large by a great deal. These slips of linen are now to be rolled up as neatly as possible with the fingers ; and in order to give them a smooth polished sur- face, they should be smartly rolled between a piece of smooth hard timber, and a plate of fine polished marble : This being continued till the whole are rendered perfectly smooth and firm, and their points being properly rounded in order to facilitate their introduc- tion, they are in this state to be kept for use. These directions will convey an idea of the method of preparing bougies, but no surgeon can ever become so expert in forming them as those artists who are daily accustomed to prepare them in large quantities. I must here again observe, however, in addition to what I had occasion to remark in a former part of this work, that bougies, properly prepared with resina elastica, are preferable, in many circumstances, to such as are made with any kind of plaster. They not only prove much more durable, but more force can be em- ployed with them, and as they do not break or crack by remaining in the urethra, they remain in it with less pain and inconvenience than any other bougie that has yet been invented. Cat-gut has frequently been used as a bougie; but after various trials being given to it, I do not find that it answers the purpose : It cannot be made sufficiently smooth, and it sometimes swells so much as to excite a good deal of irritation ; and lead, which was one of the first articles used for bougies, is so firm that it always creates much pain, while at the same time it is so apt to break that different instances having occurred of this happening in the urethra, it has now been long laid aside. The six following prescriptions are meant for the removal cf warts and other excrescences, and they answer equally well whether they proceed from Gonorrhoea or Lues Venerea. It would appear, how- ever, that there is a material difference between the warty excres cences which occur as a consequence of these diseases, and such a? 320 APPENDIX. we usually meet with from other causes; for while the former arc for the most part easily removed by any of these applications, even by the pulvis sabinae alone, the latter are seldom acted upon by any of them, if it be not by the strong solution of corrosive sublimate in No. 40. and of mercury and spirit of nitre, No. 41. both of which are possessed of a strong degree of causticity. No. 39. R. Sal-arhmon. crud. 5 i- Solve in acet. distillat. ? ii. Aq. fontan. § iv. No. 40. R. Hydrargyr muriat. vulgo. mere, sublim. corros^ Sal-ammon. crud. aa % ss. Solve in aq. fontan. ^ iv. No. 41. R. Argent, viv. ? i. Solve in spirit, nitr. fort. oz. ii. No. 42. R. Pulv. fol. sabin. Calomel, aa 5" i. M. No. 43. R. Pulv. fol. sabin. Mercur. sublim. corros. aa £ *&-■ Mercur. precip. rub. ^ i- M. No. 44. R. Alumin. ust. Mercur. precip. rub. aa ^ i. M. The following form of decoction of sarsaparilla and mezereon is of a strength which most people can bear ; when a greater propor- tion of mezereon is added, it excites sickness, and a very disagree- able sensation in the throat. I mention it here as I have had occasion to speak of it in the preceding work ; and I shall also have cause to refer to it when treating of Lues Venerea. No. 45. R. Rad. sarsa. 3* ii. Cortic. radic. mezer. ^ i ss - Coq. in aq. fontan. lb. iii. ad. lb. ii Colaturae, adde. Syrup, althese 3 i. The following is the Decoctum Lusitanicum, or Lisbon dirt-drink No. 46. R. Rad. sarsapariL Santal. alb. Rubr. aa. 5 iii. Rad. glycyrhiz. Mezerei. aa. oz. ss Ligni rhodii. Guaiaci. Sassafras, aa. 0/ i APPENDIX. 