> * -■' -\ .-tiinlh. ■-. U ■■■■, •. - ■.■.■.,■ fidiflNli'.h!?!?1!,'!!'-:,..!:' 'it:;' !: . 'i'i/iti^;;1' fi[i:-d iBJSiiti!;';-- pi',:-!;.- ■"■■ J» . ' : SURGEON GENERAL'S OFFICE LIBRARY. Section ...l-CMA- lt.^...J 250 Seft. III. Of the refolution of buboes in wo- men, 9gt Seft. IV. Of buboes in other parts, 252 Seft. V. Of the quantity of mercury neceffary for the refolution of a bubo, 2,52 Seft. VI. THE CONTENTS. Seft:. VI. Of the treatment of buboes when they fuppurate, 254 (Chap. V. Qf fome qf the confequences of buboes, 256 PART VI. £HAP» I. Qf the lues venerea, 262 Seft. I. Of the nature of the fores or ulcers pro- ceeding from the lues venerea, 264 Seft. II, Of the matter from fores in the lues venerea compared with that from chancres and buboes, 267 Seft. III. Of the local effects arifing from the conflitution considered as critical—fymp- tqmatic fever, 274 Seft. IV. Of the local and conftitutional forms of the difeafe never interfering with one another, 276 Seft, V. Of the fuppofed termination of the lu- es venerea; in other difeafes, 277 Seft. VI. Of the fpecific diftance of the venere- al inflammation, 278 Seft. VII. Of the parts moll fufceptible of the lues venerea-^of the time and manner in which they are affefted—what is meant by contamination, difpofition and aftion—- fummary of the doftrine, 279 Chap. II. Of the fymptoms of the lues venerea, 289 Seft. I. Qf the fymptoms of the firft ftage of the lues venerea, 292 Seft. II. Experiments made to afcertaln thepro- grefs and effefts of the venereal poifon, 298 Seft. III. Of the fymptqms of the fecond ftage of the lues venerea, 300 Seft, IV. Of the effefts of the poifon on the conflitution, 302 Chap. III. General obfervations on the cure of the lues ve- nerea, 304 Seft. I. Of the ufe of mercury in the cure of the lues venerea, 307 Seft. II. THE CONTENTS. Seft. II. Of the quantity of mercury neceffary to be given, 3*3 Seft. III. Of the fenfible effefts of mercury up- on parts, 3*5 Seft. IV. Of the aftion of mercury, 317 Seft; V. Of the different methods of giving mercury—externally—internally, 319 Seft. VI. Of the cure of the difeafe in the fe- cond or third ftage, 325 Seft. VII. Of local treatment, 328 Seft. VIII. Of abfcefTes—exfoliation, 329 Seft. IX. Of nodes on tendons, ligaments and fafcise, 330 Seft. X. Of correfting fome of the effefts of mercury, 331 Seft. XI. Of the form of the different prepara- tions of mercury when in the circulation, 334 Seft. XII. Of the operation of mercury on the poifon, 337 Seft; XIII. Of gum guaiacum, and radix farfa- parillae, in the venereal difeafe, 339 ClIAP. IV. Of the effefts remaining after the difeafe is cured, and of the difeafes fometimes produced by the cure, 341 Seft. I. General obfervations on the medicines ufually given for the cure, 343 Seft. II. Of the continuance of the fpitting, 348 Chap. V. Of preventing the venereal difeafe, 349 PART VII. Chap. I. Of difeafes refembling the lues venerea, which have been miftaken for it, 050 Seft. I. Of difeafes fuppofed to be venereal pro- duced by tranfplanted teeth, 362 INTRODUCTION. I '■ 1 INTRODUCTION. TW O motives have induced me to publifh the following treatife. In the firft place, I am not without hope, that feveral new obfervations, contained in it, will be deemed wor- thy of the public attention ; in the next place, I am defirous to have an opportunity of fhewing from whom fome opinions, that have made their way into the medical world, originated. But, as much of the theory, which will often be referred to in the courfe of this work, is peculiar to myfelf, it feems ne- ceffary to give an introduftory explanation of fome parts of it, in order that the terms ufed may be the more intelligible to the reader. I. OF SYMPATHY. I divide fympathy into two kinds; univerjal and partial. Univerfal fympathy is, an affeftion wherein the whole con- flitution fympathifes with fome fenfation or aftion. Partial fympathy is, an affeftion wherein one or more diftinft parts fympathife with fome local fenfation, or aftion. The univerfal fympathies are different in different difeafes ; but thofc that occur in the venereal difeafe are principally two; the fymptomatic fever, and the hectic fever. The fymptoma- tic fever is an immediate effeft of fome local injury, and fel- dom takes place in the venereal difeafe in any great degree un- der any of its forms, except in the cafe of a fwelled teflicle, which is itfelf an inftance of a partial fympathy ; the fymptoma- tic fever here, therefore, is an univerfal fympathy arifing from a partial one. The heftic fever is an univerfal fympathy with a local difeafe, which the conflitution is not able to overcome. This takes place oftener and in a greater degree in the lues venerea than in any other form of the difeafe. I divide partial fympathy into three kinds ; the remote, the contiguous, and the continuous. The remote is, where there appears to be no vifible connection of parts from whence we B can 9 INTRODUCTION. can account for fuch effefts, as in the cafe of pain of the fhoul- der in an inflammation of the liver. The contiguous is, that which appears to have no other conneftion than what arifes from vicinity or contaft of feparate parts; an inftance of which we have, in the ftomach and inteuines fympathifing with the integuments of the abdomen. The continuous is, where theie is no interruption of parts, and the fympathy runs along from the irritating point, as from a centre, which is the mofl com- mon of all fympathies. We have an example of this in the fpreading of inflammation. II. OF MORBID ACTIONS BEING INCOMPATIBLE WITH EACH OTHER. The venereal difeafe is not only fufpefted to be prefent in many cafes, where the nature of the diforder is not well mark- ed, but it is fuppofed that it can be combined with other dif- eafes, fuch as the itch and the fcurvy : thus we hear of pocky itch, and of fcurvy and the venereal difeafe combined; but this fuppofition appears to me to be founded in error. I have never feen any fuch cafes, nor do they feem to be confiftent with the principles of morbid aftion in the animal oeconomy. It appears to me, beyond a doubt, that no two aftions can take place in the fame conflitution, nor in the fame part, at one and the fame time. No two different fevers can exifl in the fame conflitution, nor two local difeafes in the fame part at the fame time ; yet as the venereal difeafe, when it attacks the fkin, bears a refemblance to thofe fymptoms which are vulgar- ly called fcorbutic, they are often fuppofed to be mixed and to exifl in the fame part. What has been called a fcorbutic conflitution, is no more than a conflitution very fufceptible of ah aftion producing eruptions on the fkin, whenever an immediate caufe takes place; and there are fome parts of the body more fufceptible of this than others, in which therefore a flighter immediate caufe is fufficient to excite the aftion ; but the eafy fufceptibility, with refpeft to one difeafe, is not a reafon why a conflitution fhould not likewife be fufceptible of other difeafes. A man may have the pox and the fmaU-pox at the fame time; that is, parts of his body may have been contaminated by the venereal poifon, 3nd the fmall-pox may take place, and both difeafes may ap- pear INTRODUCTION. 8 pear together, but not in the fame parts. If both were con- sequences of fever, and each followed the fever nearly about the fame time, it would be impoffible for each to have its re- fpeftive eruption, even in different parts, at the fame time,; two fevers, antecedent to thefe different difeafes, cannot be eo-exiftent. From this principle, I think I may fairly put the following queries. Does, not the failure of inoculation, and the power of refitting immy infections, fometimes arife from the perfon's having, at the fame time, fome other difeafe, and therefore be- ing incapable of a new aftion ? Does not the great difference in the lime, from the application of the caufe, to the appear- ance of the effeft, in many cafes, depend upon the fame prin- ciple? It has been fometimes obferved, that the punfture in the arm has fhewn no fign of inflammation in fourteen days after the application of the variolous poifon. Has there not been another difeafe in the conflitution at the time of inoculation ? Does not the cure of fome difeafes depend upon the fame prin- ciple ? The fufpenfion, or cure of a gonorrhcea by a fever, may be an inflance of this. Let me. illuftrate this principle ftill further, by one of many cafes which have come under my own obfervation. On Thurf- day, the fifteenth of March, one thoufand feyen hundred and feventy-five, I inoculated a gentleman's child ; in whofe arms it was obferved, I made large punftures. On the Sunday fol- lowing, he appeared to have received the infeftion ; a fmall inflammation or rednefs appearing round each punfture, and a fmall tumour above the furface of the fkin having been ob- ferved. On the twentieth, a. i the twenty-firfl, the child was feverifh; but I declared that the fever was not variolous, as the inflammation had not at all advanced fince the nineteenth. On the twenty-fecond, a confiderable eruption appeared, which was evidently the meafies ; upon this the fores on the arms ap- peared to go back, becoming lefs inflamed. On the twenty- third, he was very full of the meafies; the punftures on the arms'being in the fame ftate as on the preceding day. On the twenty-fifth, the meafies began to difappear. On the twenty- fixth, and twenty-feventh, the punftures began again to look a little red. On the twenty-ninth, the inflammation increafed, and there was a little matter formed. On the thirtieth, he was feized with fever. The fmall-pox appeared at the regular time, went 4 INTRODUCTION. went through its ufual courfe, and terminated favourably. In like manner, it may be obferved, that the venereal difeafe makes its appearance at different periods after infeftion. Is not this explicable on the fame principle ? III. OF THE COMPARATIVE POWERS OF DIFFER- ENT PARTS OF THE BODY—FROM SITUATI- ON— FROxVI STRUCTURE. We fhall have occafion to obferve, that the parts affefted affume the morbid aftion more readily, and continued more rapidly, when near to the fource of the circulation than when far from it; for the heart exerts its influence upon the different parts of the body in proportion to their vicinity to it ; and the more diftant that the parts are the weaker are their powers. This is, perhaps, better illuflrated by difeafe than by any aftions in health ; for in health we have no comparative trials, as no two parts of the machine, at unequal diftances from the heart, can be thrown into equal aftion, and therefore no con- clufions can be drawn. It may be obferved, that all the vital parts are near the heart. In difeafes we fee mortification, arifing from debility in the extremities, oftener than in other parts, more cfpecially if the perfon is tall; the heart not propelling the blood to thefe diftant parts with equal force. In fuch a ftate of conflitution, thofe who labour under a. hemiplegia, are often found to die at la ft, from a mortification in the extremities of the'paralytic fide. In fome of thefe cafes the arteries give way, and allow of an extravafation of the blood, and therefore we may reafonably fuppofe, that they are proportionally weak in health. We alfo find, that fuch extravafation commonly begins in the ex- tremities. This principle is not only evident in thefe two dif- eafes, but alfo in every difeafe that can affeft an animal body. It appears in the readinefs with which difeafes come on, and proceed in parts diftant from the fource of the circulation, and alfo in the fteps towards a cure. Parts differ not only in their powers, in proportion as they are nearer or further from the heart, but likewife according to their peculiar ftrufture, whereby they vary as much in the progrefs of morbid aftions as in the operations of health. An INTRODUCTION. fc An animal body is compofed of a variety of fubftances, as mufcle, tendon, cellular membrane, ligament, bone, nerve, &c. We have therefore an opportunity of obferving the com- parative progrefs of difeafes in them, and their comparative powers of performing a cure ; and we find that they differ very much from one another in thofe refpefts. How far thefe differences take place in all difeafes, I have not been able to determine ; but fhould fuppofe, that in fpecific difeafes, as fcrofula and cancer, there is in general no difference in the mode/of aftion in any of the ftruftures*, thefe difeafes pro- ducing the fame fpecific effefts in all the parts that are capa- ble of being affefted by them ; but in difeafes arifing from ac- cident, a great difference in the degrees of aftion takes place ; the parts from fuch a caufe being allowed to aft according to their natures, which obfervation holds good alfo in the venere- al difeafe. This difference appears to be chiefly in the degrees of ftrength and weaknefs in refitting morbid aftion. The lefs the natural powers of aftion are in any particular ftrufture of parts, the lefs they are able to refift difeafe ; therefore bone, tendon, ligament, and cellular membrane, go through their morbid aftions more flowly than mufcle or fkin ; and this principle is applicable to the venereal difeafe. IV. OF PARTS SUSCEPTIBLE QF PARTICULAR DISEASES. There are fome parts much more fufceptible of fpecific difeafes than others. Poifons take their different feats in the body as if allotted for them. Thus we have the fkin attacked with what are vulgarly called fcorbutic eruptions, and many other difeafes; it is alfo the feat of the fmall-pox and the meafies; the throat is the feat of the hydrophobia and the hooping-cough. The fcrofula attacks the abforbent f) ftem, efpecially the glands. The breafts, tefticles, and the conglomerate glans, are the feat of cancer. The fkin, throat, and nofe, are more readily affefted by the lues venerea than the bones and penoiteum, which, on. the other hand, fuffer fooner than many other parts, particularly the vital parts, which perhaps are not at all fuf- ceptible of the difeafe. y q~ * Here it is to be underftood, that we do not include thofe parts which have a great- er tendency to fpecific difeafes thar. what many others have; as the lymphatics to the fcrofula, the bread to the cancer. 6* INTRODUCTION. V. OF INFLAMMATION. I consider common inflammation to be an increafed ac- tion of the fmaller veffels of a part, joined with a peculiar mode of aftion, by which they are enabled to produce the fol- lowing effefts ; to unite parts of the body to each other ; to form pus; and to remove parts of the folids. Thefe effefts are not produced hy a fimple increafe of aftion or enlargement of the veffels, but by a peculiar aftion, which is at prefent perhaps not underftood, Thefe three effefts of inflammation I have called, diftinft fpecies of inflammation. That which unites parts I have call- ed, the adhefive inflammation ; that which forms pus, the fup- purative inflammation; and that which removes parts, the yj- terative inflammation,. In the adhefive inflammation the arteries throw out coagu- lable lymph, which becomes the bond of union. This how- ever is not fimply extravafated, but has undergone fome change before it leaves the arteries, fince in inflamed veins it ie found lying coagulated upon the internal furface of the veffel, which could not have happened if fimply extravafated. In the fuppurative inflammation a ftill greater change is produced upon the blood before it is thrown out by the arteries, where- by it is formed into pus ; which change is probably fimilar to fecretion. In the ulcerative inflammation, the action of the arteries does not remove the parts; that office is performed by the abforbent veffels which are brought into aftion. In the two firfl fpecies of inflammation there muft be a ehange in the difpofition and mode of aftion of the arteries; for the fuppurative fpecies cannot be confidered as fimply an increafe of the aftion of the adhefive, as its effefts are totally different; but in the third fpecies there is probably no chancre of aftion in the arteries from that of the fecond ; the aftion only of the abforbents being fuperadded, by which folid parts, and of courfe, the arteries themfelves are removed. VI. OF INTRODUCTION. t VI. OF MORTIFICATION. Mortifications are of two kinds, one preceded by in- flammation, the other not; but as the cafes of mortifications^ which will be mentioned in this work, are all of the firft kind, I fhall confine my obfervations to that fpecies. I confider inflammation as an increafed afition of that power which a part is naturally in poffeffion of. This increafed ac- tion, in healthy inflammations at leaft, is probably attended with an increafe of power: but in inflammations, which ter- minate in mortification, there is no increafe of power. On the contrary, there is a diminution of power, which, joined to an increafed aftion, becomes the caufe of mortification, by deftroying the balance which ought to fubfifl between the pow- er and aftion of every part. If this account of mortifications be jufl, we fhall find it no difficult matter to eftablifh a rational praftice ; but before we attempt this, let us jufl take a view of the treatment hitherto recommended, and fee how far it agrees with our theory. It is plain from the common praftice, that the weaknefs has been attended to; but it is as plain, that the increafed aftion has been overlooked ; and therefore the whole aim has been to increafe the aftion with a view to remove the weaknefs. The Peruvian bark, confeftio cardiaca ferpentaria, &c. have been given in as large quantities as the cafe appeared to require, or the conflitution could bear; by which means an artificial or temporary appearance of ftrength has been produced, while it Was only- an increafed aftion. The cordials and wine, upon the principle on which they have been given, are rationally adminiftered ; but there are ftrong reafons for not recommend- ing them, arifing from the general effeft which all cordials have of increafing the aftion without giving real ftrength ; and the powers of the body are afterwards funk proportionally as they have been raifed; by which nothing can be gained, but a great deal may be loft; for in all cafes, if the powers are-allowed to fink below a certain point, they are irrecoverable. The local treatment has been as abfurd as the conftitutional. Scarifications have been made quite to the living parts, that flimulating and antifceptic medicines might be applied to them, fuch * INTRODUCTION. fuch as turpentines, the warmer balfams, and fometimes the effential oils. Warm fomentations have been alfo applied as congenial to life, but warmth always increafes aftion, and ftimu- lants are improper where the aftions are already too violent. Upon the principles here laid down, the bark is the Only medicine that can be depended upon, as it increafes the powers and leffens the aftion. Upon many occafions opium will be of fingular fervice by leffening the aftion, although it does not give real ftrength. I have feen good effefts from it, both when given internally in large dofes, and when applied to th© part. To keep the parts cool is proper, and all the applicati- ons fhould be cold. The above-mentioned praftice is to be kept in view in mortifications that happen in the venereal difeafe. PART [ 9 3 PART I. CHAPTER I. OF THE VENEREAL POISON. TH E Venereal Difeafe arifes from a poifon ; which, as it is produced by difeafe, and is capable of again pro- ducing a fimilar difeafe, I call a morbid poifon, to diftinguifh it from the other poifons, animal, vegetable, and mineral. The morbid poifons are many, and they have different powers of contamination. Thofe, which infeft the body, ei- ther locally or conftitutiorially, but not in both ways, I call fimple. Thofe, which are capable of affefting the body, both locally and conftitutionally^ I call compound. The venereal poifon, when applied to the human body, pofTefTes a power of propagating or multiplying itfelf; and as it is alfo capable of afting both locally and conftitutionally, it is a compound mor- bid poifon. Like all fuch poifons, it may be communicated to others in all the various Ways in which it can be received, producing the fame difeafe in fome one of its forms. I. OF THE FIRST ORIGIN OF THE POISON. Though the firft appearance of this poifon is certainly within the period of modern hiflory, yet the precife time and. manner of its origin has hitherto efcaped our inveftigation ; and we are ftill in doubt, whether it arofe in Europe, or was imported from America. I fhall not attempt to difcufs this queftion; z\v\ thofe who with to examine at length the fafts, au- thorities and arguments brought in favour of the latter opini- on, may confult Aftruc ; and for the former a then treatife * C publifhed * Intitled, "A DifTertat'ton on the Origin of the Venereal Difeafe; proving that it was not brought from America, but began in Europe from an epidemical Diftemper., Tranflated from the original Manufcript of an eminent PhyEcian. London, printed far Robert Griffiths, 1751." OF THE VENEREAL POISOtf. publifhed in one thoufand feven hundred and fifty-one, with- out a name. The author of this treatife appears to have con- fidered the fubjeft very fully, and as far as reafoning goes ori a fubjeft of this kind, proves that the difeafe was not brought from the Weft-Indies. Not contented with this, he goes on to account for its firfl rife in Europe : but in this he is not equally fuccefsful. The fubject is a difficult one ; and the want of a fufficient number of fafts leaves too much room for conjefture. We fhall not therefore enter further into this queflion ; nor is it material to know at what period, and in what country, this difeafe arofe 5 but we may in general affirm, that as anis mals are not naturally formed with difeafe, or fo as to rUrt fpontaneoufly into morbid aftions ; but with a fufceptibility oi fuch impreffions as produce fuch aftions, difeafes mufl always arife from impreffions made upon the body : and as man is probably fufceptible of more impreffions, that become the im- mediate caufe of difeafe, than any other animal, and is befides the only animal which can be faid to form artificial impreffions upon himfelf, he is fubjeft to the greatefl variety of difeafes. In one of thofe felf-formed fituations, therefore, the impref- fion molt probably was given, which produced the venereal difeafe. II. IT BEGAN IN THE HUMAN RACE, AND IN THE PARTS OF GENERATION. In whatever manner it arofe, it certainly began in the hu- man racef as we know no other animal that is capable of be- ing infefted with this poifon. It is probable too, that the parts of generation were the firfl affefted : for, if it had taken place in any other part of the body, it might probably never have gone further than the perfon in whom it firfl arofe ; and therefore never have been known ; but, being feated in the parts of generation, where the only natural connection takes place between one human being and another, except that be- tween the mother and child, it was in the moft favourable fi- tuation for being propagated : and, as we fhall find hereafter in the hiftory of the difeafe itfelf, that no conftltutional effeft of this poifon can be communicated to others, we are led of neeeflky to conclude that Us firfl ^effects were local. " III. OF OF THE VENEREAL POISON. ii III. OF THE NATURE OF THE POISON. We know nothing of the poifon itfelf, but only its effefts on the human body. It is commonly in the form of pus, or united with pus, or fome fuch fecretion, and produces a fnnilar mat- ter in others, which fhows that it is mofl generally, although not neceffarily, a confequence of inflammation. It produces, or excites therefore, in mofl cafes, an inflammation in the parts contaminated; befides which inflammation, the parts fo contaminated have a peculiar mode of aftion fuperadded, dif- ferent from all other aftions attending inflammation ; and it is this fpecific mode of aftion which produces the fpecific qua- lity in the matter. It is not neceffary, that inflammation fhould be prefent to keep up this peculiar mode of aftion, be- caufe the poifon continues to be formed long after all figns of inflammation have ceafed. This appears from the following fafts: men having only what is called a gleet or healing chan- cre, give the difeafe to found women : and many venereal go- norrhoeas happen without any vifible figns of inflammation. In women, the inflammation is frequently very flight, and often there is not the leaft fign of it; for they have been known to infeft men, though they themfelves have had no fymptoms of inflammation, or of the difeafe in any form. Therefore the inflammation and fuppuration, when prefent, are only attendants on the peculiar mode of aftion ; the degree in which they take place depending more on the nature of the conflitution than on that of the poifon. The formation of matter alfo, though a very general, is not a conflant attendant on this difeafe ; for we fometimes fini inflammation produced by the venereal poifon, which does not terminate in fuppuration ; fuch inflammation 1 fufpeft to be of the eryfipelatous kind. It is the matter produced, whether with or without inflammation, which alone contains the poi- fon ; for without the formation of matter, no venereal poifon can exifL Therefore a perfon haying the venereal irritation in any form not attended with a difcharge, cannot communicate the difeafe to another. To communicate the difeafe therefore, it is neceffary that the venereal aftion fhould firfl take phce ; that matter fhould be formed, in confequence of, that a6hon ; and thai the matter fhould be applied tQ a found perfon or pare. That is OF THE VENEREAL POISON. That the venereal difeafe is to be propagated only by matter, is proved every day by a thoufand inftances. Married men contract the difeafe, and not fufpefting that they have caught it, cohabit with their wives, even for weeks. Upon difco- vering fymptoms of the difeafe, they of courfe defift ; yet in all my praftice I never once found, that the complaint was communicated under fuch circumftances, except where they had not been very attentive to the fymptoms, and therefore continu- ed the conneftion after the difcharge had appeared. I have gone fo far as to allow hufbands, while infefted, but before the ap- pearance of difcharge, to cohabit with their wives in order to iave appearances, and always with fafety.. I could carry this ftill further, and even allow a man, who has a gonorrhcea, to. have conneftion with a found woman, provided that great care be taken to-clear all the parts of any matter, by firfl fyring- ing the urethra ; making water ; and wafhing the glans. The matter, which is impregnated with this poifon, when it comes in corttaft with a living part, irritates that part, and inflammation is the common confequence. It muft be applied either in a fluid ftate, or rendered fluid by the juices of the part to which it is applied. There is no inftance where it has given the infe£tion in the form of vapor, as is the cafe in ma- ny other poifons. IV. OF THE GREATER OR LESS ACRIMONY OF THE POISON. Venereal matter mufl in all cafes be the fame ; one quantity of matter cannot have a greater degree of poifonous quality than another ; and, if there is any difference, it is on- ly in its being more or lefs diluted,' which produces no differ- ence in its effefts. One can conceive, however, that it may be fo far diluted as not to have the power of irritation. Thus any fluid taken into tiie mouth, capable of flimulating the nerves to tafte, may be fo diluted as not to be tafted. But if the poifon can irritate the part, to which it is applied to aftion, it is all that is required ; the aftion will be the fame, whether from a large or fmall quantity, from a ftrong or a weak folution. ; We find from experience, that there is no difference in the kind cf matter ; and no variation can arjfe in the difeafe from the OF THE VENEREAL POISON. the mattet's being of different degrees of ftrength ; for it ap- pears, that the fame matter afftfts very differently different people. Two men having been connefted with one woman, and both catching the difeafe, one of them fhall have a violent gonorrhcea or chancre, while the other fhall have merely a flight gonorrhcea. I have known one man give the difeafe to different women, and fome of the women have had it very fe- verely, while in others it has been very flight. The fame rea- soning holds good with regard to chancres. The variations of the fymptoms in different perfons depend upon the conflitution and habit of the patient at the time. What happens in the inoculation of the fmall-pox ftrengthens this opinion. Let the fymptoms of the patient, from whom the matter is taken, be good or bad ; let it be from one, who has had a great many puftules, or from one, who has had but few ; let it be from the confluent or diftinft kind ; applied in a large quantity or a fmall one ; it produces always the fame effeft. This could only be known by the great numbers that have been inoculated under all thefe different circumftances. V. OF THE POISON BEING THE SAME IN GONORRHCEA AND IN CHANCRE. It has been fuppofed by many, that the gonorrhcea and the chancre arife from two diftincl poifons; and their opinion feems to have fome foundation, when we confider only the different appearances of the two fymptoms, and the different methods of cure ; which, with refpeft to the nature of many difeafes, is too often all we have to lead our judgment. Yet, if we take up this queflion upon, other grounds, and alfo have recourfe to experiments, the refult of which we can absolutely depend upon, we fhall find this notion to be erroneous. If we attend to the manner in which the venereal poifon was communicated to the inhabitants of the iflands of the South Seas, there are many circumftances which tend to throw light upon the prefent queflion. It has been fuppofed, as no men- tion is made of a gonorrhcea at Otaheite, that it mull have been the chancre that was firft introduced into that ifland ; and that of courfe nothing but a chancre could be propagated there ; for as no gonorrhcea had been communicated, no fuch difeafe could take place. But if we were to reafon upon all the pro- ,f> bable i4 OF THE VENEREAL POISON. bable circumftances, attending the voyages to that part of the world, we fhould conclude the contrary ; for it was almolt im- poflible to carry a chancre fo long a voyage without its deftroy- ing the penis; while we know from experience, that a gonor- rhcea may continue for a great length of time. It is mention- ed in Cook's voyage, that the people of Otaheite, who had this difeafe, went into the country and were cured ; but when it became a pox, it was then incurable. This fhows, that the difeafe, which they had, mud have been a gonorrhcea ; for we know that it is only a gonorrhcea that can be cured by fimple means: and further, if it had been a chancre, and they had, been acquainted with the means of curing it, they could alf? have cured the lu^.s venerea.. Wallis left Plymouth in Auguft 17S.6, and arrived at Ota> helte in July 176.7, eleven months after his embarkation ; and if none of his men had the difeafe when he failed, there was hardly a poffibllity of their contracting it any where afterwards in the voyage. This appears to be too long for a gonorrhcea to lafl. But let us fuppofe even that Wallis carried it thither in his fhip, one or two of his crew having the difeafe. As he, flaid there five weeks, it was very poffibje, even very prpba-. ble, that fuch perfon or, perfpnn might have communicated it fo quickly as to have become the caufe of contamination of the whole crew of his (h.ip ; but as this did not happen, it is a prefumptive proof that Wallis did not carry it thither,. Bougainville left France in December 1766 ; hut he touched at feveral places where fome of his people might have got the difeafe. The lafl of which place was Rio de la PJata, which he left in November 1767, and arrived at Otaheite in April 1768, five months after. This interval of time agrees better with the ufual continuance of the difeafe, than the length of Wallis's voyage, and therefore from this circumftance it becomes more probable, that Bougainville carred it thither." Befides, it is likely that he could guard his people lefs againft the dif- eafe than Wallis ; for Wallis could have his choice of men at his firft fetting out, which was all that was neceffary to pre- vent his carrying the difeafe with him, for he ran no rifk of contracting it afterwards : but although Bougainville had the fame advantage at firft, yet he had it not afterwards, for his men were in the way of infeftion in feveral places, and he had no opportunity of changing them, and probably no great chance OF THE VENEREAL Poifcotf. of having them cured. The circumftance of the difeafe be- ing found by Bougainville at Otaheite foon after his arrival, is a kind ot proof that he carried it thither himfelf; for I ob- ferved before, that if Wallis had carried it by one man only, this man could in a Very few days have fo far propagated it, as to have fpread it through the whole fhip's crew ; and as Bougainville arrived at the ifland ten months after Wallis, there was a fufficient time for the inhabitants of the whole ifland to have been infefted, and the ravages of the difeafe muft have been evident to them immediately upon their arrival. Bougainville remained only nine days at the ifland of Otaheite, and obferved nothing of the difeafe till fome weeks after his departure, when it was found that feveral of the crew were in- fected, which mofl probably muft have happened in confe- rence of the poifon being carried there by fome of his own people. It is alfo mentioned by Cook, that the Otaheiteans flfcribed the introduction of the difeafe to Bougainville ; and we can hardly fuppofe that they would be fo complaifant to our countrymen as to accufe Bougairtvillej when they muft have known whether the difeafe was imported by Wallis or not, cfpecially as they had no reafon to be partial in favour of the people who accompanied the latter. But as we find in Cook's lafl Vovage, that the difeafe in every form is now there, and 4s we have no new intelligence of a gonorrhcea being fince in- troduced, we muft fuppofe that every form of the difeafe has been propagated from one root, which mofl probably was a gonorrhcea. If any doubt ftill remain with refpeft to the two difeafes be- ing of thfe fame nature, it will be removed by confidering that the matter produced in both is of the fame kind, and has the fame properties ; the proofs of which are, that the matter of a gonorrhoea will produce either a gonorrhcea, a chancre, or the lues venerea } and the matter of a chancre will alfo produce either a gonorrhoea, a chartcre, or the lues venerea. The following cafe is an inftance of a gonorrhcea producing a lues venerea. A gentleman twice contracted a gonorrhcea, of which he was cured both times without mercury. About iwo months after each he had fymptoms of the lues venerea ; thofe in confequence of the firft infeftion, were ulcers in the throat, which were removed by the external application of mercury ; the fymptoms in confequence of the fecond, were ^ bloiches 16 OF THE VENEREAL POISON. . i blotches on the fkin, for which alfo he ufed the mercurial ointment, and was cured. With regard to the lues venered proceeding from chancres, inftances occur fo frequently to every one's obfervation, as to require no further proof here. Since then it appears, that the gonorrhcea and chancre are the effefts of the fame poifon, it may be worthy of inquiry, to' what circumftances two fuch different forms of the difeafe are owing. To account for thefe two very different effefts of the fame poifon, It is only neceffary to obferve the difference in the mode of aftion of the parts affefted when irritated, let the ir- ritation be what it may. The gonorrhcea always proceeds from a fecreting furface*, and the chancre is formed on a non- fecreting furface ; and in this lafl, the part to which the poi- fon is applied, muft become a fecreting furface before matter can be produced. All fecreting furfaces in the body being probably fimilar, one mode of application only is neceffary to produce this difeafe in them all, which is by the poifonous matter fimply coming in cdntaft with them. But to produce the chancrej the venereal matter may be applied in three dif- ferent ways; the firfl and rhoft certain is by a wound, into. which it may be introduced ; the fecond is by applying the matter to a furface with a cuticle, and the thinner that is it allows the matter to come more readily to the cutis; and the third is by applying the matter to a common fore already formed. The poifon then being the fame in both cafes, why do they not always happen together in the fame perfon ? For one would naturally fuppofe, that the gonorrhcea, when it has ap- peared, cannot fail to become the caufe of a chancre ; and that this, when it happens firft, muft produce a gonorrhoea.' Although it does not often happen fo, yet it fometimes does; at leaft there is great reafon to believe fo. I have feen cafes where a gonorrhcea came on, and in a few days after in fome ; in others as many weeks, a chancre has appeared : and I have alfo feen cafes where a chancre has come firft; and in the courfe * By fecreting fwfaces I mean all the pafiages for extraneous matter, including alfo the duds of glands, fuch as the rmuth, nofe, eyes, anus, and urethra ; and by tioa-fecretivv furfaces, the external ficia in ge >er il. To which 1 may add a third kind of furface, leading froi.i the one to the other, as the glans penis, prblabium of t.h~ mouth, the in- : fi..le of the lips, the pudendum ; which furfaces partaking of. the proporties of each, bv.t in a. lefs degree, are capable of h !ir n7> v-d in both ways, fomstira;:-. by bt'v.g eacitei to fecretion, and at ether ti.-u;s to i>^ttiiioi». Q¥ THE VENEREAL POISON, courfe of its cure, a running and pain in making water have fucceeded. It may be fuppofed that the two difeafes arofe from the original infeftionj and only appeared at different times ; and their not occurring oftener together would almoft induce us to believe it was fo, fince the matter is the fame in boihj and therefore capable of producing either the one or the other. I fufpeft that the prefence of one irritation in thefe parts becomes in general a preventive of the other. I have already obferved, that the two parts fympathife in their difeafes ; and it is poffible that that very fympathy may prevent the appear- ance of the real difeafe ; for if an aftion has already taken place which is not venerea^ it is impoffible that another fhould take place till that ceafes ; and it is probable that this fympa- thy will not ceafe while the caufe exciting it exifts ; and there- fore when both happen in the fame perfon at the fame time, I fufpeft that either the urethra never had fympathifed with the: chancre, or if it did at firft, that the fympathy had ceafed, and then the venereal matter might ftimulate the parts to a6tion. VI. OF THE CAUSE OF THE POISONOUS QUA- LITY—FERMENTATION—ACTION. As the confideration and explanation of this point will throw fome light upon the difeafe, and cure, I may be allowed to dwell a little upon it. It has been fuppofed by fome, that the: poifonous quality of the matter arifes from a fermentation taking place in it as foon as it is formed. But whether this poifon- ous quality arifes from that caufe ; or whether the animal body has a power of producing matter according to the irritation given, whereby the living powers, whenever irritated in a par- ticular manner, produce fuch an aftion in the parts as to gene- rate a matter fimilar in quality to that which excited the ac- tion, is what I am now to confider. In the examination of this fubjeft I fhall confine inyfelf to the gonorrhcea. In fupport of either of the two opinions, it muft be fuppofed that the venereal matter has by its fpecific pro- perties, a power of irritation beyond common matter. I have already obferved, that it has the power of exciting inflamma- tion even on the common fkin, and of forming a chancre, which power is not poffeffed by common matter. In the firft opinion it muft be fuppofed, that there is- no fpecifi* inflamma-* D tior* 18 OF THE VENEREAL POISON. tion or fuppuration produced by the application of the Venereal matter, but only a common inflammation and fuppuration, and that the matter capable of producing thefe effefts afts as a ter- ment upon the new-formed matter, rendering it venereal as foon, or nearly as foon, as it is formed ; and as there is a fuc- ceffion of fecretions, there immediately follows a fucceflion of fermentations. Now, let us fee how far this idea agrees with all the variety of phaenomena attending the difeafe. Firft, it may be afked, what becomes of this ferment in many cafes where the fuppuration does not come on for fome weeks after the irritation and inflammation have taken place ? In fuch cafes we can hardly fuppofe the original venereal matter to remain, and to aft as a ferment. Secondly, when there is a ceffatioh of the difcharge and no matter formed, which fometimes hap- pens for a confiderable time, and yet all the fymptoms recur, what is it that produces this fermentation a fecond time ? No- thing can, but a new application of frefh venereal matter. When, for example, the irritation is tranflated to the tefticle and the difcharge is totally flopped, as often happens, what becomes of the virus; and how Is a new virus formed when the irritation falls back upon the urethra ? Thirdly, if the poifonous quality were produced by fermentation taking place in the matter already formed, it would not be an eafy matter to account for the fymptoms ever ceafin*; for, according to my idea of a ferment, it would never ceafe to aft if new mat- ter were continually added ; nor could any thing poffibly check it but a fubftance immediately applied to the part, which could flop or prevent the fermentation in the new matter. But as the venereal inflammation in this fpecies of the difeafe is not kept up beyond a certain time, the production of the poifon cannot depend on fermentation. Fourthly, if it depended on a fermentation in the fecreted matter, all venereal cafes would be alike, nor would one be worfe than another, except from a greater or fmaller number of fermenting places. Upon this fuppofition alfo all cafes would be equally eafy of cure ; for the fermentation would be equally ftrong in a flight cafe as in a bad one. It can only be fermentation in the matter after it has left the veffels. When the venereal matter has been applied to a fore, fo as to irritate, it produces a venereal irritation and inflammation. But even this does not always take place ; for the common matter OF THE VENEREAL POISON. 1.9 matter from the fore may remove the venereal matter applied before it can affeft the fore, fo as to produce the venereal in- flammation and fuppuration there. This experiment I have made feveral times, and have only once produced the venereal inflammation. But if the venereal matter were capable of aft- ing as a ferment, then it would in all cafes produce venereal matter, without altering the nature of the fore. The effefts, produced by the venereal poifon, appear to me to arife from its peculiar, or fpecific irritation, joined with the aptnefs of the living principle to be irritated by fuch a caufe, and the parts fo irritated acting accordingly. I fhall therefore confider it as a poifon, which by irritating the living parts in a manner peculiar to itfelf, produces an inflammation peculiar to that irritation, from which a matter is produced peculiar to the inflammation. Let us confider how far this opinion agrees with the various phaenomena attending the difeafe. Firft, the venereal matter having a greater power of irritat- ing than common matter, conveys more the idea of irritation than of fermentation. Secondly, its producing a fpecific dif- .eafe with fpecific fymptoms and appearances, fhows that it has a fpecific power of irritation, the living powers neceffarily gifting according to that irritation. Thirdly, the circumflance of the inflammation having its ftated time of appearance and termination, is agreeable to the laws of the animal ceconomy in mofl cafes, as it is a circumflance that takes place in other difeafes that have a crifis ; and when the difeafe is longer of duration in fome than in others, it is becaufe they are much more fufceptible of this kind of irritation, and there may be perhaps other concurrent circumftances. FourtMy, the vene- real inflammation being confined to a fpecific diftance, is more agreeable to the idea of a fpecific irritation, than that of a fermentation. Fifthly, we have a further proof of this opinion, from the appearance of the difeafe being tranflated from one part of the body to another, as in the cafe of the fwelled tefticle, in which the difcharge is often flopped or otherwife affefted. Sixthly, the difcharge often flops from the conftittuion being attacked by a fever, and returns after fome days or weeks, or not at all, according to the continuance of the fever, Nov/ we can plainly fee, why the fever fhould put a flop to the dif- charge, as the difpofition, produced by it^n a part, is very different from that difpofition which formed the matter; and we 20 OF THE VENEREAL POISON. we can plainly fee, why the fame difpofition to form matter fhould often return ; but how that return fhould be venereal, upon the principles of fermentation, we do not fee. Seventh- ly, the produftion by art of an irritation of another kind, which is not fpecific, removes the fpecific irritation ; now an irrita- tion of another kind cannot prevent the fermentation from going on, but may deftroy the venereal irritation. Eighthly, the circumflance of particular parts of our body being much more readily irritated than others by the venereal poifon, when in the conflitution, fhows that it arifes from an irritation, and that of a particular kind. Ninthly, we know of no other ani- mal that is fufceptible of the venereal irritation ; for repeated trials have fhewn that it is impoflible to give it to a dog, a bitch, or an afs*. It is much eafier to fuppofe, that a, dog or an afs is not fufceptible of many irritations of which the hu- man body is fufceptible, as we find to be the cafe in all other fpecific difeafes, and mofl poifons, than that the matter of the, human body is fufceptible of a change, of which that of the dog or afs is not. This argument is ftill further fuppprted by comparing the venereal poifon with other morbid poifons. The animal poi- fon, produftive of the hydrophobia, feems to be produced by a particular irritation affefting certain parts, which fliows, that if the body, or any part of the body, is irritated, it takes a difpofition to aft in a peculiar manner, and that this mode of aftion is capable of fecreting fuch juices as will throw another animal into the fame aftion. In the hydrophobia, the throat and its glands are particularly affefted; and how the faliva fhould become pf fuch ^ nature from the fame kind of matter being either carried into the conftitution, or perhaps only by the general fympathy of the conflitution with a local affeftion, and more particularly with the parts about the throat, is not eafily to be accounted for, without a fuppofition either that the sbforbed poifon circulating can produce a fpecific confiitutional aftion capable of affefting the throat and glands there, jufl as the poifon of the fmall-pox affefts the fkin, or that the circulat- ing * I have repeatedly foaked lint in matter from a gonorrhoea, chancre, and bubo, and introduced it into the vagina of bitches, without producing any effed. I have alfo in- troduced it into the vagina of a{]«, without any effect. 1 have introduced it under the f rc-pu. r. of dogs without any eff'ea. I have alfo made.incifions and introduced it under n; (kin, arid it has only produced a common fore. 1 have maue the fame experiments Mpon .vfTf?, '.vitb the fame icfi.lt. THE MODE OF VENEREAL INFECTION. 21 ing poifon has power to affeft or irritate the glands of the mouth only, or that thofe parts only are capable of immediately fym- pathifing with the part irritated, as the mufcles of the lower jaw are when they produce the locked jaw. If this theory be jufl, it explains why epidemical difeafes, arifing from particular feafons, particular conftitutions of air, &c. irritate in fuch. a manner, as to produce a fever, the effluvia of which fhall irritate in the fame manner. For it is not in the lead material how the original irritation arifes, it is only ne- ceffary that there fhould exifl in the animal a power of afting according to the ftimulus, given by that irritation. CHAPTER II. THE MODE OF VENEREAL INFECTION. EVERY infeftious difeafe has Its peculiar manner of being caught, and among mankind there is generally fomething peculiar in the way of life, or fome attending circumflance, which expofes them at one time or other to contraft fuch dif- eafes, and which, if avoided, would prevent their propagation. The itch, for inftance, is generally caught by a fpecies of civi- lity, the fhaking of hands ; therefore the hand is mofl com- monly the part firft affefted. And as the venereal poifon is generally caught by the conneftion between the fexes, the parts of generation commonly firft fuffer. From this circumflance people do not fufpeft this difeafe, when the fymptoms are any wdiere elfe, while they always fufpeft it in every complaint of thofe parts. In the lower clafs of people, one as naturally thinks of the itch when there is an eruption between the fingers, as we do in young men of the venereal difeafe from the genitals being affefted : but as every fecreting furface, whether cuticle or not cuticle, (as was explained before) is liable to be inicfted by the venereal poifon when it is applied to it, it is poffibie for many other parts befides the genitals to receive this difeafe. Therefore it appears in the anus, mouth, r.ofe, eyes, ears, and, as tfi OF THE DIFFERENT FORMS OF THE DISEASE. as has been faid, in the nipples of women who fuckle children affefted by it in their mouths ; which children have been 'in- fected in the birth from the difeafed parts of the mother. -------------- ii«iU!l3P.w ------" " CHAPTER III. OF THE DIFFERENT FORMS OF THE DISEASE. THE venereal poifon is capable of affefting the human body in two different ways ; locally, that is, in thofe parts only to which it is firfl applied; and conftitutionally, that is, In confequence of the abforption of the venereal pus which affefts parts while diffufed in the circulation. . Between the firft and fecond kind, or the local and confli- tutional*, certain intermediate complaints take place in the pro- grefs of abforption ; thefe are inflammations and fuppurations forming what are called buboes, in which the matter is of the fame nature with that of the original difeafe. When the matter has got into the conflitution, and is circu- lating with the blood, it there irritates to aftion. There are produced from that irritation many local difeafes, as blotches on the fkin, ulcers in the tonfils, thickening of the periofteum and bones. The local or firft kind is what I have called immediate, arlfinj; immediately upon the application of the venereal pus. Of this kind there are two forts feemingly very different from one an- other. In the firft there is a formation of matter without a breach in the folids, called a gonorrhcea. In the fecond there is a breach in the folids, called a chancre. Neither of thefe two ways, in which the difeafe fhows itfelf, is owing to any thing peculiar in the kind of poifon applied, but to the differ- ence in the parts contaminated. The readinefs with which the parts run into violent aftion in this fpecies of inflammation, is greater or lefs according to the * I have called this form of th? difeafe, conftitutional: yet it is not ftriclly fo, foj every complaint in conll-qasiice-of it is truly local, and is produced by the fimple applt- cation of the poifon to the p-vu. OF THE DIFFERENT FORMS OF THE DISEASE. 23 the nature of the parts affefted; which perhaps does not arife from any fpecific difference in the parts, but is according to the common principle of fenfibility and irritability; for we find that the vagina is not fo much difpofed to inflammation in this difeafe, as the urethra is in the fame fex, becaufe it is not fo fenfible. However it is poflible, that there may be fome fpecific difpofition to irritation and inflammation in the urethra in man; and what would incline me to think fo is, that this canal is fub- jeft to be more frequently out of order than any other, pro- ducing a great variety of fymptoms. I. VARIETIES IN DIFFERENT CONSTITUTIONS. This difeafe, when it appears in the form either of a go- norrhoea or a chancre* differs very much in the violence of its fymptoms in different people. In fome it is extremely mild, in others extremely violent. When mild, it is generally fimple in its fymptoms, having but few, and thofe of no great extent, being much confined to the fpecific diftance ; but when violent, it becomes more complicated in its fymptoms, having a greater variety, and extending itfelf beyond the fpecific diftance. This does not arife from any variety in the fpecific virtue of the poifon, but from a difference in the difpofition and mode of aftion of the body, or parts of the body ; fome being hardly fufceptible of this or any irritation, others being very fufcepti- ble of it, and of every other irritation, fo as readily to run into violent aftion. The venereal irritation however dees not always follow thefe rules; for I have known young men, in whom a fore from common accident has healed up readily, yet the irrita- tion attending a gonorrhcea has been violent, and a chancre has inflamed and fpread itfelf with great rapidity, and even has mortified. On the other hand, I have known young men in whom a fore from common violence has been healed with great difficulty, yet, when they had contrafted a gonorrhoea or chancre, the difeafe has been mild and eafily curable. In particular people it is either mild or fevere for the mofl part, uniformly. In the firft ftated difpofitions it is not in- variably fo, but then I believe there is fome indifpofition at the time. I have known feveral gentlemen who had their go- norrhoeas fo flight in common, that they frequently cured themfelves; 24 LUES VENEREA, CAUSE OF OTHER DISEASES. themfelves; but it has fo happened, that a gonorrhcea has been remarkably fevere, and has obliged them to apply for afc - fiftance, but then they were foon attacked with the fymptoms of a fever, and when the fever has gone off, the fymptoms of the gonorrhcea have immediately become mild. I may now alfo obferve, that when the difeafe is in the form of a lues venerea, different conftitutions are differently affefted, in fome its prog.cii is very rapid, in others it is veiy How. CHAPTER IV. OF THE LUES VENEREA BEING THE CAUSE OF OTHER DISEASES. EVERY animal may be faid to have natural tendencies to morbid aftiong, which may be eonfidered as predifpof- ing caufes, and thefe may be called into aftion whenever the immediate caufe takes place, which may be fuch as to have no conneftion with thefe tendencies, ahd cannot therefore be eonfidered as the caufe of the difeafe. One difeafe excites another, and therefore is fuppofed to be the fole caufe of it, as flight fevers, or colds, fmall-pox, and meafies, become fre- quently the immediate caufe of fcrofula, ahd certain derange- ments of the natural aftions of the body often bring.on the gout, agues, and other difeafes; but thefe difeafes will be al- ways more or lefs according to the conflitution and parts; and the conftitutions will differ according to circumftances, which may be numerous; two of thefe, however, will be local fituation, and age. In this country, the tendency to fcrofula arifes from the climate,-which is in many a predifpofing caufe, and only re- quires fome derangement to become an immediate caufe and produce the whole difeafe. The venereal difeafe alfo becomes often the immediate Caufe of other diforders, by calling forth latent tendencies to aftion. This does not happen from its being venereal, but from its having deftroyed the natural aftions, fo that the mo- ment LUES VENEREA, CAUSE OF OTHER DISEASES. 2(5 ment the' venereal 'aftion and difpofition is terminated, the other takes place; and I have feen, in'many cafes, the ten- dency fo very ftrong, that it has taken place before the vene- real has been entirely fubdued ; for by purfuing the mercurial courfe the fymptoms have grown worfe ; but by taking up the new difpofition, and rendering it lefs aftive than the venerea!, the venereal has come into aftion anew ; and thefe effefts have taken place alternately feveral times. In fuch cafes it is a lucky circumflance when the two modes of treatment can be United ; but where they aft in oppofition it is very unfortunate. If the venereal difeafe attacks the lungs, although that difpo- fition may be correfted, confumption may enfue ; and in like manner where the bones, are. affefted, or the nofe, fcrofulous fwellings or fiftula lacrymajis may be the confequence, though the difeafe may have been cured.,. Many of the difpafes arifing from this fource appear to be peculiar to fuch caufes, and feem to be formed out of the con- flitution, the difeafe, and method of cure ; it is therefore dif- ficult to fay of "what nature fuch a difeafe may be.; but it will in general have a particular tendency from the constitution ; and if we are acquainted with the general, tendency of a con- flitution, • we are to fufpeft that as the ftrongefl caufe, and that the difeafe will partake more of it than. the other. In this country thefe complaints have mofl commonly a fcrofu- lous tendency, and are often truly fcrofulous, the difeafe par- taking more of that difpofition than any other. r .. . . Parts have.alfo, their peculiar tendency to difeafes, which are flrpmger than thofe of the conflitution at large, and when injured they will-of courfe fall into the morbid aftion arifing from fuch tendencies, therefore, when parts have had their natural aftions deftroyed by a venereal irritation, thofe ten- dencies will be brought into aftion ; and therefore the difeafes arifing from the tendencies of fuch parts are to be kept in view. ' They will be affifted likewife by local fitiiation, and age# '■ In particular countries, and in young people, the tendency i(f fcrofuria will be predominant; therefore buboes in them will more readily become fcrofulous. In old people they may form cancers ; and when in parts of the body which have % particular tendency to cancer, that difeafe will more readily take place. E, The 26 LUES VENEREA, CAUSE OF OTHER DISEASES. T;ie want of knowledge and of attention to this fubjeft, has been the caufe of many miftakes ; for whenever fuch ef- fefts have been produced in confequence of the venereal dif- eafe, it has immediately been blamed, and not only as a caufe, but it has been fuppofed to be the difeafe itfelf. This is an inference natural enough for thofe who cannot fee that a vari- ety of caufes are capable of producing one effeft, or in other words, that where the predifpofing caufe is the fame, a vari- ety of immediate caufes may produce the fame aftion. It fhows great ignorance, however, to fuppofe the venereal dif- eafe can be both the predifpofing and immediate caufe. When the venereal difeafe attacks the urethra, it often be- comes itfelf the predifpofing caufe of abfceffes, and many other complaints; when it attacks the outfide of the penis, forming chancres, they often ulcerate fo deep as to communi- cate with the urethra, producing fiftula in the urethra, and often continued phymofes. In defcribing difeafes which, like the venereal difeafe, ad- mit of a great variety of fymptoms, we fhould keep a middle line, firft giving the mofl common fymptoms of the difeafe in each form, then the varieties which mofl commonly occur, and lafl of all the mofl uncommon ; but it will not be eafy to take notice of every poffible variety. Therefore, when a variety occurs not mentioned, it is not to be fuppofed that the author is leading his readers affray, or is unacquainted with the difeafe at large. If his general principles are juft, they will help to explain mofl of the Angularities of the difeafe. PART [ V ] PART II. CHAPTER I. OF GONORRHOEA. " ,; HEN an irritating matter of any kind is applied to a fecreting furface, it increafes that fecretion, and changes it from its natural ftate (whatever that may be) to fome other. This, in the prefent difeafe, is pus. When this takes place in the urethra, it is called a gonor- rhcea ; and as it arifes from the matter being applied to a non- cuticular furface, which naturally fecretes fome fluid, it is of no confequence in what part of the body this furface is; for, if in the anus, it will produce a fimilar difcharge there, and a fimilar effeft on the infide of the mouth, nofe, eyes, and ears. It is conceived by fome, that gonorrhoeas may take place without the above-mentioned immediate caufe ; that is, that they may arife from the conflitution ; if fo, they muft be fimilar to what is fuppofed to be a venereal ophthalmia. But from the analogy of other venereal affeftions proceeding from the conflitution, I very much fufpeft the exiftence of either the one or the other ; for when the poifon is thrown upon the mouth, throat, or nofe, it produces ulcers, and not an in- creafed fecretion like a gonorrhcea. But we never find an ulcer on the infide of the eye-lids in thofe ophthalmias ; and gonorrhoeas in the urethra are too frequent to proceed from fuch a caufe. Till about the year 1753, it was generally fuppofed, that the matter from the urethra, in a gonorrhcea, arofe from an ulcer or ulcers in that paffage ; but from obfervation it was then proved that this was not the cafe. It may not be improper to give here a fhort hiflory of the difcovcry that matter may be formed by Inflammation without ulceration. In the winter of 1749, a child was brought into the: room, ufed for diffeftion, in Covent Garden ; on opening of whofe w e8 OF GONORRHOEA. whofe thorax a large quantity of pus was found loofe in the cavity, with the furface of the lungs and the plura furred over with a more folid fubftance fimilar to coagulable lymph. On removing this from thofe furfaces, they were found entire. This appearance being new to Dr. Hunter, he fent to Mr. Samuel Sharp, defiring his attendance; and to him it alfo ap- peared new. Mr. Sharp, 'afterwards, in the year 1750, pub- li'fhed his Critical Inquiry, in which he introduced this faft, M That matter may be formed without a breach of fubftance ;" not^mentioning whence he had derived this notion,") It was ever after taught by Dr. Hunter in his leftures. We, howe- ver, find writers adopting it without quoting either Mr. Sharp or Dr. Hunter. So much being known, I was anxious to examine whether the matter in a gonorrhoea was formed in the fame way. In the fpring of 1753, there was an execu- tion of eight men, two of whom I knew had at thatitime very fevere gonorrhoeas. Their bodies being procured for this par- ticular purpofe, we were very accurate in our examination,, but found no ulceration. The two urethras appeared merely a little blood-fhot, efpecially near, the glans. . This being ano- ther new faft afcertained, it could not efcape Mr.. Gat.aker, ever, attentive to his emolument, who was then attending'Dr. Hun- ter's leftures, and alfo praftifing diffeftion under me. He publifhed foon after, in 1754, a treatife on this difeafe, and explained fully, that the matter in a gonorrhcea did not arife from an ulcer, without mentioning how he acquired this know- ledge ; and from that time fucceffive writers have repeated the fame doctrine. Since the period mentioned above,. I have copflantly paid particular attention to this circumflance, and have opened the, urethra of many who at the time of| their death had a gononhcea, yet have never found a fore in any ; hut always obferved that the urethra near the glans was more blood-fhot than ufual, and that the lacunas were often filled with matter. I have indeed feen an inftance of a fore a little within the urethra ; but this fore was not produced by any ulceration ol the furface, but from an inflammation taking place, prob-ibly, in one of the gfinds, which produced an ;:bfcefs in the part/ and that abfeefs opened its way into the urethra. The very fame fore opened a way through exter- nally at the t;;r;:um, fo that there-was a new paff;i.onorrhoea cannot be continued by the application of either its own or frefh matter ; but that a man could not get a frefh go- norrhoea, nor a chancre, if he applied frefh venereal matter to the parts when the cure is nearly completed, and continued the application ever after, or at Jeafl at fuch intervals as were with- in the effect of habit. I can conceive that in time the parts ."nay become fo habituated to this aoplication as to be infenhble of * When trsatiniref pus, in my leftures, I obferved that I was inclined to believe that no matter, of whoever kind, can produce any effect, upon the part that formed it: nor do I believe that the matter of any fore, let it be what it will, ever does or can do any hurt to that fore; for the parts which formed the matter a;e of the fame nature, and cannot be irritate 1 by that which they produced, except exfaneous matter is joined with it. The gland whi'J) forms the poifon of the viper, and the duct whirh conveys it to the tooth, are not irritated by the poifon : and it would appear from Abbe Fontana's experimentSi that the viper cannot be affe&ed by its own poifon. Vide I rate fur le Venin de la Vi- pere, par M. F. Fontani, vol. I. page 22. If what 1 have now advanced is true, wip- ins, or w^iLing away mater j;.i:i the idea of keeping the parts clean, is in every cafe OF GONORRHOEA. c5. of it; for by a conflant application, the parts would never be allowed to forget this irritation, or rather never become unac- cuftomed to it ; and therefore this fupply of frefh matter could not affect the parts fo as to renew the difeafe till they firft re- covered their original and natural flate ; and then they would be capable of being affefted again. This opinion is not derived from theory only, but is found- ed on experience and obfervation. A man immediately after having fuffered a gonorrhoea, fhall have frequent connections with women of the town, and that for years fucceflively, without being infe6ted; yet a frefh man fhall contraft it immediately from the very fame woman; and if the firft mentioned man were to be out of the habit of this irritation for fome time, he then would be as eafily infefted as the other. Where this habit is not fo ftrong as to prevent altogether the parts from being affefted, ftill it will do it in part; and it is a ftrong proof of this, that moil people have their firft gonorrhoea the mofl fevere, and the fuc- ceeding ones generally become milder and milder till the dan- ger of infeftion almoft vanifhes. This feems to be explained by the following fafts. A mar- ried man who had had a communication with his wife only for feveral years, flept with a woman with whom he had formerly cohabited. She gave him a fevere gonorrhcea, and declared that fhe was not confcious of being difeafed. He put himfelt and her under my care ; and while they were going on with their cures they ftill continued their intercourfe, which I readily allowed. He got well, and it was fuppofed fhe got well alfo. The intercourfe was continued between them for many months after, without any mifchief received on his fide, or any fufpi- cion of remaining difeafe on hers. At lafl this conneftion was broken off, and fhe formed ano- ther attachment: fhe no fooner formed this new attachment, than fhe gave her new lover a gonorrhoea ; fhe now flew to me for a cure, and declared that fhe had no conneftioa but with the two gentlemen before-mentioned ; and therefore that the prefent difeafe muft be the fame for which I had attended her formerly. Her fecond lover was not a patient of mine ; but I gave her medicines which fhe very much ncgleft^i taking. Her lover continued his conneftion, as the firft had done, for feveral months after he had got well, without any further mfec- tion from her ; but unfortunately her firft lover returned about a twelve- 36 OF GONORRHOEA. a twelve-month after; and thinking himfelf fecure, as fhe liv- ed in peace with the prefent, renewed his acquaintance with her, and but once, the confequence however was, a gonorrhcea. Had the woman the gonorrhoea all this time ? And what was the reafon thofe gentlemen did not catch the difeafe, except that the acquaintance had been interrupted for fome time ; was it the effeft of habit by which the parts loft their fufceptibility of that irritation ? The cafe of a young woman from the Magdalen hofpital is a ftriking proof of this, as far as circumftances can prove a faft. She was received into that houfe, and continued the ufual time, which is two years. The moment fhe came out fhe was pick- ed up by one who was waiting for her with a poft-chaife to carry her off immediately. She gave him a gonorrhoea. This opinion of parts being fo habituated to this irritation as hardly to be affefted by it, is ftrcngthened by obferving, that in the gonorrhcea the violent fymptoms fhall often ceafe, and the difeafe fhall ftill continue, fpinning itfelf out to an amazing length, with no other fymptoms than a difcharge ; yet that dif- charge fhall be venereal. This I have frequently feen; and the following is an abftraft of a Angular cafe of this kind. A gentleman had conneftion with a woman of the town, and received a venereal gonorrhcea in the beginning of April 1780. He, at firft, could hardly believe it to be venereal, as he had kept the woman in the country, where flie had fcarcely ever been out of his fight; but the violent pain in making water, ' great running, chordee, and fwelled tefticle, convinced him that it was venereal. When the cure was going on tolerably well, and he had got the better of one fwelled tefticle, the other began to fwell; however, all the fymptoms gradually difappear- ed, except the chordee, hardnefs of the epididymis, and a fmall gleet which was flimy. On the 12th of June he went into the country ; while he was in the country the chordee went off, dnd the hardnefs of the epididymis entirely difappeared, but ftill a flimy gleet remained, although but trifling. September the firft, he married a young lady, and endea- vouring to enter fhe vagina, he found great difficulty, which brought on a return of the chordee, and an increafed difcharge. On the 10th, flie began to complain of heat, and pain, and of a difficulty and frequency in making water, and when fhe made water there was forced out fome matter ; fne had alfo a dull hea- vy OF GONORRHOEA. 37 vy pain, and a fenfe of weight at the bottom of her belly, and round her hips, with great forenefs of the parts when fhe fat; thefe fymptoms had been preceded by an itching about the ori- fice of the vagina. By taking a mercurial pill, and rubbing the parts with mer- curial ointment, in about eight days the violence of the fymp- toms abated. They were now allowed to cohabit, but whene- ver they came together, the pain which fhe fuffered was excef- five. The parts were wafhed with.a folution of corrofive fub- limate and fugar of lead, and anointed with mercurial ointment, which applications being continued for fome time, the forenefs went off. He was treated medically, and afterwards all was well. Here was a venereal gonorrhcea contrafted about the begin- ning of April ; all the fymptoms had difappeared by the firft of June, and there only remained fome of the confequences, fuch as chordee, hardnefs of the epididymis, and a difcharge of a lit- tle flimy mucus, which could only be obferved in the morning. In a fhort time the chordee and hardnefs in the epididymis had entirely gone off, and merely the fmall difcharge of mucus which appeared only in the morning remained ; yet three months after he communicated the difeafe to his wife. I was confulted in the following cafe by the furgeon who at- tended : July 13th, 1783, a perfon had connefticm with a wo- man of the town : the 30th, that is feventeen days after, a go- norrhoea came on, which was violent. He took mercurial pills and gentle purges; in twelve days the violent fymptoms abated, and about the 4th of September the difcharge was flopped. The 9th it began to appear again, but only lailed a few days; and would come and go in this way fometimes every two days; oft- en fix or feven days. On the 28th of September he had con- neftion with his wife, while he had a fmall difcharge. The 9th of Oftober he had conneftion again, and three days after fhe complained of heat in making water, with a difcharge and other fymptoms of gonorrhcea which were violent. About the latter end of Oftober her complaints were almoft removed; fome only of the fymptoms appearing and difappearing till January 1784, when he had connection with her to try whether fhe could give it him, viz. three months after the fecond conneftion, and in fourteen days after this he had all the fymptoms of a gonorrhcea. April 29th he was not perfeftly well, having a difcharge with a pain 38 OF GONORRHOEA. a pain in the perinaeum, and fhe alfo had a difcharge. If this lafl attack in January 1784, in him was a gonorrhcea, then of courfe flie muft have had it; and alfo of courfe he muft have loft his in the intermediate time, between the 9th of 06tober 1783* and Jahuary 1784 ; for if he had had it alfo then, it could not have produced any effeft upon him. It was impoflible to fay whether they had now the infeftion or not, for any trials upon themfelves would prove but little, except one of them only h:>d it fo as to infeft the other; but if both had it, no alteration could take place in either ; as it could not be afcertained whether they had the difeafe or not, and as there were fufpicious fymptoms in both, when joined with all the circumftances, I agreed with the attending furgeon, it was mofl prudent to treat them as if aftually affefted with a gonorrhcea. If it L> true, as is afferted in the voyage round the world, that the venereal difeafe was carried to Otaheite, it fhows that it can be long retained after all ideas of its exiftence have ceafed; and when it is retained for fuch a length of time it is mofl probably in the form of gonorrhoea*. In like manner, a venereal bubo, if it couldbe kept a confider- able time between the point of fuppuration and refolution, would become indolent from habit, continue in that point of fufpenfion, and remain perhaps almoft incurable ; fuch I think I have feen. IV. OF THE VENEREAL GONORRHOEA. In treating of the feat, extent, and fymptoms of gonorrhoea, I fhall begin with fuch particulars as are conftant or mofl fre- quent, and take them as much as poffible in the order they be- come lefs^fo; for there is confiderable variety in different go- norrhoeas. V. OF THE SEAT OF THE DISEASE IN BOTH SEXES. The feat of this difeafe, in both fexes, is commonly the parts of generation. In men it is generally the urethra ; tho' it fometimes takes place on the infide of the prepuce and fur- face of the glans. In women it is the vagina, urethra, labia, clitoris, or nymphae. The * Vide page 14, OF GONORRHOEA. 39 The difeafe has its feat in thefe parts from the manner in which it is caught. But if we were to confider the furface of contaft fimply in men, we fhould naturally fuppofe that the glans penis, or the orifice of the urethra, would be the firft, or indeed the only parts affefted; yet mofl commonly they are not; for though there are cafes where the glans is affefted, and where the difeafe goes no further, I believe, it feldom attacks the ori- fice of the urethra, without paffing fome way along that canal. How far it ever can be faid to affeft the prepuce only, I am not quite certain, although I believe it fometimes happens : for I have feen inflammation there, as well with, as without, a dif-^ charge from the urethra, which appeared to me to be venereal.* I have feen in fuch cafes the inflammation extending into the loofe cellular membrane of the prepuce, and producing a phy- mofis ; and this inflammation I fufpeft to be of the eryfipela- tous kind. When the difeafe attacks the glans, and other external parts, as for inftance the prepuce, it is principally about the root of that body, and the beginning of the prepuce, the parts where the cuticle is thinneft, and of courfe where the poifon mofl rea- dily affefts the cutis; but fometimes it extends over all the glans and alfo the whole external furface of the prepuce. It produ- ces there a forenefs or tendernefs, with a fecretion of thinnifh matter, commonly without either excoriation or ulceration. I am not certain, however, that it does not fometimes excoriate thofe parts; for I once faw a cafe, where almoft the whole cu- ticle was feparated from the glans. The patient affured me that it was venereal; and, from the particular circumftances, which he related, I had no reafon to think his opinion ill founded. He never had had any fuch complaint from conneftion with wo- men Before that time. Perhaps the difeafe begins oftener on thofe parts than is commonly imagined ; but, being defended by a cuticle, they are but little fufceptible of this kind of irritation; and this may be the reafon why a permanent effeft is not produ- ced, and why it is often fo flight as not to be obferved. When the glans or prepuce, or both, fuffer the venereal inflammation, it often refts there and goes no further, not being attended with a difcharge of matter, nor with pain in the urethra. This the foll6wing cafe illuftrates. A young gentleman, from Ireland, fiept with a woman at Briflol; and a fortnight afterwards he had intercourfe with ano- ther 40 OF GONORRHOEA. ther woman in London, which lafl happened to be on a Mon- day, and on the Tuefday, or the day following, he obferved a difcharge from the end of his penis when covered with the pre- puce. On the Saturday following he applied to me. Upon examination, I found that the running came from the infide of the prepuce, near to the glans; and the corona glandis, as alfo that part of the prepuce behind it, appeared to be in a tender and excoriated ftate, and covered with matter. He told me he had once had a gonorrhcea before ; and upon being afked if it was in the fame place, he faid it was. Not being certain how far this might be venereal, I made the following inquiry ; whe- ther he had been fubjeft to fuch excoriations before he had vifit- ed women ? And his anfwer was, that he never had ; and that he had not this complaint always after coition, but only twice, as has been above-mentioned ; which, being uncommon, in- clined him to fuppofe the effeft to be venereal. I fufpe£t, that, when the prepuce fwells in a gonorrhoea of the urethra, producing a phymofis, which is often the cafe, it arifes from the fame difeafe having affefted its infide, and that, not being fufficient to produce ulceration, It goes no further. It feems probable that this inflammation is of the eryfipelatous kind ; a circumflance very neceffary to be known in the cure. The urethra is the part in which this form of the venereal dif- eafe is mofl frequent; and, although the inflammation, attend- ing the difeafe in this part, has many of the common fymptoms of inflammation, yet it can hardly be called inflammatory, when moderate ; at leaft it does not conftantly produce all the effefts of common inflammation, though there is a tendency towards it. The parts feldom have all the charafteriftic fymptoms; for there is no throbbing fenfation ; there is but little pain, except from the irritation of the urine and diftenfion of the parts; the inflammation feldom goes deeper than the furface ; and we have therefore rarely any tumefaftion or thickening of the parts. It fhould rather feem to be an error loci on the furface of the urethra, like a bloodfhot eye. The fecretion of pus with fo little inflammation, is perhaps) owing to thefe parts being naturally in a ftate of fecretion ; therefore the tranfition from an healthy to a difcafed fecretion is more eafily produced. It fometimes happens, however, that the parts do inflame confiderably, and the inflammation goes deep into the cellular, or rather reticular membrane of the OF GONORRHCEA. 4* the corpus fpongiofum urethrae, efpecially near the glans. Sometimes .it extends further along the corpus fpongiofum urethra, producing tumefaction, that is, an extravafation of the coagulable lymph, which is the common caufe of chor- dee. It may be obferved in general, that in moll cafes when fuppuration is produced, there is a decreafe of inflammation. The inflammation in the reticular membrane of the furrounding parts would appear not to be always confined to the adhefive ftage ; for in thofe parts we have fometimes fuppurations, ef- pecially in the perinaeum, which fuppurations I fufpeft to be in the glands, as will be taken notice of hereafter. The gonorrhoea does not always attack an urethra other- wife found ; nor does it always attack an urethra the relative parts of which are always found. Thus we have people con- tracting this difeafe while they are affefted with ftriftures, fwelled proftate gland, as alfo difeafed tefticles, or fuch tef- ticles as very readily run into difeafes ; by which the malady becomes more complicated and requires more attention in the method of cure. Sometimes fuch difeafes are relieved by the o-onorrhcea, at other times increafed. VI. OF THE MOST COMMON SYMPTOMS, AND THE ORDER OF THEIR APPEARANCE. Although the irritation muft always begin firfl, yet it Is not certain which of the fymptoms, in confequence of that irritation, will firfl appear ; for any one may appear fingly without the others, though this is rarely the cafe. The firft fymptom, when carefully attended to, is generally an itching at the orifice of the urethra ; fometimes extending over the whole glans* a little fulnefs of the lips of the urethra ; the effefts of inflammation is next obfervable, and foon after a running appears; the itching changes into pain, more par- ticularly at the time of voiding the urine ; there is often no pain till fome time after the appearance of the difcharge, and other fymptoms ; and in many gonorrhoeas there is hard- Iv any pain at all, even when the difcharge is very confider- able ; at other times the pain, or rather a great degree of forenefs will come on long before any difcharge appears. G There *. Thefe fymptom? are mod carefully obferved by thofewho are under apprehenfions of luvii)2 the diieafe, and. therefore are attentive to every liu',cfe:.:.:>;oii ubout thole ^-.ts. 42 OF GONORRHOEA. There is generally at this time a greater fulncfs in the penis, and more efpecially in the glans, although it is not near [o full as when erefted, being rather in a ftate of half ereftion. Befides this fuhiefs, the glans has a kind of tran- fparencv, efpecially near the beginning of the urethra, where the fkin is diftended, being fmooth and red, refembling a ripe cherry, this is owing to the reticular membrane at this time be- ing loaded with a quantity of extravafated ferum, and the veffels filled with blood. Near the beginning of the urethra there is in many cafes an evident excoriation, which is marked by the termination of the cuticle all round ; the furface of the glans alfo is often in an half excoriated ftate, which gives it a degree of tcndernefs, and there oufes out from it a kind of matter, as has been before obferved. The canal of the ure- thra becomes narrower, which is known by the ftream of the Urine being fmaller than common ; this proceeds from the fulnefs of the penis in general, and from the internal mem- brane of the urethra being fwollen by the inflammation, and alfo from its being in a fpafmodic ftate. Befides thefe changes, the fear of the patient, whilft void- ing his urine, affifts in diminifhing the ftream of urine. The ftream, as it flows from the urethra, is generally much fcat- teied and broken as foon as it leaves the paffage, which is owing to the internal canal having become irregular, and is not peculiar to a venereal gonorrhoea, but common to eve- ry difeafe of the urethra that alters the exaft and natural fi- gure of the canal, even although the irregularity is very far back, as we find in many difeafed proftate glands. There is frequently fome degree of harmorrhnge from the ure- thra. This I fuppofe arifes from the diftenfion of the veffels, more efpecially when there is a chordee, or a tendency to one. There are often fmall fwellings obfervable along the lower furface of the penis in the courfe of the urethra. Thefe, I fuf- peft, are the glands of the urethra fo enlarged as to be plainly felt on the outfide. They inflame fo much in fome cafes as to fuppurate ; and according to the laws of ulceration, the matter is brought to the fkin, forming one, two, or more abfceffes along the under furface of the urethra, and fome of thefe break- ing internally form what are called internal ulceus. 1 have ob- ferved in feveral cafes a tumor on the under fide of the penis where the urethra is, which would fwell at times vciy. confide- rably, OF GONORRHOEA. 43 rably, even to the fize of a fmall flattened nut, inflame, and then a gufh of matter flowing from the urethra, would almoft. immediately fubfide. The difcharge has continued for fome time, gradually' diminiming till it has entirely gone off and the tumor has been almoft wholly reduced ; yet after fome months it has fwelled in the fame manner again, and terminated in the fame way. How far thefe tumors, and the matter they dif- charge, are really venereal when they appear firft, may be doubt- ful ; and it is difficult to determine this, frflm the patients in general having recourfe to medicine immediately ; but in their fubfequent attacks they are certainly not venereal, for they cure themfelves. , I have fufpefted thefe tumors to be the dufts, or lacunae of the plands of the urethra diftended with mucus from the mouth of the duft being clofed, in a manner fimilar to what happens to the duft leading from the lachrymal fack to the nofe ; and in con- fequence of the diflenfion of the dufts or lacunas, inflarnmation and fuppuration come on, and ulceration takes place, which opens a way into the urethra ; but this opening foon clofes up and occafions a return. Cowper's glands have been fufpeft- ed to inflame, and hardnefs and fwelling have been felt exter- nally very much in the fituation of them, which coming to fup- puration have produced confiderable abfceffes in the perinae- um. Thefe tumors break either internally or externally, and fometimes in both ways, making a new paffage for the urine, called fiftulae in perinaeo. A forenefs is often felt by the patient all along the under fide of the penis, owing to the inflamed ftate of the urethra. This forenefs often extends as far as the anus, and gives great pain principally in erections ; yet it is different from a chordee, the penis remaining ftraight. Erections are frequent in mofl gonorrhoeas. Thofe arifing from the irritation at the time, often approach to a priapifm, efpecially when there is the above-mentioned forenefs, or when there is a chordee. Priapifms often threaten mortification in men ; and I have feen an inftance of it in a dog. The ereftion never fubiidcd, and the glans penis could not be cvoered by the prepuce, from the fwelling of the bulb. The penis mortified and dropped, off 5 the bone in it was denuded, and an exfoliation followed. As opium xA OF GONORRHOEA. opium is of great fervice in priapifm, there is reafon to fuppofe the complaint is of a fpafmodic nature. VII. OF THE DISCHARGE. The natural flimy difcharge from the glands of the urethra is firfl changed from a fine tranfparent ropy fecretion to a wa- tery, whitifh fluid; and the natural exhaling fluid of the ure- thra, which is irrlfended for moiflening its furface, and which appears to be of the fame kind with that which lubricates ca- vities in general, becomes lefs tranfparent; and both thefe fe- cretions becoming gradually thicker, a flume more and more the qualities of common pus. In fome cafes of gonorrhoea, the glands that produce the flime which is fecreted in confe- quence of lafcivious ideas, are certainly not affefted; for I have " feen cafes, when after the paffages had been cleared of the ve- nereal matter by making water, the pure flime has flowed out of the end of the penis, on fuch occafions. When this mat- ter is more in quantity than what lubricates the urethra, it is forced out of the orifice by the periftaltic aftion of that canal, and appears externally*. The matter of gonorrhoea often changes its colour and con- fiflence, which is owing to the difpofition of the parts which form it; fometimes from a white to a yellow, and often to a greenifh colour. Thefe changes depend on the increafe or de- creafe of the inflammation, and not on the poifonous quality of the matter itfelf; for any irritation on thefe parts, equal to that produced in a gonorrhcea, will produce the fame appear- ances ; and the changes in the colour of the matter are chiefly obfervable after it has been difcharged upon a cloth, and become dry. The appearance upon the cloth is of various hues ; in the middle the matter is thicker or more in quantity, and it is there- fore generally of a deeper colour ; the circumference is paler, becaufe the wafery or ferous part of the matter has fpread fur- ther, and at the outer edge of all it is darkeft: this lafl appear- ance is owing to its being only water with a little flime, in which fome of the tinge is fufpended, which when dry gives a tranfpaiency * That the ur.-thra lias confoemh*'- rowers of aftion, is evident in a vaft number of inftances ; and that aftion is principally from behind forwards. We find that a bougie may be worked out by the aftion of the urethra. This aftion I believe is often inveud, ;.£ in fpafmodic ltranguries. OF GONORRHOEA. A5 ♦ranfparency to the part, that takes off from the white colour of the linen, h is very probable that there is a fmall extravafa- tion of icd blood in all the cafes where the matter deviates from the common colour, and to this the different tinges feem to be owing. As this matter arifes from a' fpecific inflammation, it has a greater tendency to putrefaction than common matter from a healthy fore, and has often a fmell feermngly peculiar to itfelf. As it fhould appear that there is hardly a fufncient furface of the urethra inflamed to give the quantity of matter that is often produced, efpecially when we confider that the inflammation does in common go no further than two or three inches from the external orifice, it is natural to. fuppofe that the difcharge is produced from other parts, the office of which is to form mu- cus for natural purpofes, and which are therefore more capable of producing a great quantity upon flight irritations, which hardly rife to inflammation. Thefe parts I have obferved, are the glands of the Urethra. In many cafes where the glands have not been after death fo much fwelled as to be felt externally ; and where I have had an opportunity of examining the urethra of thofe who have had this complaint upon them, I have always been able to difcover, that the dufts or lacunae leading from them have been loaded with matter, and were more vifible than In the natural ftate ; I have obferved too, that the formation of the matter is not confined to thefe glands entirely, for the inner furface of the urethra is commonly in fuch a ftate as not to fuf- Ter the urine to pafs without confiderable pain ; and therefore mofl probably this internal membrane is alfo affefted in fuch a manner as to fecrete a matter. This difcharge in common cafes fhould feem not to arife much further back in the urethra than where the pain is felt, although it is commonly believed that it comes from the whole of the canal, and even from Cowper's glands and the proftate, not even what are called the vcficulae feminales*. But the truth of this I very much doubt. My reafons for fuppofing that it comes only from the furface where the pain is, are the fol- lowing. If the matter arofe from the whole furface of the ure- thra, and from the glands near the bladder, there would certain- ly be many other fymptoms than do actually occur; for inftance, if * Thofe bags are cert.iinly not refervoirs for the r»m°-'. The difference between the contents of them and the femen gave me the firft fufpicion of this; and irom feveral ex, periments on the human body, as alfo a comparative view of them in othtr animals, I h..vc b"en abk to prove that they are not. 46 OF GONORRHOEA. if all the parts of the urethra beyond the bulb, or even in the bulb, were affefted fo as to fecrete matter, that matter would be gradually fqueezed into the bulb as the fern en is, and from thence it would be thrown out by jerks ; for we know that no- thing can be in the bulbous part of the urethra, without ftimu- lating it to action, efpecially when in a ftate of irritation and inflammation. In fuch a ftate we find that even a drop of urine is not allowed to rc/ft there; and alfo if an injeftion of warm water only is thrown into the urethra as far as the bulb, the mufculi accelerators are uneafy till they act, and throw it out. Hence it is natural to fuppofe that, If the membranous and bul- bous part of the urethra, with the veficulae feminales, proftate and Cowper's glands, affifted in forming the matter, whenever it collected in the bulb it would probably be immediately thrown forwards by the mufcles above-mentioned, and we fhould be fenfible of it every moment of the day. But fuch fymptoms are feldom obferved. Sometimes indeed a fpafmodic contrac- tion of thefe mufcles occurs, which may probably arife from this caufe, though it is more frequently felt immediately after the urine is discharged. When the inflammation is violent, it often happens that fome of the veffels of the urethra burft, and a difcharge of blood enfues, which is. in greater quantity at the clofe of voiding urine. This however happens at other times, and generally gives tempora- ry eafe. Sometimes this blood is in fmall quantity, and only gives the matter a tinge, as I obferveo\when treating of the co- lour of the difcharge. The erections of the penis often ftretchthe part {o much as to become a caufe of an extravafation of blood. This extravafation generally increafes the forenefs at the time of emptying the bladder, and in fuch a ftate of parts the ure- thra is ufually fore when preffed, yet the bleeding diminifhes the inflammation, and often gives eafe. VIII. OF THE CHORDEE. The chordee appears to be inflammatory in fome cafes, and fpafmodic in others ; we fhall treat fiift of the inflamma- tory chordee. When the inflammation is not confined merely to the fur- face of the urethra and its glands, but goes deeper and affefts the reticular membrane, it produces in it an extravafation of coagulable OF GONORRFIOEA. 