321 Antimoiv cmd. 5 ii. misce, et infunde in aqua: fontanae bill- lientis. lb. x. per horas xxiv. dxen, coque ad lb. v. cola^ turx capiat, a lb. iss. ad. lb. iv. quotidie. Vel R. Rad. sarsaparillae. " Ligni sassafras. Ligni santal. rubri. Guaiaci aa. Cortic. rad. mezer. Semin. coriand. ^ Vi7 Coq. in aq. fontan. lb. xx. ad. lb. x. Sumat lb. ss. ter quaterve indies. Unguentum e calce zinci. No. 47. R. Olei olivarum opt, 5 iiL Cerae albae. Sperm, cetae aa. J m - Leni calore liquesc. dein adde. florum zinci 5 ss. Unguentum e lafiide calaminare, No. 48. R. Olei oliv. opt. ^ iii. Cerae albs. 5 iss. Sperm, ceti. 5 ss. Lapid. calamin. pptt. J v. M. S. A, VOL. II. THE following Appendix contains formulas of all the medicines erurnevated in the second volume, as well as of some others occa- sionally employed by other practitioners in the cure of Lues Vene- rea. No. 1. Emfilastrum hydrargyri,vulgo,Emfilastrum c — form of using - and - Alopecia, description of method of treatment of Anomalous Symptoms, description of method of treatment of Antidote, definition of the term Anumony Crude, useful in venereal eruptions Aqua Phagadenica, form of - Asthma Venereal, cases of cured by mercury Atrophy, a symptom of Lues Venerea described - venereal, method of treatment of Vol Page, U. 265 ib. I. 75 ib. . ib. II. 23 - 317 L 141 n. sir i. 63 n. 314. 316 - 7S 251 V 81 254 - 108 243 - 324 289 - 83 ib. •> 255 B. Balsams Astringent, used in injections , , their use in Gleet . , form of using in injection and Bark Peruvian, useful in Gonorrhoea - m swelling of the testis Barytes Muriated, its effects in sores succeeding to buboes . observations on the use of Bladder, inflammation of Blindness, from Lues Venerea - ■ description of - venereal, method of treatment of Blisters, use of m Gonorrhoea - II n. i z useful in Gleet - their utility in deranged sensations of the bladder and perineum sometimes useful in hernia humoralis ... ■ in certain kinds of swellings - n. Blood-letting, when indicated in Gonorrhoea - - L useful in Chordee - local, useful in the treatment of bubo IT, 63 116 314 316 75 205 233 326 86 77 ib. 251 73 119 188 205 247 78 93 225 INDEX.. Blotches, venereal '- - .- • - most frequent seat of - - how distinguished - — — . cure of - Borax; its utility in removing- mercurial salivation Bougies __..--- — often useful in gleet - — — — observations on — chief objects in the formation of ■ directions for the use of - ■■ ■ i. " sometimes slip into the bladder time of remaining in the urethra ... should not be allowed to remain long in the bladder ■ - much perseverance necessary in their application ■ — formulae for preparing 1 - Bubo, definition of - may take place without chancre, or any previous mark of infection produced by the absorption of the syphilitic virus seat of ----- - frequently more than one cause of being always external - description of - ■* - '■' " suppurates more quickly than other glandular tumours how distinguished from other tumours in the groin — — often connected with scrophula - sometimes connected with erysipelas — — in women, situation of — — at first, always local - - - . - method of treatment of suppuration of, never to be encouraged — — discussion of, always to be attempted remedies to be applied for • suppurated, treatment of - object in opening - different methods of opening Indolent, state of described Calces of Mercury, activity of differences between the Calammans Lapis, form of using in injection Calomel, used in injections in Gonorrhoea forms of using in injection — ' — observations on frictions with, in the inside of the mouth Camphor proves useful in chordee form of using in injection and Cantharides, useful in gleet — — ■ form of using in injections Carimcles, or fleshy excrescences in the urethra Cataracts, from Lues Venerea effect of mercury upon Catheter, observations on the use of the Caustic, danger of introducing into the u?ef3ira Vol. Page. II. 50 - 51 5:; - 243 171 I. 115 118 . 151 153 . 154 157 - 158 160 . 165 n. 26 . 26 xtion 21 . 21 26 - 27 28 - 29 30 - 31 ib. - 32 35 . ib. 223 - ib. ib. . 224- II. 228 . ib. . 229 . 233 II. 133 134 313 1. 62 II. 313 - 142 146 I. 92 II. 313 - 316 I. 114 JL 317 I. 144 II. 77 - 252 J. 193 - 167 INDEX. Caustic, caution, in applying to chancres experiment concerning - method of using 1 ... - its utility in sores succeeding to buboes in venereal ulcers - Chancre within the urethra, instance of the matter of does not produce Gonorrhoea does not always precede buboes - - described - - - - • different periods of appearing - seat of - - - - - - • matter of ----- - varieties of ... in some instances, rapid progress of - - ■ remarkable instances of - 1 in women - - . cure of - - should be healed speedily - the cure of, not always to be effected by the internal use of mercury never to be trusted to local remedies alone most quickly cured by the use of caustic inflamed state of, relieved by leeches dangerous haemorrhage from inflamed state of, not hurt by mercury clean state of various applications for treatment of, when conjoined with phymosis in women, method of treatment of Vol Page. 11. 