47 coah- inh c- tion Irom that matter which was lodged in the vagii.a by the unfound mar:, and yet the woman may not catch the difi afj ; for the matter may be wafhed away before It irritates the vagi- na, and this woman may be fufpeftLd of having a gonorrhcea, and apparently with great jufticc. A repetition of thefe cir- cumftancts may be the caufe of many women appearing to have the difeafe for yeais, without really having it. Again, I have feen a bubo come on at a time when the patient was not Scnfi. ble of any diforder nil ii;,;c accord -to th- cca- ftitutlon. * OF GONORRHOEA. 73 patient having had for fome time a frequency in making water. In Such caSes I have not Succeeded with them ; they not only do no good, but they often do harm ; for I have feen them make the inflammation fpread further in the urethra* ; and I think I have had reafon to fufpeft that they have been the caufe of abfceffes in perinaeo. But in cafes that are mild, and in conftitutions that are not irritable, injeftions often fucceed, and remove the difeafe almoft immediately. The praftice however ought to be attempted with caution, and not perhaps till milder methods have failed : two grains of corrofive Sublimate diffolv- ed in eight ounces of diftilled water, are nearly as good an in- jeftion as any of the kind. But an injeftion of only half this ftrength may be ufed, where it is not intended to attempt a cure fo quickly. If, however, the injeftion, even in that propor- tion, gives confiderable pain in its application, or if it occafi-i ons a great increafe of pain in making water, it fhould be di- luted. Sedative injeftions will always be of fervice in cafes where the inflammation is confiderable,. not by leffening the difeafe itfelf, but by leffening the difeafed aftion, which always allows the natural aftions of the part more readily to take place; they are likewife very ufeful in relieving the painful feelings of the patient. Perhaps the beft Sedative we have is opium, as well when given by the mouth or anus, as when applied to the part affefted in the form of an injeftion. But even opium will not agree, or aft as a fedative in all conftitutions or parts ; on the contrary, it often has oppofite effefts, producing great irritabi- lity. Lead may be reckoned a Sedative, So Sar as it abates inflammation, while at the Same time it may aft as a gentle aftringent. Fourteen grains of faccharum faturni, in eight ounces of diftilled water, make a good fedative aftringent injeftion. The drinking freely of diluting liquors may perhaps be con- sidered as having a fedative effeft, as it in part removes fome of the caufes of irritation, rendering the urine lefs ftimulating, either to the bladder, when the irritation is there, or to the urethra in its paffage through it; and it is poffible that dilut- ing may leffen the fufceptibility of irritation. The vegetable mucilages of certain Seeds and plants, and the emollient gums L are * It is however to be remarked, that this fymptom is not alwavs to be attribut-J to the injefticio for it often h^rfer,: when none has beer, uhi, 74 OF GONORRHOEA. are recommended ; but I SuSpeft that this praftice is founded on a mechanical notion, and that none of them are of much Ser- vice. I believe the advantage arifes chiefly from the quantity of water that is drunk, and that if the water be joined with any thing, Spirits excepted, that can induce the patient to drink free- ly, the purpofe is fully anfwered. I have, however, been in- formed by fome patients, that they have thought that when the liquids they drank were impregnated with mucilaginous fub- ftances, they have leSs uneafineSs in makHg water. Emollient injeftions are the propercft applications where the inflammation is veiy great. They are moft probably ufeful by firll fimply wafhing away the matter, and then leaving a Soft application to the part ; in which way I can conceive them to be of Singular Service, by leflening the irritating effefts of the urine. Indeed praftice proves this, for we often find that a Solution of gum arabic, milk and water, or Sweet oil, will lefSen the pain and other Symptoms, when the more aftive in- jeftions have done nothing, or have Seemed to have done harm. It very often happens that the irritation is fo great at the ori- fice of the urethra, that the point of the Syringe cannot be Suf- fered to enter ; when this is the cafe nothing Should be done in the way of injeftion till the inflammation abate. Emollients may likewife be uSed externally in form of fomentation. The aftringent injeftions can only aft by leflening the dif- charge. They can have no fpecific effeft upon the inflamma- tion ; but as they muft affeft the aftions of the living powers, it is poffible they may alter the venereal difpofition. They fhould only be ufed towards the latter end of the difeafe, when it has become mild, and the parts begin to itch. But this fhould be according to circumftances, and if the difeafe begins mildly, they may be ufed at the very beginning ; Sor by gradually lef- fening the difcharge without increafing the inflammation, we complete the cure, and prevent a continuation of the difcharge, catted a gleet. Injeftions of this kind very probably Stimulate in Such a way as to make the veffels of the part contraft, and probably hinder the aft of fecretion. We can hardly fuppofe that they aft chemically by coagulating the juices. They will U.wc an irritating quality if ufed ftrong, which in Seme mea- iuic defhoys their ailiingency, or rather make the parts aft con- trary to v,-h,.t they would do from the application of a Simple aihindent. Thus they often increafe the difcharge infte«d of leffening OF GONORRHOEA. 75 leffening it, by which means the difeafe alfo may be cured, In the fame way as by irritating injeftions, that is, by altering tl ' difpofition of the inflammation. When more mild, thev < en flop the difcharge, without however in all cafes hafi< m the cure ; for the inflammation may ftill continue even lor...< . than it otherways would have done if the tendency to fecreuon had not been flopped. I have already obServed, that a Surface that difcharges has affumed the complete aftion of the difeafe, which is one flep towards a cure or termination. However, it fometimes happens, that an aftringent injeftion will cure a flight irritation in a very few days. My experience has not taught me that one aftringent is much better than another. The aftringent gums, as dragon's blood, the balfams, and the turpentines diffolved in water ; the juices of many vegeta- bles, as oak bark, Peruvian bark, tormentil root, and perhaps all the metallic Salts, as green, blue, and white vitriols ; the Salts oS mercury, and alSo alum; probably all aft much in the Same way ; although we may affert that they do not always aft equally well in every gonorrhcea, for on our changing the in- jeftion we Sometimes Succeed after Several others have been tried in vain. The external applications are generally poultices, and fo- mentations ; but they can be of little Service, except when the external parts, fuch as the prepuce, glans, and orifice of the urethra, are in fome degree inflamed ; the lafl indeed is almoft always more or leSs affefted. When the glands of the urethra are fo much fwelled So as to be felt externally, the applanation of mercurial ointment to the part may be proper, but noft probably this will be of more fervice after the inflammation has fubfided. Indeed mer- curial ointment is often applied to all the external furface of thofe parts when in a ftate of inflammation, with an emolli- ent poultice over it. I am not perfeftly Satisfied of the utility of this praftice. CHAP, 7G OF GONORRHOEA. CHAPTER V. OF THE CURE OF GONORRHOEA IN WOMEN. IN women the cure of the gonorrhcea is nearly the fame as in men ; but the diSeaSe itfelf is milder, and the Secondary fymptoms lefs numerous in women. This arifes from there not being fo many parts to be affefted, and from thofe parts not be- ing either of fo great extent, or fo liable to inflammation; Hence the cure becomes more fimple. When the difeafe is in the vagina only, it is cafily cured. In- jeftions are the beft means that can be ufed, and, after the ufe- of them, it may be proper to anoint the parts, as far up as pof- fible, with mercurial ointment*, and alfo to wafh the external parts often with the injeftion. If the inflammation has attacked the urethra, injeftions there cannot be So conveniently uSed, as it is almoft irnpofljble for the pat:ent to throw an injeftion into that canal. The injeftions, recommended in the cure in men, are equal- ly Serviceable here ; but they may be made doubly ftrong, as the parts of women are not nearly fo irritable as the common feat of this difeafe in men. If what I have faid of the difeafe in women be jufl, we muft fee that it will be a difficult thing to Say, with any degree of certainty, when the patient is well; becauSe, whenever the Symp- toms have ceafed, the Surgeon and the patient will naturally Stfp- poSe the cure to be complete : but a new trial of thofe parts may prove the contrary ; or in cafes, where the diSeaSe has ne- ver affefted the urethra, but only the vagina, and ftiil more where no Symptoms have ever been obServed, it will be more difficult to fix the date of the cure; but general experience muft direft the praftitioner. When the Inflammation runs along the dufts of the glands, whether thofe of the mouth of the vagina, or urethra, or affefts the glands themfelves, the Same method is to be followed ; in particular, the mercurial ointment is to be freely applied to the parts. If the inflammation on the mouths of the dufts Is fo great ' as * Kow far mercurial ointment affifts in the cure I have not been able to determine * the ufe of it arifes jr.c/e from a kind of y..u\. j| aua^y tj,dr, tca\ ...xv^nencc in fuch cales. OF GONORRHOEA. 77 as to Shut them up, the duft and glands will fuppurate, and form abfceffes: in fuch cafes it will be neceffary to open them, or enlarge the opening already Sormed, and dreSs the abSceSs as a chancre or bubo. In the caSe of a fimple running, the constitutional treatment will be taken notice of hereafter; but if any fuppuration follow, the conflitution is to be treated as in chancres and buboes 5 for moft probably abforption will take place, and its effefts mint be guarded againft. CHAPTER VI. OF THE TREATMENT OF THE CON- STITUTION IN THE CURE OF THE GONORRHOEA. IN the cure of the gonorrhoea, the conflitution is in Some caSes to be as much attended to as the parts affefted, if not more ; but in general this is not neceffary. The know- ledge of the conflitution is to be obtained in a great meaSure from the local Symptoms, and as far as the conftitutional treat- ment can be made fimilar to the local, they fhould correSpond. We find in many ftrong plethoric conftitutions, where both the powers and aftions are great, that the Symptoms are violent. TheSe conftitutions have generally a ftrong tenden- cy to fever of the inflammatory kind ; and probably the mofl diftinguilhing mark of fuch a conflitution is that of the fymp- toms not extending beyond the Specific diftance. Many me- dicines, which might be of Service in another conflitution, will often prove hurtful here, in fo much as to increafe the very fymptoms they were meant to relieve. I have feen even opiate clyflers, though they relieved at firft, yet in the end produce or increaSe fever, and by that means increafe all the fymptoms. I have (een the balSam capivi, given in Such ca- Ses, increafe the inflammatory fymptoms, probably by flop- ping the difcharge in part, which appears to be falutary. The treatment of fuch a conflitution, when affefted with this dif- eafe, confifts chiefly in evacuations, the beii qf which are bleeding 78 OF GONORRHOEA. bleeding and gently purging. To live Sparingly, and above all to uSe little exerciSe, is neceffary ; for although fuch a treat- ment docs not leffen the venereal ucitation, yet it leffens the violence of the inflammation, and dious the parts to relieve themfelves. In this kind of conization, therefore, the dif- eafe is in the end fooneft cured, as there is not a tendency to a continued inflammation. In the weak and irritable conflitution, the Symptoms are frequently very violent, arifing from great aftion in the parts, and often extend beyond the fpecific diftance ; the inflamma- tion running along the urethra, and even affefting the bladder. Inftead of evacuations, which would rather aggravate the fymptoms than relieve them, the conflitution fhould be Strength- ened, and thus it will be lefs fufceptible of irritation in general. I have Seen patients whoSe conftitutions were fuch, that they were never fure of twenty-four hours health, where the inflammation has been both confiderable, and extenfive. I have Seen evacuations tried, and the Symptoms increafed; but as Soon as the bark was given freely, they have become al- moft immediately mild ; and without ufing any other medi- cine the patients have Soon recovered. The medicine here afted upon the conflitution, deftroyed the irritability, gave the parts a true and healthy SenSe of the venereal irritation, and brought the inflammation to that ftate in which it ought to be in a healthy Subject, whereby the conflitution was enabled to cure itSelf. So capricious fometimes is this form oS the diSeaSe in its cure, that the acceffion of an accidental fever has flopped the difcharge, the pain in making water has ceafed, and the go- norrhoea has finally terminated with the fever. In others I have feen all the Symptoms of the gonorrhcea ceafe on the ac- ceffion of a fever, and return when the fever has been Subdu- ed. In Some I have Seen a gonorrhcea begin mildly, but a Se- vere Sever coming on, and continuing for feveral days, has greatly increafed the Symptoms, and on the fever going off, the gonorrhcea has alfo gone off. Although a fever does not always cure a gonorrhcea, yet as it poffibly may, nothing fhould be done while the fever lafts; and if it continues after the fever is gone, it is then to be treated according to the fymptoms. Unfortunately there are cafes where no known method lef- fens the fymptoms; evacuations have produced no abateinenr, the OF GONORRHOEA. 79 the flrengthening plan has been as unSucceSsful; Sedatives and emollients have procured no relief; and time alone has per- formed the cure. In fuch cafes the foothing plan I believe is the beft, till we know more of the difeafe. Aftringents fhould not be ufed, their aftion upon the inflamed parts being uncertain, for they often do not leffen the inflammation or the pain, although they may perhaps leffen the difcharge. The turpentines, eSpecially the ballam capivi, and Canada ba4- fam, leffen the difpofition of the parts to form matter, which effeft has always a falutary appearance ; but as they have not at the fame time the power of leffening the inflammation, they can be of little Service. Befides the various effefts arifing Srom the difference of con- flitution in the gonorrhcea, we find that it is confiderably affeft- ed by the patient's way of life, during the inflammatory State, and alfo by other difeafes attacking the conflitution at the fame time. But this is common to all other difeafes: for when- ever we have a local difeafe, in which light I have eonfider- ed a gonorrhcea, it is always affefted by wdiatever affefts the conflitution. Moft things that hurry, or increafe the circu- lation, aggravate the fymptoms, fuch as violent exercife, drink- ing too much of ftrong liquors, eating ftrong indigeftible food ; fome kinds of which aft fpecifically on thefe parts, there- by increafing the fymptoms more than fimply heating the bo- dy, Such as peppers, Spices and Spirits. From what has been Said in general, it muft appear that a gonorrhcea is to be cured in the Same way as every other in- flammation ; and it muft alfo appear, that all the methods ufed are only to be eonfidered as correftors of irritation in ge- neral, and of difordered circulation. In caSes that have begun mildly, where the inflammation has been but flight, or in thoSe caSes where the violent Symptoms above taken notice of have Subfided, Such medicines as have a tendency to leffen the diScharge may be given along with the local remedies before-mentioned. The turpentines I believe are the moft efficacious; cantharides; the falts of fome metals, fuch as of copper, and lead, and alSo of fome earths, as alum, are Strongly recommended as aftrin- gents when given internally. Whatever methods are uSed for the cure, locally or confti- tutionally, it is always neceffary to have in view the poffibility of Some of the matter being abforbed, and afterwards appearing in 8d OF GONORRHOEA. in the form of a lues venerea; to prevent which, I Should be inclined to give Small doSes of mercury internally. At what time this mercurial courfe fhould begin is not eafily aScertained, but if the obfervation be juft, that a diSpofition once formed is not to be cured by mercury, but that mercury has the power of preventing a difpofition Srom Sorrtiing, as was formerly ex- plained, we fhould begin early and continue it to the end of the difeafe, till the formation of venereal matter ceafes, and even for fome time after. The mercurial ointment may be ufed where mercury difagrees with the ftomach and inteftines. This praftice appears to be more neceffary it the diScharg« has continued a confiderable time, and eSpecially if the treat- ment has been fimply by evacuants, for in the former cafe there is a greater time for abforption, and in the latter we may Sup. pofe a greater call for it, Such medicines having no effeft in carrying off the virus. To prevent a lues venerea being produced by abSorption, a grain of mercurius calcinatus taken every night, or one at night and another in the morning, may be Sufficient; but fhould be continued in proportion to the duration of the difeaSe. The SucceSs of this praftice in any particular caSe can nevef be aScertained, becauSe it is impoffible to fay when matter has been abforbed, except in cafes of buboes; and where it is not known to be abforbed, it is impoffible to Say that there would have been a lues venerea if mercury had not been given, as ve- ry few are infefted from a gonorrhcea, although they have tak- en no mercury. It is, however, fafefl to give mercury, as we may reafonably fuppoSe it will often prevent a lues venerea, as it does when given during the cnre of a chancre or bubo, where we know, from experience, that without it the lues venerea would certainly take place. CHAP- OF GONORRHOEA. 81 CHAPTER VII. OF THE TREATMENT OF OCCASIONAL SYMPTOMS OF THE GONORRHOEA. AS the following fymptoms are only occafional conSequen- ces of a venereal gonorrhcea, being the effefts of an irri- tation on the urethra, and therefore not venereal, they are to be treated in the fame manner as if they had arifen from any other caufe. I. OF THE BLEEDINGS FROM THE URETHRA. It has been already obferved, that when the inflammation is violent, or fpreads along the urethra, there is frequently a dif- charge of blood from the veffels of that part. In fuch bleed- ing, the balfam capivi, given internally, has been of fervice; and it may be fuppofed that all the turpentines will be equally ufeful. I have not found any good effefts from aftringent injeftions; and in fome cafes, have fufpefted that they have been the cauSe of this complaint. They always go off in the ufual time of the cure of the gonorrhcea. II. OF PREVENTING PAINFUL ERECTIONS. Opium, given internally, appears to have great effefts in preventing painful ereftions in many cafes. Twenty drops of tinct-ura thebaica, taken at bed-time, has procured eaSe for a whole night. The cicuta likewife Seems to have Some powers in this way. III. OF THE TREATMENT OF THE CHORDEE. In the beginning of this complaint, bleeding from the arm is often of fervice, but it is of more immediate fervice to take away blood from the part itfelf by leeches; for we oft- en find by a veffel giving way in the urethra, and a confider- able haemorrhage enSuing, that the patient is greatly relieved. Relief will often be obtained by expofing the penis to the ftea:n of hot water. Poultices likewife have beneficial effects ; M and 82 OF GONORRHOEA. and both fomentations and poultices will often be affifted in removing inflammation by the addition of camphor. Opium given internally is of Angular fervice, and if it be joined with camphor the effeft will be ftill greater; but opium in fuch caSes afts rather by leffening the pain than by removing the inflammation, though by preventing ereftions it may be Said to obviate the immediate caufe of the complaint. - When the chordee continues after all other fymptoms are gone, little or nothing in the way of evacuation feems to be neceffary, the inflammation being Subdued, and a confequence of it only remaining, which will ceafe gradually by the abSorp- tion of the. extravafated coagulable lymph; therefore bleed- ing in this cafe can be of no ufe. Mercurial ointment appli- ed to the parts will promote the abforption of the extravafated coagulable lymph; for experience has fhown that mercury .has confiderable powers in exciting abforption ; the friftion itfelf alfo will be of ufe. In one cafe confiderable benefit Seemed to reSult from giving the cicuta, after the common me- thods of cure had been tried. Eleftricity may be of fervice. This fymptom is indeed often longer in going off than ei- ther U)e running or pain, but no bad confequences arife from it; its declenfion is gradual and uniform, as happens with moft confequences of inflammation. In relieving the chordee, or the remains of it which ap- pear to aiife from fpafm, I have known the bark of great fer- vice. Evacuations, whether from the parts, or from the conflitution, generally do harm. IV. OF THE TREATMENT OF THE SUPPURA- TION OF THE GLANDS OF THE URETHRA. Suppurations in the glands of the urethra are to be treated as chancres. Therefoie mercury ought to be given, as will be explained hereafter. Should a fuppuration take place in Cowper's glands, it demands more attention ; the abfceSs muft be opened freely, and early, as the matter if confined may make its way either into the Scrotum or urethra, whence would ariSe bad conSe- quences. Here alSo mercury muft be given, and perhaps as freely as in a bubo. In fliort, the treatment Should be the fame as in a venerea! ulcer; and in this refpeft it will differ from OF GONORRHOEA. 83 fiom the treatment of thofe abfceffes which arife in confe- quence of ftrifture. V. OF THE TREATMENT OF THE AFFECTION OF THE BLADDER FROM GONORRHOEA. When the difeafe extends as far as the bladder, it produc- es a moft troublefome complaint, from which however bad confequences feldom arife. But I fufpeft that it fometimes has laid the ground-work of future irritation in that part, which has proved very troublefome, and even dangerous. Opiate clyfters, if nothing in the conflitution forbid the ufe of them, procure confiderable temporary relief. The " warm bath is of fervice, although not always; and bleeding free- ly, if the patient is of a full habit, often does good. Leeches alfo applied to the perinaeum "have good effeft; but in many conftitutions bleeding will rather do harm ; and we fhould be cautious in making ufe'of this evacuation, for it has been al- ready obferved, that many of thefe cafes are rather from fym- pathy than inflammation. As this affeftion of the bladder often continues for a confiderable time, producing other fym- pathies in the neighbouring parts, and is not in the leaft mi- tigated by the methods commonly ufed, I would recommend the following trials to be made ufe of in Such caSes. An opi- ate plaifter to be applied to the pubes or the Small of the back, where the nerves of the bladder take their origin; a fmall blifter on the perinaeum, which is of fervice in irritations of the blad- der arifing from other caufes, VI. OF THE TREATMENT OF THE SWELLED TESTICLE. When the tefticle Sympathises either with the urethra or bladder, and is inflamed, reft is the beft remedy ; the horizon- tal pofition of the body is the eafieft, as fuch a pofition is the beft for a free circulation. If the patient cannot fubmit to an horizontal pofition, it is absolutely neceffary to have the tefti- cle well SuSpended. Indeed the patient will be happy in having recourSe to that expedient as foon as he is acquainted with the eafe which it affords. In 84 OF GONORRHOEA. In this complaint perhaps no particular method of cure can be laid down. It is to be treated as inflammation in general, by bleeding and purging, if the conflitution requires them, and by fomentation and poultices. Bleeding with leeches has often been of fervice. This we cannot well account for, as the veffels of the Scrotum have but little conneftion with thoSe of the tefticle. As I do not look upon the fwelling of the tefticle to be ve- nereal, mercurials, in my opinion, can be of no fervice in thefe caSes while the inflammation continues, but are uSeful when that is gone, and the induration only remains. Vomits have been recommended in fuch caSes, and are Some. times of fervice. I have known a vomit remove the fwelling almoft inftantaneoufly. The effefts of the vomit moft proba- bly arife from the fympathy between the ftomach and the tefti- cle. Opiates are of fervice, as they are in moft irritations of thofe parts. When fuch fwellings Suppurate, which they fel- dom do, they require only to be treated as common Suppura- tions, and mercury need not be given. In the hiilory of this difeafe I obferved, and indeed it has been obServed by mofl writers, that when a Swelling comes up- on the tefticle in conSequence of a gonorrhoea, the running ceafes; or when the running ceafes, the tefticle Swells; but which is the cauSe, or which is the effeft, has not yet been af- certained. It has been alfo obferved, that when the running returns, the tefticle then fhowed the firft fymptoms of recove- ry ; fo that by the tefticle having loft its Sympathifing aftion, the aftion is reftored to the urethra. And here alSo it has not yet been aScertained, which is the cauSe, or which is the effeft; but Srom a Suppofition that the ceffation of the difcharge in the urethra is the caufe of the fwelling, it has been attributed to the mode of treatment of that irritation, and by fome to in- jeftions. It has been adviSed by many, and attempted by Some, to procure a return of the running ; but the methods ufed have hardly been founded upon any Sound principle. Mr. Brom- field appears to have been the firft who recommended a treat- ment Suitable to this theory, which was to irritate the urethra 10 Suppuration again, by introducing bougies. I have not Seen that benefit that could have been wifhcd, or that the firft idea might induce us to expeft, from this praftice. Some have gone *uither; by recommending the introduction of venereal matter iiua OF GONORRHOEA. 85 into the urethra ; but this appears to be only conceit, and is founded upon a fuppofition that fuch fwellings arife only from venereal irritations; but I have already obferved that they are produced by other caufes. It is generally a long time before the fwelling of the tefti- cle entirely fubfides, although it does fo more quickly at firfl than fwellings of this part arifing from other caufes. Before it becomes lefs, it generally becomes Softer, commonly on the anterior furface ; and by degrees the whole becomes perhaps Softer than natural, and then it diminifhes. It Is ftill much longer (Sometimes even years) before the epi- didymis returns to its natural ftate; Sometimes it is never re- duced to its natural fize and foftnefs. However this is of no great confequence, as no inconvenience refults from a continu- ance of the hardnefs fimply ; though fometimes perhaps fuch tefticles are rendered totally uSeleSs. I never had an opportu- nity of examining the tefticle of one that was known to have this complaint; but have examined tefticles where the epididy- mis has had the fame external feel, and where the canal of the vas deferens has been obliterated. But this I fufpeft to feldom happen, for there are people who have both tefticles fwelled, and notwithftanding difcharge their femen as before. It is in this ftage of the complaint that refolvents may be of fervice, fuch as mercurial friftion joined with camphor. Like- wife we may ufefully apply fumigations with aromatic herbs in order to Stimulate the abforbents to take up the Superfluous mat- ter. Elecfricity has been in Some caSes of Singular fervice. VII. OF THE DECLINE AND TERMINATION OF THE SYMPTOMS OF GONORRHOEA. The decline of the diSeaSe is generally known by an abate- ment of fome or all of the above-mentioned fymptoms. The pain in the part becomes lefs, or terminates in an itching Simi- lar to what is felt in the beginning of many gonorrhoeas, and at lafl entirely goes off. The fenfe of wearinefs about the loins, hips, tefticles, and Scrotum, is no longer felt, and the tranf- parent cherry-like appearance of the glans penis gradually dif- appears. Thefe are the moft certain figns of an abatement of the difeaSe, The 86 OF GONORRHOEA. The running becomes leSs, or if it does not dimlnlfh, be- comes firft whiter, then of a paler colour, and gradually ac quires a more flimy and ropy confiftence, which has always been eonfidered as the mofl certain Sign of an approaching cure. When the running becomes more flimy it is then changed from matter to the natural fluid which lubricates the paffage, and al- fo to that fluid which appears to be preparatory to coition ; but it is often very inconflant in its appearances, arifing frequent- ly from different modes of living, exerciSe, or other cauSes. It very often happens that all the fymptoms fhall totally disap- pear, and the patients Shall think themSelves cured, and yet thefame fymptoms fhall come upon them anew, commonly indeed mild- er than at firft, though in fome cafes as violent, or even more violent; and this takes place fometimes at a confiderable di- ftance of time. I have known the Symptoms return a month after every appearance of the difeafe had been removed. How- ever in fuch cafes they feldom lafl long. How far this fecond attack is to be looked upon as truly venereal, has not as yet been aScertained. Nothing can prove it absolutely to be vene- real but the circumflance of having given it to a Sound perfon. What may be the cafe with thofe in whom it has returned foon after the going off of the fymptoms, I will not pretend to fay; but I fhould very much fufpeft that where the patient has con- tinued well for a month, a return cannot be venereal. This is only conjefture ; and if we were to reafon upon it, we might eafily reafon ourfelves into a belief of its being venereal; tor if the parts can fall back again into one mode of aftion, that of inflammation and fuppuration, there can be no reafon why they fhould not fall back again into the fpecific mode of aftion. However, as the common effeft of irritation is fuppuration, and as the fpecific fuppuration requires a peculiar irritation, it is eafier to conceive that the parts may fall into the common mode of aftion, than in both. It is poffible, however, that in fuch caSes, it is only the venereal aftion may be only SuSpend- ed, fimilar to what happens between the contamination and complete appearance of the difeafe. In women re-urns of the fymptoms are more frequent than in men, particularly of the difcharge ; which being Similar to the fluor albus, and frequently taken for that difeafe, gives lefs Sufpicion, although they aic perhaps equally virulent as thoSe in men. The OF GONORRHOEA. 8/ The diftinftion between a gonorrhcea and a gleet is not yefc afcertained, for the inflammation fubfiding, the pain going off, and the matter altering, are no proofs that the poifon is der ftroyed. It is no more neceffary there fhould b« a continuance of the inflammation to produce the fpecific poifon, than there Should be a continuance of the inflammation to produce the gleet, as will appear evident from two cafes before related*. The firfl of theSe caSes fhows that the inflammation is not neceffary to the exiftence of the venereal poifon; and on the contrary, the inflammation may exifl after the matter difcharg- ed has ceafed to be venereal. I have known cafes where the inflammation and difcharge have continued for twelve months, and with confiderable violence : in the mean time a free inter- courfe with women has not communicated the difeafe. How- ever, this is not an abSolute proof that there is no virus in th« difcharge. ,----------- nij-gaBiiT --------■— CHAPTER VIII. OBSERVATIONS ON THE SYMPTOMS WHICH OFTEN REMAIN AFTER THE DISEASE IS SUBDUED. IT often happens after the virus is deftroyed, and the vene- real inflammation removed, that fome one, two, or mose of the fymptoms fhall continue, and perhaps prove more ob- ftinate than the original diSeaSe itSelf. Some of thefe fymp- toms fhould continue through life, and even new ones fhall fometimes arife as foon as the firfl have fubfided. All theSe Symptoms are commonly imputed by the patients themSelves, and what is ftill worSe, by Some of the profeffion. to the ori- ginal difeafe having been ill treated. But certainly fo far as we are yet acquainted with the diSeaSe and method of cure, this is not true ; for the methods of treatment, though nume- rous, may be Said to be very Similar; and we fhall find thefe fymp- toms not to be confequences of «my one mode of treatment, but * Vide page 36 and *j. 8$ OF GONORRHOEA. but that they happen indifcriminately after them all. Yet I can conceive that many conftitutions, and particular parts, often require one mode of treatment in preference to ano. ther, and probably require modes that we are not as yet ac quainted with ; but if thefe peculiarities of conflitution, or parts, are not yet known, which muft often be the cafe, the prac* titioner is not to be rafhly accufed of ignorance. In the introduftion I obferved, that the venereal difeafe is capable of calling into aftion fuch fufceptibilities as are remark- ably ftrong, and peculiar to certain conftitutions, and coun- tries ; and that as the Scrofula is predominant in this country, fome of the effefts of gonorrhcea may partake of a fcrofulous nature. The fymptoms which continue after the virus is gone, do not owe their continuance to the fpecific qualities of the vi- rus, but to its effefts upon the parts, fuch as inflammatiwi and its confequences; for the fame degree of inflammation, arifing from any other caufe, would leave mofl of the fame effefts. But I fufpeft that the continuance of the difcharge, called a gleet, is an exception to this ; for we find that it u often cured by the fame mode of aftion which would produce the other fymptoms, that is, inflammation ; and we find in general that a diScharge brought on by violence of no fpeci- fic kind, does not lafl longer than the violence, even although the caufe has been continued for fome time, as is often the cafe during the ufe of bougies. The firft of the continued fymptoms may be reckoned the remains of the difagreeable SenSation excited by the original diSeaSe. The Second, the diScharge called a gleet. The third, the chordee. The fourth, the irritable ftate of the bladder. The fifth, the increafe and hardnefs of the epididymis. I. OF THE REMAINS OF THE DISAGREEABLE SENSATIONS EXCITED BY THE ORIGINAL DISEASE. The difagreeable fenfations which continue In the urethra and glans, happen moft frequently when the bladder has fym- pathifed with the urethra during the difeafe ; for then there are often OF GONORRHOEA. ^9 often the remains of the old Shooting pains in the glans, or on its Surface, which take their riSe from the bladder. TheSe, however, commonly go off, feldom being the forerunners of any bad fymptoms, and therefore are not to be eonfidered as part of the difeafe, but merely a confequence ; yet they are often very troublefome, and teazing to the patient, keeping his mind in doubt, whether he is cured or not, which makes him frequently become the dupe of ignorant or defigning men. As thefe remaining fenSations vary confiderably in their na- ture, perhaps no one method of treatment will always be proper. I have known a bougie, introduced a few times, take off en- tirely the difagreeable fenfation in the* urethra ; and I have known it do no good. Gentle irritating injeftions ufed occa- fionly will often alleviate in fome degree thofe complaints. A grain of corrofive Sublimate to eight ounces of water makes a good injeftion for this purpofe ; but all fuch applications are in general no more than palliatives. I have known the ufe of hemlock relieye the Symptoms ve- ry much, and in Some cafes entirely cure them; while in ma- ny others it has not had the leaft effe6t. A blifter applied to the perinaeum will entirely cure fome o£ the remaining fymptoms, even when they extend towards the bladder, as will be explained hereafter. Indeed it appears to have more effeft than any other remedy. A blifter to the Small of the back will alfo give relieS, but not So effeftually as when applied to the perinaeum. The following cafes are remarkable inftances oS this. A PortugueSe gentleman, about twenty-five years of age, had con- tracted a venereal gonorrhcea, of which he was cured ; but two years after many of the fymptoms ftill continued, and even with confiderable violence. The Symptoms were the following; a frequency in making water, and when the inclination came on he could not retain it a moment ; a ftraining, and pain in the bladder after voiding it; a conftant pain in the region of the bladder ; a Shooting pain in the urethra, which extended eften to the anus ; ftrange fenSations in the perinaeum ; a Senfe of wearinefs in the tefticles ; and if he at anv time pre fled his thighs clofe together, the pain or SenSalion in the perinaeum was excited. It was fuppofed at Lifbon that he had the ftone, iind he came over to London for a cure of that dif.-a(e. lie was examined, but no ft one was ioun-l. He was ordered to N vvafh 9° OF GONORRHOEA. wafh the external parts every morning with cold water, wHicfi he did for a fortnight, but found no benefit. I was confultcv, and inSormed of all the above-mentioned circumftances. Asa Staff had been paffed, there could be no ftrifture ; however,' I thought it was poffible there might be a diSeaSed proftate gLm',, and therefore examined him by the anus ; but found that glar I of its natural fize and firmnefs. As there was no vifible alic; - ation of ftrufture any where to be found, I looked upon i'.,■: diSeaSe as only a wrong aftion of the parts, and therefore ,. dered a blifter to be applied to the perinaeum, which being kept open ©nly a few days, all the Symptoms were entirely removed. He retained his water as uSual ; all the difagreeable Senfationi went off; and the bliflered part was allowed to heal. About a fortnight after, he got a frefh venereal gonorrhcea, which alarmed him very much, as he was afraid it might bring back all his former fymptoms, which however did not return, and he was foon cured of the gonorrhcea. He ftaid in London fome time after, vfithOut any relapfe. Another caSe, was that of a gentleman's Servant in the country. He had, Srom a venereal cauSe, a diSagreeable SenSation whenever he made water, alSo a running, and Some degree of chordee; which fymptoms he had laboured under for a confiderable time. He had gone through a courSe oS mercu- ry which dafted two months, on a Suppofition that the vene- real virus not being deftroyed, but without benefit. He had after that been bled, ufed powders oS gum arabic and traga- canth, and taken calomel in Small doSes, with no better Succefs. He then had recourfe to injeftions and bougies of all kinds, but with no better fuccefs. On the ground of the fymptoms not being venereal, but only wrong aftions of the parts, a blif- ter was applied upon the perinaeum, repeated and kept open fix days, upon which the fymptoms totally disappeared, and had not recurred a twelvemonth afterwards. This praftice is not only of fervice where there has been ?. preceding gonorrhoea, but I have Sound it remove, almoft 1m mediately, Suppreflions of urine from other caufes, where i\: turpentines and opium, both by the mouth and' anus, h,-1 proved ineffectual, and when the catheter had been nece'sTari:- introduced twice t day to draw off the water. But of this more fully hereafter. E.'cftrici ' OF GONORRHOEA. 9l Eleftiicity has been found to be of fervice in Some cafes, and therefore may be tried either in the firft inftance, or when other means have failed, II. OF A GLEET. Whatever method has been had recourfe to in the cure of the venereal inflammation, whether injeftions have been uSed or internal medicines, (mercurials, purgatives, or aftrin- gents) it often happens that the formation of pus fhall con- tinue, and prove more tedious and difficult of cure than the original difeafe. For as I have already obferved, the vene- real inflammation is of fuch a nature as to go off of itfelf, or to wear itfelf out: or, in other words, it is fuch an aftion of the living powers as can fubfifl only for a certain time. But this is not the cafe with a gleet, 'which Seems to take its riSe Srom a habit of aftion which the parts have contracted, and as they have no diSpofition to lay afio\e this action, it of courfe is continued; Sor we find in thoSe gonorrhoeas, which lafl long, and are tedious in their cure, that this habit is more rooted than in thofe which go off Soon, This diSeaSe, however, has not always the diSpofition to continue, for it often appears to ftop of itfelf, even after every method has been ineffectually ufed. It is moft probable, that this arifes from fome accidental changes in the conflitution, not at all depending upon the nature of the diSeaSe itSelf. I have SuSpefted that there was Something Scrofulous in fome gleets. We find frequently that a derangement of the natural aftions of a part will be the caufe of that part failing into Some new diSeaSe, to which there may be a ftrong ten- dency in the conflitution. We find that a cold falling on thr eyes produces a fcrofulous weaknefs in thofe parts, with a confiderable diScharge. There are often fcrofulous fwellings in the tonfils from the fame caufe. This opinion of the nature of dome gleets is ftren}thencd by the methods of cure, for we find that the fea-bath cures more .gleets than the common cold bath, or any other mode of bath- ing. I have never yet tried the internal ufe of thofe medi- cines which are generally given in the fcrofula ; but I hav~ found »fea-water diluted, and ufed as an injection^ cure fome gk-jts, though it is net always effectual. A gleet 92 OF GONORRHOEA. A gleet is generally underftood to arife from a wcsknefs; this certainly gives us no idea of the diSeaSe, and indeed there is none which can be annexed to the exprefllon. By media- nical weaknefs is underftood the inability to perform fome aftion, or Suflain Some Sorce. By animal weakneSs the Same is under- flood. But when the expreflion is applied to the animal's performing an uncommon, or an additional aftion, I do not perfectly underfland it. Upon this idea of weaknefs depended in a great meafure the method of cure ; but we fhail find that the treatment, founded on this idea, is fo far from anfwering in all cafes, that it oft- en does harm, and that a contrary praftice is fuccefsful. A gleet differs from a gonorrhcea, firft in this, that though a conSequence of it, it is perfectly innocent with refpeft to in- feftion. Secondly, when it is a true gleet it is generally dif- ferent in fome of the conflituent parts of the difcharge, which confifts of globular bodies floating or wrapt in a flimy mucus inftead of a ferum> But the urethra is fo circumftanced as feafily to fall back into the formation of pus, and this com- monly happens upon the leaft increafe of exercife, eating or ng indigeftible food, or any thing which increafes the ition or heats the patient. The virus, however, I be- does not return ; but of this I am not certain, for are cafes that make it very doubtful, as was before ob- m inclined to SuSpeft that a gleet arlSes from the furface urethra only, and not from the glands ; for I have ob- in feveral inftances, that when the paffage has jufl been j, either by the diScharge oS urine, or by the uSe of an ^ on, a lafcivious idea has caufed the natuial flime to flow ure, which I do SuppoSe would not have happened if the fecreting the liquor, had affifled in Sorming the gleet. deet is Suppo'fed to be an attendant upon what we call a d conflitution ; but I can hardly fay that I have obServed be the cafe; at leaft, I have Seen inftances where I fhould •xpefted Such a termination of a gonorrhoea, if this had general caufe, but did not find it; and 1 have Seen it in conftitutions, at leaft in appearance, in every other re- fpe6t. Gleets do not in all ciScsariSe Srom preceding gonor- rhoeas, but Sometimes from other diSeaSes of the urethra. A ftrifture in the urethra is, I believe, almoft always attended with OF GONORRHOEA. 93 with a gleet. It Sometimes ariSes alSo from a difeafe in the proilate gland. When a gleet docs not arife from any evident cauSe, nor can be SuppoScd to be a return of a former gleet in confequence of a gonorrhcea, a ftrifture, or difeafed proftate gland is to be fuf- pefted; and inquiry fhould be made into the circumftances of making water, whether the ftream is Smaller than common— whether there be any difficulty in voiding it—and whether the calls to make it are frequent. If there fhould be fuch fymptoms, a bougie, of a fize rather leSs than common, ought to be uSed, which, if there is a ftrifture, will ftop when it reaches It; and if it paffes on to the bladder with tolerable eaSe, the. diSeaSe is probably in the proftate gland, which fhould be next examined. But more fully of both thefe complaints hereafter. III. OF THE CURE OF GLEETS—CONSTITU- TIONALLY—LOCALLY. As this diScharge has no Specific quality, but depends upon the conflitution of the patient, or nature of the parts themfelves, there can be no certain or fixed method of cure ; and as it is very difficult to find out the true nature of different conftituti- ons, or of parts, it becomes equally difficult to prefcribe with certainty the medicines that will beft fuit this difeafe ; for So great is the variety in conftitutions, that what in one caSe prove.; a cure, will in another aggravate the complaint. There are two ways of attempting the cure of this com- plaint, conftitulionally, or locally. Medicines, taken into the conflitution with a view to the cure of gleet, may be fuppofed to aft in three ways, as fr -ci- fics*, ftrengtheners, and aftringents. The fpecific power of internal medicines upon thofe parts is not very great, however we find that Som remark here, that by fpecific I do not mean a fpecific for the difeafe, but only fuch medicines as ait lpecifically on the parts concerned, as the turpen- tines, cantharides, &c. 94 OF GONORRHOEA. or fix days, I have never continued them longer. And even where they have either leffened or totally removed the gleet in that time, it will often recur upon leaving them off. and there- fore they Should be continued for Some time after the Symptoms have disappeared. I have known caSes where the gleet has dis- appeared immediately upon the uSe of the balfam capivi, and recurred upon the omiffion of it; and I have alfo feen where that medicine has kept it off Sor more than a month, and yet it has recurred immediately upon laying it afide, and ftopped again as quickly, when the patient has returned to it. In Such caSes the other methods of cure fhould be tried. The balfams may either be given alone, or mixed with other Subftances So as to make them leSs diSagreeable. The general ftrengtheners of the habit need only be given when the parts aft merely as parts of that habit. The whole be- ing difpofed to aft properly, theSe parts are alSo diSpofed to aft in the fame way. By general ftrengtheners are here meant, the cold bath, Sea-bath, the bark and fteel. Aftringents taken into the conflitution have no great powers, and iS they had, they might be very improper, as any thing that could act with powers in the conflitution equal to what would be neceffary here, might very much affeftmany natural operations in the animal ceconoray. The aftringent gums, and Salt of fteel, are commonly given. The fecond mode of cure is by local applications ; thefe may be divided into four, which are, Specifics, aftringents, irritat- ing medicines, and fuch as aft by derivation. The fpecifics applied locally, we may reafonably SuppoSe will have greater effefts than when given internally, becauSe they may be applied Hronger than can Safely be thrown into th« circulation. Of this I think I have had experience. The aftringents commonly ufed are, the decoction of the bark, white vitriol, alum, and preparations of lead. The aqua vitriolica ccerulea, of the London Difpenfatorv, diluted with eight times its quantity of water, makes a very good aftringent injection. The fame obfervations that I made on the fpecifics are applicable to the aftringents ; I believe that they aft nearly in the fame manner, and have the fame effeft. What their mode of aftion is it is difficult to fay. When either of thefe methods have been ufed, and have had the defired effeft, they Should be continued for a confiderable time after the Symptoms have disappeared, and the time muft If OF GONORRHOEA. 95 ;be in proportion to the duration of the complaint, or the fre- quency of its returns. If it has been of a long flanding, we may be fure that the difpofition for fuch a complaint is ftrong ; and if it has returned frequently, upon the leaft increaSe of cir- culation, we may expect the fame thing to happen again; there- fore to correct the bad habit, it is neceffary to continue the me- dicines a confiderable time. Irritating applications are either injections or bougies, Sim- ple, or medicated with irritating medicines; violent exerciSe may be eonfidered as having the Same effeft. Such applications fhould never be uSed till the other methods have been fully tri- ed and found unfuccefsful. They differ from the foregoing by producing at firfl a greater difcharge than that which they are intended to cure ; and the increafed difcharge may or may not continue as long as the application is ufed. It becomes there- fore neceffary to inquire how long they are to be uSed to pro- duce a cure of the gleet. That time will generally be in pro- portion to the violence ufed, and the nature of the parts which form the matter ; and according to the difpofition being ftrong or weak joined to its duration, and the greater or lefs irritabi- lity of the parts. If the parts are either weak or irritable, or both, an irritating injeftion fhould not be ufed ; if ftrong, and not irritable, it may be ufed with Safety. In this lafl cafe, if it is an injeftion that ftimulates very confiderably, perhaps it may be Sufficient to uSe it twice or thrice a day. I knew a gentle- man who threw into the urethra, Sor a gleet of two years Hand- ing, Goulard's extraft of lead undiluted, which produced a moft violent inflammation, but when the inflammation went off, the gleet was cured. Two grains of corrofive Sublimate to eight ounces of water are a very good irritating injeftion. If it is a gleet of old {landing, it may require a week or more to remove it, even with an irritating injeftion ; and if the injeftion is lefs irritating, fo as to give but little pain, and to increaSe the diScharge in a Small degree, it may require a fortnight. But one precaution is very neceffary refpeft;r^ the ufe of irritating injeftions; it fhould be firfl known if pof- fible, that they will do no harm. To know this may be dif- ficult in many caSes, but the nature of the parts is to be af- certained as nearly as poffible, that is, whether thev had ever been hurt before hy fuch treatment; whether they are So SuS- ceptible ol iniution, as that the in nation m;y be expected to run qu" OF GONORRHOEA. run along the urethra and proruce Symptoms in the bladder ; for in Such caSes irritating applications do not anSwer, but on tbe contrary, often produce worfe diforders than thofe which they were meant to cure. Bougies may be claffed with the iniuiiing applications, and in many caSes they act very violently as Such. They appear to be more efficacious than injections,' but they require longer time to produce their full effeft. A fimple, or unmedicated bougie, is in general Sufficient Sor the cure of a gleet, and re- quires a month or fix weeks application before the cure can be depended on. If bougies are made to flimulate otherwife than as extraneous bodies, then a fhorter time will generally be fuf- ficient; probably the beft mode of medicating them, would be by mixing a little turpentine, or a little camphor with the com- position, So as to aft Specifically on the parts; but great care Should be taken not to irritate too much. The fize of the bougie fhould be Smaller than the common, and need only be five or fix inches long, as it Seldom happens that a greater extent of the urethra has the diSpofition to gleet; but no harm will ariSe from paffing a bougie of the common length through the whole extent of the urethra. In the cure of a gleet, attempted by means of the bougie, we have no certain rules to direct us when it fhould be left off"; as the difcharge will often continue as long as the bougie is ufed. If upon leaving off the bougie after the ufe of it for fe- veral weeks, the running ceafes, then we may hope there is a cure performed; but if it fhould not be in the leaft diminifh* ed, it is more than probable that bougies will not effeft a cure, and therefore it is hdrdiy neceffary to have recourSe to them again. Yet it the gleet is in part diminifhed, it will be right to begin again, and probably it may be proper to increaSe the ir- ritating quality of the bougie, In order to fuit it to the dimi- nifhed irritability of the parts. The fourth mode of cure is by Sympathy, or by producing an irritation in another part of the body, which fhall deftioy the mode of action in the urethra. I knew a cafe of obftinate gleet attended with very difagree- able fenSations in the urethra, eSpecialiy at the time of making water, removed entirely by two chancres appearing upon the glans. The patient had taken all the medicines commonly re- commended, and had applied the bougie, without cfieft. A £':riih::~Mn OF GONORRHOEA. 97 A gentleman informed me, that he had cured two perfons of sleets, by applying a blifter to the under fide of the urethra ; and I have known Several old gleets, after having baffled all common attempts, cured by electricity. All thefe different methods of cure alter the difpofition of the part. In whatever way the cure is attempted, reft or quietnefs In mofl cafes is of great confequence ; for,* as I have obferved, exercife is often a cauSe, not only of its continuance, but of its increafe and return. But this idea is not to be too rigidly adhered to, efpecially in cafes which have been treated unfuc- cefsfully ; as I have known fome that have got immediately well by riding on hoifeback after long difufe of that exercife. Regularity and moderation in diet fhould be particularly at- tended to ; for irregularities of this kind either hinder the cure or bring on a return of the difeafe. Intercom fe with women often caufes a return, or increafe of gleet, and'in fuch cafes it gives fufpicion of a frefh infecti- on ; but the difference between this, and a frefh infeftion is, that here the return will follow the connection fo cloSe, as to be almoft immediate, and that circumflance joined with the other Symptoms will in general aScertain the nature of the difcharge. The cure of the gleet in women is nearly the fame as in men, except in the ufe of what I have called Specifics to the parts ; Sor as the gleet in women is principally from the vagi- na, I believe that this part is not more affefted by the turpen- tines than other parts are; but as the vagina is leSs irritable than the urethra in men, the aftringents which are applied to it may be considerably ftronger. Neither can we uSe the bougie in caSes of gleet in the vagina ; and when the gleet is only from the urethra, I imagine it is hardly ever attended to in women,. IV. OF THE REMAINING CHORDEE. This Symptom, I have already obferved, often remains af- ter everv mark of the true virus is removed, and may or may not be an attendant on any of the other continuing fymptoms. Mercurial ointment, applied to the part, may be of fervice, and If joined with camphor, its powers will be increafed. I have kr.own electricity cure a chordee of long Handing. It it it f!r: Sp.tfiuwdir chor'ee that remains, bat k fhould be gp'cn. O V. Oi> 98 OF GONORRHOEA. V. OF THE CONTINUANCE OF THE IRRITA- TION OF THE BLADDER. The irritation of the bladder Sometimes continues after eve- ry other fymptom is ceafed, and it may be an attendant upon all, or any of the other continuing fymptoms ; it Seldom lafls with the Same violence, although it is often very troublefome. When this irritation is kept up with the Same violence, the bladder itSelf may be fufpefted of being difeafed ; or it may arife from its conneftion with other parts, fuch as the urethra, or proftate gland ; for a ftrifture in the urethra coming on will prove the cauSe of its continuance, and a difeafe in the • proftate gland will do the fame. Neither of thefe difeafes will probably follow the gononhoea fo cloSely as to keep up this irritation, though perhaps they may have been taking place prior to the gonorrhoea, and fo j contribute to its increafe, 'and continuance ; which may pro- j bably be aScertained by a hiftory of the patient preceding the prefent complaint; however, before the bladder itfelf is attempt- I ed to be cured, a bougie fhould be paffed, and if no ftrifture is found, then the proftate gland fhould be examined, as fhall be defcnbed. When the diSeaSe is in the bladder only, I think the pain is principally at the cloSe of making water, and for a little while after. The cure of this fymptom confifts in opiate clyfters, cicuta, bark, Sea-bathing, and I fhould be inclined to recom- mend the application of a blifter to the perinaeum in men. How far opiate clyfters can affect the bladder in women as they do in men, I am not certain. VI. OF THE REMAINING HARDNESS OF THE EPIDIDYMIS. This fymptom I have obferved remains long after every other fymptom is removed, and may continue even for life, but Seldom or ever any bad confequences happen from it, if the vas deferens is not rendered impervious ; and not even then if' it is only in one tefticle, the other being equal to all the purpofes of generation. As this is the cafe, we muft at once See, that no certain method of sefoLtion is yet known. The . application OF GONORRHOEA. 99 aopllcation of the fleam of hot water with camphor, may be tried, efpecially in fuch cafes as are not diSpoSed to be perma- nent; and the Scrotum may be rubbed with mercurial oint- ment joined with camphor. But, in moft cafes, this praftice will prove too tedious, or rather too inefficacious to be long perfdfed in. PART [ i°° 1 „-P A R T III. CHAPTER I. OF DISEASES SUPPOSED TO ARISE IN CONSEQUENCE OF VENEREAL IN- FLAMMATION IN THE URE- THRA OF MEN. THE gonorrhoea produces, or at leaft is SuppoSed to pro- duce, befides thoSe diSorders already mentioned, many others which are totally different from the original difeafe. How far the'y do all or any of them arife in confequence of this difeafe, is not clear ; but as they are diSeaSes of the ure- thra, and are both numerous and important, I mean to treat fully of them in this place. If any of thefe difeafes arife from ' a gonon h-:;a, they are moft probably not the confe- quences of any fpecific quality in the venereal poifon, but are Such as might be produced by 2ny common inflammation in thofe parts, as was obferved of the continued fymptoms. In this invefligation we fhall find Some of the complaints arifing out of each other, fo that there is frequently a Series of ihem. Thus a ftrifture of the urethra produces an Irrita- ble bladder, a frequent defire to make water, increaSed ftrength of the bladder, a dilatation of the urethra between the blad- der and ftrifture, ulceration, fiftulse in perinaeo, dilatation of the ureters and enlargement of the pelvis of the kidneys, be- fides other complaints that are fympathetic, Such as Swellings of the tefticle, and of the glands in the groin. I fhall treat of the difeafe of thofe parts in the older in which they moft commonly arife. • It may be obServed that moft of theSe diSeaSes, efpecially diminution of diftcnfibility in the bladder, attack men advanc- ed beyond middle age, although many, if not all of them, are at times found in younger Subject, and the circumflance <■ the;: SUPPOSED CONSEQUENCES, &c. xci tVir appearing at this period ariSes probably in Some degree from along habit of an unnatural mode of life producing ma- ny difeafes, fuch as gout ; for certainly fuch complaints do not fo frequently take place among the more uncivilized nations. The mofl frequent difeafe in the urethra is an obstruction to the paffage of the urine ; it happens both in young and old, although moft frequently in the latter. Before I begin to treat of this fubjeft, I fhall, for the better underftanding of the whole, make fome obfervations on the ufe of this paffage In its natural State. It may firft be obferved, that the urethra in man is employ- ed for two purpofes. On this occafion I may he allowed to make the following general remark, that nature has not been able to apply any one part to two ufes with advantage, as might be illuftrated in many inftances in different animals. The ani- mals whofe legs are both for Swimming and walking, are not good at either, as Seals, otters, ducks, and geeSe. The ani- mals alSo whoSe legs are intended both for walking and flying, are but badly formed for either, as /he bat. The fame ob- fervations are applicable to fifhj for the flying filh neither fwims, nor flies well; and whenever parts intended for fuch double func- tions are difeafed, both are performed imperfectly. This is im- mediately applicable to the urethra, for it is intended as a canal or paffage, both for the urine, and the Semen. The urine re- quires the fimpleftof all canals, and oS no greater length than the diftance from the bladder to the external furface, as we find the urethra in women, birds, the amphibia, and fifh ; but the paffage for the femen in the quadruped required to be a com- plicated canal, and of a length capable of conveying the fe- men to the female, provided with many additional and necef- fary parts, as the corpus Spongiosum urethra, muSculi accele- ratores, Cowper's glands, proftate glands, and veficulae femi- nales. As all thefe parts are to Serve the purpoSe of genera- tion, and as the difeafes of this canal are principally Seated in them, we at once See how much the urinary organs muft Suffer from a conneftion with parts fo numerous, and So liable to diSeaSe ; and what adds to the evil is, that the aftions of the urinary organs are conftant, and abfolutely neceffary fof the well-being of the machine, whereas the evacuation of the fe- men takes place only during a certain portion of life, is then only occasional, imcl never effentialiy neceffary to the exHl- en«.e JC2 SUPPOSED CONSEQUENCES ence of the individual. The force of this obfervation is at once feen by making the compaiifon between the inconvenience that attended the expulflon of the urine in the male, and in the female. The canal of the urethra is liable to fuch difeafes as are ca- pable of preventing in fome degree the paffage of the urine through it; and in fome of thefe difeafes the paffage at lafl be- comes completely obftru6ted. In all caSes there is a diminu- tion of the fize of the canal, but in different ways. There are five modes of obftruftion, four of which are difeafes of the paf- fage itfelf, the fifth is a confequence of the diSeaSes of other parts. Three of the former are a leffening of the diameter of the paffage; the fourth an excreSeence in the paffage; the filth ariSes from the fides being compreffed, which may be done either by exterior contiguous fwellings, or by a Swelling of the proftate gland. I. OF STRICTURES. The three firft I fhall now confider, of which the firft is the true permanent ftrifture arifing from an alteration in the ftruc- ture of a part of the urethra. The fecond is a mixed cafe, compofed of a permanent ftrifture and SpaSm. The third is the true SpaSmodic ftrifture. Moft obftruftions to the paffage of the urine, if not all, are attended with nearly the fame fymp- toms, fo that there are hardly fufficient marks for diftinguifh- ing the different caufes. Few take notice of the firft Symptoms of a ftrifture till they have either become violent, or have been the caufe of other inconveniences ; for inftance, a patient fhall have a confiderable ftrifture without obServing that he does not make water freely; he fhall even have, in conSequence of a ftrifture, a tendency to inflammation, and Suppuration in the perinaeum, and not feel any obftruftion to the paffage of his urine, nor SuSpeft that he has any other complaint than the in- flammation in the perinaeum. In all of thefe obftruftions the ftream of water becomes fmall, and that in proportion to the obftruftion ; but this Symptom, though probably it is the firft, is hot always obServed by the patient. In Some the water is voided only in drops, and then it cannot eScape notice; in others the ftream of urine is forked, or Scattered; under fuch circum- ftances the paffage Should be examined with a bougie ; and if one OF GONORRHOEA. . 103 one of a common fize paffes with tolerable eaSe, the fifth caufe of obftruftion is to be fufpefted, which will moft probably be found to be a Swelled proftate gland ; Sor any other cauSe that can produce a compreflion of the fides oS the urethra, Sufficient to ohftruft the urine, will be known to the patient, Such as a tumor forming any where along the canal, or an inflammation along its fides. If therefore neither of thefe are known to ex- ill, the proftate gland fhould be examined, as will be defcnb- ed hereafter. The SpaSmodic obftruftion will commonly explain itSelf when the fymptoms are well inveftigated ; for the obftruftion arifing from this caufe will not be permanent. Thefe obftruftions, but more particularly that from a permanent ftrifture, is generally attended with a difcharge of matter or a gleet. This is often eonfidered by the patient as the whole diSeaSe, and he applies to the Surgeon for the cure of a gleet. The Surgeon often perfe- veres in attempting the cure of this diSeaSe; but no SucceSs at- tending him, at lafl other Symptoms are obServed, and a Stric- ture is SuSpefted either by the Surgeon or patient. In diSeaSes of this paffage, (and alfo of the proftate gland and bladder, there is commonly an uneafineSs about the perinaeum, anus, and lower part of the abdomen, and the perSon can hardly croSs his legs without pain. CHAPTER II. OF THE PERMANENT STRICTURE. IN the permanent ftrifture* the patient feldom complains till he can hardly procure a paffage for the urine ; and fre- quently has a confiderable degree of ftrangury, and even other rympioms that happen in flone and gravel, which are there- fore too frequently fuppofed to be the caufes of the complaint. The difeafe generally occupies no great length of the paffage ; at leaft in moft of the cafes that I have feen, it extended no further in breadth than if the part had been furrounded with a piece Vide plate I, £;. i. 104 SUPPOSED CONSEQUENCES a piece of packthread; and in many it had a good deal of that. appearance. I have however feen the urethra inemdarly con*, trafted for above an inch In length, t.wmg to its coats, or in- terna! membrane, being irreguuily thmhencu, and forming a winding canal. A ftrifture does not arife in all cafes from an equal contrac- tion of the urethra all round, but in fome from a conn action of one hie, which probably has given the idea of its having arif- en from an ulcer on that fide. This contraction of one fide only, throws the paffage to the oppofite fide, which often ren- ders it difficult to p;afs the bougie. The contracted part is whi'er than any other part of the urethra, and is hauler in its confiftence. In Some few cafes there are more ftriftures than, one. I have feen hair a dozen in one urethra ; fome of which were more contracted than others ; ahd indeed many urethras that have a ftrifture have Small tightneffes in other parts of them. This we learn from Succeffive rcfiftance felt in pafling, the bougie. Every part of the urethra is not equally fubjeft to ftriftures,. for there appears to be one part which is much more liable to them than the whole of the urethra befides, that is about the huibous part. Wt and them however Sometimes on this fldft of the bulb, but very Seldom beyond It. I never Saw a Stric- ture in that part of the urethra,which paffes through the pro- ftate gland; and the bulb, befides being the moft frequent feat of this difeafe, has likewife the ftriftures formed there of the word kind. They are generally flow in forming, it being often fe- veral years from their being perceived before they become ve- ry troublefome. The fame ftrifture is not at all times equally had ; for we find that in warm weather it is not nearly fo troublefome as in cold : thefe changes are often very quick, a cold day, even an hour of cold weather, fhall produce a change in them ; and the Same ftrifture is almoft always worfe in winter than in Sum- mer. However, this observation is not free from exceptions; I knew one cafe that was always worfe in the Summer. There are other circumftances befides cold that make a ftrifture worfe, A gentleman who had an ague, always found the ftrifture in- creafed during the fit. It is alfo increafed by drinking, vio- lent exercife, and by the retention of urine after an inclination to void It has been felt. This lafl caufe is often So orcat as to prod iic- OF GONORRHOEA. 105 produce a total ftoppage for a time. It is fometimes rendered much worSe by a Small calculus paffing from the bladder, of the formation of which this ftrifture was probably the caufe. The calculus not paffing will produce a total ftoppage of urine, the caufe of which can hardly be known at the time ; and if known, it could not be remedied without an operation*. It is impoffible to fay what is the caufe of that alteration in the ftrufture of the urethra which diminishes the canal: it has been afcribed to the effefts of the venereal difeafe, and oSten to the method of cure ; but I doubt very much iS it commonly, or even ever, ariSes from thefe caufes ; yet as moft men have had venereal complaints fome time or other, it is natural to afcribe the ftrifture to them ; and therefore it may be very dif- ficult to refute this opinion. Many reafons however can be given why we fhould fuppofe that it is not commonly a confe- quence of a venereal inflammation. Strictures are common to moft paffages in the human body; they are oSten to be found in the cefophagus; in the inteftines, eSpecially the rec- tum ; in the anus; in the prepuce producing phymofis; in the lachrymal duft producing the diSeaSe called the fiftula lachry- malis, where no difeaSe had previoufly exifled. They Some- times happen in the urethra where no venereal complaint has ever been. I have Seen an inftance of this kind in a young man of nineteen, who had had the complaint for eight years, and which therefore began when he was only eleven years of age. It was treated at firft as ftone, or gravel. He was o£ a fcrofulous habit, the lips thick, the eyes fore, a thickened cornea of one eye, and the general habit weak. This ftrifture was in the ufual place, about the membranous part of the ure- thra. I have feen an inftance of a ftrifture in the urethra of a boy of four years, and a fiftula in perinaeo in conSequence of it. They are as common to thofe who have had the go- norrhoea flight, as thofe who have had it violently. I knew a young gentleman who had a very bad ftrifture. He had had Several gonorrhoeas, but they were So flight that they Seldom lafted a week ; nor in any of them did the pain extend beyond the fraenum ; but the ftrifture was about the membranous part. Cafes of this kind occur every day. They are never found to come on during the venereal inflammation, nor fur Some tunc after the infeftion is gone. There has been. P thirty, •' Vide plate III. 106 SUPPOSED CONSEQUENCES thirty, and Sometimes forty years, between the cure of a gohor* rhcea and the beginning of a ftrifture, the health being all that time perfeftly good. If they arofe in confequence of the ve- nereal inflammation, we might expect to find them of Some extent, becaufe the venereal inflammation extends fome way; and we Should alSo expect to find them moft Srequent in that part of the urethra which is moft commonly the feat of the venereal difeafe. But I remarked before, that they are not fo frequent there as they are in other parts of the urethra. It is fuppofed by many, that ftriftures arife from the ufe of injeftions in the cure of gonorrhoea ; but this opinion appears to be founded in prejudice ; for I have feen as many ftriftures' after gonorrhoeas, that have been cured without injections, aa after thofe cured with them. Such modes of accounting for flriftures give no explana- tion of thofe where there has been no previous gonorrhoea, or where the gonorrhcea has not been cured by injeftions ; and indeed if we confider the mode of cure of ftriftures, we muft fee that an injeftion is a mild application to the urethra, com- pared to a bougie ; yet a bougie has never been fuppofed, or known to be the caufe of a ftrifture. Further, fome have in- jected by miftake very irritating liquors, fuch as the undiluted extract of lead, and cauftic alkali, without giving the leaft ten- dency towards a ftrifture, although they produced violent in- flammation, and even ftoughing of the internal membrane of the urethra. By many they have been fuppofed to have ariSen from the healing of ulcers in the urethra ; but as I never Saw an ulcer in theSe parts, except in conSequence of a ftrifture, and as I do not believe there ever i* an ulcer in the caSe of a common gonorrhoea, I can hardly SubScribe to that opinion. I. OF THE BOUGIE. The bougie, with its application, is, perhaps, one of the greateft improvements in furgery which thefe laft thirty or for- ty years have produced. When I compare the praftice of the. prefent day with what it was in the year 1750, I can fcarcely be perSuaded that I am treating the Same diSeaSe. I remem^ ber, when about that time, I was attending the firft hofpitaU in OF GONORRHOEA. 107 in this city, the common bougies were either a piece of lead* or a fmall wax candle; and although the prefent bougie was then known, yet a due preference was not given it, or its particular merit underftood, as we may fee from the publica- tions of that time. Daran was the firft, who improved the bougie and brought it into general uSe. He wrote profeffedly on the diSeaSes for which it is a cure, and alfo of the manner of preparing it; but he has introduced fo much abfurdity in his deScilptions of the difeafes, the modes of treatment, and of the powers and com- poGtion of his bougies, as to create difgufl. However, this ahfurdlty has been much more effectual in introducing tl»e bou- gie into univerfal ufe, than all the real knowledge of that time, direfted by good fenfe, could have been. Such extravagant recommendations of particular remedies are not at all time9 without their ufe. Inoculation would have ftill been praftifed with caution, had it not been for the enthufiafm of the Suttons. Preparations of lead would not have been fo univerfally appli- ed if they had not been recommended by Goulard in the moft extravagant terms; nor would the hemlock have come into fuch general ufe if its true merits only had been held forth. Improvements are often over-rated ; but they come to their true value at lafl: Sutton has told us, that the cold regimen^ in extreme, is infinitely better than the old method ; but from general praftice we have learned that moderation is beft, which is all we yet know. When Daran published his observations on the bougie, eve- ry Surgeon Sat to work to diScover the compofition, and each conceived that he had found it out, from the bougies he had •made producing the effefts defcribed by Daran. It never oc- curred to them that any extraneous body, of the fame fhape and confiftence, would do the fame thing. II. OF THE TREATMENT OF THE PERMANENT STRICTURE. The cure of the permanent ftrifture is, I believe, to be ac- cotnplifhed only by local applications. Mercury has been giv- en * When lead was ufed in place of bougies, it has happened that a piece of the end has broken off in the bladder, which has been diffolved by injefting quickfilver. I at firit liitpeded that quickfilver could not come in contaft with lead, while iu water, fr. as to diffolve it, but upon making the experiment I found it futcceded. 108 SUPPOSED CONSEQUENCES en upon the erroneous fuppofition of its being venereal ; but without SucceSs. The cure is either a dilatation of the con. trafted part, or a deftruftion of it by ulceration, or efcharotics. The dilatation is performed by the bougie ; and this is Seldom or ever more than a temporary cure ; Sor although the paffage may be dilated Sufficiently for the urine to pafs, yet there is al- ways the original tendency to contraffion, which generally re? curs fooner or later*. The ulcerative proceSs is alSo affefted by a bougie, and the deftruftion by efcharotics, is by means e>t cauftics. It often happens in ftriftures, that the paffage is fo diminifhed as hardly to allow any water to pafs, producing often a total ftoppage; nor will a bougie immediately pafs; and if it can be made to pafs; yet no water follows it when withdrawn. In fuch cafes therefore we muft have recourfe to. the means that afford a temporary relief; fuch as the warm bath, which counteracts the effefts oS cold, and quiets any fpaSms that may have taken place in the parts, and clyfters with opium, which ftill have more effeft. Producing an eva- cuation by ftool, oSten leffens the SpaSm, Sor a SpaSmodic fup- preflion of urine frequently arifes from a conftipation, even where there is no ftrifture. The cure by dilatation is, I imagine, principally mechani- cal when performed by bougies, the powers of which are in ge- neral thofe of a wedge. However, the ultimate effeft of them is not always fo fimple, as that oSa wedge upon inanimate mat- ter ; for preffure produces aftion oS the animal powers, either to adapt the parts to their new pofition, or to recede by ulcera- tion, which gives us two very different effefts oS a bougie, and of courSe two different intentions in applying them ; one to pro- duce dilatation, the other ulceration ; which lafl is not always fo readily effected. It generally happens, as has been already ohferved, that the diSeaSe has gone confiderable lengths before application has been made for a cure, and therefore the ftrifture has become confi- derable, * In cafes of ftrifture, when a patient applies for relief, it may often be proper to in- quire into the hiftory of the cafe, previous to the paffing of a bougie; efpecially to in- quire ji he ever ufed bougies before; if he has, then to inquire inio the refult • if they ruffed readily, or .f they did not pafs the flrifture at all: if the fi.fr, then nothine fur- ther need be afked; but if the laft, then inquiie if he or his furgeon obferved that they were gaining ground With the bougie, viz. If the bougie went further in before it was left off than atfirft ; if fo, then to arte him how far. If they have vif.bly gained ground with-' out getting through the ftrifture, I am afraid that the ufe of the bougie rr.uft not he rur- fued, becaufe it is moft probable that a new paffage has been formed, which makes the fifing of the bougie into the tincture impoffible. OF GONORRHOEA. * * 109 rlerable, in fo much that it is often with great difficulty that a fmall bougie can be made to pafs. If the cafe is fuch as will readi- ly admit the end of a fmall bougie to pafs, let it be ever fo fmall, the cure is then in our power. It often happens however, that the ftrifture is fuch, as will refill the paffing of a fmall bougie at firft, and even after repeated trials. Yet it is neceffary to perfevere with a fmall bougie, for fometimes it happens that the paffage through the ftrifture is not in a line with the urethra itfelf, which of courfe obftrufts the bougie; fuch ftriftures I SuSpeft are not equally placed all round So as to throw the Small paffage remaining into the centre of the canal. In many cafes where the ftrifture is very confiderable, much trouble is given by occafional SpaSms, which will either refift the bougie altogether, or only let a very Small one paSs; though at another time they will admit one larger. In Such caSes I have been able to get the point of the bougie fometimes to en- ter, by rubbing the perinaum externally with the finger of one hand while I puflied the bougie on with the other. This, though it does not always fuccecd, yet is worth trying. Whe- ther it alters the pofition of the ftrifture fo as to give entrance to the point of the bougie, or by fympathy removes the fpaSrn, 1 will not abfolutely determine ; but, 1 believe, it rather afts by fympathy. In fuch cafes of fpafm in the ftrifture, I have often fucceeded by letting the bougie remain a little while clofe to the ftrifture, and then pufhingit on ; this mode fo often fuc- ceeds that it fhould always be attempted when the bougie does not pafs, or only paffes occafionally. This will be mentioned more fully when we fhall confider the SpaSmodic ftrifture. The SpaSm may probably be taken off by dipping the glans- penis into cold water, which Succeeds Sometimes in the com- mon ftrangury, but this cannot be So eafily done while a bou- gie is in the paffage. In cafes of a permanent ftrifture, though the bougie does not at firft pafs, yet after repeated trials it will every now and then find its way, which helps to render a future trial more certain and eafy. It however too often happens that the future fucccfs does not immediately depend upon paffing the bougie once or twice; for it fhall pafs to-day and not to-morrow ; and this un- certainty fhall lafl for weeks, notwithftanding every trial we can make. Yet I may obferve, that in general its introduction be- comes SUPPOSED CONSEQUENCES comes gradually leSs difficult, and therefore in no cafe fhould we deSpair of fuccefs. It is imagined by Some that the beft time Sor trial in theSe ca- fes is juft after making water, as ihe paffage is SuppoSed to be clear and more in a ftraight line; but this is not confirmed by praftice. It is not an eaSy matter In caSes where the paffage is very fmall, to know whether the bougie has entered the ftrifture or not; for fuch flender bougies as muft generally be ufed at firft, bend fo very eafily that the introducer is apt to think it is paf- fing while it is only bending. A furgeon, however, fhould in general firft make himfelf acquainted with the fituation of the ftrifture by a common Sized bougie, and afterwards make uSe of a fmaller one, and when he comes to the ftrifture pufh gent- ly, and for a little time only. If the bougie has paffed further into the penis, he will know how far it has entered the ftric- ture by taking off the preffuie from the bougie ; for if it recoil he may be fure that it has not paffed, at leaft has not paffed Sar but only bent; for the natural elafticity of the bougie, and the direction of the paffage having been altered by it, will force it hack again. But if it remain fixed and do not recoil, he may be Sure that it has entered the ftrifture. In ufing a very Small bougie, however, theSe observations are not fo applicable, for it may be bending, or bent, without being perceptible. It oft- en happens that a bougie will enter only a little way, perhaps not more than one-tenth of an inch, and then bend if the pref- fure be continued. To determine whether this be the cafe, it is neceffary to withdraw the bougie and examine its end ; if the •end be blunted we may be fure the bougie has not entered in the leaft. but if it be flattened for an eighth or tenth of an inch, or grooved, or have its outer waxy coat pufhed up for that length, or if there be a circular impreffion made upon the bougie where the ftrifture is, or only a dent on one fide, both of which lafl I fufpeft arife from fpafm at the time, we may then be Sure that it has paffed as far as thefe appearances extend. It becomes then neceffary to introduce another exactly of the fame fize and in the Same manner, and to let it remain as long as the patient can bear it, or convenience will allow ; and by repeatinp- this we may overcome the ftrifture. Sometimes we can judge of its having entered the ftrifture, by pulling it gently out; for if it flick a little at the firft pull, we may be certain it has entered ; but OF GONORRHOEA. in but the appearance of the bougie itfelf will give the heft infor- mation*. In fuch cafes I have always direfted my patient to preServe the bougie for my infpeftion, exaftly in the fame form it was when it was withdrawn ; but when it paffes with eafe this nicety is not neceffary. The time that each bougie fhould remain in the paffap-e, muft be determined by the feelings of the patient; for it fhould never give pain, if poffible. To go beyond this point is to deftroy the intention, to increafe the very fymptoms that are meant to be relieved, and to produce irritation, which Sor a time renders the further application of the bougie improper. While the bougie is paffing, if the patient feel very acutely, it fhould not be left in the urethra above five, or at moft ten minutes, or not fo long, if it give great pain ; and each time of application fhould be lengthened fo gradually, .as to be in- fenfible to the Seelings of the patient, and the irritability of the parts. I have known it days, nay in many patients weeks, be- fore they could allow the bougie to remain in the paffage ten or even five minutes, and yet in time they have been able to bear it even for hours, and at taft without any difficulty. The beft time to let it remain in the paffage is when the patient has leaft fo do ; or in the morning, while he is in bed, pro- vided he can introduce it himSelf. The bougie fhould be increafed in fize, according to the fa- cility with which the ftrifture dilates, and the eafe with which the patient bears the dilatation. If the parts are very firm, or very irritable, the increaSe of the fize of the bougie fhould be flow, gradually Healing upon the parts, and allowing them to adapt their ftrufture to the increafed Size. But if the fenfibility of the parts will allow of it, the increaSe oS the fize of the bou- gie may be Somewhat quicker, though never more quick than the patient can bear with eaSe. The increaSe fhould be conti- nued till a bougie of the largeft fize paffes freely; nor fhould this * It may be remarked, that there are fome lacunae (Vide plate I, fig. 2.) near, and alfo a little way beyond the glans penis, which often ftop the bougie, and give at firft the idea of a ftrifture. I have known them taken for fuch ; and when the bougie ftops fo near to the glans this is to be fufpefted, and therefore we ihould vary the direction of the point of the bougie, bearing it againft the underfide of the urethra. When the bougie ftops in one of thofe lacunae,.I think that the patient appears to have more pain than from a real ftrifture. The valvular part of the proftate gland formed by difeafe (Vide plate IV.) very often obftrufts the bougie, and is taken for a ftrifture by thofe who are not well acquainted with the different obftruftions in this canal; and by thofe who are, it is a means of diftov ring difeafe in this part; and indeed in a natural ftate of pans I think I can afcertain when 1 come to this part with a bougie, SUPPOSED CONSEQUENCES this be laid afide till after three weeks, or a montli, in order to habituate the dilated part to its new pofition, or to take off the habit of contracting from the part as much as poffible; but, as was obferved before, the permanency of this cure can Seldom be depended upon. Inftead of proceeding with the caution recommended, it has been praftifed with fuccefs for a time, to force a common Siz- ed bougie through a ftrifture that only allowed a Small one to paSs. This, I SuppoSe, either tore the ftrifture or weakened it by ftretchlng it Suddenly So as to render it unable to recover its contractile power Sor a confiderable time after. I have Seen where this has produced good effects, and Sor a time removed the permanent ftrifture, and prevented SpaSm. This is a prac- tice, however, which 1 have never tried ; having always pre- ferred the mild treatment where I could paSs a bougie. I have known the paffing of the bougie remove, almoft im- mediately, a fwelling of the tefticle, which had arifen from the ftrifture ; therefore fuch a Symptom fhould not prevent the uSe of the bougie. In caSes of ftriftures, where the bougie is ufed, the patient is commonly in other refpefts well, and is with difficulty per- fuaded to reftrain Srom his common habits, often making too free in eating, drinking, and exercife; which are all in many cafes pernicious, more efpecially where inflammation and fuppura- tion have taken place. It is therefore the duty of the furgeon to reftrift the patient for fome time within certain bounds, till he finds by trials what the parts are capable of bearing with- out producing inflammation. III. OF THE CURE OF STRICTURE BY ULCERATION. The cure of a ftrifture by means of ulceration is likewife effefted by a bougie. This method may be employed both in cafes where a bougie will, and where it will not paSs. In the firft caSe there is not the Same neceffity for ulceration as in the fecond, becaufe where a bougie will pafs there is no immedi- ate danger arifing from the ftrifture, which may therefore be dilated, as has been defcribed. But if this method fhould be preferred to a flow dilatation, which allows the parts time to adapt themfelves to their new pofition, the ftrifture may be deftroyed OF GONORRHOEA. i*3 deftroyed by producing ulceration in the parts, efpecially if they are not irritable, but admit of confiderable violence. When this is intended, the bougie Should be introduced as far into the ftrifture as poffible, and the fize of it increafed as faft as the fenSations of the patient can well bear. This will produce ulceration in the part preffed, which is a more lafting cure, becauSe more of the ftrifture is deftroyed than whemthe parts are fimply dilated. I believe, however, there are few patients that will fubmit to this praftice ; and indeed few will be able to bear it; for I have feen it bring on violent fpafms on the part, which have produced fupprefTion of urine, and proved very troublefome. Therefore as there is no abfolute neceffity in Such caSes for purfuing this method, I do not re* commend it as a general praftice, although there have been cafes in which it has Succeeded. Where this method is to be praftifed, it might probably be right to accuftom the paffage to a bougie for fome time before fuch violence is ufed. If the fmalleft bougie, which can poffibly be made, cannot be made to pafs by fome degree of force, dilatation becomes impracticable, and it is neceffary that fomething clfe fhould be done for the relief of the patient; for the deftruftion of the ftrifture muft be effefted. In many cafes it may be proper to attempt this by ulceration of the part; for we find from expe- rience, that a ftrifture may be removed by the fimple preffure of a bougie. This effeft muft arife from the irritation of ab- forption being given to the difeaSed part, which from the ftric- ture not being an originally formed part, nor having the pow- er of refiftance^ equal to the original one, is more SuScepti- ble of ulceration, and thereby is abforbed. The bougies which are onlv to produce ulceration in confequence of their being applied to the ftrifture, need not be fo fmall as in the former cafes, as they are not intended to pafs; and by being of a com- mon fize they will alfo be more certain in their application to the ftrifture. The force, applied to a bougie, in this cafe fhould not be great; for a ftrifture is the hardeft part of the urethra; and if a bougie is applied with a confide'dble de- gree of preffure, and left in the paffage, it Sometimes happens that the end of it flips off the ftrifture before there is time for ulceration, and makes its way into the fubftance of the cor- pus fpongiofum by the fide of the ftrifture ; and if the pref- fure he continued ftill longer, it will make a new paffage#be- SUPPOSED CONSEQUENCES yond the ftriftuie in the corpus fpongiofum urethrrc*. Ihi: more readily happens if the ftrifture be in the bend of the ca- nal, as in Such caSes the bougie can hardly be applied exaftly to it, not having the Same curve. Such miSchief I have feen more than once; and Sometimes the bougie has been pufhed fo far as to make its way into the reftum. It often requires a confiderable time before the whole is So far ulcerated as to admit the bougie, and this tires the patient and almoft makes him defpair of a cure. In this procefs great attention fhould be paid to the feeming progrefs of the cure ; for if it appears to the furgeon that he is gaining ground by the bougie paffing further in, and yet the patient does not make wa- ter better in the leaft, then he may be fure that he is forcing a new paffaget. When the ftrifture has fo far yielded to thefe means as to ad- mit a Small bougie, the dilatation is to be made as in the for- mer cafe where a bougie paffed at firft. Whenever a bougie of a toleiable fize, paffes with cafe, and the parts and patient ha.ve become accuftomed to it, it is no longer neceffary that the Surgeon fhould continue to paSs it; the patient may be allowed to introduce bougies himSelf; and when he can do it readily, the bufinefs may be trufled to him, as he can make uSe of tr.em at the moft convenient times, fo that they may be applied, lon- ger at a time and oftener, the furgeon only attending occafion- ally. This praftice of the patient under a furgeon's eye, by which he is taught how to pafs them, becomes more neceffary, as ftriftures are difeafes that commonly recur ; therefore no man, 'who has ever had a ftrifture, and is cured of it, fhould rely on the cure as lafting, but fhould be always prepared for a return ; and ihould always have Some bougies by him. He fhould not go a journey, even of a week, without them ; and the number fhould be according to the time he is to be abfenf, or to the place whither be is going ; for in many pans of the world he cannot be fupplled with thera. The bougies for fuch purpofe fhould be of different Sizes, as it is uncertain in what degree the diSeaSe may return. Bougies, in all caSes, Srom their fhape, and from the aftion of the parts, readily flip out, whereby the cure is retarded ; but * Viae plate II, fig. 4. + This makes it neceffary in all cafes of ftriftures where bougie* will not oafs, to be very particular in our inquiries, wliethei the patient has ufed bougies formerly; and whe- ther there maynctbe reafon to believe that they had uken a wrong direction. OF GONORRHOEA. "5 but it is much worSe when they paSs into the bladder; which can only take place in caSes where the ftrifture is in fome mea* Sure overcome. The confequence of a bougie paffing into the bladder muft at once appear in its fulleft force to every one • it Subjects the patient in moft cafes to be cut as for the ftone ; and indeed if it is either not foon thrown out, or cut out, it becomes the bafis of a ftone. A young man was cut for a bou- gie only a fortnight after it had paffed into the bladder; and it was almoft wholly crufted over with calculous matter. Bou* gies have been known to be forced out of the bladder along with the water by the aftion of that vifcus, and in Several folds. It is probable that the bladder in a natural ftate has not power Sufficient to perform fuch an aftion ; but we Shall fhow that in cafes of ftriftures, where the refiftance to the paffing of the wa- ter is very much increafed, the ftrength of the bladder becomes proportionably greater. This happens principally in ftriftures of long ftanding. Such accidents are often obServed before the outer end of the bougie has got beyond the projefting part of the penis, but even then it is difficult of extraction. I have Succeeded in Some of theSe caSes by fixing the bougie in the urethra Some way below its end; Sor inftance, in the perinaeum, by preS- Smg againft it with one hand, and pufhing back the penis up- on the bougie with the other hand ; then laying hold of the penis upon the bougie, removing the preffure below, and draw- ing the whole up; and by performing thefe two motions alter- nately, I have been able to lay hold of the end of it. Howe. ver, this does not always Succeed, Sor when the bougie is either Small, or becomes Soft, it will not admit of the penis being pufhed down upon it without bending ; or if the thick end or the bougie has got beyond the moveable, or projefting part of the penis, then this mode of treatment becomes impractica- ble. I have Succeeded in theSe lafl caSes with the forceps for extrafting the ftone out of the urethra ; but if it has got into the bend of the urethra, this praftice will alfo fail ; and in fuch a ftate it would be moft advifeable to pafs a catheter down to it, and cut upon that; and probably the above-mentioned forceps Introduced through the wound might then lay hold ot its end ; or by cutting a little further, fo as to e-Xpofe Some part of the bougie, it might be eafily extracted, without the necef- fity n6 SUPPOSED CONSEQUENCES fity of cutting into the bladder. This part of the operation, however, would be very difficult in a fat or lufty man. To prevent the inconveniency of the bougie coming out, or the mifchief of its paffing in, it is neceffary to tie a Soft cot- ten thread round that end of the bougie which is out of the ure- thra, and then round the root of the glans. This lafl part Should be very loofe, for an obvious reafon ; and the projeft- ing part of the bougie fhould alfo be bent down upon the pe- nis, which makes it both lefs troublefome, and more Secure. IV. OF THE APPLICATION OF CAUSTIC TO STRICTURES. When a bougie can readily paSs, there is no neceffity for ufing any other method to remove the ftrifture : but there are too many cafes where a bougie cannot be made to pafs, or fo feldom that it cannot be depended upon for a cure. This may arife from feveral caufes. Firft, the ftrifture may be fo tight as not to allow the fmalleft bougie to pafs. Secondly, the orifice in the ftrifture may not be in a line with the ure- thra, which will make it uncertain, if not impoffible, to pafs a bougie. Thirdly, there may be no paffage at all, it having been obliterated by difeafe, and the urine paffed by fiftulae in perinaeo. The firft very rarely occurs, for if the paffage in the Stric- ture be in a line with the general canal, a Small bougie will eommonly paSs; and although it may not readily do So upon every trial, it will be Sufficient to make way for another bougie which is all that is wanted. The fecond cafe, where the canal is not in a line with the common paffage, may arife from three caufes. Firft, when the ftrifture is in the bend of the urethra, although the paf- fage through it may be in the centre of the canal, yet as the bougie cannot have the exact curve, it will be very uncertain in its application. Secondly, from an irregularity In the for- mation of the ftrifture, which may throw the paffage to one fide, even in the Straight part of the urethra ; and thirdly, from ulceration having taken place, producing fiftulae in perinseo which often make the canal irregular in its courfe. The third cafe where the application of the cauflic may he neceffary, is where there is no paffage at all, which happens from OF GONORRHOEA. 