210 - ib. 212 - 232 237 I. 26 32 - 215 n. 12 . 13 ib. > 14 ib. . 16 17 • ib. 208 ib. lercu ry ib. - 209 210 - 215 216 - 218 ib. - 219 ib. 81 254 I. 91 ib. n. 234 L 226 - 75 116 - 206 n. 63 i. 104 208 _ 209 n. 52 i. 72 Chops in the hands and feet described - method of cure of Chordee, definition of - - produced by inflammation - Cicuta, sometimes useful in sores succeeding to buboes Circumcision, observations on the operation of - Cold Bathing, useful in Gonorrhoea in Gleet - in swelling of the testis Cold and Dampness, dangerous effect of in Lues Venerea Consequences of Gonorrhoea Virulenta - - Cord Spermatic, swellings of : remedies applied for Corona Veneris, what - Cowper's Glands, affections of - D. Deafness, from Lues Venerea - - - - II. 80 s method of treatment of 253 Decoctum Lustiamcum, or Lisbon diet -drink, formulae of - 320 Ligni guaiaci, form of - - - - - 325 Sarsaparillae ------- ib. Mezerei - = „..- ib. Deranged Sensations in the bladder and urethra - - I. 183 , no t easily accounted for - 186 remedies to be used in - - - - 187 Diarrhoea excited by mercury, remedies for n. 174 Diseases, different, may exist at the same time on the same part - 58 Dropsy, syphilitic, case of cured by mercury - - - 304 Duncan, Dr. his opinion of the action of mercury - - 112 Vol. Page. II. 234 81 I. 204 II. 321 - 326 - 307 . 177 - ib. - 210 I. 27 - 222 n. 70 ib. - 71 - 247 INDEX. Electricity, its utility in the indolent state of Bubo Elephantiasis, a symptom in Syphilis - Emetics, their utility in Hernia Humoralis - Emplastrum Mercuriale, form of Lithargyri, form of - Epilepsy Syphilitic, case of, cured by mercury Eruption induced by mercury, description of remedies for Escharotics, their utility in chancres - - - Excoriations from Gonorrhoea do not require mercury > in the parts of generation of women Excrescences Venereal, about the anus ... ■ — description of - *— - =► — — in women, sometimes produce buboes cure of - * F. Fever, as a symptom of Lues Venerea II. 84 — — Venereal, observations on - 257 Fistula in Perinxo, most frequent cause of - - - I. 166 Fluor Albus, its resemblance to Gonorrhoea ... 95 — how to be distinguished from Gonorrhoea 97 . cured by astringent injections - ib. Frenum, sometimes necessary to cut II. 214 Fumigations with Mercury, in what manner applied - - 137 — — — — i sometimes useful in chancres -> 214 ~ t]ieir utility in sores succeeding to Buboes - 232 G. Gangrene induced by Chancres, rapid progress of •> H. 215 « ■ opium the best remedy for - 216 mercury does harm in - 217 325 270 I. 214 215 217 105 107 108 - • ib. 110 111 114 116 Gargansma e borace, form of Gilchrist, Doctor, his Essay on Sibbens Glands in the Grom, swell.ngs of »■■ remedies employed in Glaus and Prepuce, excoriations of - Gleet, import of the term remarkable case of - . arises from different causes . often the effect of local relaxation seldom of general debility remedies useful in inflammation useful in diet recommended in relieved by a seton in perinaeo - 120 ■ a frequent consequence of strictures in the urethra - * ib. — — sometimes relieved by opiates .... 123 Gonorrhoea and Lues Venerea appeared at different periods : - 18 r- a much more frequent disease, than pox - - 26 INDEX. Vol. Page Gonorrhoea translation of the matter of - > - » I. 28 — the matter of, does not produce chancres - 32 — and syphilis sometimes remain long distinct - - 33 — time of appearing- ----- 37 — symptoms of - - - - ; - - 38 — sympathetic pains in 39 — in women ------ 41 matter of ----- - 42 — manner of infection in 43 — remarkable fact in - . - - 44 — matter of, not produced by ulcers - 45 — produced by inflammation - 46 ■ — resemblance of to catarrh - - - - 47 — prognosis in ----- 48 — general observations on the cure of 50 — first stage of - 57 — . regimen in ------ 68 — low diet improper in. - .--,,- ..'