117 from ulceration and abfceffes in the perinaeum opening external- ly ; and in the healing of them the paffage is often clofed up entirely. In all the above-mentioned cafes I have fucceed- ed with the cauftic beyond expectation. If the obftruftions are any where between the membranous part of the urethra and the glans, where the canal is nearly ftraight, or can eafily be made fo by the introduction of a ftraight inftrument, it becomes an eafy matter to deftroy them by cau- ilic ; but if beyond that, it becomes then more difficult; how- ever at the beginning of the bend of the urethra the obftruc- tion may be fo far removed as to admit of the paffing of a bougie, or at leaft to procure a tolerably free paffage for the urine. I have feen feveral cafes where it was thought ne- ceffary to follow this praftice, and it fucceeded fo well that after a few touches with the cauftic the bougie could be paffed, which is all that is wanted. The fuccefs in thefe cafes was fuch as would incline me to have recourfe to this praftice ve- ry early : indeed whenever I could not paSs a Small bougie through the ftrifture. I look upon the cauftic as a much Sa- fer method than ufing preffure with a bougie, for the reafon before-mentioned, that is, on account of the danger of mak- ing a new paffage, without deftroying in the leaft any part of the obftruftion. Molt of the ftriftures I ever examined after death, appeared to have been in the power of fuch treatment ; however, I have feen one or two cafes, where the contraftion was of fome length and irregular, which would have puzzled me if I had at- tempted to cure with the cauftic ; becaufe I fhould have been apt to fufpeft that I was making a new paffage by my gaining ground, and yet not relieving the patient by the removal of the fymptoms. I have often tried this praftice in ftriftures where there were alfo fiftulae in the urethra, and where the water came through different paffages. Such cafes were not the moft favourable ; yet I fucceeded in the greater part of them, that is, I overcame the ftrifture and could pafs a bougie freely. I have feen feve- ral cafes of fiftulae of thefe parts, where the natural paffage was obliterated by the ftrifture, in which I have fucceeded with the cauftic, and the fiftulous orifices have readily healed. It does not happen always in cafes of obftruftion to the paf- fage of the urine, that when the obftruftion is removed by the cauftic, n8 SUPPOSED CONSEQUENCES cauftic, and the water of courfe paffes fieely, a bougie will al- fo pafs. This I apprehend arifes fiom the cauftic not having deftroyed the ftrifture in a direct line with the urethra, fo that a bougie cannot catch the found ureihra beyond. But this ap- pears to me of little confequence, as it is as much in the power of the bougie to prevent a return at this part as if it paffed on to fhe bladder; for if the water flows readily, it is cenain that the cauftic has gone beyond the ftrifture, although it may not be in a direct line, and that the only rifk of a return of ob- ftruftion will be at the old ftriftuie ; but as a bougie can now pafs beyond that part, it does as much good as if it paffed into the bladder ; for I have known Several caSes where the bou- gie appeared to have the Same effeft as if it had paffed on to the bladder. The application of the cauftic need not be longer than a mi- nute, and it may be repeated every day, or every other day, allowing time for the Slough to come off. But there are other caufes that may prevent the repetition of the cauftic, befides waiting for the Separation of the Slough ; tor Sometimes the ufe of it brings on irritation, inflammation, or SpaSm in the part, which frequently occaftons a total fuppreffion of urine for a time, againft which all the means, ufed commonly on fuch occafions to procure relief, muft be employed, and we muft wait till thefe fymptoms are gone off. If the patient can make water imme- diately after the application it will be proper ; as it will wafh away any cauftic that may have been diffolved in the paffage, which it left would irritate the parts. A little water injected into the urethra will anSwer the Same purpoSe. About the year 1752, I attended a chimney-Sweeper labour- ing under a ftrifture. He was the firft patient I ever had un- der this diSeaSe. Not finding that I gained any advantage af- ter fix months trial with the bougie, I conceived that I might be able to deftroy the ftrifture by efcharotics*; and my firlt at- tempt was with red precipitate. I applied to the end of a bou- gie fome Salve, and then dipped it into red precipitate. This bougie I paffed down to the ftrifture; but I found that it brought on confiderable inflammation all along the infide of the paffage which I attributed to the precipitate being rubbed off in patting the bougie. I then introduced a Silver cannula down to the ftrifture, * Having lately looked over fome authors on this difeafe, I find that this is not a new idea. OF GONORRHOEA. no. .ftrifture, and through this cannula paffed the bougie with pre- cipitate as before. Not finding, however, that the patient made water any better, and not as yet been able to pafs the fmalleft bougie through the ftrifture, I fufpefted that the pre- cipitate had not fufficient powers to deftroy it. I therefore took a fmall piece of lunar cauftic and faftened it on the end of a wire with Sealing wax, and introduced it through the cannu- la to the ftrifture. After having done this three times, at two days interval, I found that the man voided his urine much more freely. Upon the application of the cauftic a fourth time, my cannula went through the ftrifture*. A bougie was afterwards paffed Sor Some little time till he was perfeftly well. Having fucceeded fo well in this cafe, I was encouraged to apply my mind to the invention of fome inftrument better fuited to the purpofe than the above-mentioned, which I have in fome degree effefted, although it is not yet perfeftly adapted to all the Situations of ftrifture in the urethra. The cauftic fhould be prevented from hurting any other part of the canal; which is beft done by introducing it through a cannula to the flric- ture, making it protrude a little beyond the end of the cannula, by which it afts only upon the ftiicture. The cauftic fhould be fixed in a fmall portcrayon. It is neceffary to have a piece of Silver the length of the cannula, with a ring at one end, and a button at the other of the fame diameter with the can- nula forming a kind of a plug, which fhould project beyond the end of the cannula that enters the urethra, by which means it makes a rounded end ; or the portcrayon may be formed with this button at the other end. The button being intro- duced into the cannula, it fhould be paffed into the urethra, and when it reaches the ftrifture the Silver plug fhould be withdrawn, and the portcrayon with the cauftic introduced in its place ; or, if the plug and portcrayon are on the fame inftrument, then it Is only withdrawing the plug, and introducing the portcray- on with the cauftic. This plug, befides giving a Smooth round- ed end to the cannula, anSwers another good purpoSe, by pre- •venting the cannula from being filled with the mucus of the urethra, as it paffes along, which mucus would be coilefted in the end of it, diffolve the cauftic too Soon, and hinder its ap- plication to the ftrifturet. ,r * Wifeman had the fame idea, but probably the clumfy way in which he attempted to put it in execution might be the reafon why he feenu not to have purfucd it. f Vide plate II, fig. I, . . . ' SUPPOSED CONSEQUENCES If the ftrifture be in the bend of the urethra, the cannula may be bent at the end alfo ; but it becomes more difficult to introduce a piece of cauftic through fuch a cannula, for the plug and portcrayon muft alfo be bent at the end, which can- not be made to pafs through the ftraight part of the cannula ; but this I have in fome meafure obviated by having the can- nula made flexible, except at the end where it is to take the curve*. After the bougie can be made to pafs, the caSe is to be treated as a common Stricture, either by dilating it flowly, or by quick- ly increafing the fize of the bougie, and thus continuing the ulceration. There are Sometimes more ftriftures than one ; but it fel- dom happens that they are all equally ftrong. One only be- comes the object of our attention. The Smaller ones may, how- ever, be Sufficient to hinder the paffing the cannula to that which is to be deftroyed by the cauftic. When that is the cafe, thoSe fmall ftriftures are to be dilated with bougies, as in common, till they are fufficiently large to allow the cannula to pafs. CHAPTER III. OF STRICTURES IN WOMEN. OBSTRUCTIONS to the urine in women, I believe, ge- nerally arife from ftrifture, although not always ; for I have known them produced by comprefhon from fome adja- cent fwelling ; and they are common in uterogellation, as alfo in dropfical or Scirrhous ovaria. But Such catiSes are common- ly known long before this effeft is produced, by which the fup- preflion is eafily accounted for. It may alfo ariSe from excre- fcences as in men. How far a ftrifture, in the urethra of this Sex, is really a conSequence of a venereal inflammation, I am not certain • but fhould SuppoSe it is not; and for ftronger reafons ftill than thofe * Vide plate II, fig. a and 3. OF GONORRHOEA. 1'2J thofe which I gave in Speaking oS the cauSe of ftriftures in men; for I can fay, that none of the ftriftures that I have feen in wo- men, have arifen in conSequence of this diSeaSe ; at leaft I had no reaSon to believe that they did ; and I have obServed before, that in mofl women, who have the venereal difeafe in the form of a gonorrhcea, it feldom attacks the urethra. Therefore if we find a ftrifture in a woman. ,who has had the difeafe, we are not to impute it to that, at leaft till we can afcertain the ure- thra was affefted; and even then it will remain doubtful. Strictures are not near fo common in women as in men. This may be owing to the great difference there is in the length of the two canals ; but more efpecially to the canal in women being more Simple, and intended only Sor one purpofe. The ftrifture in women does not produce Such a variety of fymp- toms, or fo much mifchief, as in men, there not being fo ma- ny parts to be affefted. I. OF THE CURE OF STRICTURES IN WOMEN. The cure of ftriftures in the urethra of women is Similar to that in men : but it is rather more Simple from the Simpli- city of the parts. There is, however, an inconvenience at- tending the paffing the bougie in women, that does not occur in men, which is, that in moft caSes it muft be paffed for them, it being hardly poffible for a woman to introduce a bougie her- felf. The-confinement of the bougie is alfo more difficult, for although it can eafily be prevented Srom going into the hiad- der by bending the outer end down upon the mouth of ^he-va- gina ; yet it is very difficult to prevent them from flipping out. It will be neceffary to have a bandage of the T kind paffing down between the labia over the bend of the bougie. It appears to me that the cauftic would anfwer extremely well in fuch cafes, and therefore I fhould prefer it to the bou- gie, both for convenience and efficacy. II. OF THE GLEET IN CONSEQUENCE OF'^A STRICTURE. , I HAVE already obferved, that it happens generally, if not always, that there is a gleet when there is a ftrifture in the ire- R ^ thra. 122 SUPPOSED CONSEOUENCES thra. This I SuppoSe to ariSe from the Irritation produced in the urethra beyond the ftrifture, bv the urine in its paffage dif- tending this part too much, which diflenfion is increafed by the increafed ftrength of the bladder. This fymptom often leads us to the knowledge of a ftrifture, or at leaft gives a fufpi- cion of fuch a difeafe ; and when a ftrifture is known to be the caufe, no attempts fhould be made to cure the gleet, lor it is generally cured when the ftrifture is removed ; but if it ftill re- mains it may be cured as recommended in the common gleet, as probably arifing Srom a cauSe different from a ftrifture. — ■ntf ----■ CHAPTER IV. OF STRICTURE ATTENDED WITH SPASMODIC AFFECTION. THERE are very few ftriftures that are not more or lefs attended with SpaSm; but Some much more than others, the SpaSm being in Some caSes more the difeafe than the ftric- ture itSelf. But real ftriftures are attended with occafional con- traftions, which make the paffing of the urine much more dif- ficult at one time than another. In all the cafes that I have Seen of this kind, when not attended with SpaSms, the difeafe is not formidable ; but when the parts are in a SpaSmodic ftate, the fymptoms are as violent as in the fimple ftrifture. As this is a mixed caSe, it has all the charafters both of the permanent and fpafmodic ftrifture ; Sor the urethra in Such cir- cumftances is in a ftate fimilar to what it is in the true SpaSmo- dic kind, being very irritable, giving great pain in paffing of the bougie, and often rejefting it altogether; as will be taken notice of when we fhall treat of that diSeaSe. Upon confidering this fubjeft we fhould at firft hardly be diS- poSed to believe that the Spafm in the urethra is in the ftriftured part, which can fcarcely be fuppofed capable of contraction; and it might therefore naturally be referred to the found part of the urethra, as being brought on by the waters not flowing freely. If this is a juft mode of accounting for it, we muft SuppoSe OF GONORRHOEA. ^o fuppofe that the contraftion is behind the ftrifture, that being the only part dilated by the water ; and fuch urethras being ve- ry irritable, that part may contract fo as to ftop the flowing of the water altogether. But fome circumftances that occur in praftice, giving reafon to believe that fuch ftriftures have the power of contraftion ; for we find the bougie grafped by the ftrifture when allowed to remain fome time. And the circum- flance of the ftriftured parts refufing the bougie at times is al- fo a proof of the fame. There is fometimes this fingular circumflance attending thefe cafes, that when there ariSes a gonorrhcea, or any other diS- charge of matter from the urethra, or an increafe of an old gleet, the paffage becomes free, and allows the urine to pafs as u- Sual; but Such relief is uncertain and only temporary ; for when- ever the difcharge ceafes the SpaSmodic affeftion returns. I think it is probable that it is only the SpaSm that is affefted by the diScharge, and not the real ftrifture. Two remarkable ca- Ses of this kind fell under my obfervation, which I fhall now relate. A gentleman had for a long time a complaint in the urethra attended with a ftrifture, which was SuppoSed to be originally from a venereal complaint. It was often attended with a dif- charge which always produced a flight fever on its coming on ; but while the difcharge lafted, the difficulty in making water was relieved, and that in proportion to the greatnefs of the difcharge ; and whenever he got a frefh gonorrhcea the fame thing happened. Another gentlema'n had a difficulty in making water, fuppo- fed to arife Srom a ftrifture. It was generally attended with fuch a running as is common to ftriftures ; but when that dif- charge was much increafed, then the ftrifture was leSs in pro- portion. During this complaint he contrafted two different infections, both of which relieved him of the ftrifture for the time. As this is a mixed diSeaSe, it may be thought proper to treat it with bougie for the real ftrifture, and for the other to ufe the method hereafter recommended for the cure of fpafm. It fometimes happens in thefe mixed kinds, that a bougie does not immediately pafs, but is rejefted by the fpafm ; yet by letting it lie in the urethra almoft clofe to the ftrifture for ten, fifteen, or twenty minutes, you will often make it pafs. This is 124 SUPPOSED CONSEQUENCES is as it were ftealing upon it, and the water will often flow al- though the bougie is not attempted to be paffed on. It is of- ten relieved by gentle irritating injeftions. CHAPTER V. OF SOME CIRCUMSTANCES ATTEND- ING THE USE OF BOUGIES—THEIR FIGURE AND COMPOSITION. IN cafes of ftriftures, where a bougie is ufed as a wedge, not as a ftimulant, and where the ftrifture is fo far overcome as to let a bougie pafs on, the queflion is, whether it may be better to pafs the bougie through the whole length of the ure- thra, So that the end of it fhall be in the bladder, or only to pafs it through the ftrifture a little way, fo that its end fhall re- main in the urethra. Nothing but experience can determine this queflion ; and, perhaps, in Such caSes we Seldom make a fair trial, generally pufhing the bougie on to the bladder; though if we obferve the confequences of the bougies not paffing in thofe cafes, where they either cannot pafs far beyond the Stric- ture, or not at all, we find no inconvenience arifing from this circumflance, except when they are applied with too much force, fo as to make a new paffage. Th - common idea is, that it will be more hurtful to allow the end of the bougie to lie in the urethra than in the bladder; but this Seems to be more founded in theory than praftice. Some people have Such a quantity of calculous matter in their urine, or fo great a difpofition in their urine to depofit its cal- culous matter, that it only requires the preSence of an extrane- ous body in the bladder to become an immediate caufe of ftone; for I have obferved in fome, that the end of a bougie cannot remain in the bladder a few hours without being covered with a crufl of calculous matter. Such people I have generally advl- Sed to uSe as much exercife as all other circumftances will allow. Bougies, when firft introduced, often produce fickneSs, and fometimes even fainting. 1 have feen a patient become fick, the OF GONORRHOEA. 125 the colour leave his face, a cold Sweat come on, and at lafl a deliquium ; but all theSe effefts Soon go off, and Seldom return tipon a Second or third trial. They at firft produce an irrita- tion on the urethra, which gives pain in the time of making wa- ter, but goes off on repetition. They produce a fecretion of pus in thofe cafes, where there was none, and generally in- creafe the diScharge where there is one previous to the applica- tion of them ; but this effeft gradually ceafes. It frequently happens, that fwellings in the lymphatic glands of the groin arife from the ufe of bougies ; but I never faw them advance to fuppuration. As in moft of fuch cafes there is a diScharge of matter previous to the bougie being paffed, they can hardly be owing to the abforption of matter, but muft arife from fympathy. When treating of the ftrifture, I obServed that it was often the caufe of a fwelling in one or both tefticles ; and further, that the paffing of a bougie often removed that complaint. I may now obferve, that a very common confequence of the paf- fing a bougie is a fwelling of the tefticle. This alfo arifes from fympathy, and like the Swelling of the glands, is a common effeft of all irritations of the urethra. It may not be improper here to add fome obfervations on the figure and compofition of bougies. They ought to be about two inches longer than the diftance between the glans and the ftrifture, or more if they can pafs freely, fo as always to allow an inch to bend upon the glans, and another to pafs beyond the ftrifture. The thicknefs Should be according to the Size of the ftrifture ; at firft, Such as will paSs with a Small degree of tight- nefs, and this fhould be gradually increafed as the contrafted part enlarges. But when the urethra has become of the natu- ral fize, the bougie need not be Surther increaSed, but its uSe Still continued, as has been obferved. With regard to the fhape, they fhould not taper from end to ■ end when very fmall, but fhould be nearly of an equal thick- nefs till within an inch of their Smalleft end, after which they fhould taper to a point, Sorming a round wedge fitted to paSs in- to the ftrifture ; and this Sorm gives them greater ftrength than when made to taper from one end to the other. The confiftence ought to vary according to the nature of the cafe, and Size of the bougie. If the ftrifture be near the glans, a Stiff bougie may be uSed, and the whole may be made to ta- per 126 SUPPOSED CONSEQUENCES per gradually, becaufe a Short bougie will always have fuffici- ent ftrength for any preffure that is neceffary ; but iS the Stric- ture be deeper Seated, as about the bulb, where the paffage be- gins to take a curve, the bougie muft be a little thicker in its body to Support the neceffary preffure, If the fliifture be any where in the bend of the urethra, or near the bladder, the bou- gie fhould be very flexible, (although this is contraty to our ge- neral pofition) becauSe in this cafe it muft bend in order to adapt itSelf in the curve of the paffage, which it ought to do with eafe ; for when it bends with difficulty it does not make its pref- fure upon the ftrifture, but upon the back part of the urethra, and therefore oes not enter fo eafily; which circumflance makes it more difficult to enter a ftrifture near tlie bladder, than near the glans. In the compofition of the bougie the confiftence is the moft material thing to be eonfidered ; the medical proper- ties, as far as known, being of little confequence. The ma- terials of which they are commonly made, are wax, oil, and litharge. The litharge gives them fmoothnefs, and takes off the adhefive quality which they would have if made of wax and oil only. A compofition which anSwers well, is three pints of oil of olives, one pound of bees wax, and a pound and an half of red lead, boiled together upon a flow fire for fix hours. I. OF A NEW PASSAGE FORMED BY BOUGIES. The greateft evil arifing from the improper ufe of the bou- gie, and the moft dangerous is, where it makes a new paf- fage*. I mentioned before that this generally arofe from an attempt to produce ulceration by the application of the end of the bougie to the ftrifture in cafes where a bougie could not paSs ; for in thofe cafes where a bougie paffes there can be no danger of fuch an effeft. This new paffage is feldom carried fo far as to produce ei- ther an increafe of the prefent difeafe, or a new one, although fometimes this happens ; yet it prevents the cure of the ori- ginal difeafe, for it renders both the application of the bou- gie and cauftic to the ftrifture fo uncertain, that a continu- ance of either is dangerous, as it may increafe the mifchief and at lafl produce very bad confequences. This * Vide plate II, fig. 4. OF GONORRHOEA. 127 This new paffage is generally along the fide of the old one, when in that part of the urethra which is on this fide of the bend, and it is made in the Spongy Subflance of the urethra ; but when it is made at the beginning of the bend, then it paf- fes on in a ftraight line through the body of the urethra, about the beginning of the membranous part, going through the cel- lular fubftance of the perinaeum towards the reftum. When the new paffage is made between the glans and the bend of the urethra, it may take place on either fide of the canal equal- ly, in the fpongy fubftance of the urethra, between the canal and the fkin of the penis, or Scrotum ; and it may be between the canal and the body of the penis. The Situation of it will make fome difference in the operation neceffary Sor the cure of this complaint. When a new paffage is made, I know of no other method of cure but to open the part externally ; and the opening muft be made in that part of the urethra which is mofl convenient for coming at the ftrifture ; regard being had to the other ex- ternal parts, fuch as the fcrotum. If the ftrifture be before the fcrotum, the new paffage will be there alSo, and therefore the operation muft be made of courfe before that part; but if the ftrifture is oppofite to the Scrotum, the bottom of the new paffage may alfo be oppofite to this part ; but if the new paf- fage is of a confiderable length, its bottom or termination may be in the beginning of the perinaeum ; and in either Situation the operation muft be begun behind the Scrotum, or indeed may be made a little way into it. But iS the ftrifture and new paf- Sage are in the perineum, then the operation is to be per- formed there. The method of performing this operation is as follows. Pafs a Staff, or any Such inftrument, into the urethra as far as it will go, which will probably be to the bottom of the new paffage ; and that we may be certain is beyond the ftrifture. Feel for the end of the inftrument externally, and cut upon it, making the wound about an inch long, if the difeafe be before the Scrotum ; and an inch and an halS, or more, if in the perinaeum. If the new paffage be between the urethra and the body of the penis, then you will moft probably get into the found urethra before you come to the inftrument or new paffage ; if fo, it is not neceflary to go further in order to get into the bladder, as we may be certain that this part of the urethra is behind the ftric- ture. 128 SUPPOSED CONSEQUENCES ture. Having proceeded fo far, take a probe, or Some Such inftrument, and introduce it into the urethra by the wound; and paSs it towards the glans, which will be paffing it forwards towards the ftrifture. If it meet with an obftruftion there, we may be certain it is the ftrifture, which is now to be got through, and which will afterwards be eafily enlarged. To complete the operation, withdraw the probe, and introduce in the room of it a hollow cannula forwards to the Stricture ; then take another cannula and introduce it from the glans downwards till the two cannulas oppoSe each other, having the ftrifture between them ; an affiftant laying hold of the urethra on the outfide, between the finger and,thumb, juft where the two cannulas meet, to keep them in their places ; then through the upper cannula introduce a piercer, which will go through the ftrifture, and pafs into the lower cannula ; this done, with- draw the piercer, and introduce a bougie into the fame can- nula, in the fame way, being careful that it paffed into the low- er cannula, then withdraw the lower cannula, and the end of the bougie will appear in the wound ; lay hold of the bougie there, and withdraw the upper cannula over the bougie, leaving the bougie in the urethra ; now the lower end of the bougie is to be directed into the urethra leading on to the bladder, and pufhed on to that vifcus. It may be further neceffary to lay the whole of the new paffage open, that it may all heal up ; for it is poffible that this new paffage may often receive the bougie, to be applied in future, which would be troublefome, and might prove an obftruftion to the cure. If the new paffage be between the fkin and the canal of the urethra, after cutting down to the inftrument, you muft go further on in Search of the natural canal, and, when you have found it, introduce a probe into it towards the gfans to find the ftrifture ; and when this is done, go on with the operation as above deScribed. The bougie muft be left in the paffage, and as it may be found difficult afterwards to introduce'another readily into the bladder, the longer^he firfl is allowed to remain, fo much the more readily will the fecond pafs. I am not yet certain but that it would be better to pufti on the hollow cannula at firft, and keep it there for fome days, at leaft till the inflammation is over and the parts have adapted themfelves to that body, which will make a bougie pafs more eafily afterwaids. The boueies muft be OF GONORRHOEA. 12q be gradually increaSed in fize, and continued till the wound is healed up. The firft cafe of a new paffage, formed by a bougie, which I ever faw, was at the hofpital of the third regiment of guards^ about the year 1765. A young foldier who had a ftrifture, for the cure of which he had bougies regularly paffed for near half a year without any relief. The bougie had gone further than at firft by two inches, and therefore Seemed to have gain- ed ground on the ftrifture. This Seemed to juftify the conti- nuance of the praftice ; but it being fufpefted that there was Something more than was then underftood, I was conSulted, and without forefeeing what was really the cafe, I propofed that an opening fhould be made into the urethra where the obftruc- tion was, and carried further back if neceffary, in Search of the Sound urethra. This was accordingly done in the follow- ing manner : the grooved Staff was firft paffed as far down as it could go, which was to the bottom of the new paffage;, the fcrotum was pulled up upon the penis, when the end of the Staff was prominent towards the fkin a little way above the pe- rinaeum, and there an incifion was made on the end of the Staff about an inch long: this diSengaged the end of the ft a ft, which was pufhed out at the wound ; then Search was made for the other orifice which led to the bladder, on a Suppofition that that orifice was the ftrifture ; but none being to be found, we tried to trace it by blowing with a blowpipe into the bottom and lower part of the wound ; but no orifice could be obferv- ed. We then began to fufpeft, that we were not in the ure- thra. To determine if we had been in the urethra, I began to diffeft with care the parts at the bottom of the wound, and laid bare the mufculi acceleratores. I then made an incifion into the body of the urethra and came to the true canal, which was eafily discovered. When this was done we paffed a probe on to the bladder, then withdrew, turned, and paffed it from this wound towards the glans penis, but found that it went not much more than two inches that way, and then ftopped. This (truck us with a new idea of the cafe ; for we were now fure that the end of the ftaff had not been in the urethra, but in a new paffage made in the Spongy part of the urethra, for two inches beyond the ftiifture. We now paffed a ftaff from the glans down the urethra, and another up from the lafl wound, to fee at what diftance the ends of the two inftrnments were, S which r?,o SUPPOSED CONSEQUENCES which would give us the length of fhe flrifture. We found, by taking hold of the urethra between the finger and thumb 01* the out fide, that the two ends were cloSe together. What was to be done next was our confideration ; it immediately llruck us that we might force our way thrdugh the ftrifture with Safe- vy. The gentleman, who affifted me in the operation, paffed at blowpipe one-fifth of an inch in diameter (being not Sufficient- ly fiinii(hed with inftruments) from the wound forwards to the ftrifture ; and then I took a Silver cannula, open at boih ends, which had an iron piercer longer than itSelf, and paffed it down to the ftrifture Srom the glans ; and now the end of the cannu- la oppofed the end of the blowpipe, and they were almoft clofe upon one another. They were kept in this pofition, with the finger and thumb applied on the outfide of the penis, like fplints on a broken bone. I then introduced the piercer and pufiled it on, which went through the ftrifture into the hollow of the blowpipe. Great care was taken not to pufh too forcibly, left the two ends of the hollow tubes ihould flip by ofie another, which they would do if not held firmly, as actually happened twice in this cafe; but we Succeeded the third time. I then pufhed on the cannula through the ftrifture, and with it pufh- ed out the blowpipe. The next objeft was to pafs a hoiiow bougie along the urethra to the bladder, to do Which the fmall end of it was introduced into the cannula, which being pufhed on forced out the cannula at tl>e wound ; we then paffed a di- rcftor into the orifice of the urethra, leading on to the bladder, and put the end of the bougie into the groove of the dircftor, and pufhed it along the groove to the bladder ; and before we withdrew the dircftor we turned it round with its back to the bougie, that the enrJ of the bougie might not ftop againff the end of the groove, and So be pulled out again. After all this was done, one flitch was made in the urethra, but the exter- nal wound in the fkin was left for the paffage of the urine, that it might not infinuate itfelf into the cellular membrane. We dreffed the wound Superficially, and applied the T bandage, which was flit to go on each fide of the fcrotum, and jult where it came to the fcrotum we tied the two ends together, which Supported the fcrotum and kept it forwards on the penis ; and the two ends that came from this knot on each fide of the fcro- tum were tied to the circular part that came round the body. The patient had fome flight fever ;jr a day or two, and the urine OF GONORRHOEA. 131 urine came partly through the bougie and partly by the fide of it through the wound. A Swelling of one tefticle ctr the fteam of warm water and vine- gar ; and this application to the perinaum never failed of making him void his urine. t Dr. Home, in his experiments on this medicine, found that large doles brought on the ftrar.pury in women. Strangury is the frequent effeft of turcentir.e taken for foT.e time. i52 SUPPOSED CONSEQUENCES and a habit of paffing it. The bougie has likewife this advan- tage, that in many cafes, where the part SpaSmodically affefted will not allow it to pafs, it may be allowed to lie clofe to the ftrifture; for it is not always neceffary for the bougie to pafs through the conftrifted part; for a bougie, which has only paffed a very little way into the urethra, has Sometimes been effectual, if fuffered to flay there till the defire of making wa- ter is perceived. In fuch cafes, even when the bougie paffes into the bladder, it is neceffary to let it flay in the paffage till the inclination to make water comes on. If the water does not follow on the firft attempt, it will be proper to make another ; or if only part follows the bougie, it will be neceffary to introduce it again. This circumftance of the water following the bougie with more certainty, if it is allowed to flay till the inclination comes on, is a proof that the difpofition in the bladder to con- tracting, removes in fome degree the difpofition to contrac- tion in the urethra* Some attention is neceffary with refpeft to the paffing of the bougie in theSe caSes ; Sor the urethra being more irritable than common, it often refills the bougie beSore it reaches the true SpaSmodic part. When this is the caSe, Sorce is not to be uSed ; but we fhould rather wait a little with patience, and then make another attempt to pufh it on. Dipping the end of the penis in very cola water often removes the fpafm, and the wa- ter flows immediately and freely. In moft cafes there is an uneafy SenSation at the end of the penis, which leads the patient to rub thofe parts, and fome- times, though rarely, during the friftion, the water will pafs. Gentle irritating injeftions, thrown in only a little way, often give eafe. They may be fuppofed to aft in a manner Some- what fimilar to a bougie that does not pafs, and by irritating one part of the urethra to produce a, relaxation in the other* They aft in fome cafes as a preventive. III. OF THE PARALYSIS OF THE URETHRA. In oppofitlon to the foregoing diSeaSe, there is the want of power of contraftion of the urethra ; but this is not fo fie- quent a cafe as the former. This diSeaSe is attended with f\ mptoms contrary to thoSe of the foregoing ; the bladder is hardly OF GONORRHOEA. *53 hardly allowed to be filled fo as to give the ftimulus of reple- tion ; but the water dribbles away infenfibly as faft as Secreted by the kidneys; or if the bladder is filled So as to receive the ftimulus for expulfion, then it immediately takes place, and the water flows, if the perSon does not aft with the mufculi acceleratores; but Sometimes in Such cafes the power of con- traction of thefe mufcles is loft, and then the water will flow, whether the perfon will or not, there being little or no power of retention. There is great difference in the degrees of vio- lence of this difeafe; IV. CURE OF THE PARALYSIS OF THE URETHRA; It is to be cured by ftimulants, as a blifter to the loins, of a blifter to the perinaeum. It may be ufeful to immerfe the Seet in cold water. Tinfture of cantharides, taken internally, fif- teen or twenty drops once or twice a day, according to their effefts, are of Singular fervice in Some caSes. A man came to St. George's hofpital with this complaint; I ordered him the before-mentioned medicine, and it had fuch an effeft as to bring on the contrary difeafe, Or a fpafmodic affeftion of the urethra, fo that he could not make water when he had the inclination ; but an injeftion of opium removed this complaint, and he was then well. In this cafe a Sew drops lefs, probably would have effefted a cure without any incon- venience. V. OF CARUNCLES OR EXCRESCENCES IN THE URETHRA. Strictures are not fuppoSed to be the only cauSes of ob- ftruftion to the paffage of urine in this canal ; excrefcences or caruncles are likewife mentioned by authors as happening fre- quently. From the familiarity with which they talk of them, and the few inftances in which they really occur, one would SuSpeft that this CauSe of obftruftion Was originally founded in opinion, and not obfervation, and afterwards handed down as matter of faft. If caruncles had been at firft defcribed Srorh aftual examination of cafes, the language would have accorded with the appearances, and they would have been eonfidered a* feldom the cauSes of obftruftion compared with ftriftures. How- X ever/* 1^4 SUPPOSED CONSEQUENCES ever, they do Sometimes happen, although but rarely. I have in all my examinations of dead bodies feen only two, and thefe were in very old ftriftures, where the urethra*had Suffered con- siderably. They were bodies rifing from the furface of the ure- thra like jrranulations, or what would be called polypi in other parts of the body. It is poffible they may be a Species of in- ternal wart; lor I have Seen warts extend Some way into the beginning of the urethra, having very much the appearance of granulations. Moft probably it will not be poffible in the liv- ing body to diftinguifh caruncles, excrcScences, or rifings in the urethra, from a ftrifture ; for I cannot conceive that they can produce any new Symptoms, or peculiar Seel to the examiner. VI. OF THE CURE OF THE EXCRESCENCE OR CARUNCLE. . I should very much SuSpeft that this diSeaSe is not to be' cured by the bougie; at leaft dilatation in Such caSes is not to be attempted, as there is no contraftion. If therefore the bou- gie is of any ufe, it muft be in making the carnofity ulcerate from its preffure, which probably may be done by a large bou- gie preffing upon it with confiderable force. But if this Should not have the defired effeft, I fliould certainly recommend or ufe the cauftic, if the parts are So Situated as to admit of the application ; and from Such practice I fhould not doubt of a cure. But the difficulty lies in diftinguifhing the difeafe from the true ftrifture ; for although authors talk of caruncles as common, and give us the method of treatment, yet they have not told us how we are to diftinguifh them from ftriftures. I have never met with a caruncle in women. ---------■ingmfn -------- CHAPTER VIII. OF THE SWELLED PROSTATE GLAND. ANOTHER difeafe of the parts furrounding the urethra, which r» often very formidable, is a fwelling of the pro- ftate OF GONORRHOEA. t,r flate gland. This is of more ferrous confequence than any of the former cauSes oS obftruftion, becauSe we have fewer me- thods of cure, for we cannot deftroy it as we do the ftrifture, nor can Nature relieve herfelf by forming new paffages; we have, however, often the means of temporary relief in our power, which is not the cafe in the ftrifture ; for mofl com- monly we can draw off the water by the catheter. The fwelling of the proftate gland is moft common in the decline of life. The ufe of this gland is not Sufficiently known . to enable us to judge of the bad confequences that attend its difeafed ftate, abftrafted from Swelling. Its fituation is Such, that the bad effefts of its being Swelled muft be evident, as it may be Said to make a part of the canal of the urethra, and there- fore when fo difeafed as to alter its fhape and fize, it muft ob- flruft the paffage of the urine. When it fvvells It does not leffen the Surface of the urethra at the part like a ftrifture ; on the contrary, it rather increafes it; but the fides of the canal are compreffed together, producing an obftruftion to the paf- fage of the urine, which irritates the bladder, and brings cm all the fymptoms in that vifcus that ufually arife from a ftrifture or ftone. From the fituation of the gland, which is principally on the two fides of the canal, and but little, if at all, on the . fore part, as alfo very little on the pofterior fide, it can only , fwell laterally, whereby it preffes the two fides of the canal together, and at the Same time ftretches it from the 'anterior edge or fide to the pofterior, So that the canal, inftead of be- ing round, is flattened into a narrow groove. Sometimes the gland fwells more on one fide than the other, which makes an, obliquity in the canal paffing through it, BeSides this effeft of the lateral parts Swelling, a Small por- tion of it, which lies behind the very beginning of the urethra, fwells forwards like a point, as it were, into the bladder/ aft- ing like a valve to the mouth of the urethra, which can be feen even when the fwelling is not confiderable, by looking upon the mouth of the urethra from the cavity of the bladder in a dead body. It fometimes increafes So much as to form a tu- mor*, projefting into the bladder Some inches. This projec- tion turns or bends the urethra forwards, becoming an obstruc- tion to the pafTige of a catheter, bougie, or any fuch inftru- ment; and it often raifes the found over a Srrul' ftone in the bladder, * \Az pbtcs IV and VI. 1,56 SUPPOSED CONSEQUENCES badder, fo as to prevent its being felt. The catheter fliould for this part be more curved than is neceffary Sor the other parts of the urethra. In Such caSes I have frequently paffed firft a hollow elaftic catheter till it has reached this point, and after- wards a ftilet or brafs-wire properly curved So as to go over the prolate gland. The advantages of this method are. that if the hollow catheter paffes, no more is neceffary; and, if it does not, the curved wire will pafs along the hollow bougie much eafier both to the Surgeon and patient than it would have done if it had been intrpduced at firft with the hollow bougie over it; for it would endeavour to adapt the urethra to the curve : ■whereas, when introduced afterwards, the Stilet afts only on the infide of the hollow bougie, which the patient hardly feels. A gentleman had been often founded for a ftone, and yet no ftone could be found ; but it afterwards appeared that there was a ftone, which, together with the fwelling of the proftate