..» ib. — second stage of - - - - - ^ TO — third stage of - 77 — - fourth stage of 85 — in women --._.. 95 — always a local disease- - 99 Gonorrhoea spuria, what - 217 — observations on - 218 — means of distinguishing from Lues Venerea 219 ~ method of curing ... 220 — excited by savine applied to the urethra - 235 Gonorrhoea simplex - - - - - - 236 — observations on ib. *— remarkable case of 237 — may be produced by the matter of fluor albus 239 — may excite swelling of the testis - - 241 — — swellings of the inguinal glands ib, — necessity of discriminating - 242 — method of cure - - ib Guaiacum, observations on - - - 11= 192 — proofs of its power as an anti-syphilitic - - 193 Gutta Serena, from Lues Venerea - 7? H. Haemorrhages from the urethra -.,.-•- — produced by chancres, remedies for Headach, syphilitic case of, cured by mercury Hernia Humoralis, what - — femoralis, sometimes mistaken for bubo Herpes, similar to Venereal eruptions - Hunter Mr. John, some of his opinions examined, Vol. II, page; 103. & 175 Hydrocele, sometimes induced by hernia humoralis Hyoscyamus, proves useful in chprdee T» Impotency, what , * » « I. 126 — — ' causes of \« - ..■» - * IK vol, ii, 43 I. 94 II. 216 305 i 194 II, 33 53 23. 58. 92. I, 199 P. IIxDEX, tmpotency frequently induced by local weakness — seldom the effect of general debility two stages of - « first stage of second stage of - - - relieved by electricity - by hyoscyamus „ ma y occur from swelling of the epidydymis J: flammation, slight degree of, necessary for the production of bubo II. Injections, their early application recommended < not to be used while the testes are swelled strength of « ■ — manner of using » - - ■ frequency of using , - - - sometimes do harm .... - general observations on the use of - . ■■ ' stimulating, useful in gleet - astringent sometimes useful in gleet Vol. Page. I. 127 128 190 - 130 132 - 134 ib. - 197 II. 23 I. 59 , 61 64 - 65 66 - 75 102 , ib„ 118 n. 313 lormulse of K. Kidneys sometimes affected in Gonorrhoea - I. 47 Kino, an useful ingredient in injections - 63 useful in haemorrhagies - - - - - - 94 forms of using in injection - - - -II. 314 . its utility La Diarrhoea - - - - - 175 L. Lapis Calaminaris used in injections - -.. - I. 62 L ider, spirit oi, an application for chancres - - II. 218 Le L, Lsed in i jections I. 63 Leeehes, .ueir utility in hernia humoralis - 198 their bites, observations on - 221 Lime Water, when useful in gleet - 122 Lmnnentum Cerae, form of II. 326 Lips, method of treating chancres on - ... 220 Lixivium Causticum, form of usmg in injections, - 317 Lues Venerea, sometimes takes place Without chancres - I. 24 appeared in Europe before Gonorrhoea - 33 — appeared at OUheite before Gonorrhoea - - ib. ■ when first accurately described - -II. 7 in what manner communicaced 8 ■ — often given by an infected nurse to a child, and vice versa ib. may be communicated by the milk in nursing - 9 ■ ■ — matter of, may be absorbed from any part of the sur- face of the body - ib„ • matter of, is not readily absorbed from the stomach 10 ■ symptoms of 12 the cause of its breaking out sooner in some than in others 25 < cannot be cured by evacuants - - - 107 — in infants ----.. 257 — proofs of -»«.„* 259. — ., =™_ . cases of - . , :■ . - * ■- - * ib-, INbE^c Lues Venerea, how to be treated . ■ — remarkable case of - — some peculiarities of form of — — its power m inducing- other diseases Lymphatic vessels of the penis, swellings of — — — remedies useful in — — — two cases of Lithargyri acetum s form of Vol Page,. - II. II. 263 266 268 284 210 213 ib. 315 M. Mania Syphilitic, case of, cured by mercury- Mel Mercuriale, form of - Mercury not necessary in Gonorrhoea ! useful in a thickened state of the bladder — — never proves useful in gleet - apt to do harm in hernia humoralis - crude, form of using in injection Mercunus sublimatus cotrosivus, form of using in injection Mercury, partial use of, a remarkable effect of ■ general observations on - — — general effects of on the system — — stimulating effects of - f distressful symptoms induced by - ■ — operation of in the cure of syphilis - — u'ritation excited by, not necessary in the cure — does not cure syphilis by the evacuation which it