gland, had been the cauSe of his death. John Doby, a poor penfioner in the Charter-houSe, had been Several years afflifted with the ftone in the bladder, and. was relieved Srom all the Symptoms by an enlargement of this part of the proftate gland, preventing the flones from falling down upon the neck of the bladder and irritating thofe parts. A twelvemonth after that the fymptoms of the ftone had gone off, he was attacked with a ftrangury, to relieve which, many ineffectual attempts were made both with the bougie and cathe-. ter; but it foon proved Satal. Upon examination of the parts in the dead body, the proftate gland was found enlarged to a fize fix times greater than what it is in common, and the ure- thra, paffing through it, was a flit about an inch and half in length, the two fides of which were clofe together, the upper end towards the pubes and the lower towards the rectum. This flit was formed by the fides of the proftate gland only fwelling, and the right fide was the moft enlarged, having its furface next the urethra rounded or convex, and the left fide was exactly fitted to it, having its furface hollowed in the fame proportion. The fmall projefting point of the gland was So much enlarged as to come forwards into the cavity of the bladder and fill up entirely the paffage at the neck of it. The bladder itfelf was very much enlarged and thickened in its coats, and contained above twenty Stones, moft of them lying behind the projefting procefs of the proftate gland, and the reft lodged in fmall facs, i^ade OF GONORRHOEA. »S7 jnade by the internal membrane being pufhed fome little way between the fafciculi of mufcular fibres. The proftate gland when Swelled, generally becomes firmer 5n its confiftence. The effefts of thefe fwellings are very con- fiderable, for they Squeeze the fides of the urethra clofe together, and the projefting point hinders in Some degree the urine from entering the paffage, and in many cafes ftops it entirely. Fur- ther, the increafed firmnefs of the fubftance of the gland hin- ders it from yielding to the force of the urine, So that little or none can pafs. It will be unneceffary to relate the particular fymptoms which this diSeaSe occafions ; they are Such as ariSe from any ftoppage of urine, producing an irritable bladder. When a difficulty in making water takes place, a bougie is the inftrument which the furgeon will naturally have recourfe lo, and if he finds the paffage clear, which he often will, in fuch cafes he may very probably fufpeft a ftone. If Search is made and no ftone Selt, he fhould naturally SuSpeft the proftate gland, eSpecially if the found or inftrument ufed meets with a full ftop, or paffes with Some difficulty jufl at the neck of the bladder. He fhould examine the gland. This can only be done by introducing the finger into the anus, firft oiling it well, placing the fore part of the finger towards the pubes ; and if the parts, as far as the end of the finger can reach, are hard, making an eminence backwards into the reftum, fo that the finger is obliged to be removed from fide to fide, to feel the whole extent of fuch a fwelling, and it alfo appears to go be- yond the reach of the finger, we may be certain the gland is confiderably fwelled, and is the principal caufe of thofe fymp- toms. I have known cafes where the common catheter has been pufhed through the projefting part of the gland into the blad- der, and the water then drawn off; but in one patient the bleed- ing from the wound paffed into the bladder and increafed the quantity of matter in it. The ufe of the catheter was attempt- ed a fecond time, but, not fucceeding, I was Sent for. I paf- fed the catheter till it came to the flop, and then SuSpefting that this part of the proftate projefted forwards, I introduced my finger into the anus, and found that gland very much enlarged. By deprefling the handle of the catheter, which of courfe raif- ed the point, it paffed over the projection ; but unfortunately the blood had coagulated in the bladder, which filled up the holes 158 SUPPOSED CONSEQUENCES holes in the catheter (o that I was obliged to withdraw it, and clear it repeatedly. This I practifed feveral days; but Suf- pefting that the coagulum muft in the end kill, I propofed cut- ting him as if for the ftone ; but he died before it could be conveniently done, and the diffeftion, after death, explained the cafe to be what I have now defcribed. In fome of thofe cafes where this part of the gland fwells into the bladder in form of a tumor, the catheter has been known not to bring off the water at times when it appeared to have paffed; and upon the death of the patient when the parts have been examined, it was imagined that the catheter, in the living body, had made its way into the tumor fo as to have been buried in it at thofe times*. From the knowledge of the above-mentioned facts, when- ever I find the urine does not flow immediately upon introduc- ing the catheter into the bladder, I have pufhed it on and de- preffed the handle fo as to reach the fundus of the Madder with the end of the catheter, and have always fucceeded. For the more ready introduftion of the inftrument, a catheter made flexible at the point only lor about an inch, 19 perhaps beft, as it is more under the command of the hand than when wholly flexible. If the bougie be ufed, it mould be firft warmed and then ve- ry much bent at the point, and allowed to cool in this pofition, and paffed quickly with the concave fide upwards, before it kffes the bend in its paffage. But the bougie does not anfwer fo well as the catheter, becaufe upon withdrawing the bougie the fides of the gland foon clofe again. I have known where the water has paffed by the fide of the bougie with more free- dom than when it was pulled out, becaufe the bougie gave a ftraightnefs to this part of the canal, which it had not when the bougie was withdrawn. The following cafe is a ftrong in- ftance of the inconveniences arifing from Such a diSeaSe of the proftate gland. A gentleman was attacked with a fupprefTion of urine; a ca- theter could not be paffed, but a bougie relieved him. He con- tinued well for five years ; but the f^.me complaint returning, the bougie could not be paffed, and the difeafe was fuppofed to be a ftrifture. A catheter however paffed, although with a good deal of difficulty ; and the bougie, though oficn tried, could * Vide plate VI. Of GONORRHOEA. \q could not be paffed, excepting once, juft after ufing the cathe- ter. I was Sent for, and tried the bougie with as litth; lacccl>, and was obliged to have recourfe to the catheter. I paffed it with great eafe, and the water was drawn oir. The late Mr. Tomkyns, who had Daraa's bougie, was called ; but he was not more SucceSsful, and was obliged to have recourSe to the catheter ; but Such violence was uSed as to caufe a good deal of -blood to come from the urethra, and after all it did not fuc- ceed. I was again confulted, and paffed the cuh^ter, but with much more difficulty than before, which made mc believe that the paffage had been a good deal torn. Upon taking out the: catheter I paffed a large bougie into the bladder with great eafe; this I allowed to remain for three days, and he made water to- lerably freely by the fide of It. The moment I drew out the bougie I attempted to paSs another, but did not Succeed, al- though I gave it the natural bend of the paffage. Upon with- drawing thoSe bougies that did not paSs, I obServed that all of them had a bend at the point, contrary to the direction of thfr paffage ; this made me SuSpeft, that the place which ftopped the bougie was on the pofterior Surface, and that by being pufhed on, it bent forwards into the paffage, and of courfe the point turned back. I therefore took a thick bougie ; and, before I introduced it, I bent the point almoft double, So that it could not catch at the pofterior Surface of the urethra, where I fup- pofed the ftop to be : this point of the bougie rubbed all along the anterior and upper furface of the urethra, by which mean's it avoided catching on the pofterior furface, and It paffed with great eafe into the bladder. He made water by the fide of the bougie, as beSore. He had been Sor Some time troubled with fit3 of an intermittent, which at firft were very irregular, but he- came afterwards more regular. In one of the cold fits, the bougie, being in the urethra, gave him great pain, and oblig- ed him at lafl to pull it out, on which he had immediate eafe. The SenSation was as if it ftretched tire paffage too much, and it Seemed to come out with difficulty. This looks as if there was a contraftion of the urethra, as well as of the veffels of the fkin, in the cold fit ; So that this diSpofition runs deep. By giving the bougie this bend, he was able for the future to pafs them with great eafe. I may juft ohferve, that by intro- ducing the finger into the anus, I Sound the proftate gland much enlarged. Many 160 SUPPOSED CONSEQUENCES Many patients, while labouring under any of the before^ mentioned difeaSes of the urethra, and Sometimes even after they have been cured of them, find great pain in throwing for- wards the Semen, having a SenSation as if it Scalded. This ariSes from the very irritable ftate which the mufcles of this part are in, giving great pain by their own aftion. I. OF THE TREATMENT OF THE SWELLED PROSTATE GLAND. The methods, praftifed in the above cafes, afforded only temporary relieS; yet Such muft be had recourSe to in order to prevent the conSequences of retaining the urine too long. As a temporary relief from pain, as alfo to remove fpafm, opiate clyfters fhould be thrown up once or twice a day. A certain cure, I am afraid, is not yet difcovered. I have Seen hemlock of Service in Several cafes. It was giv- en upon a fuppofition of a fcrofulous habit. On the fame principle I have recommended fea-bathing ; and have feen confiderable advantages from it, and, in two cafes, a cure of fome Handing. In one caSe in which I was conSulted, the Surgeon had found that burnt fponge had reduced the Swelling of the gland very confiderably. This diSeaSe, like the ftrifture, produces complaints in the bladder ; but in this the bladder is more irritable, perhaps Srom the cauSe being nearer to that viScus. DiSeaSes of the veficulae Seminales are very familiarly talked of ; but I never faw one. In cafes of very confiderable indu- ration of the proftate gland and bladder, where the furrounding parts have become very much affefted, I have feen thefe bags alfo involved in the general difeafe ; but I never faw a cafe where it appeared that they were primarily affefted. In a cafe of a Swelled proftate gland, with Symptoms of an irritable bladder, in a young gentleman about twenty years of age, Mr. Earle tried a blifter to the perinaeum; but not find- ing the defired effeft, and conceiving a greater irritation and diScharge to be neceffary, he paffed a Seton in the direction of the perinaeum. The orifices were about two inches diftant from each other. The Symptoms of irritability in the bladder began to abate, and in time went entirely off.. Upon exami- nation1 OF GONORRHOEA. 161 nation of the proftate gland, from time to time, it was found to decreafe gradually till it was nearly of the natural Size. The feton was continued Some months, and upon its being with* drawn the Symptoms began to return. It was adviSed to in- troduce it again -r which was accordingly done, but without the former good effeft. - • ' '■■mttfc^liw...... ----• CHAPTER IX. OF THE DISEASES OF THE BLADDER, PARTICULARLY FROM THE BE- FORE-MENTIONED OBSTRUC- TIONS TO THE URINE. ALL the diSeaSes of the urethra, as alfo the diSeaSes of the proftate gland, I have now treated of; and fhall next confider the effefts of them upon the bladder ; as alfo the diS- eaSes of that vifcus, independent of affections of the urethra. The difeafe of the bladder arifing from obftruftion alone, Is increaSed irritability, and its conSequences, by which the blad- der admits of little diftenfion, becomes quick in its aftion, and thick and ftrong in its coats. But prior to the deScription of the effefts of the difeafes of the urethra on the bladder, it will be neceffary Sor the better underftanding of the whole, to make fome remarks upon thofe diSeaSes of the two parts, in which we find that each affects the other; and thefe I fhall confider without having any regard to the caufe, but only the general effefts when they are difeafed. It may be obferved, that every organ in an animal body is made up of different parts, the func- tions or aftions of which are totally different from each other, although all tend to, produce one ultimate effeft. In moft, if not in all, when perfect, there is a fuccefllon of motions, one naturally arifing out of the other, which in the end produces the ultimate effeft ; and an irregularity alone in thefe aftions will conftitute diSeaSe, at leaft produce verv diSagreeable effefts, and often totally fruftrate the final intentions of the organs. I may be allowed alfo to prcmiSc, that the natural width of: fhe urethra gives Such a refiftance fo the force or power of the Y bladder 16a SUPPOSED CONSEOUENCES bladder in expelling the urine, as is eafily overcome by the na- tural aftion of the bladder ; but when the canal is leffened, ei- ther by ftrifture, SpaSm, Swelled proftate gland, or any other means, this proportion is loft, by which means the bladder finds greater difficulty than natural, and is of courfe thrown into an increafed aftion to overcome the refiftance, which becomes a caufe of thfc irritability and increafed ftrength of this vifcus in Such diSeaSes. It is to be underftood, that in a Sound ftate of thefe two parts, the bladder and urethra, the contraftion of the one pro- duces a relaxation of the other, and vice verfa ; So that their natural aftions are alternate, and they may be eonfidered as an- tagonift mufcles to one another." Thus when the ftimulus of expulfion of the urine takes place in the bladder, which im- mediately produces contraftions in it, the urethra relaxes, by which means the urine is expelled from the bladder and allow- ed to pafs through the urethra ; and when the aftion ceafes in the bladder, the urethra contrafts again like a Sphincter muf- cle*, for the purpofe of retaining the urine which flows into the bladder from the kidneys till it gives the ftimulus for ex- pulfion again. But in many difeafes of thefe two parts, this r.eceffary alternate action is not regularly kept up, the one not obeying the Summons of the other. This irregularity arifes perhaps oftener from difeafe in the urethra, than in the blad- der ; for the aftion of the urethra depends upon the aftions of the bladder; and if it is not difpofed to obey the notices of the bladder, then there muft be an irregularity as to time. which produces very troublefome fymptoms. We find in many diSeaSes of the urethra, fuch as ftriftures and fpafms, as alio in difeafes of certain parts belonging to this canal, fuch as the proftate, and Cowper's glands, that there is a greater difpofition in this canal Sor contraftion, than com- mon, So that when the bladder has begun to aft, the water is not allowed to flow, the urethra not immediately relaxing ; aud the moment Such a fymptom takes place, every other pow- er takes the alarm, and is brought in to affift the bladder, fuch dj {training violently with the abdominal muScles, and muScles of * It m'.y be remarked, that many fphinfter mufcles have two caufes of aftion ; one wl.L-h may be called i.ivolu.uary, depending on the natural ufes and aftions of the parts "j the other is voluntary, where a greater degree of aftion can be produced by the command of th; will; and when a difeafed aftion takes place, it is probably of this voluntary ac- tjdii, lb: it is an increafed afti-j:. '*. :r the iuiuial, whkh the voluntary is. OF GONORRHOEA. [163 «f refpiration, from all which there is violent pain in the parts immediately concerned, efpecially in the glans penh;. This difeafe has different degrees of violence. When flight, the diftance in time between the contraftion of the bladder, and the relaxation of the urethra is but fhort, only giving a momentary pain and ftraining, before the urethra relaxes, and the water flows according to the dilatation of the urethra, which, in many of thefe cafes, is but very fmall. In others the dif- tance of time is very long, many ftraining for a confiderable time before a drop will come ; and what does come is often only in drops ; and fometimes before the whole urine can be expelled in this way, the fpafm of the urethra comes on again, and there is a full ftop, which gives excruciating pain for a ■while ; but at laft the bladder is as it were tired, and ceafes to aft. But as the urine in fuch cafes Is feldom all difcharged, and often but a very little of it, the Symptoms Soon recur; and in this way, with a cail to make water perhaps every hour out of the four and twenty, the patient drags on a miSerable fife. The bladder, in all cafes of obftruftion, whether conftant, as in the permanent ftrifture, or fwelled proftate gland, or on- ly temporary, as in the fpafmodic ftrifture, is generally kept diftended, but much more fo in the permanent ftrifture; and when the irritation of fulnefs comes on, which is very frequent, the contraftion of that vifcus becomes violent, in proportion to the refinance : the Sympathetic contraction of the mufcles ci the abdomen takes place, and is alfo violent, yet the water at fuch times Shall only dribble, and be diScharged in Small quan- tity ; and in the SpaSmodic ftrifture often not a drop fhall pafs, So that the bladder is never entirely empty ; and what does paSs is no more than what is Sufficient to take off the irritation of fulnefs ; by which means thefe aftions become more fre- quent, and confequently there is almoft always a conftant ooz- ing of urine from the penis between the times of making wa- ter. This however is not always the cafe, for the bladder fometimes is fo irritable as not to ceaSe acting till it has eva- cuated the whole water ; and even then it is not at eafe. but ftill Strains though there is nothing to throw out,, the aftion of the bladder becoming a caufe of its own continuance. In all fuch affections of the bladder there is a fenfation of pain and itching combined in the glans penis, If j64 SUPPQSED CONSEQUENCES If the fymptoms are more urgent than what can be account- ed for upon the fuppofition of a ftrifture or diSeaSe of the pro- ftate gland, a ftone is to be fuSpefted. I, OF THE TREATMENT WHERE THE ACTIONS OF THE URETHRA AND BLADDER DO NOT EXACTLY ALTERNATE. The cure, where the diSeaSe arifes Srom SpaSm alone, con- fifts in removing the diSpofition to over-aftion in the urethra, and the irritable diSpofition of the bladder when the urethra does not obey it. Perhaps opiate clyfters, as a temporary means of relief, are the very beft medicines that can be adminiftered. I have known a blifter to the loins, or to the perinaeum, remove the fpafm, in a great meafure, from the urethra. When the circumflance of the ultimate aftions of thefe parts not being regular ariSes from ftrifture, Swelled proftate gland, or any mechanical obftruftion to the urine, then that cauSe muft be removed, as has been fully defcribed in the treatment of thefe diSeaSes. II. OF THE PARALYSIS OF THE BLADDER FROM OBSTRUCTION TO THE PASSAGE OF THE URINE. We may obServe that the bladder is a part eafily deprived of its power of contraftion ; for we find in many debilitating difeafes and long illneffes from any caufe, as fever, gout, and confiderable local diSeaSes which debilitate, that the bladder oft- en becomes paralytic, and the water muft be drawn off. We may alfo obferve when the bladder has been diftended consi- derably, Srpm whatever cauSe, So as to have its contractile pow- er deftroyed, that there is a confiderable extravaSation of blood from the inner Surface of the bladder, So that the water which is evacuated is often extremely bloody. I have feen in cafes where the patient has died with this obftruftion npon him, that the inner membrane of the bladder has been almoft black, be- ing loaded with extravafated blood, but this Symptom of bloo- dy urine goes off, as the bladder acquires again its powers of §ftiom In OF GONORRHOEA. 165 In the diSeaSes of the urethra, before defcribed, when not properly, or in time, attended to, and in caSes of ftrifture, where Nature has not been able to relieve herfelf, the water muft of courfe be retained in the bladder, which is perhaps al- ways productive of another difeafe, that is, the lofs of the pow- er of contraftion of that vifcus. Although this one effect, the retention of urine, ariSes Srom very different cauSes, as before related, yet immediate relief muft be given in all of them, which can only be affefted by the evacuation oS the water. Ac- cording to the nature of the obftruftion, the mode of evacua- tion will be different, and will be of two kinds, one by the na- tural paffage by means of an hollow tube, the other by an ar- tificial opening made into the bladder. ; If the caufes of fuppreffion are either SpaSmodic affections of the urethra, a Swelled proftate gland, inflammation in the Sur- rounding parts of the urethra, or Rumors preffing upon it, as happens in pregnant women, immediate relieS may be procur- ed by means of a catheter, becauSe under Such circumftances a catheter will moft probably paSs, the fides of the canal being merely forced together by fpafm, or external preffure. A bougie, although it will alfo paSs under Such circum- ftances, will not anSwer So well, becauSe a bougie muft be with- drawn before the water can flow, which will allow the caufe of the obftruftion to exert again its full force ; and if the SpaSm fhould now exifl, yet the bougie will not anfwer, unleSs there be a power of aftion in the bladder ; for it is with difficulty that the urine can be made to pafs through the urethra, by pref- fing the abdomen only. When the catheter is paffed, it will be neceffary to make the patient ftrain with his abdominal mufcles, as alfo with his muf- cles of refpiration, to Squeeze out the water, the bladder hav- ing no power of contraction, and even this will not be Suffici- ent, Sor it will be neceffary to prefs on the region of the pubes with the hand to make the water flow. In caSes where there is a confiderable degree of debility in the bladder, or in thoSe caSes where there is a confiderable flran- gur-y and of long Handing, and where a fmall quantity of urine in the bladder gives the flimulus of fulnefs to that vifcus, which is always attended with confiderable urgency to make water ; and where only very Small quantities are evacuated, the bladr der not being emptied at each time of making it, and when a catheter, 166 SUPPOSED CONSEQUENCES catheter, either rigid or flexible, can with readinefs be paffed, the queflion is, What is the beft way upon the whole to eva- cuate the water? There are three ways in which it can be done, one, bv allowing the parts to do their own bufineSs as much as they can, and this at firft fight might be SuppoSed to be the very beft ; but it is in Some caSes the very worft ; for the fre- quency of the inclination to make water arifing from the water not being wholly evacuated each time, the evacuation not rea- dily taking place, increafes the effort, and for a few minutes pro- duces excruciating pain, keeping up a confiderable and almoft conftant irritation in all thofe parts, which few can bear. Ano- ther method is, to draw off the water each time with a catheter, but this in many cafes is next to impracticable; for fuppofing the operation to he performed only twice or three times in the day, we fhall find that this is oftener than what fhould be done. The third method is, to leave the catheter almoft cbnftantly in the bladder. Which of thefe three methods is likely to give, on the whole, the leaft irritation muft depend upon circumftances attending different cafes. Where the frequency and the urgency is great, and the flowing of the water difficult, either the fecond or the third is to be purfued ; and when the fymptoms are fuch that a catheter muft be paffed very often, I believe it had better be left in, only taking it out occasionally. I think this is Support- ed by observation and experience. It Sometimes happens in caSes of Swelled proftate gland, that the catheter cannot be paffed without the utmoft difficulty, and when this has been the caSe I have left it in the bladder, for fear of not being able to pafs it again, and continued it there till the bladder has Sufficiently recovered its tone, which is known by its being able to throw the urine through the catheter ; after which that inftrument may be withdrawn. If the SpaSm, in Such caSes as ariSe Srom that cauSe, Should Still continue after the bladder has recovered its tone, we muft continue the ufe of the catheter. But it often happens that the fpafm leaves the urethra before the bladder recovers its power of contraftion, the difeafe becoming then Simply a paralyfis of that viScus. One of the firft Symptoms of the bladder beginning to regain its power of contraftion is, the fenfation of fulnefs, or an in- clination to make water, and when that SenSation comes on the patient OF GONORRHOEA. 167 patient fhould be allowed to make Water, but not to force it, for that circumftance alone will bring on the SpaSm if the urethra is not very ready to dilate. I have feen however in fome cafes, that flight fenfation is not altogether to be depended upon, for it required a little retention more effectually to ftimulate the blad- der to aftion, and then the water has paffed more freely. The Spafmodic contraftion of the urethra does not appear to give up its aftion fimply upon the ftimulus or inclination to make water, and not till the bladder begins to have the power of contraftion; tor in caSes where the bladder is paralytic, and yet Senfible of the ftimulus arifing Srom being full, as it does not contract, the urethra does not relax, and the water cannot be made to pafs. It would appear, that, as the bladder recovers of the paraly- fis, it is not able to contain So much water as uSual. There- fore the patients are obliged to make water often, and of courfe in fmall quantities. III. OF THE CURE OF THE PARALYSIS OF TliE BLADDER, FROM OBSTRUCTION ARISING FROM PRESSURE OR SPASM. The removal of the caufes of the paralyfis of the bladder was fully defcribed when we were treating, of the difeafes which produce that complaint, and the immediate relief, when the bladder is rendered inactive, has juft now been eonfidered ; the paralyfis itfelf is therefore the only remaining thing to be at- tended to. In this difeafe there are often contrary indications of cure, for a fpafm is very different Srom a paralyfis ; and if the Suppreffion is from fpafm, and that ftill continues, then what may be good for the paralyfis, may be bad Sor the SpaSm. As in fuch cafes the water can be drawn off, the bladder fhould be firfl attended to. Stimulants and ftrengtheners are uSeful; blif- ters to the loins to roufe the bladder to aftion, and blifters to the perinaeum, to take off the SpaSm Srom the urethra, often Succeed. Electricity is Sometimes of Singular Service, when applied in Such caSes to the perinaeum. Through the whole of the cure the urine muft be drawn off frequently, becaufe the bladder fliould not be allowed to be diftended, which other- ways would be the confequence; and the'SenSation arifing from the diftenfion of that vi.Sclis is a very opprcfSve one. A gentleman i68 SUPPOSED CONSEQUENCES A gentleman was at times attacked with a difficulty in mak- ing water, which he paid no attention to, as it had always gone off; but at laft he was taken So bad as to be obliged to have recourSe to the catheter, which afforded only a temporary relief. The fpafm continued, and I was Sent Sor. When 1 paffed the catheter, I was obliged to preSs the lower part of the abdomen to fqueeze out the water, for the bladder appeared to give but little afliftance. I ordered a blifter to the loins, which gave Some power of contraftion to the bladder, and took off fome of the SpaSm in the urethra, but ftill he was very little relieved. I then directed a blifter to be applied to the perinaeum, which immediately removed his complaint. CHAPTER X. OF A SUPPRESSION OF URINE—AND OPERATIONS FOR THE CURE OF IT. IN caSes of total Suppreflion of urine arifing from ftriftures, or other caufes where a catheter cannot be paffed, and where every other method recommended is impracticable, an artificial opening muft be made into the bladder for the evacu- ation of the water. There are three places where this open- ing may be made, and each has had its advocates. This ope- ration has not been eonfidered in all its circumftances In dif- ferent patients, fo as to direct the young furgeon in the varie- ty of cafes that may occur; for under fome circumftances the operation is more advifable in one place than another; and indeed it may Sometimes be next to impoffible to perform it in a particular part. The opening may be made firft in the perinaeum, where we now cut Sor a ftone ; Secondly, above the pubes, where cutting for the ftone was formerly praftifed ; and thirdly, from within the reftum, where the bladder lies in contaft with the gut. The firft queflion which naturally occurs, is, Which of thofe Situations is the moft proper for the Safety of the patient, the evacuation of the water, and the conveniency of operating, when OF GONORRHOEA. i69 when no particular circumftance forbids either of the Situ- ations ? On the firft view of the Subject, one would be apt to pre- fer that above the pubes, or Srom the reftum, as the bladder is nearer to either, and the parts more adapted to an operation than from the perinaeum, where we muft cut at random. TheSe two Situations, although the moft proper in this reSpeft, under certain circumftances, yet may become the mofl improper, for they are fubjeft to greater changes than the perinaeum. ' The reafons that may render it very improper above the pu- bes are, the pcrfons being very fat, or the bladders not diftend- ing Sufficiently fo as to rife above the pubes, which is common enough in difeafes of thofe parts. • In very fat people it will be found that the fubftance to be ■cut through may be three, or four inches, which will not on- ly make the operation very unpleafant, but often improper; for Such thickneSs oS parts will make the Swell of the bladder very obfeure and uncertain ; in many the bladder is fo difeafed as to allow of but little diftenfion, and in fuch ihe fymptoms of fulnefs come on very early, perhaps when there is only a few ounces of water colleftedi But if the retention has been for fome confiderable time, as twenty-four hours, then we may fup- pofe fhat the bladder has allowed of diftenfion to a much great- er degree, which may in Some cafes be aScertained by introduc- ing the finger into the reftum. But where the bladder diftends, and the parts are So thin that ,it can be plainly felt above the pubes, I See no material objec- tion to this fituation ; and it has this advantage over the ope- ■ ration by the reftum, that a catheter can more eafily be intro- duced, and kept in, which will be neceffary to be done till the caufe is removed. It may be neceffary here to mention Some precautions reSpeft- ing the keeping the inftrument in the bladder ; as alSo the beft kind to be uSed. It muSt be a hollow tube, and fhould reach as Sar as the pofterior Surface of the bladder, for upon the con- traftion of that vifcus its anterior part recedes backwards and downwards Srom the abdomen towards its fixed point, which may draw the bladder off from the tube. But as the diftance between the Skin oS the abdomen and pofterior Surface of the bladder cannot be exactly afcertained, the cannula may be ei- ther too iouir, or too fhort; if too long, its end may prefs up* Z on i-o SUPFOSED CONSEQUENCES on the pofterior furface of the bladder and produce ulceration there, and In time work its way into the reftum. lo avoi this'mifchief, as'alfo the inconveniences arifing from its being too fliort, and the bladder flipping off from its end, I would recommend the tube to be made with a curve, and to he wit > its convex fide on the pofterior part of the bladder, which be- ing a large furface, and following nearly the fame curve as the cannula, lefs mifchief is to be expected. The openings into the cannula ma}' be made on the concave fide. It would probably be both Safer and eafier for the patient, to have the curved end of the catheter introduced into the ure- thra from the bladder. The paffing of it into the urethra is very practicable; and we know that fuch a bndy lying in tha urethra is not productive of any mifchief. A common cathe- ter paffed in this way enters So far as to bring the handle al- moft flat to the belly, at moft only a little bolfter between the catheter and belly is neceffary, and then with a piece of tape fixed to the handle of the catheter it might be faftened to the body, or a fliort catheter might be made with ears to fix the tape to*. • In caSes where the cannula has remained in the ure- thra Some time-, the artificial paffage will become in fome de- gree permanent, So that it may be taken out occasionally, and cleaned from any flony matter that may be attached to it. To avoid this part of»the operation it has been recommended to have two cannulas, one within the other, that by drawing out the inner it might, be cleaned, and again introduced ; but in moft cafes it will alSo be neceffary to withdraw the outer one, as its external Surface will contract a cruft. The fecond method, or punfture by the anus, will more •commonly admit of being performed than that above the pubes; for it does not require that diftenfion of bladder which the other does, therefore not fo often impracticable from that caufe; and perhaps the only obftacle here is a fwelled proftate gland. In rr.any of thefe cafes of difeafes of the urethra, the "proftate trfand is very much fwelled, which I can conceive may make the proper place for the punfture very uncertain ; for the pro- ftate gland, in fuch cafes, will be preffed down towards the anus, * Where this operation is performed in confequence of a ftridure, I kave conceived that by paffing a catheter into the urethra from the bladder till it comes to the ftrifture, and then paffing another ftraight cannula from the glans down the urethra, that the two may nearly meet, onW having the ftrifture between thein ; and a piercer may be paffed down andtorced into the end of the one from the bladder, ?.r.d afterward* either a bou.;e or hollow catheter introduced. OF GONORRHOEA. i7.i anus, before the bladder, and will be the firft thing Selt by the finger. Care muft therefore be taken to diftinguifh the one from the other, which can only be done by getting the finger beyond the proftate gland, which may not be practica- ble ; and if practicable, it may not be an eafy matter to diS- tinguifh the one from the other, as a thickened and diftended bladder may feem to be a continuation of the fame tumor. However, if the objections given to the performing of it above the pubes exifl, I fhould prefer operating by the reftum; for al- though the probability of fucceeding here may not be apparently greater than above the pubes, yet,the chances are in its favour. I muft however obferve here, that the objeftions which I have Started, are only raiSed in my own mind from my know- ledge of the diSeaSes of thofe parts, and not from cafes of fup- preffion of urine under all the before-mentioned circumftances having occurred to me in praftice. A cafe of a total fupprefTion of. urine arifing from ftrifture, where no inftrument could be. paffed by the natural paffage, and where a punfture was made into the bladder, from the reftum, with fuccefs, is related.in the PhiloSophical Tranfac- tions, by Dr. Hamilton of Kings-Lynn in Norfolk*. What led Dr. Hamilton to do it here," was a difficulty which was found in paffing the clyfter-pipe Into the reftum, which induced him to introduce his finger into the anus, and he found the bladder So.prominent in the reftum as to give the hint of performing the operation there. The man was put into the fame pofition as In the operation for the ftone, and a trochar was introduced upon the finger into the anus, and thruft into the lower and moft prominent part of the tumor, in the direftion of the axis of the bladder, .and upon withdrawing the piercer the water flowed out through the cannula. A ftraight catheter was then introduced through the cannu- la, left the.orifice in the bladder fhould be drawn off from the cannula. Then the cannula was pulled out over the catheter, which was left in till the whole water was evacuated, and vas then withdrawn. The bladder, notwithftanding this perforation, retained the water as ufual, till the inclination to make it came on ; and V.'h.M * Philofophical Tranfaftions for the Year 1776, vol. 6'h ]'■>" ';'■' 172 SUPPOSED CONSEQUENCES when he performed the aftion of making water, the orifice in the bladder Seemed to open, and it rufhed out by the anus. This continued about two days, when the water began to find its natural paffage, and a bougie was introduced into the blad- der, through the urethra, which gave a free paffage for the water, and of courfe lefs came by the anus ; fo that on the Sixth day after the operation the whole came by the natural paffage. The man continued the ufe of the bougie till the ftrifture was dilated. Dr. Hamilton further remarks, that in thofe cafes of fup- preffion of urine, in general, he has found that calomel and, opium, in large dofes, anfwer better than any thing he has tried. He is convinced, from repeated trials, that the fpeci- fic efficacy is in the calomel, as large doSes of opium alone have proved ineffectual; but he does not fay that calomel alone v. ill anfwer. He orders ten grains of calomel with two of opiu;-r, to be repeated in fix hours if it has not anfwered in that tirr.e; and he fays he has Seldom been obliged to give a third dofe. This method of tapping the bladder was firfl fuggefied by Monf. Fleurant, Surgeon to the Charite, at Lyons, in the year 17.30. The operation was performed at that time, and an ac- count of it was afterwards publifhed by MonS. Pouteau, in 1760, with the hiftory c> the caSes, in all which the opera- tion was performed by Moni. Fleurant. The propriety of performing the operation in this part occurred to him in a manner fimilar to that before-related of Dr. Hamilton; for in introducing the finger into the reft urn to examine the ftate of the bladder in a caSe where he was going *o punfture in the perinaeum, he Sound the bladder So prominent there, and So much within the reach oS his inftrument that he immediate- ly altered his intention, and performed it in this part. He ve- ry readily drew off the water, and kept the cannula in, with a T bandage, til! the urine came the right way, and then with- drew it, and all terminated well. But there was a good deal of trouble on account of the cannula being left in on > - ■ I muft own, however, that I have not feen cafes enough to enable me to give all the varieties that commonly happen, and of courfe to give all the advantages and disadvantages of each method. I. OF ALLOWING A CATHETER TO REMAIN IN THE URETHRA AND BLADDER. In cafes of debility of the bladder, and where a catheter paffes with difficulty, or with great uncertainty, and in cafes where it muft be ufed frequently, and for a length of time, it will be neceffary to keep an inftrument in the urethra and blad- der, fo as to allow the water to pafs through it freely. A common catheter, or one made of the elaftic gum is perhaps the beft inftrument; but it muft be fixed in the canal; this will be beft done by its outer end being tied to fome external body, as I fhall now defcribe. When the catheter is fairly in the bladder, the outer end is rather inclined downwards, near- ly in a line with the body. To keep it in this pofition we may take the common Strap or belt-part of a bag-trufs, with two thigh-flraps either fixed to it or hooked to it, and coming round each thigh and Sorwards by the fide of the fcrotum, to be faft- ened to the belt where the ears of the bag are ufually fixed. A fmall ring or two may be fixed to each ftrap juft where it paffes the Scrotum or root of the penis ; and with a piece of Small tape the ends of the catheter may be fixed fo thofe rings, which will keep it in the bladder. A bit of a rag about four or five inches long, with a hole at the end of it, paffed over the exterior end of the catheter, and the loofe end allowed to hang in a baSon, placed between the thighs, will catch the water which cannot diSengage itfeli from the catheter, and keep the 176 SUPPOSED CONSEQUENCES the patient dry ; or if another curved pipe is introduced into the catheter, it will anfwer the Same purpoSe. Under Such treatment the bladder will never be allowed to be diftended ; and when the patient wants to have the bladder in Some degree emptied, he has only to Strain with his abdo- minal muScles, by which means he will be able to throw out a great deal at each time. . As the bladder begins to recover its aftions, the patient will find that an inclination to make water will come on, and at thofe times he will alfo find that the water will come from him without ftraining with the abdominal mufcles; when this takes place readily the catheter may be taken out, and it will be found that he will-be able in future to make water of himfelf. If it is neceffary to keep in the catheter a confiderable time, it will be the cauSe of a great deal of flime and mucus being formed in the urethra and bladder ; but I believe this is of no confe- quence. I have known a catheter kept in this way for five months without any inconveniency whatever. In all cafes where it is neceffary to keep an extraneous body for. a confiderable time in the bladder, whether in an artificial paffage or the natural one, it will be proper a few days after its firft introduftion to withdraw it and examine whether it is in.- crufting, or filling up in its cavity with the calculous matter of the urine. If, after remaining in the bladder for fome days, it has contrafted none, we need be under no apprehenfions of its doing it; but if, as frequently happens, it Should have col- lected a confiderable quantity, then it will be neceffary to have it occafionally withdrawn and cleaned. The beft method pro- bably of doing this is to put it in vinegar, which will Soon dif- folve the ftony matter. II. OF THE INCREASED STRENGTH OF THE BLADDER. The bladder, in fuch cafes as have been defcribed, having more to do than common, is almoft in a conftant ftate of irri- tation and aftion ; by which, according to a property in all mufcles, it becomes ftronger and ftronger in its mufcular coats; and I fufpeft, that this difpofition to become ftronger from re- peated aftion, is greater in.the involuntary mufcles than the voluntary ; and the reafon why it fliould be fo, :^, I think, very OF GONORRHOEA. 177 very evident ; for in the involuntary mufcles-the power fliould be in all caSes capable of overcoming the refiftance, as the power is always performing fome natural and neceffary aftion ; for whenever a difeafe produces an uncommon refiftance in the involuntary parts, if the power is not proportionably increaSed, the diSeaSe becomes very formidable; whereas, in the voluntary muScles, there is not that neceflity, becaufe the will can ftop t^never the mufcles cannot follow ; and if the will is fo dif- e-aSedas not to ftop, the power in voluntary muScles fhould not increaSe in proportion. I have Seen the muScular coats of the bladder near half an inch thick, and the fafciculi fo ftrong as to form ridges on the infide of that cavity*;-and I have alfo feen the fafciculi very thin, and even wanting in fome parts of the bladder, fo that a hernia of the internal coat had taken place between the fafci- culi, and formed pouchest. Thefe pouches arife from the thin parts not being.able to fupport the aftions of the ftrong; as happens in ruptures at the navel, or rings of the abdomen. III. OF THE DISTENSION OF THE URETERS. It fometimes happens that the irritation from the diftenfion of the bladder, and the difficulty in throwing out its contents, is fo great, that the urine is prevented from flowing freely into that vifcus from the ureters, which become thereby preterna- turally diftended. The pelvis of the kidneys, and infundibula are alfo enlarged ; but how Sar this dilatation of the ureters and pelvis is really owing to a mechanical caufe, I am not So clear; or whether it is not a difpofition for dilatation arifing out of the ftimulus given by the bladder. In Some caSes of long fland- ing, where the bladder was become very thick, and had been for a long time acting with great violence, it had affefted the mamillae, fo that the furface of thefe proceffes produced a mat- ter, and perhaps even the fecreting organs of the kidneys, So A a that * This appearance was long fuppofed to have arrferi from a difeafe of that vifcus: but> upon examination I found that the mufcular parts were found and drftin:1; that they were only increafed in bulk in proportion to the power they had to exert; and that it was not a confequence of inflammation, for in that cafe parts are bonded into one indiftindt + This is perhaps the caufe of the ftone being often found in a pouch formed in ths Madder: for the bladder hi cafes of ftone is often very ftrong, which arifes from the vio- lent contraftion of that vifcus, caufed by the irritation ot the ftone on the tides oi it> rtid alfo from thefbr.e beirg often oppofed to the mouth of thr u-rr.hra m the time c *»k'.:-c W-er. ifi SUPPOSED CONSEQUENCES that the urine Secreted was accompanied with a pus, arifing from the irritation being kept up in all thefe parts. The urine in the above cafes is generally Stale, even before it is thrown out of the bladder, which when joined with the circumftance of the linen being conftantly kept wet, by the al- moft continual difcharge of urine, becomes very offenfive, and it is hardly poffible to keep the patient fweet. IV. OF IRRITABILITY IN THE BLADDER INDE- PENDENT OF OBSTRUCTIONS TO THE PAS- SAGE OF THE URINE. Another difeafe of the bladder, connected with the prefent fubjeft, is, where that vifcus becomes extremely irritable, and will not allow of its ufual diftenfion. The Symptoms of this difeafe are very Similar to thoSe arifing from obftruftions to the paffage of the urine in the urethra, but with this difference, that in the prefent difeafe the urine flows readily, becauSe the urethra obeys the Summons and relaxes ; however, there is oSt- en confiderable ftraining, after the water is all voided, arifing from the muScular coat of the bladder Still continuing its con- tractions. This irritability of the bladder often ariSes from local cauSesr as a ftone, cancer, or tumors Sorming on the infide, all which produce irritability of this vifcus. In Such caSes the ftraining is violent, for the cauSe ftill remains which continues to give the ftimulus of Something to be expelled, and the bladder con- tinues to contract till tired, as In the caSes of fimple irritabili- ty : and then there is a refpite Sor a time; but this reSpite is of fliort duration, Sor the urine is Soon accumulated. This diSeaSe will in the end be fatal, by producing an hectic fever. V. OF THE CURE OF SIMPLE IRRITABILITY OF THE BLADDER. When the fymptoms arife Srom irritability alone, and not from a ftone, or any local affeftion, the nature of the com- plaint may not at firft be fo obvious ; temporary relief may, however, be procured by opium, which is moft effectual in flight and recent caSes ; and if it be applied as near to the part as , OF GONORRHOEA. *7$ ss poffible, its effefts will be more evident; and therefore it may be given by clyfter as well as by the mouth. I fhould, however, be inclined to rely on a blifter applied to the perinaeum, or to the lower part of the fmall of the back, or upper part of the facrum, if more convenient, than to any other method of cure. In all cafes, where there is an irritation of the bladder, the patient fhould never endeavour to retain his water beyond the inclination to make it. It hurts the bladder and increafes its irritability ; and indeed I am apt to think that this circumftance, even in found parts, is often a predifpofing caufe of difeafe in this vifcus and its appendage, the urethra ; for I have known feveral cafes where it has brought on the fpafmodic ftrifture in the urethra, in found parts; and it is frequently an immedi- ate caufe of ftrangury in thofe who have either a ftrifture, or a difpofition to SpaSms in thoSe parts. A gentleman, in perfect health, from retaining his urine be- yond the inclination, in the play-houfe, had all the fymptoms of an irritable bladder brought on, which continued for feve- ral years, rendering him miSerable. VI. OF A PARALYSIS OF THE ACCELERATORES URIN/E. In many irritations of the bladder, the urethra not only re- laxes direftly on the ftimulus to make water being felt in that vifcus, as has been defcribed, but a paralyfis fometimes takes place in the voluntary mufcles of thofe parts, fo that the will cannot command them to contraft to hinder the inconveniences that may attend an immediate evacuation of that fluid. If we attempt to ftop the water, which is an aft of the will, it is vain ; the acceleratores will not obey, and the water flows. A blifter applied to the perinaeum will have confiderable ef- fefts in removing this complaint. CHAPTER 180 SUPPOSED CONSEQUENCES CHAPTER XI. OF THE DISCHARGE OF THE NATU- RAL MUCUS OF THE GLANDS OF THE URETHRA. THE fmall glands of the urethra, and Cowper's glands, fecrete a flimy mucus, fimilar to the white of an egg not coagulated. This feldom appears externally, or flows from the urethra, but during the indulgence of lafcivious thoughts, and is feldom or never attended to, excepting by thofe who are un- der apprehenfions either of a gonorrheea coming on, or ima- gine the laft infeftion is not gone off entirely, and'are therefore kept in conftant terror by this natural difcharge. They often find it In Such quantity as to leave Spots on the fhlrt, but with- out colour ; and often after toying, the lips of the urethra are as it were glewed together by it, from its drying there, which appearances alarm the mind of the patient without caufe. Al- though this is only a natural diScharge, and is Secreted, at Such times, under the Same influence which naturally produces it, it muft be owned, that it is commonly much increafed in thoSe cafes oS debility arifing from the mind, which is probably not eafily to be accounted for. It would feem that the conteft be- tween the mind and the body increafes this fecretion, Sor it cannot be eonfidered as a diSeaSe of the parts. I. OF THE DISCHARGE OF THE SECRETIONS OF THE PROSTATE GLAND AND VESICUL^E SEMINALES. This complaint is imagined to be the confequence of the ve- nereal difeafe m the urethra; but how far this is really the cafe is not certain; though mofl probably it is not. It is a difcharge of mucus by the urethra which generally comes away with the lafl drops of urine, efpecially if the bladder is irritable ; and ftill more at the time of being at flool, particularly if the pati- ent be coftive; for, under Such circumftances, the ftraining or aftions of the mufcles of thofe parts are more violent. It has £c::erdHy been fuppofed that this difcharge is Semen ; and the difefc OF GONORRHOEA. 181 diSeaSe is called Seminal weakneSs: but it appears Srom many experiments and observations, that the diScharge is undoubted- ly not Semen. It is only the mucus Secreted either by the pro- ftate gland, by thoSe bags improperly called veficulae Seminales, or both ; and it may not be improper to give here the diftin- guifhing marks between theSe two fluids. Firft, we may ob- serve the diScharge in queflion is not of the fame colour with the femen, and is exactly of the colour of the mucus of the pro- ftate gland, and of thofe bags. It has not the fame ftnell, and in- deed it hardly has any fmell at all. The quantity, evacuated atone time, is often much more confiderable than the evacuation of Semen ever is ; and it happens more Srequently than it could poffibly do were the difcharge Semen. It is a diSeaSe'that oft- en attacks old men, where one can hardly SuppoSe much Se- men to be Secreted ; and we find that thofe, who are affefted with this diSeaSe, are no more deficient in the fccretion and evacuation of the femen, in the natural way, than before they had the diSeaSe. If the mind be at eafe, this fhall take place immediately after a difcharge of femen, as well as before, which could not be the cafe were it femen. Further, if thofe that labour under this complaint, are not connected with wo- men, they are fubjeft to nocturnal difcharges from the imagi- nation, as perfons are who are perfeftly found ; and indeed moft patients, when made acquainted with thefe circumftances, become very Senfible that it is not the Semen. It is not clear what the diSeaSed ftate of the parts is upon which this difcharge depends; whether there is a larger fecre- tion of this mucus than natural, or whether it is entirely ow- ing to a preternatural, uncommon aftion of thofe parts ; and if this laft why thefe parts fhould be put into aftion when the bladder, reftum, and abdominal mufcles are thrown into aftion to expel their contents, is not eafily explained. It is plain that the moft violent aftions of thefe parts are neceffary to produce this evacuation ; Sor it does not come with the firft of the urine, nor, in general, with an eafy ftool. As it was thought to be a feminal difcharge, it was imagin- ed to arife from a weaknefs in the organs of generation ; and as frequent difcharges of the femen in the natural way general- ly weaken, it was therefore imagined that this difcharge muft alfo weaken very confiderably ; and the imagination will ope- rate So ftrongly as to make the patients believe they really are weakened. j82 SUPPOSED CONSEQUENCES weakened. Whether the cauSe of fuch a difcharge is capable of weakening, I will not pretend to fay ; but I believe that the difcharge fimply does not. Fear, and anxiety of mind may really weaken the patient. In the cafes I have feen of this kind, the mind has been more affefted than the body. From my own praftice, I can hardly recommend any one medicine, or way of life, for removing this complaint. In one cafe I found confiderable benefit frorVgiving hemlock in- ternally. The idea, that has been formed of the difeafe, leads to the 1 praftice generally recommended, fuch as giving ftrengthening medicines of all kinds; but I never faw any good effefts Srom any of them ; and I fhould rather be inclined to take up the Soothing plan to prevent all violent aftions. Keeping the body gently open will in Some degree moderate the 'diScharge, and, probably may effeft a cure in the end. CHAPTER XII. OF IMPOTENCE. r I ^HIS complaint is by many laid to the charge of OnaniSm ,JL at an early age ; but how Sar this is juft, it will in many cafes be difficult to determine ; for, upon a ftrift review of this fubjeft, it appears to me to be by far too rare to originate from a praftice fo general. How far the attributing to this practice fuch a confequence, is of public utility, I am doubtful, particularly as it is follow- ed moft commonly at an age when confequences are not fuffi- ciently attended to, even in things lefs gratifying to the fenfes; but this I can fay with certainty, that many of thofe, who are affefted with the complaints in queflion, are miferable from thts idea ; and it is fome confolation for them to know that it is poffible it may arife from other caufes. I am clear in my own mind, that the books on this fubjeft have done more harm than good. In the caSes of this kind that have come under my care, al- though the perSons themfelves have been very ready to SuppoSe that OF GONORRHOEA. i8& that the difeafe has arifen from the caufe here alluded to ; yet they did not appear to have given more into the praftice than common ; and in particular, the worft cafe I have ever feen was where but very little of this praftice had ever been ufed, much lefs than in common among boys. Nothing hurts the mind of a man fo much as the idea of in- ability to perform ell the duty of the fex. If his fcrotum hangs low it makes him miSerable ; he conceives immediately that he is to be rendered incapable of performing thofe afts in which he prides himSelf moft. It is certain, that the relaxa- tion or contraftion of the fcrotum, is in fome degree a kind ot Sign of the conflitution; but it is of the conflitution at large, hot of thoSe parts in particular. NurSes are So Senfible of the contraftion of that part being a Sign of health in the.children under their care, that they take notice of it. The relaxation of it in them cannot be SuppoSed to ariSe Srom Inability to per- form thoSe afts at one time more than another. The face is one of the figns of the conflitution, and has as much to do with thofe peculiar afts as the fcrotum. However, we muft allow that this part is much more lax than what we fhould con- ceive was intended by Nature, even in young men who are well in health ; but as this is very general, I rather SuSpeft that it ariSes from the circumftances of the part being kept too warm, and always SuSpended, the mufcles hardly ever being allowed to aft, So that they have leSs Sorce. How Sar it is the Same in thoSe countries where the dreSs does not immediately SuS- pend thoSe parts, I have not been able to afcertain. Warmth appears to be one cauSe ; for we find that cold has generally an immediate effeft; but this is perhaps owing to its not being. accuftomed to cold, which if it were, it might poffibly become as regardlefs of it as it is of warmth. What the difference is in this part, in a cold and warm climate, all other circum- ftances the fame, I do not know. But whatever may be the caufe, if it is really in common more lax than intended by Nature, it is of no confequence as to the powers of generar lion. The tefticles will Secrete whether kept high or low. I. OF IMPOTENCE DEPENDING ON THE MIND. As the parts of generation are not neceffary for the exift- ence or lupport of the individual, but have a reference to Something, >8* SUPPOSED CONSEQUENCES Something elfe in which the mind has a principal concern, a complete aftion in thofe parts cannot take place without a per- feft harmony of body and of mind ; that is, there muft be both a power of body, and difpofition of mind ; for the mu.d is fubjeft to a thoufand caprices, which affect the actions of thefe parts. Copulation is an aft of the body, the Spring of which is in the mind ; but it is not volition ; and according to the State of the mind So is the aft perSormed. To perform this aft well, the body fhould be in health, and the mind fhould be perfeft- ly confident of the powers of the body ; the mind ihould be in a ftate entirely dlfengaged from every thing elfe ; it Should have no difficulties, no fears, no apprehenfions ; not even an anxiety to perform the aft well; for even this anxiety is a ftate of mind different from what fhould prevail; there fliould not be even a fear that the mind itfelf may find a difficulty at the time the aft fhould be performed. Perhaps no function of the machine depends fo much upon the ftate of the mind as this. The will, and reafoning faculty, hwe nothing to do with this power ; they are only employed in the aft, fo far as vo- luntary parts are made ufe of; and if they ever interfere, which they Sometimes do, it often produces another ftate of the mind which deftroys that which is proper for the perform- ance of the aft ; it produces a defire, a wifh, a hope, which are all only diffidence and uncertainty, and create in the mind the idea of a poffibility of the want of SucceSs, which deftroys the proper ftate of mind, or neceffary confidence. There is perhaps no aft in which a man Seels himSelS more interefted, or is more anxious to perform well, his pride being encaged in fome degree, which, if within certain bounds, would produce a degree of perfection in an aft depending upon the will, or an aft in voluntary parts ; but when it produces a ftate of mind contrary to that ftate, on which the perfection of the aft depends, a failure muft be the confequence. The body is not only rendered incapable of performing this aft, by the mind being under the above influence, but alfo by the mind being perfeftly confident of its power, but confcious of an impropriety in performing it ; this, .in many cafes, pro- duces a ftate of mind which fhall take away all power. The ftate of a man's mind, reSpefting his Sifter, takes away all power. A confcientious man has been known to lofe his powers on find- ing OF GONORRHOEA. it$ itig the woman, he was going to be connected with, unex- pectedly a virgin. Shedding tears ariSes entirely from the ftate of the mind, al- though not fo much a compound aftion as the aft in queflion ; for none are fo weak in body that they cannot fhed tears ; it is not fo much a compound aftion of the mind and ftrength of body, joined, as the other aft is; yet if we are afraid of fhed- ding tears, or are defirous of doing it, and that anxiety is kt pt up through the whole of an affefting fcene, we certainly fhall not Shed tears, or at leaft not So freely as would have happened from our natural feelings. From this account of the neceffity of having the mind inde- pendent, refpefting the aft, we muft fee that it may very often happen that the ftate of mind will be fuch as not to allow the animal to exert its natural powers; and every failure in- creafes the evil. We muft alfo fee Srom this ftate oS the caSe, that this aft muft be often interrupted ; and the true caufe of this interruption not being known, it will be laid to the charge of the body, or want of powers^ As thefe cafes do not arife from real inability, they are to be carefully diflinguifhed from fuch as do ; and perhaps the only way to diftinguifh them is, to examine into the ftate of the mind refpefting this aft. So trifling often is the circumftance which fhall produce this in- ability, depending on the mind, that the very defire to pleaSe Shall have that effeft, as in making the woman the Sole object: to be gratified. CaSes of this kind we See every day ; one of which I fhall relate as an illuftration of this Subject, and alSo of the method ot cure. A gentleman told me, that he had loft his virility. After above an hour's inveftigation of the cafe, I made out the Sol- lowing Safts : that he had, at unneceffary times, ftrong erefti- ons, which fhowed that he had naturally this power; that the erections were accompanied with defire, which are all the na- tural powers wanted ; but that there was ftill a defect Some- where, which I SuppoSed to be from the mind. I inquired, i£ all women were alike to him, his anfwer was, no ; fome wo- men he could have conneftion with, as well as ever. This- brought the defect, whatever it was, into a fmaller com pafs; ar.d it appeared that there was but one woman that produced this inability, and that It arofe from a defire tr>perform the afl B b wiril = 86 SUPPOSED CONSEQUENCES with this woman well ; which defire produced in the mind a doubt, or fear of the want of SucceSs, which was the cauSe of the inability of performing the aft. As this arofe entirely Srom the ftate of the mind, produced by a particular circumflance, the mind was to be applied to for the cure ; and I told him that he might be cured, if he could perfeftly rely on his own power of Self-denial. When I explained wdiat I meant, he told me that he could depend upon every aft of his will, or refolution ; 1 then told him, if he had a perfect confidence in himfelf in that refpeft, that he was to go to bed to this woman, but firfl promiSe to himSelf, that he would not have any conneftion with her for fix nights, let his inclinations and powers be what they would; which he engaged to do; and alfo to let ine know the refult. About a fortnight after, he told me, that this refolution had produced fuch a total alteration in the ftate of his mind, that the power foon took place : Sor inftead of going to bed with the fear of inability, he went with fears that he fhould be poffeffed with too much defire, too much pow- er, So as to become uneaSy to him, which really happened ; for he would have been happy to have Shortened the time; and when he had once broke the Spell, the mind and powers went on together; and his mind never returned to its former ftate. II. OF IMPOTENCE FROM A WANT OF PRO- PER CORRESPONDENCE BETWEEN THE AC- TIONS OF THE DIFFERENT ORGANS. I lately obServed, when treating oS the diSeaSes o£ the urethra and bladder, that every organ in an animal body, with- out exception, was made up of different parts, whofe func- tions, or aftions, were totally different Srom each other, al- though all tending to produce one ultimate effeft. In all Such organs, when perfect, there is a fucceflion of motions, one na- turally arififig out of the other, which in the end produces the ultimate effeft ; and an irregularity alone, in thefe aftions, will conftitute.difeafe, at leaft will produce very difaoreeable effefb, and often totally fruftrate the final intention of the or- gan. I come now to apply this principle to the actions of the tefticle and the penis; for we find that an irreoularity iu the"ac- tiuus of thefe parts Sometime happens in men, producing im- potence < OF GONORRHOEA. 187 potence : and Something fimilar, probably, may be one caufe oS barrenneSs in women. In'men, the parts fubfervient to generation may be divided into two, the effential, and the acceflbry. The tefticles are the effential ; the penis, &c. the acceflbry. As this divifion ariSes from their ufes or aftions in health, which exactly cor- refpond with one another; a want of exaftnefs in the con c- fpondence, or fufceptibillty of thofe aftions, may alfo be di- vided into two : where the aftions are reverfed, the acceflbry taking place without the firft or effential, as in ereftions of the penis, where neither the mind, nor the tefticles, are ftimulated to aftion ; and the fecond is where the tefticle performs the ac- tion of fecretion too readily for the penis, which has not a cor- refponding ereftion. The firft is called priapiSm ; and the Se- cond is what ought to be called Seminal weakneSs. The mind has confiderable effeft on the correspondence of the aftions of thefe two parts ; but it would appear in many in- ftances, that ereftions of the penis depend more on the ftate of the mind, than what the fecretion of the femen does; for ma- ny have the fecretion, but not the ereftion; but in fuch, the want of ereftion appears to be owing to the mind only. Priapifin often arifes fpontaneoufly, and often from vifible irritation of the penis, Such as the venereal gonorrhoea, espe- cially when violent. The SenSation of fuch ereftions is rather uneafy than pleafant, nor is the SenSation of the glans at the time Similar to that arifing Srom the,ereftions oS defire, but more like to the SenSation oS the parts immediately after coi- tion. Such as arife fpontaneoufly are of more Serious confe- rjuence than thofe from inflammation, as they proceed, proba- bly, from caufes not curable in themfelves, or by any known methods. The priapifm arifing Srom inflammation of the parts, as in a gonorrhcea, is attended with nearly the fame fymptoms; but generally the SenSation is that of pain, proceeding from the inflammation of the parts. It may be obferved, that what is faid of priapifm, is only applicable to it, when a difeafe in it- felf, and not as a fymptom of other difeafes, which is fre- quently the cafe. The common praftice in the cure of this complaint is to or- der all the nervous and Strengthening medicines, Such as bark, va- lerian, mufk, camphor, and alSo the cold hath. I have hen goot cl:.v:'4 i88 SUPPOSED CONSEQUENCES effefts from the cold bath; but fometimes it does not agree with the conflitution, in which cafes I have found the warm bath of fervice. Opium appears to be a fpecific in many cafes; from which circumftance I fhould be apt, upon the whole, to *ry a Soothing plan. Seminal weaknefs, or a fecretion and emiffion of the fe- men without ereftions, is the reverfe of a priapifm, and is by much the worft diSeaSe of the two. There is great variety in the degrees of this difeafe, there being all the gradations from the exaft correspondence of the aftions of all the parts to the tefticles acting alone ; in every cafe of the difeafe there is too quick a fecretion and evacuation of the femen. Like to the priapifm, it does not arife from defires and abilities, although when mild it is attended with both, but not in a due propor- tion ; a very flight defire often producing the Sull effeft. The fecretion of the femen Shall be So quick that fimple thought, or even toying fhall make it flow. Dreams have produced this evacuation repeatedly in the fame night; and even when the dreams have been So flight, that there has been no conSciouSnefs of them when the Sleep has been broken by the aft of emiffion. I have known cafes, ., where the tefticles have been fo ready to Secrete, that the leaft friftion on the glans has produced an emiffion : I have known the Simple aftion of walking or riding, produce this effeft, and that repeatedly, in a very fliort Space of time. A young man, about four or five and twenty years of age, not fo much given to venery as moft young men, had theSe laft-mentioned complaints upon him. Three or four times in the night he would emit; and if he walked fail, or rode on horfeback, the fame thing would happen. He could fcarce- ly have conneftion with a woman, before he emitted, and in the emiffion there was hardly any SpaSm. He tried every fup- pofed ftrengthening medicine, as alfo the cold bath, and fea- bathing, but with no effeft. By taking twenty drops of laud- anum, on going to bed, he prevented the night-emiffions ; and by taking the Same quantity in the morning, he could walk or ride, without the before-mentioned inconvenience. I directed this praftice to be continued for Some time, although the dif- eafe did not return, that the parts might be accuftomed to this healthy ftate of aftion ; and I have reafon to believe the gen- tleman is now we:!. It was found neceffary, as the conflmi- ''.cu OF GONORRHOEA. 1% tion became more habituated to the opiate, to increaSe the dofe of it. The fpafms, upon the evacuation of the femen, in fuchca^ fes are extremely flight, and a repetition of them foon takes place ; the firft emiffion not preventing a Second; the confli- tution being all the time but little affefted*. When the tefti- cles aft alone, without the acceflbry parts taking up the ne- ceffary and natural conSequent aftion, it is ftill a more melan- choly diSeaSe; for the fecretion ariSes Srom no vifible or Sen* fible cauSe, and does not give any vifible or Senfible effeft, but tuns off fimilar to involuntary Stools, or urine. It has been obServed that the Semen is mote fluid than natural in fome of thefe cafes. There is great variety in the difeaSed aftions of thefe parts, of which the following cafe may be eonfidered as an example. A gentleman has had a ftrifture in the urethra Sor many years, Sor which he has frequently ufed a bougie, but of late has neglected it. He has had no connection with woman for a confiderable time, being afraid of the confequences. He has often in his Sleep involuntary emiflions, which generally awake him at the paroxySm ; but what SurpriSes him moft is, that often he has fuch, without any femen paffing forwards through the penis, which makes him think that at thofe times it goes backwards into the bladder. This is not always the cafe, for at other times the femen paffed forwards. At the time the Semen Seems to paSs into the bladder, he has the erec- tion, the dream, and is awakened with the Same mode of aftiori, the fame fenfation, and the fame pleafure, as when it paffes through the urethra, whether dreaming or waking. My opi- nion is, that the Same irritation takes place in the bulb of the urethra without the femen, that takes place there when the'fe- men enters, in confequence of all the natural preparatory fteps, whereby the very fame aftions are excited as if it came into the paffage; Srom which one would SuppoSe that either Semen is not Secreted, or iS it be, that a retrograde motion takes place in the aftions of the acceleratores urinae; but if the firft be the caSe, then we may SuppoSe that in the natural ftate the ac- tions of thofe muScles do not ariSe fimply from the ftimulus of the * It is to be eonfidered that the conftitution is commonly affedted by the fpafms only, and in proportion to their violence, independent of the fecretion and evacuation of the femen. But in fome cafes even the ereftion going off without the fpafms on the emiflion4 foall produce the fame debility as if they had taken place. too SUPPOSED CONSEQUENCES the Semen in the part; but Srom their aftion being a- termination of a preceding one making part of a Series of actions. 1 hus they may depend upon the friftion, or the imagination of a friftion on the penis, the tefticles not doing their parr, and the fpafm in fuch cafes arifing from the friftion and not from the fecretion. In many of thofe cafes of irregularity, when the ereftion is not ftrong, it fhall go off without the emiffion ; and at other times an emiffion fhall happen almoft without an ereftion ; but thefe arife not from debility, but affections of the mind. In many of the preceding cafes, wafhing the penis, fcro- tum, and perinaeum, with cold water, is often of fervice; and to render it colder than we find it in fome feafons of the year, common fait may be added to it, and the parts wafhed when the Salt is almoft diffolved. CHAPTER XIII. OF THE DECAY OF THE TESTICLE. IT would appear from Some circumftances, that the parts of generation are not to be eonfidered as neceffary parts of the animal machine, but only as parts Superadded for particu- lar purpofes ; and therefore only neceffary when thofe parti- cular purpofes are to be anfwered; Sor we may obServe, that they are later of coming to maturity than any other parts, and are more liable to decay. Thus far in their natural properties they are different from moft other parts of our body, the teeth only excepted, which are fimilar in fome of thofe circumftances. The tefticles appear to be more fubjeft to fpontaneous dif- eafe than any other part of the body ; but what is the moft An- gular thing of all, is the wafting of thofe bodies. One or both tefticles fhall wholly difappear, like to the thymus gland, or membrana pupil'aris, &c. in the infant. This we do not find in any parts of the body which are effential to its ceconomv; excepting the parts are of no further ufe, and might become hurtful in the body, as in the inftance of the membraua pupil- laris; but the tefticles do not undergo this change, as if in confequence OF GONORRHOEA. 191 tonfequence of an original property ftamped upon them, as is the cafe of the thymus gland, whenever the age of the per- fon is fuch as to render them ufelefs; but are liable to it at any age, and therefore the difpofition is in the tefticles them- felves, independent of any conneftion with the animal ©eco- nomy. An arm, or leg may lofe its aftion, and may wafte in part, but never wholly. Tefticles have been known to wafte in caSes of rupture, probably from the conftant preffure of the inteftine. Mr. Pott has given us cafes of this kind. I have feen, in the hy- drocele, the tefticle almoft wafted to nothing, probably Srom the compreffion of the water; but in all thefe the caufes of waft- ing are obvious, and would probably produce Similar effefts in other parts of the body under the fame circumftances; but a tefticle without any previous difeafe waftes wholly ; or at other times it inflames, either fpontaneoufly, or from fympathy with the urethra, becomes large, and then begins to fubfide, as in the refolution of common inflammation of the body, but does not flop at the former fize, but continues to decay till it wholly difappears. The following cafes are inftances of this. Cafe I. A gentleman about nine years ago had a gonor- rhoea, with a bubo, which fuppurated. A fwelling of one of the tefticles came on, for which he ufed the common methods of producing refolution, and Seemingly with SucceSs. All the other Symptoms being removed, he thought himSelS quite well; but Some time aSter, he Sound that the tefticle, which had been .fuelled, was become rather Smaller than the other, which made him now pay attention to it; this decreaSe continued till it wafted entirely. For Some years paft there has been no ap- pearance of a tefticle. He is not in the leaft different in in- clination, or powers, from what he was before. Cafe II, communicated by Mr. Nanfan. " A gentleman, aged about eighteen, who never had any venereal complaint, has had two different attacks of the Same nature, one in each tefticle. February 3, 1776, after fkating a few hours, with- out having, to his knowledge, received any injury from it, he was feized with a violent pain and inflammation of the left tefticle, which in a few days increafed much in fize. A Sur- geon being Sent Sor, followed theufual treatment in fuch cafes of inflammation. In about fix weeks, the inflammation and Swelling gradually Subfided, Some hardneSs only remaining. A mercurial igi SUPPOSED CONSEQUENCES mercurial plainer was now applied, which, after being worn for fome time, was left off. The tefticle ever fince has con- tinued gradually to decreafe, and is no larger than a horSebean; indeed the body of the tefticle is quite decayed, nothing remain- ing but what feems part of the epididymis. It appears to have no fenfe of pain, except when preffed, and is very hard and uneven on its Surface. The Spermatic chord is not in the leaft affefted. Oftober 20, 1777, he was Seized in the fame man- ner in the right tefticle without any apparent caufe, whereupon I was applied to. He was immediately bled, took an opening mix- ture, after that a faline mixture with tartar emetic; and a fomen- tation and embrocation of fpiritus mindereri, and fpiritus vini, was ufed. On the 27th, a cataplafm was applied of linfeed meal and aqua vegeto-mineralis. This treatment was perfifted in till about the middle of November. The inflammation went off, and the tefticle feemed much in the natural ftate. On December 10, I was applied to again ; it feemed to be growing hard, and decreafing in fize, much in the Same manner as the other had done, which made him very unhappy. I ordered him fome pills with calomel and tartar emetic, in hopes of increaf- ing the Secretion of the glands in general, and making fome change in the tefticle. At firft this method feemed to be of fervice, but foon loft its effefts, and the tefticle began to de- creaSe juft as the other did." Mr. Adair and Mr. Pott were conSulted with me, but nothing could be thought of that could give any hopes of fuccefs. I advifed him to employ the parts in their natural uSes, as much as inclination led him; but all was to no purpoSe, the tefticle continued to decreafe till not a veftige was left. Cafe III, communicated by Dr. Cothom, of Worcefter. "A young man, aged Sixteen, was Suddenly Seized with great cold'- nefs and Shivering, attended with Srequent rigors. During this paroxyfm, which continued three hours, his pulSe was fmall and contrafted, and So exceedingly quick that the ftrokes of the artery were with difficulty counted. This period was fucceeded by an intenfe heat, and a ftrong, hard, full pulfe, en which account he was copioufly bled ; and a dofe of cool- ing phyfic was immediately adminiftered, and a clyfter thrown up to promote its more Speedy effefts. In the evening the bleeding was repeated. All this day he complained of excru- ciating pain in his loins, and the fide of his belly dcScending down OF GONORRHOEA. 193 down into the fcrotum. On examining the part affefted, I Saw an appearance oS inflammation in the groin of the left fide, and a great tenfion about the ring of the abdominal muS- cles, with an enlargement of the tefticles. TheSe parts were now ordered to be Somented with a difcutient fotus ftrongly impregnated with crude Sal ammoniac, and to be bathed with Spiritus mindereri, and Spiritus volat. aromat. before the ap- plication of each Stupe ; and he was directed to take fix grains of the pulv. antimonialis, with fifteen grains of nitre every three hours ; his food to be thin gruel, with fruit and lemon- juice, and his drink barley-water with Sugar and nitre. Not- withflanding this antyphlogiftic plan of frequent cooling phy- fic, anodynes, three emetics, and thirteen blood-lettings, the fe- ver continued, and the pain, inflammation and tumor increaSed till the eighth day, including the firft day of Seizure ; when Seeing no hope of diScuffing the tumor, the tefticle being near- ly as large as a child's head, I attempted by emollient SotuSes, and maturating catapiaSms, to bring it to Suppuration. On the 10th, a fluctuation was perceptible; and on the 12th, much more So, the Scrotum having then put on a livid appearance. I ufed every poffible argument Sor permiffion to open it, but he being now quite eaSy, would not admit it. On the 15th, the patient was again attacked with rigors, coldneSs and fhiver- ing, Succeeded by a great feverifh heat, which Soon terminated in a proSuSe Sweat, yet no pain attended this paroxySm. In the evening, however, the tumor was So prominent that I was of opinion it would open fpontaneoufly before morning, when I hoped to obtain his confent to enlarge the aperture ; but this not happening, and all intreaties, relating to the neceffity of an incifion, proving ineffectual, I contented mySelf with giv- ing the bark with elixi-r of vitriol. From this time, after every paroxyfin of fever, the tefticle was obferved to decreafe. Not being permitted to make an incifion, and his ftrength and ap- petite continuing gobd, I began to entertain hopes of SucceSs without it, and adviSed him to perfifl in the uSe of the tonic and antifeptic plan, with the addition of ftupes wet with the decoction of bark, to be conftantly applied ; by which means, at the end of thirty days from the firft Seizure, the pus was to- tally abSorbed. The tefticle then appeared to be of the Size of an hen's egg, and was as hard as a Schirrus. I directed it to be rubbed, night and morning, with equal parts of the unguent. C c nicrcur. i94 SUPPOSED CONSEQUENCES, Sec. mercur. fort, and liniment, volat. camphorat. and ordered, in* ternally, fome mercurial alteratives, with a decoction of bark. By thefe aids his night-fweats, and every other difagreeable fymptom, gradually abated; he gathered ftrength, flefh and Spirits, very faft, and the difeafed tefticle went on conftantly decreafing, though very Slowly, Sor near twelve months ; at the expiration of which time there was no other appearance of it than a confufion of loofe fibres, obvious to the feeling, in the upper part of the fcrotum. About a month ago the patient confented to my examining it. Of the tefticle there was not the leaft veftige, neither could I perceive the tunica vaginalis on that fide in the groin ; but upon the os pubis, and a little under it, I could embrace with my fingers and thumb the chord, .and diftinguifh the veffels, which were without the leaft degree of hardnefs or fchirrofity ; and if I preffed one in particular, I gave him exquifite pain for a mo- ment. He is in perfect health, of a ftrong, robuft conflitu- tion, and has fine healthy children ; the only change which he has perceived in the conflitution has been a propenfity to grow Sat, which neither temperance, nor violent exerciSe on horSeback, daily, with little reft, will prevent." PART [ '95 ] PART IV. CHAPTER I. OF CHANCRE. I HAVE been hitherto Speaking of the effefts of this poifon, when applied to a fecreting furface and without a cuticle ; of the intention of Nature in producing thefe effefts, and of all the confequences, both real and fuppofed. I now mean to ex- plain its effefts when applied to a Surface that is covered with a common cutic/e, as the common fkin of the body, which on Such a Surface will be found to be very different from thofe I have been defcribing. But I may be allowed here to remark, that the penis, the common feat of a chancre, is, like every part of the body, liable to difeafes of the ulcerative kind; and from fome circumftances, rather more fo than other parts; for if attention is not paid to cleanlinefs, we have often excoria- tions, or Superficial ulcers, Srom that cauSe ; alSo, like almoft every other part that has been injured, theSe parts, when once they have Suffered Srom the venereal diSeaSe, are very liable to ulcerate anew. Since then this part is not exempted from the common difeafes of the body, and as every difeafe in this part is fufpefted to be venereal, great attention is to be paid in forming our judgment of ulcers here. Venereal ulcers commonly have one character, which how- ever is not entirely peculiar to them, for many fores that have no difpofition to heal, (which is the cafe with a chancre) have fo far the Same character. A chancre has commonly a thick- ened bafe, and although in fome the common inflammation fpreads much further, yet the fpecific is confined to this bafe. The future, or confequent ulcers are commonly eafily diftin- guifhed from the original, or venereal, which will be defcrib- ed hereafter. It is an invariable effeft, that when any part of an animal is irritated to a certain degree, it inflames and forms matter, the i96 OF CHANCRE. the intention of which is, to remove the irritating caufe. Thi3 proceSs is eafily effefted when it is on a Surface whofe nature is to Secrete; but when on a Surface whofe nature is not to Se- crete, it then becomes more difficult, for another proceSs muft be Set up, which is ulceration. This is not only the caSe in common irritations, but alSo in Specific irritations from morbid poiSons, as the venereal diSeaSe and Small pox. The variolous matter, as well as the venereal, produces ulcers on the fkin ; hut when it affefts Secreting Surfaces, a difeafed fecretion is the confequence ; and this is different in different parts ; on the tongue, infide of the mouth, uvula and tonfils, the coagulable lymph is thrown out in Sorm of floughs, fomewhat Similar to the putrid Sore throat; but in the fauces and all down the cefo- phagus, a thickifh fluid, in appearance like matter, is Secreted. When the irritation is applied to a Surface whofe cuticle is thin, and where there is a Secretion naturally, as the glans pe- nis, or infide of the prepuce, there it fometimes only irritates, fo as to produce a difeaSed Secretion, as was deScribed ; but this is not always the effeft of fuch irritation on fuch furfaces. They are often irritated to ulceration, and producing a chancre. The poifon has, in general, either no difpofition, or not fuf- ficient powers to blifter or excoriate the common fkin ; for if it did, the fymptoms mofl probably would be at firft nearly the Same, if not exaftly fo, with a gonorrhcea ; that is, a diScharge cf matter from a furface, without a cuticle, newly inflamed ; for it is reafonable to SuppoSe, that the poiSon would produce on that excoriated furface a Secretion of matter, which would be at firft a gonorrhcea, and which, very probably, would af- terwards fall into the fecond mode of aftion or ulceration, and then become a chancre. There are three ways in which chancres are produced ; firft, by the poifon being inferted into a wound ; Secondly, by be- ing applied to a non-Secreting Surface ; and thirdly, by be- ing applied to a common fore. To whichever of thefe three different Surfaces it is applied, the pus produces its Specific in- flammation and ulceration, attended with a Secretion of pus. The matter, produced in conSequence of thofe different modes of application, is of the Same nature with the matter applied, becauSe the irritations arc the Same in both. The poiSon much more readily contaminates, iS it is appli- ed to a frefh wound, than to an ulcer, in this refembling the inoculation OF CHANCRE. 197 inoculation of the fmall pox. Whether there are any parts of the Skin, or any other part of the body, more fufceptible of this irritation than others, in confequence of local application, is not yet afcertained. This form of the difeafe, like the firft, or gonorrhoea, is ge- nerally caught on the parts of generation, in confequence cf a conneftion between the fexes ; but any part of the body may be affefted by the application of venereal matter, efpecially if the cuticle Is thin. I have feen a chancre on the prolabium, as broad as a Six- pence, caught the perSon did not know how*. The penis, and particularly the prepuce, being the parts moft commonly affeft- ed by this Sorm of the difeafe, are fo conftrufted as to fuffer much from it, efpecially when they are very SuSceptible of fuch irritation ; for the conftruftion alone produces many inconve- niences, befides confiderable pain, while under the diSeaSe, and in general retards the cure. The chancre is not So Srequent an effeft of the poifon as the gonorrhcea ; and I think very good reafons may be affigned for it, although there are more modes than one of catching it, as I juft now mentioned ; but the parts in two of them, to wit, the wound, and the fore, are feldom in the way of being infected ; therefore when it is caught it is commonly by the fame mode of application with that of the gonorrhcea ; but as the cuticle cannot be affefted by this poiSon, this covering act- ing as a guard to the cutis, it is often prevented from coming in contaft with it; and indeed it is almoft Surprifing that the cutis fliould be affefted by it, where it has Such a covering, excepting about the glans, the infide oS the prepuce, or other parts of the body, where this covering is thin. The propor- tion which the caSes oS gonorrhoea bear to thoSe of chancre is as four or five to one. When it is caught in men, it is generally upon the fraenum, glans penis, prepuce, or upon the common fkin of the body of the penis ; and fometimes on the forepart of the Scrotum ; but I think moft Srequently on the fraenum, and in the angle between the penis and glans. Its affefting theSe parts ariSes Srom the manner in which it is caught, and not Srom any Spe- cific * That this fore was a chancre I made no doubt, for befides its difeafed appearance, be !nd a bubo forming in one of the glands under the lower jaw, on the fame fide. I; .5 moft | robable that his own fingers were the cenyeyers. i98 OF CHANCRE. cific tendency in theSe parts to catch it more than others : and its affefting the fraenum, &c. more frequently than the other parts of the penis arifes from the external form of this part, which is irregular, and allows the venereal matter to lie undif- turbed in the chinks ; by which means it has time to irritate, and inflame the parts, and to produce the Suppurative, and ul- cerative inflammation In them. But as this matter is eafily rubbed off from prominent parts, by every"thing that touches them, it is a reafon why fuch parts in general fo often efcape this difeafe. The diftance of time between its application, and its effefts upon the part is uncertain ; but, upon the whole, it is rather longer in appearing than the gonorrhcea; however this depends in fome meafure on the nature of the parts affefted. If it be the fraenum, or the termination of the prepuce into the glans, that is affected, the difeafe will in general appear earlier; thefe parts being more eafily affefted than either the glans, common fkin of the penis, or fcrotum ; for in Some caSes where both the glans and prepuce were contaminated Srom the Same applica- tion of the poiSon, it has appeared earlier on the prepuce. I have known caSes where the chancres have appeared twen- ty-four hours after the application of the matter ; and others where it has been ftven weeks. A remarkable caSe of this kind was in a gentleman who had not touched a woman for Se- ven weeks, when a chancre appeared. That this was a vene- real chancre was proved, by his having had the lues venerea from it, and being under a neceffity of taking mercury. An officer in the army had a chancre which appeared two months after he had had any conneftion with a woman. After the laft conneftion he marched above an hundred miles, when the chan- cre broke out, and only gave way to mercury. This, like moft other inflammations which terminate in ul- cers, begins firft with an itching in the part; if it is the glans that is inflamed, generally a fmall pimple appears full of mat- ter, without much hardnefs, or feeming inflammation, and with very little tumefaction, the glans not being fo readily tu- mefied from inflammation as many parts are, efneciallv the prepuce; nor are the chancres attended with So much pain or inconvenience as thofe on the prepuce; hut if upon the fne- num, and more efpecially the prepuce, an inflammation more confiderable than the former Soon follows, or a: leaft the ef- fects OF CHANCRE. 