excites — antidotal powers of, proofs of - — acts as an antidote in the cure of syphilis — . preparations of - - - — in what manner rendered active - — different methods of exhibiting- - — fumes of - — — in some cases an useful remedy Mercurial preparations from triture, observations on - Mercurius alkalisatus, observations on — ■ calcinatus, observations on - — — form of - — sublimatus corrosivus observations on = — — form of - — cinereus, observations on — — form of - — acetatus, observations on - Mercurial frictions, observations on . - Mercury absorbed, quantity of difficult to ascertain Mercurial course, duration of - - - ' - - Mercury alterative, course of described — observations on - - — ■ > — » not to be depended on for the cure syphilis — quantity of necessary to be employed — course of regimen to be observed in - — patients taking, ought not to go abroad — course of, a caution previous to - ■ — how far to be considered as a certain cure for syphilis — course of, its failure m the cure of syphilis <— how to be applied for the discussion of buboes II. 309 322 I. 102 103 124 2o4 II. 313 316 59 99 100 ib. 101 102 103 106 108 110 130 131 137 ib. ib. 139 140 ib.. 323 141 323 143 324 143 144 145 152 153 154 of 155 157 167 168 173 188 192 -' ' 99 -i Vol Page. II. 227 - 323 - ib. . 324 , 198 . 199 I. 204 n. 177 - 51 INDEX, Mercury should "be given irr every stage of bubo — Van Swieten's solution of Mercurius dulcis, form of prazcipitatus ruber, form of Mezereon, observations on — method of exhibiting — useful in hernia humoralis Morbid state of the system induced by mercury Mucus, attraction between and mercury N. !N*odes, definition of ----- H. 62 — most frequent situation of - - -"'.'- 63 — description of - 64 — cause of their being painful ib. — cure of------- 244 — when they ought to be laid open - 246 o. Obstructions in the urethra ^ » . - - I. 134 spasmodic of the urethra - 137 Ointment mercurial, strength of - - - -II. 147 observations on the use of - - - 148 absorption of, promoted by friction - - 149 Onanism, the baneful effects of I. 129 Opiate Clysters useful in Gonorrhoea - 79 Opiate Clysters useful in Gleet ..... 123 Opiates useful in chordee ----„. 92 — their utility in mortification ... . 137 Opium used in injections in Gonorrhoea - - - 63 — proves hurtful in impotency ..... 133 — its utility in spasms of the urethra ... 141 — an useful remedy in swelling of the testis ... 200 — forms of using in injection - - - - II. 314 — its utility in removing salivation - - - - 171 — observations on ...... cjqI i — when first employed in the cure- of syphilis - •* ib^ — proves chiefly useful by allaying irritation ... 202 i — large doses of given in Lues Venerea ... 203 — external application of - - - - - ib. — its utility in irritability of the bladder and urethra - I. 183 — in sores succeeding to buboes - - - - n. 232 f — often particularly useful in venereal ulcers - - 242 Pains, venereal, how distinguished from rheumatism Paraphymosis, what .... — — observations on operation for - Phthisis Venereal', case of, cured by mercury ft 6? 1 218 228 229 i. 2$d Vol Page- ■f> I. 218 - 223 • ib. - 227 II. 323 . 325 . 172 • 243 • 322 II. 320 I. 31 II. 265 ,» « 282 I. 77 II. 325 INDEX. Fhymosis, what = — observations on • — remedies employed in — operation for described Pilulae e Mercurio Sublimato Corrosivo — Plummeri - constitution in which they prove useful ■■ their utility in venereal blotches Plenk's solution, form of -v Powders Escharotic, formula of * Pox, no stage of ever induces Gonorrhoea Pregnancy, not always an objection to the use of mercury Prophylactics, observations on - Prostate Gland, affections of Pulvis Doveri, form of - R. Remedies used in Lues Venerea, general observations on * II. 98 Resina Elastica, the best material for bougies, = - - I, 153 Rheumatism Syphilitic, case of, cured by mercury - II. 294 Ring Worm, what ... • 53 Routine of practice to be guarded against - 130 Saccharum Satumi, form of using in injections Sal Ammoniac, form of using in injections Salivation not necessary for the cure of syphilis — method of preventing . — method of removing - — m»st effectually relieved by local applications — not always increased by more mercury Sarsaparilla, observations on - — method of exhibiting - Savine, its influence in removing warts - Scrcphula, observations on Scrotum, thickening of Scurvy, observations on . — and a course of mercury induce similar effects Sea Bathing useful in certain stages of bubo — its utility in venereal swellings of the testis Semicupium proves useful in deranged sensations of the bladder Sibbens, what - • - — description of - — method of cure of — method of preventing = Sinuses in perinseo, how to be treated - — - produced by buboes, distressful effects of Solutions Escharotic, formulae of $ore Throat, venereal =-..-. — - description of -,..-.- — often accompanied with erysypilas — sometimes productive of deafness — sometimes penetrates to the bones — sometimes mistaken for otte affections. It 315 . 316 169 a ib. 170 . ib. 171 - 196 197 I. 234 II. 191 - 82 189 * 191 234 - 250 I. 188 IL 268 ib„ . 272 273 I. 76 II. 230 . 320 37 = ib 38 - 39 40 * 41 NBEX. Spasms of the urethra relieved by blood-letting — by blisters o • — by electricity — by bougies Strictures in the urethra, observations on *, — seldom the consequence of ulceration — — nor of the rupture of blood-vessels - ' — — nor of the use of injections — most frequently induced by relaxation — not to be cured by mercury ... — cured with most certainty by bougies Sweating induced by mercury, method of preventing Symptoms, from the sudden stoppage of Gonorrhoea not venereal Syphilis, remarkable cure of * " - .; * Vol. Page I. 141 - 142 ib - 143 146 148 ib. . 149 150 . 151 ib 11. 176 I. 23 II. 173 T. Tendons and ligaments not often affected in Lues Venerea Testicle, swelling of, from Lues Venerea - — difference between it and hernia humoralis — how distinguished from sarcocele Testes, both, sometimes swell in Gonorrhoea — swelled, symptoms produced by — sometimes swell from sympathy — swelling of, most frequently the effect of inflammation — — seldom end in suppuration — remedies employed for removing - — decay of ----- — — induced by onanism - — — stopped by a blister applied over the scrotum Throat, ulcers in, cured by caustic Trochisci Keyseri, form of - Tumours in the substance of the urethra Turpethum Mmerale, observations on _ 72 73 . 74 i 194 . ib. 196 . 195 197 . 198 205 . 206 ib. ii. 237 . 324 i. 135 ii. 143 U. and V. Vas Deferens, swellings of the = Venereal swelled testicle, cure of - - - Verdigris, useful in Gleet ----- — an useful application in chancres Vinegar, steams of, useful in swellings of the testis Virus Venereal, observations on - — first acts upon the fluids — its action in inducing other diseases — may remain long latent ... — not to be removed by an alterative course of mercury Vitriol used in injections - - - - - Vitriolum Album, form of using in injections Ulcers Venereal, old, when they do not readily produce bubo — distinguishable into two kinds — description of in the nose and mouth — in the mouth, how distinguished from other affections e*i venereal, some parts of the body more liable to than others **-* rise and progress of I. 22 II. 248 I. 114 II. 218 I. 201 II. 86 - 88 284 o 312 ry ib. I. 64 II. 315 - 23 24 - ■ 42 45 55 *. 56 INDEX, Vol Page. Ulcers Venereal, peculiar appearance of the matter of - EL 56 — ordinary seat of ----- 57 — succeeding" to buboes described - 6X — v a frequent cause of their obstinacy - 62 — venereal, cure of - 236 — frequent cause of difficulty in curing* - 239 Unguentum e Calce Zinci. form of ... . «, 321 — lapide calaminari - ib. — mercuriale, form of - - - - - 322 — citrinum ----.. 324 — mercuriale album - = . - . 326 — — rubrum - - - - ib. — exiErugine --.-.. ib. — saturninum ---... ib. Urine, remarkable effect of in gangrene - 215 Uva Ursi, its utility in Gonorrhoea - - - ' I. 89 — in affections of the bladder - » - . 103 Warts on the genitals , — observations on - — produced by irritation ... — sometimes the consequence of syphilis — — more frequently of Gonorrhoea — removed by escharotics — — by stimulants - Weeping eye, how produced by ulcers in the nose Women not so susceptible of Gonorrhoea as men <=— not liable to strictures in the urethra FX!S T IS, I. 232 231 232 ib. ib. 234 ib. II. 44 I. 95 125