199 fefts of the inflammation are more extenfive and vifible. ThoSe parts bein^ compoSed of a very loofe cellular membrane, afford a ready paffage for the extravafated juices; continued fympa- thy alfo more readily takes place in them. The itching is gradually changed to pain ; the furface of the prepuce is in fome cafes excoriated, and afterwards ulcerates : in others a fmall pimple, or abfeefs appears, as on the glans, which forms an ulcer. A thickening of the'part comes on, which at firft, and while of the true venereal kind, is very circumfcribed, not diffufing'itSelf gradually and imperceptibly into the furround- ing parts, h"t terminating rather abruptly. Its bafe is hard, and the edges a little prominent. When it begins on the frae- num, or near it, that part is very commonly wholly deftroy- ed, or a hole is often ulcerated through it, which proves ra- ther inconvenient in the cure, and in general it had better, in fuch caSes, be divided at firft. IS the venereal poiSon fhould be applied to the fkin, where the cuticle is more denSe than that of the glans penis, or frae- num, fuch as that upon the body of the penis, or fore part of the fcrotum, (parts which are very much expofed to the appli- cation of this matter) then it generally appears firft in a pim- ple, which is commonly allowed to Scab, owing to its being expoSed to evaporation. This Scab is generally rubbed off, or pufhed off, and one larger than the firlt forms. I think there is lefs inflammation attending theSe laft, than thoSe on the frae- num and prepuce, but more than thoSe upon the glans. When the difeafe is allowed to go on, So as to partake of the inflammation peculiar to the habit, it becomes in many inftances more diffufed, and is often carried fo far, as to pro- duce difagreeable fymptoms, as phymofis, and Sometimes pa- raphymofis, greatly retarding the cure ; but flill there is a hardneSs peculiar to this poifon, furrounding the fores, efpeci- ally thofe upon the prepuce. When thefe ulcers are forming, and after they are formed, or in the ftate of inflammation, it is no uncommon thing for the urethra to fympathlfe with them, and give a tickling pain, efpecially in making water ; but whether or not there is ever a difcharge in the urethra from fuch a caufe I will not deter- mine ; but if a difcharge never takes place but when the difeafe really attacks the urethra, it would make us fuppofe that this Sympathy is not really inflammatoiy ; or if it is carried fo far as 200 OF CHANCRE. as to produce inflammation, yet that it is not of the fpecific kind. However it is poffible in thoSe cafes where there is a gonorrhcea preceded by a chancre, that this gonorrhcea may ariSe from fympathy, and is not a difeaSe proceeding from the original contamination, nor from the matter of the chancre. That the SenSation in the urethra, in thoSe inftances where there is no diScharge, is from fympathy, and not from the urethra being attacked with the difeafe at the time that the matter laid the ground-work for the chancre, is evident from the following obfervation. I have feen it happen more than once, when the feat of the chancre had broke out a fecond time, and where no new or Srefh infeftion had been caught, that the patient complained of the fame tickling or flight pain in the urethra before any difcharge had taken place in the be- ginning ulcerations. From the fame connection of parts I have feen a chancre coming upon the glans abfolutely cure both a gleet and an irritation all along the paffage of the urethra. So great was the previous irritation in this cafe, that I SuSpefted a ftrifture ; but on paffing a bougie Sound none. In confequence of the urethra fympathifing with the chan. ere, the tefticles and fcrotum will further SympathiSe with the urethra, and become affefted. I have Seen this Sympathy ex- tend over the whole pubes, and So ftrong that touching the hairs gently on the pubes has given diSagreeable fenSations, and even pain. In Speaking of the local, or immediate effefts oS the vene- real diSeaSe, I mentioned that they were Seldom wholly Speci- fic, and that they partook both oS the Specific and the constitu- tional inflammation ; and therefore it is always very neceffary to pay Some attention to the manner in which chancres firft appear, and alSo to their progreSs; Sor they often explain the nature of the conftitution at the time. If the inflammation Spreads faft, and considerably, it Shows a conftitution more difpofed to inflammation than natural. If the pain is great, it fhows a ftrong difpofition to irritation. It alfo fometimes hap- pens that they begin very early to Sorm floughs ; when this is the caSe they have a ftrong tendency to mortification. TheSe additional Symptoms mark the conftitution and direct the Suture mode of treatment. When there is a confiderable loSs of fubftance, either Srom Qoughing or ulceration, a profufe bleeding is no uncommon circumftance, OF CHANCRE. 201 circumftance, more efpecially if the ulcer is on the glans; for it would appear that the adhefive inflammation does not fuffi- ciently take place there to unite the veins of the glans fo as to prevent their cavity from being expofed, and the blood is al- lowed to efcape from what is called the corpus fpongiofum urethrae. The ulcers, or floughs, often go as deep as the corpus cavernofum penis, where the fame thing happens. I. OF THE PHYMOSIS AND PARAPHYMOSIS. These difeafes arife from a thickening of the cellular mem- brane of the prepuce, in conSequence of an irritation capable of producing confiderable and diffuSed inflammation, which, when it does happen, is generally in confequence of a chancre in this part. This irritation, however, and inflammation, fome- times attacks the prepuce, even when the difeafe is in the form of what I SuSpeft to be a gonorrhcea of the glans and pre- puce*, Sometimes even in the common gonorrhoea, but moft frequently of all from a chancre in the prepuce. When ilus difeafe or tumefaction takes place in confequence of a chancre, I fufpeft that there is an irritable difpofition in the habit ; for it is plain there is more than the Specific aftion, the inflamma- tion extending beyond the Specific diftance. It may be obServed here, that the prepuce is no more than a doubling of the fkin of the penis when not erefted, for then it becomes too large for the penis, by which provifion ilw glans is covered and preServed when not neceffary to be r.fed, whereby its Seelings are probably more acute. When the pe- nis becomes ereft, it in general fills the whole fkin, by wlmii the doubling forming the prepuce in the non-ereft ftate is un- folded, and is employed in covering the body of the penis. The difeafes called phymofis and paraphymofis being a thick- ening of the cellular membrane of this part, they will com- monly be in proportion to the inflammation and diftenfibility of the cellular membrane of the part. The inflammation oft- en runs high, and is frequently of the erifypelalous kind; be- fides, in Such parts where the cellular membrane is fo veiy looSe, the tumefaction is confiderable, and the end of the pic- puce being a depending part, the ferum is accumulated in it, which, in many inflammations, is allowed to pafs from the in- D d flamed * S:e page 39, where this jor.orrhxa is mention: 1, £C2 OF CHANCRE. flamed to fome more depending part, as in an inflammation of the leg or thigh, where the foot commonly fwells or becomes cedematous in conSequence oS the deSccnt ,of the Serum extra- vaSated above. A natural contraftion of the aperture of the prepuce is very common, and fo ftrong in Some, that thoSe under Such con- itruftion of parts have a natural and conftant phymofis. Such a ftate of parts is often attended with chancres, producing ve- ry great inconveniences in the time of the cure ; and in thofe cafes of confiderable diffufed inflammation, a diSeaSed phymo- fis, fimilar to the other, unavoidably follows ; and, whether difeafed or natural, It may produce the paraphymofis Simply by the prepuce being brought back upon the penis ; for this tight part acting as a ligature round the body of the penis, behind ihe glans, retards the circulation beyond the ligature, produc- ing an cedematous inflammation on the inverted part of the prepuce. When the paraphymofis takes place in confequence of a natural tightneSs only, although attended with chancres, yet it has nothing to do with the conftitution, this being only accidental ; however, in either caSe, a paraphymofis is to be confidcredas in Some degree a local violence. This natural phymofis is So confiderable in Some children as not to allow the urine to paSs with eaSe, hut in general be- foir.es larger and larger, as boys grow up, by Srequent endea- vours to bring it over the glans, by which the bad cohSequences, that would otherways enSue in it when affected with diSeaSe, are often prevented. This part of the prepuce, although in moft men it is loofe enough to produce no inconvenience in a natural ftate, yet it Sometimes contracts without any vifible cauSe whatever, and becomes So narrow as to hinder the water Srom getting out, even after it has got free of the urethra, So that the whole ca- vity of the prepuce fha!l be< filled with the urine, and give great pain. The cafts that I have feen of this kind have been principally in old men. When the prepuce is In its natural pofition it then covers enf.rely the glans, and is commonly a little looSe before it ; but v-hen it begins to fwell.and thicken, mere and more of the fkin of the penis is drawn forwards over the glans, and the glans at the fi.me time is pufhed backwards by the fwtiilno- arrainft its cmd. I have Seen the prepuce projecting from Such a caufe more OF CHANCRE. more than three inches beyond the glans, and its aperture much diminifhed. The prepuce often becomes in fome degree inverted by the inner fkin yielding more than the outer, having a kind of neck where the outer fkin naturally terminates. From the tightnefs and diftenfion o£ the parts in a ftate of tumefaction it becomes impoffible to bring it back over the penis, fo as to invert it, and expofe the fores on the infide. Such a ftate of the prepuce is very often productive of bad confequences, efpecially when the chancres are behind the glans, for the glans being between the orifice of the prepuce and the fores, it there fills up the whole cavity of the prepuce between the chancres and opening, and often fo tightly that the matter from the fores behind cannot get a paffage forwards be- tween the glans and prepuce, by which means there, is an ac- cumulation of matter behind the corona glandis, forming an. abfeefs which produces ulceration upon the Infide of the pre- puce ; this abfeefs opens externally, and the glans often pro- truding through the opening, throws the whole prepuce to the oppofite fide, the penis appearing to have two terminations. On the other hand, if the prepuce is loofe, wide, and is ei- ther accuftomed to be kept back in its foun/t ftate, or is pulled back to drefs the chancres, and is allowed to remain in this fituation till the above tumefaction takes place, then it is call- ed a paraphymofis ; or if the prepuce is pulled forcibly back after it is fwelled, it is then brought from the ftate of a phy- mofis, as before-defcribed, to that of a paraphymofis. This laft-defcribed Situation of the prepuce is often much more troublefome, and often attended wii.li worfe-Symptoms than the former, efpecially if it fhould have been changed from a phymofis to a paraphymofis. The reafon of which is, that the aperture of the prepuce is naturally lefs elaftic than either the internal inverted part, or the external fkin ; there- fore, when the prepuce is pulled back upon [he body of the penis, that part giafps it tighter than any other part of the fkin of the penis, and more fo in proportion to the inflammation ; the confequence of which is, the fwelling of the prepuce is di- vided into two, one Swelling clofe to the glans, the other be- hind the ftrifture or neck. This ftrifture is often fo gve<-t «s to interrupt the free circulation of the blood beyond it, which alfo aflifts ia inercafinj the Swelling, adds to the flrlclme, and oiieu 2o4 OF CHANCRE. often produces a mortification of the prepuce itfelf, by which means the whole difeafed part, together with the ftrifture, is fometimes removed, forming what may be called a natural cure*. In many cafes the inflammation not only affefts the Skin of the penis, in which is included the prepuce, but it attacks the body of the penis itfelf, often producing adhefions, and even mortification in the cells oS the corpora cavernoSa, either of which will deftroy the diftenSibility of thofe parts ever after, giving the penis a curve to one fide in its ereftions. This Sometimes takes place through the whole cellular Subftance of the penis producing a fliort and almoft inflexible Stump. The adhefions of thofe cells do not proceed from venereal inflammation only ; they are often the confequences of other diSeaSes, and Sometimes they take place without any vifible caufe whatever. A gentleman, Sixty years of age, who has been lame with the gout thefe twenty years paft, has for thefe eighteen months had the penis contrafted on the left and upper fide, fo as to bend that way very considerably in ereftions, which ereftions are more Srequent than common. Query: Is the gout the caufe of this, by producing adhefi- ons of the cells of one corpus cavernofum, fo as not to yield to, or allow of the influx of blood on that fide ? And is the irritation of the gout the caufe of the frequency of the erections? CHAPTER II. OF CHANCRES IN WOMEN. OMEN are fubjeft to chancres, but from the fimplicir ty of the parts the complaint is often lefs complicated than in men. For in this Sex we have only the diSeaSe and con- ftitutional * A yc::r- man came into St. George's Vofpital, with a paraphymofis in confeouenre cf chancres on the inf.de of the prepuce. All the parts before the ftridture, formed r>y ( ,e prepuce, mortified <>r»l dropped off. I ordered nothing but common dreflingj, and ;> hraled very readily, and he lett the hofpital cured of the local complaint. Whether or r - abforption had t.i!:en place, previous to the mortification, 1 do not know, as I never *.....:- local application to that vifcus ; and if a folution of five grains is thrown hi j a vein, it will produce vomiting before we can conceive it to have got to the veffek or th- ftormch. The fame effeds are produced from an infufion of jalap thrown in* i!u vei:;J( th... are commonly produced >vheu taken into the ftomach and bowels. OF CHANCRE. •ii to mix the mercury with opium, or perhaps preparations of lead as white or red lead, to diminifh the aftion of the parts. The oftener the dreffings are Shifted the better, as the mat- ter from the fore Separates the application from the difeafed parts, by which means the effefts are loft or diminifhed. Three times every day, in many cafes, is not oftener than neceffary, efpecially if the dreffings are of the unftuous kind, for they do not mix, like watry dreffings, with the matter, So as to impart fome of their virtues to it, which would in a proportional de- gree affeft the fore. Chancres after having their venereal taint corrected, often become ftationary, and having acquired new difpofitions, in- creaSe the quantity of diSeaSe in the part, as will be taken no- tice of hereafter. When they become ftationary only, they may often be cured by touching them Slightly with the lunar cauftic. They Seem to require that the SurSace which had been contaminated, or the new flefh which grows upon that SurSace ihould be either deftroyed or altered before it can cicatrife ; and it is Surprifing often how quickly they will heal after be- ing touched., and probably once or twice may be fufficient. HI. OF THE TREATMENT OF PHYMOSIS IN CONSEQUENCE OF, OR ATTENDED WITH CHANCRE. From the hiftory which I have given of the difeafe, we muft See that a phymofis may be oS two kinds, one natural with the diSeaSe Superadded, the other brought on by diSeaSe. 1 he firft may be increaSed by the diSeaSe; but if otherways it is not fo troublefome as the other. Such phymofes as ariSe Srom the diSeaSe, I have obServed, depend upon the peculiarity of the conftitution. In either cafe it is often not practicable to apply dreffings to the chancres on the infide of the prepuce. A phymofis fhouldV prevented, if poffible ; therefore up- on the leaft figns of a thickening of the prepuce, which is known by its being retracted with difficulty and pain, the pa- tient fhould be kept quiet; if in bed fo much the belter, as in an horizontal pofition the end of the penis will not be So de- pending, but may be kept up. If confinement in bed cannot be complied with, then the end of the penis Ihould be kept up to the belly if poffi'Jle, but this can hardly be done when the 212 OF CHANCRE. perfon Is obliged.to walk about; for the extravafated fluids dc fcending and remaining in the prepuce, contribute often more to render the prepuce incapable of being drawn back than the inflammation itfelf. When the difeafed phymofis completely takes place, the Same precautions may be followed; but as the fores cannot be dreff- ed in the common way, we muft have recourfe either to dref- fings in Sorms of injeftions, or the operation for the phymofis. If we ufe injeftions only, they Should be often repeated as they are only temporary applications. The dreffings in form of injections Should be mercurial, ei- ther crude mercury rubbed down with a thick Solution of gum arable, which will affift in retaining Some of the injeftion be- tween the glans and prepuce ; or calomel with the Same, and a proportion of opium. In the proportion of thefe no nicety is required ; but if a Solution of corrofive Sublimate is made ufe of as an injeftion, fome attention is to be paid to its ftrength. About one grain of this to an ounce of water will be as much as the SenSation of the part will allow the patient to bear; and if this gives too much pain it may be lowered by adding more water. After the parts are as well cleaned as poffible with this injee tion, it will be neceffary to introduce other mercurial applica- tions of fome kind to remain there till the parts want cleaning again, which will be very foon ; fuch as are mentioned before will anfwer this purpoSe very well; but I have my doubts about the propriety of ufing any irritating medicines or injeftions in Such cafes. As often as he voids his urine, the patient may wafh the parts, by preffing the orifice of the prepuce together, fo as to obli-re the water to run back between the prepuce and glans : immediately after this the patient fhould ufe the mercurial ap- plications, otherways this operation of wafhing may do harm, as it will be wafhing away the former application of mercury ; but in many cafes the parts are So fore as not to allow of this praftice. A poultice of linfeed meal alone, or of equ.il parts of this and bread fliould be applied. This poultice is to be made with water, to which one-eighth of laudanum has been added. But previous to this, and, immediately after the cleaning, it would be very proper to let the penis hang over the fleam of hot wa- OF CHANCRE. et5 fcr, with a little vinegar and Spirits of wine in it, which is the neateft way of applying fomentations. The oftener this Is praftifed the better; for thus a mercurial application is kept in contaft with the diSeaSed parts a greater number of the hours out of the twenty-four, than otherways could be were the matter allowed to lie on the parts. When to the above-mentioned fymptoms a bleeding of the chancre is added, I do not know a more troublefome complaint, becauSe here the cells or veins have no great diSpofition Sor con- traftion*. Oil of turpentine gives the beft ftimulus for the contraftion of veffels of all kinds ; but where bleeding arifes from an irritable aftion of the veffels, which is Sometimes the caSe, then Sedatives are the beft applications. Whatever is ufed in Such a State of the prepuce muft be injected into the part. When in conSequence of the treatment the inflammation begins to go off, and the chancres to heal, it will be neceffary to move the prepuce upon the glans as much as they will allow of, to prevent adhefions which Sometimes happen when there have been chancres on both Surfaces oppofite to each other. Indeed the praftice here recommended is Such as will in gene- ral prevent Such confequences. If this has not been properly attended to, and the parts have grown together, the confequences may not be bad ; but it muft be very difagreeable to the patient, and a refleftipn up- on the Surgeon. I have Seen the opening into the prepuce So much contraft- ed Srom all theSe internal ulcers healing and uniting, that there was hardly any paffage for the water. If the paffage in the pre- puce So contrafted be in a direct line with the orifice of the urethra, then a bougie may be readily paffed ; but this is not always the caSe : it often happens that they are not in a direct line, therefore an operation becomes neceffdry. The opera- tion confifts in either Slitting up part of the prepuce, or remov- ing part of it, but as thefe parts have become very indiftinft Srom the adhefions, either the flitting it up, or removing part of it, becomes a difficult operation. Whenever the urethra is discovered, * I fufpecT: that where chancres bleed profufely, the blood comes either from the fltns, when there are chancres there, or from the fpongy fubftance of the urethra where the chancre has be5un about the fraenum, for we feldom fee profufe bleedings from the prepuce when its infide is the feat of the chancre and tan be expofed; but indeei in fn.h n-iil-i the infl unmation i. not violent. si4 OF CHANCRE. difcovered, or can be found out by a bougie, that is to be in- troduced, and its application repeated till the paffage becomes free and has got into the habit of keeping fo. I obferved formerly that this tumefaftion fometimes produc- ed a confinement of the matter formed by the chancre, and that while this effeft lafted no fubfiding of the inflammation or tumefaftion could take place ; that therefore thofe difeafes continued to exifl, and that the part thus circumftanced came under our definition of an abfeefs ; that is, the formation of matter in a ftate of confinement. Although it never has been eonfidered in this light, yet the neceffary treatment fhows it to be Such. This confifts in laying it open from the external ori- fice to the bottom where the matter lies, as in a Sinus, or fiftula, So as to diScharge it. However the intention annexed to this praftice was not to allow of the difcharge of the matter of the Sore, but to admit oS the application of dreffings to it, for it has been recommended and praftifed, where there was no par- ticular confinement of matter, which I have not found to be neceffary, merely for that purpofe, as we are in poffeflion of an internal remedy ; and if the opening produces no other good, but the allowing of the application of dreffings it is not fo material, becaufe the fores may be wafhed with an injection, through a fyringe. IV. OF THE COMMON OPERATION FOR THE PHYMOSIS PRODUCED BY CHANCRES. The common operation for the phymofis is flitting the pre- puce nearly its whole length, in the direftion of the penis ; but even this is fometimes thought not fufficient, and it is directed to cut the prepuce in two different places, nearly oppofite to one another. When it was thought proper to be done in this way, it was imagined that it was Seldom neceffary to cut the whole length of the prepuce. It will in fome degree depend on cir- cumftances, which praftice is to be followed. If it is a natu- ral phymofis without tumeSaftion, and the chancre is near the orifice of the prepuce, which in fuch cafes it moft probably will be, as the glans is not denuded in coition fo as to have chancres deeper Seated, then it may be neceffary only to go as far as the chancres extend. From OF CHANCRE. s 15 From the common fituation of the chancre, this difeafe o£ the phymofis ariSes more commonly from the tumefaftion of the parts; and from the idea I have endeavoured to give of the inconveniences arifing from this phymofis, where the chancres are placed behind the corona, producing a confine- ment of the matter behind the glans, flitting open the prepuce a little way cannot be fufficient, for in fuch cafes it muft be expofed to the bottom, or no good can arife from the operation. Although this operation will not take off the tumefaction of the prepuce fo as to allow it to be brought back, yet it will allow of a free difcharge of the matter, and alfo in fome cafes it will allow of dreffings being applied to the fores ; but not in all, for the tumefaftion will not allow more of an inverfion of the prepuce than before, and in fuch the fores cannot have dreffings applied to them. In many caSes it will be Sound that So violent an operation is improper ; Sor it oSten happens that while the inflammation is fo very confiderable, there is danger of increafing it by this additional violence, of which mortification may be the conSe- quence ; while on.the other hand there are caSes where a free- dom given to the parts would prevent mortification, fo that the furgeon muft be guided by the appearances, and other cir- cumftances. Befides theSe reaSons for and againft the opera- tion arifing Srom the diSeaSe itSelf, it will not always be con- sented to by the patients themSelves, Sor Some have Such a dread of operations that they will not fubmit to cutting inftruments; however in thofe cafes where the matter is confined, it will be abfolutely neceffary to have an opening Somewhere Sor the diS- charge of it. This is often produced by the ulcerative procefs going on on the infide, which makes an opening direftly through the Skin, laterally, which affords a direftion for the Surgeon ; therefore the opening may be made direftly into the cavity of the prepuce, through the fkin, on the fide of the penis, by a lancet ; or a fmall cauftic may be applied there, for which the lapis fepticus is the moft convenient. The opening will allow of the difcharge of the matter, and alfo admit any proper wafh to be thrown in. But this open- ing fhould not be a large one, as in many cafes the conSe- quence of this lateral opening proves very troublefome ; tor, from the tumefaftion of the prepuce, the glans is Squeezed on all fides, and rather more backwards upon the body of the pe- nis, 210 OF CHANCRE. nis, than in any other direftion, by which means it is often forced1 through this opening, whereby the glans is direfted to one fide, and the prepuce to the oppofite, having a forked ap- pearance. Befides, this ftate of the parts tightens the Skin of the penis round the root of the glans, acting there fomewhat like a paraphymofis, and fometimes makes the whole prepuce mortify and drop off, which is often a lucky circumftance; but if this is not the confequence, then amputation of the prepuce- becomes neceffary ; however this fhould not be done till all inflammation is gone off, and the chancres are cured, when pro- bably the tumefaftion of the prepuce will have confiderably fubfided. A mortification of the prepuce is Sometimes a conSequence of chancres, when attended with violent inflammation, even without any previous operation ; and I have feen caSes where the glans and part of the penis have mortified, while the pre- puce has kept its ground. But I Should SuSpeft in all Such cafes, that there is fome fault in the conftitution, and that the inflammation is of the eriSypelatous, not of the true fuppura- tive kind. I have Seen the mortification go So Sar as to remove the whole of the difeafed prepuce, and the parts have put on fo Savour- able an appearance, that I have treated it as a common Sore, and no bad confequences have happened. In this caSe the diS- eaSe performed what is often recommended in other diSeaSes of this part, that is clrcumcifion ; but this is not always to be trufled to, for if abforption of the venereal matter has taken place, previous to the mortification, a lues venerea will be the confequence, although the parts heal very readily. V. OF THE CONSTITUTIONAL TREATMENT Or PHYMOSIS. In thofe cafes where violent inflammation has attacked the Seat of a chancre, producing phymofis, as before-defcribed, and often fo as to threaten mortification, a queflion naturally oc- curs, What is to be done ? Is mercury to be given freely to get rid of the firft caufe ? Or does that medicine increaSe the effeft while it deftroys the cauSe ? Nothing but experience can determine this. I fhould incline to believe, that it is neceffary that mercury fhould be given, for I arn afraid our powers to correct OF CHANCRE. zi? correct Such a constitution, while the firft caufe Subfifls, are weak. However, on the other hand, I believe the mercuiv Should be given Sparingly ; for if it affifts in diSpofing the con- ftitution to Such Symptoms, we are gaining nothing, but may loSe by its uSe. I therefore do fuppofe that Such medicines, as may bethought neceffary for the conftitution, fhould be given liberally, as well as the fpecific. Bark is the medicine that probably will be of moft general ufe ; opium in moft cafes of this kind will alfo be of Singular Service. The bark fhould be given in large quantities, and along with it mercury, while the virus is ftill fuppofed to exifl. Or if the inflammation has arifen early in the diSeaSe, they may be then given together So as to counteract both diSeaSes, and not allow the inflammation to come to fo great a height as it Would otherways do it mer- cury was given at firft alone. This inflammation may be fo great in many caSes, or be So predominant, that mercury may increaSe the difpofition and therefore become hurtful. Where this may be SuppoSed to be the caSe bark muft be given alone. VI. OF THE TREATMENT OF THE PARAPHY- MOSIS FROM CHANCRES. A prepuce in the ftate of ihflammation and tumefaftion, and which has been either kept back upon the body of the pe- nis while inflaming, or pulled back when inflamed, feldom can be again brought forwards while in this ftate, therefore becomes alfo the Subject oS an operation, which confifts in di- viding the Same part, as in the phymofis, only in a different way, arifing Srom its difference of Situation ; the intention of which operation is to bring the prepuce, when brought for- wards, to the ftate of a phymofis that has been operated upon. This operation becomes more neceffary in many cafes under this difeafe than under the phymofis, becaufe its confequences are generally worfe ; Since, befides the real diSeaSe, viz. in- flammation, tumefaftion, ulceration, &c. there is a mechani- cal caufe producing its effefts, by grafping the penis, which can of itfelf produce inflammation where the prepuce is natu- rally tight, as has been obferved. From whatever caufe it arifes it often produces mortification in the parts between the ftric- ture and the glans if it is not removed. This removal fome- times happens naturally by the ulceration of the ftriftmed part; F £ but 2rS OF CHANCRE. but an operation Is generally neceffary ; and it is more trou- blefome than in the former cafe, becauSe the Swelling on each fide of the ftrifture covers or cloSes in upon the tight part and makes it difficult to be got at. The beft way appears to be to Separate the two Swellings as much as poffible where you mean to cut, So as to expofe th? neck, then take a crooked biftory which is pointed, and paff- ing it under the fkin at the neck divide it; no part of the two fwellings on the fides need he divided, for it is the loofeneSf _ of the fkin in theSe parts which admits of their Swelling When this is done the prepuce may be brought forwards over the glans; but as this diSeaSe arofe Srom chancres which may require being dreffed, and as the ftate of a phymofis is a very bad one for fuch treatment, it may be better now that the ftric- ture is removed, to let it remain in the Same fituation till the whole is well. If the paraphymofis has ariSen Srom a natural tightneSs of the prepuce, and its being forced back from accident,, then no particular treatment after the operation is neceffary, but to go on with the cure as recommended in chancres. It is indeed probable that in confequence of the violence produced by the pofition of the prepuce, as alfo by the operation, a confidera- ble inflammation may enSue ; but as this will be an inflamma- tion in conSequence of violence only, local treatment for the inflammation will be fufficient. But if it is a paraphymofis in conSequence oS a diSeaSed phy- mofis, then the Same mode of treatment becomes equally ne- ceffary as was recommended in the phymofis attended with confiderable inflammation ; and probably rather more attend- on is neceffary here, as violence has been added to the former difeafe. VII. OF THE CURE OF CHANCRES BY MERCURY GIVEN INTERNALLY. While chancres are under local treatment, as before-de- Scribed, it is neceffary to give mercurials internally, both for the cure of a chancre and the prevention of a lues venerea ; and we may reafonably venture to affirm, that the venereal difpofition of chancre will hardly ever withfland both local and internal mercuiials. In OF CHANCRE. 219 Xh caSes of chancres where local applications cannot eafily he made, as in caSes of phymofis, internal mercurials become absolutely neceffary ; and more So than if they could be con- veniently and freely applied externally. However, even in fuch cafes, internal mercurials will in the end effeft a cure ; So that, we need Seldom or ever be under any apprehenfion of not cmSng fuch a difeafe. In every cafe of a chancre, let it be ever fo flight, mercu- ry Should be given Internally; even in thoSe caSes where they were deftroyed on their firft appearance. It fliould in all cafes be given the whole time of the cure, and continued for Some time after the chartcres are healed ; for as there are perhaps few chancres without abforption of the matter, it becomes ab- solutely neceffary to give mercury to aft internally, in order to hinder the venereal diSpofition Srom Sorming. How much mercury fhould be thrown into the conftitution in the cure of a chancre, for the prevention of that conftitu- tional affeftion, is not eafily afcertained, as there is in Such caSes no diSeaSe aftually formed fo as to be a guide, it muft be uncertain what quantity Should be giveh internally. It muft in general be according to the fize, number, and duration of the chancres. If large, we may fuppofe that the abSorption will be proportioned to the Surface, and if long continued, the ab- forption will be according to the time ; and if they have been many, large, and continued long, then the greateft quantity is neceffary. The circumftances therefore attending the chancre muft be the guide for the Safety of the conftitution, efpecially in thofe cafes where Some StreSs in the Cure is laid upon the external remedy. The mercury given to aft internally muft be thrown in ei- ther by the Skin or ftomach, according to circumftances. The quantity in either way fliould be Such as may in com- mon affeft the mouth flightly ; which method of giving mer- cury will be eonfidered hereafter. When the fore has put On a healthy look, when the hard bafis has become Soft, and it has Skinned over kindly, it may- be looked upon as cured. ' But in very large chancres it mav not always be neceffary to continue the application of mercury either for external or inter- nal aftion till the fore is healed ; for the venereal aftion is juft c2o OF CHANCRE. juft as foon deftroyed in a large chancre as it is in a Small one; for every part of the chancre being equally affefted by the mer- cury, is equally eafy cured. But the fkinning is different; for a large fore is longer in fkinning than a fmall one. A large chancre therefore may be deprived of its venereal aftion long before it is fklnned over ; but a Small one may probably fkin over before the venereal poifon Is entirely fubdued. In the after cafe, both on account of the chancre and conftitution, it will be erring on the fafe fide to continue the medicine a lit- tle longer, which will moft certainly in the end effeft a cure : for we may reaSonably SuppoSe that the quantity oS mercury ca- pable of curing a local effeft, although affifted by local applica- tions, or of producing in the conftitution a mercurial irritation fufficient to hinder the venereal irritation from forming, will be nearly as much as will cure a flight lues venerea. I have formerly laid it down as a principle, that no new ac- tion will take place in another part of the body, however con- taminated, whilft the body is under the beneficial operation of mercury ; but there are now and then appearances wh'.ch occur under the cure that will at firft embarrafs the praftitioner. I have fuSpefted that the mercury flying to the mouth and throat has Sometimes produced floughs in the tonfils, and theSe have been taken for venereal. The following cafes in fome degree explain this. A young gentleman had a chancre on the prepuce, with a flight pain in a gland of one groin, for which I ordered mercu- rial ointment to be rubbed into the legs and thighs, efpecially on the fide where the gland was fwelled, and the chancre to be dreffed with mercurial ointment. While he was purSuing this' COurSe the chancre became cleaner, the hardneSs at the bale went off, and the pain in the groin was entirely removed. About three weeks after the firft appearance of the difeafe, he was attacked with a fore throat, and on looking into the mouth I found the right tonfil with a white flough which appeared to be in its fubftance, with only one point yet expofed. From my mind being warped by the opinion that thefe complaints pro- ceeded from the chancre, I immediately fuSpefted that it was venereal ; and the only way I could account for this feeming contradiftion in one part healing while another was breaking out, wa.% the.1 the healing Sore was treated locally as well as constitutionally, OF CHANCRE. S2* conftitutionally, while the tonfil, or the conftitution at large, was only treated conftitutionally, which was inSufhcient. Soon after this another gentleman was under my care for ve- nereal fcurffs, or eruptions on his fkin, for which he ufed mer- curial friftion till his mouth became fore ; and in this ftate he continued for three weeks, in which time the eruptions were all gone, difcolourations being left only where the eruptions had been, yet at the end of three weeks a Slough Sormed in pne of the tonfils, exactly as in the former cafe. This made me doubtful how tar fuch cafes were venereal. I ordered the friftion to be left off, to fee what courfe the ulcers would take ; the flough came out and left a foul fore : I waited ftill longer, and in a day or two it became clean and healed up. The firlt-mentioned cafe 1 did not fee to an end ; but I learned that the patient continued the mercury and got well; and the ulcer in the throat was SuppoSed to be venereal; but from the circumftances of the other cafe I now very much doubt of that. It is more than probable that thefe effefts of mercury only take place in conftitutions that have a tendency to fuch com- plaints in the throat. I know this to be the cafe with the laft- mentioned gentleman ; and it is alfo probable that there may be an increaSed diSpofition at the time, either in conSequence of the mercury, or fome accidental caufe. I have reafon to fuppofe that mercury in fome degree increafes this diSpofition, which I fhall further take notice of when treating of the cure of the lues venerea. In the cure of chancres I have fometimes feen, when the original chancre has been doing well, and probably nearly cured, that new ones have broken out upon the prepuce, near jo the firft, and have put on all the appearance of a chancre; but fuch I have always treated as not venereal. They may be Similar to Some conSequences of chancres, which will be taken notice of hereafter. As fwellings oS the abSorbed glands take place in conSequence of other abforptions befides that of poifons, we fhould be care- ful in all caSes to afcertain the cauSe, as has been already de- scribed ; and here it may not be improper ftill to obServe fur- ther, that in the cure of chancres, fwellings of the glands fhall arife, even when the conflitution is loaded with mercury fuffi- cient for the cure of the fores; but then the mercury has been throws 222 OF CHANCRE. thrown into the conftitution by the lower extremity; and therefore there is great room for SuSpicion that Such Swellings are not venereal, but ariSe Srom the mercury : Sor a real bubo, Srom abSorption of venereal matter, if not come to fuppuration, will give way to mercury rubbed into the leg and thigh. In fuch cafes I have always defifted from giving the mercury in this way when I could give it by the mouth. CHAPTER IV. OF THE CURE OF CHANCRES IN WOMEN. THE parts generally affefted with chancres in this Sex, are more Simple than in men, by which means the treatment in general is alSo more Simple ; but in moft caSes they require nearly the Same, both in the local application of mercury, and in throwing it into the conftitution. It may be SuppoSed how- ever, that it will be neceffary in many caSes to throw into the conftitution more mercury than in men ; becauSe in general there are more chancres, and the Surface of abforption of courfe larger. As it is difficult to keep dreffings on the female parts, it is" proper they fhould be wafhed often with Solutions of mercury; perhaps corrofive Sublimate is one of the beft, as it will aft as a Specific, and alfo as a flimulant when that is wanted ; but id chancres that are very irritable, the Same mode of treatment as was recommended in men is to be put in praftice. After- wards the parts may be befmeared with a mercurial application, either oily or watry, to be frequently repeated according to the circumftances of the caSe. If the ulcers fhould have fpread, or run up the vagina, great attention fhould be paid to the healing of them; for it Sometimes happens that the granulations contraft confiderably So as to draw the vagina into a Small canal ; at other times the granulations will unite into one another and cloSe the vagina up altogether; therefore in Such caSes it will be neceffary tO keep OF CHANCRE. 2*$ keep fome fubftance in the vagina till the fores are Skinned, fof which purpofc probably lint may be fufficient. ---------—p—BRjwi CHAPTER V. OF SOME OF THE CONSEQUENCES OF CHANCRES, AND THE TREATMENT OF THEM. AFTER the chancres have been cured, and all venereal taint removed, it fometimes happens that the prepuce ftill retains a confiderable degree of tumefaftion, which keeps up the elongation and tightneSs which it acquired from the dif- eafe, fo that it cannot be brought back upon the penis to ex- poSe the glans. For this perhaps there is, in many cafes, no cure ; how- ever it is neceffary to try every poffible means. The fteam of warm water, fomentations with hemlock, and alfo fumigations with cinnabar, are often of Singular fervice in this cafe. But if the parts ftill retain their Size and form, it may be very proper to remove part of the overgrown prepuce ; how much, muft be left to the discretion of the furgeon. I fliould SuppoSe, that all that part, which projects beyond the glans penis, may be cut away. The beft way of removing it Is by the knife ; but great care ihould be taken to diftinguifh firft the projefting prepuce from the glans. When this is perfeftly afcertained, the penis being held horizontally, an incifion may be made on the upper fur- face, and followed down with caution ; becauSe if the incifion Should be too near the glans there may be danger of cutting it. The parts may be allowed to heal with any common dref- fings, as it is to be eonfidered as a Srefh wound ; however it will not heal So readily as a Srefh wound made in an entirely Sound part, becauSe the operation confifts in taking away only a Superfluous part of a difeafed whole ; and what is left is dif- eafed, but not So as to produce any future mifchief. Some care may be neceffary in the healing of the parts ; for it is very poffible that the cicatrix may contraft, and ftill form; a phy- 324 OF CHANCRE. a phymofis. This will be beft prevented by the patient himi Self if he brings the prepuce often back upon the penis ; but it fhould not be attempted till the part is nearly healed ; and it is to be performed with great care, and Slowly; I. OF DISPOSITIONS TO NEW DISEASES DURING THE CURE OF CHANCRES. Chancres, both in men and women, often acquire new difpofitions in the time of the cure, which are of various kinds, Some of which retard the cure, as defcribed, and, when the parts are cured, leave them tumefied and indolent, as in the enlarg- ed prepuce. In others a new diSpofition takes place, which prevents the cure or healing of the parts, and often produces a much worfe diSeaSe than that Srom which it aroSe. They al- So become the cauSe of the formation of tumors on thefe parts, which will be taken notice oS hereafter. 1%* Such new diSpofitions take place oftener in men than in wtf- men, probably from the nature of the parts themfelves. They feldom or never happen but when the inflammation has been violent, which violence arifes more Srom the nature of the parts than the difeafe, and therefore belongs more to the nature of the parts or conftitution than to the diSeaSe. However, I can conceive it may alSo take place where the inflammation has not been violent. In general they are SuppoSed to be cancerous, but I believe they Seldom are ; although it is not impoffible that fome may be fo. Of this kind may be reckoned thofe continued and often in- creafed inflammations, fuppurations, and ulcerations, becom- ing diffufed through the whole prepuce, as alfo all along the common fkin of the penis, which bectomes of a purple hue ; the cellular membrane every where on the penis being very much thickened fo as to increafe the fize of the whole con- fiderably. The ulceration, on the infide of the prepuce, will fometimes increafe and run between the fkin and the body of the penis, and eat holes through in different places till the whole is re- duced to a number of ragged fores. The glans often fhards the fame fate till more or lefs of it is gone ; frequently the urethra at this part is wholly deftoyed by ulceration, and the uiinc OF CHANCRE. 225 urine is discharged Some way Surther back. IS a ftop is not put to the progreSs of the diSeaSe, the ulceration will continue till the parts are entirely deftroyed. I SuSpeft that Some of. thefe cafes are fcrofulous. As this is an acute cafe, immediate relief fhould be given, if poffible ; but as it may arife from various peculiarities in the conftitution, and as theSe peculiarities are not at firft known, no rational method can be here determined. The decoction of SarSaparilla is often of Service in Such caSes, but requires to be given in large quantities. The German diet-drink* has been of lingular fervice ; I knew a cafe of this kind cured by it, after every known remedy had been tried. The extract of hemlock is fometimes of fervice. I have known Sea-bathing cure theSe complaints entirely. A gentleman came from Ire- land with a complaint of this kind, and after having tried eve- ry common, and known method, without effeft, as farfaparil- la, hemlock, Germamdiet-drink: and aSter having uSed a great variety oS dreffings, (which were all at laft laid afide, and opi- um only retained to quiet the pain) he bathed in the Sea and got well. It may be Sometimes neceffary to paSs a bougie, to hinder the oxifice of the urethra from clofing or becoming too Small in the time of healing in fuch cafes. II. OF ULCERATIONS RESEMBLING CHANCRES. It often happens that after chancres are healed, and all the virus gone, the cicatrices ulcerate again, and break out in the form of chancres. Although this is "moft common in the feat of the former chancres, yet it is not always confined to them ; for fores oft- en break out on other parts of the prepuce ; but ftill they ap- pear to be a confequence of a venereal complaint having been there, as they feldom attack thoSe who never had gonorrhcea or chancres. They often have So much the appearance of chan- G g cres, * The following formulas have been much recommended as diet-drinks. Take of crude antimony, "pulverized, tied up in a bit of rag; puntice-ftone, pulverized, tied up in the fame, of each one ounce; China-root, fticed ; farfapar;lla-root, diced and bruif- ed, of each half an ounce ; ten walnuts, with their rinds, bruifed; fpring-water, four pints; boiled to half that quantity ; filter it, and let it be drank daily in divided dofes. Take farfaparilla, Saunders-woaJ, white and red, of each three ounces ; liquorice and mezereon, of each half an ounce; of lignum, rhodium, guaiacum, fafiafras of each one ounce; crude antimony, two ounces ; mix them and infufe them in boiling w.u.-r, ten pints, for twenty-four hours; and afterwards boil them to five pints, of which l«t the dofe be from a pint and an lull to four pintr a day. 26 OF CHANCRE. cres, that I am perfuaded many are treated as venereal that are really not fuch : they differ from a chancre in general by not Spreading So faft, nor fo far; they are not So painful, nor fo much inflamed, and have not thofe hard bafes that the venere- al Sores have, nor do they produce buboes. Yet a malignant kind of them, when they attack a bad conftitution, may be taken for a mild kind of chancre, or a chancre in a good con- ftitution. Some StreSs is to be laid upon the account that the patient gives of himfelf: but when there is any doubt, a little time will clear it up. I have feen the fame appearances after a go- norrhoea; but that more rarely happens. It would appear that the venereal poiSon could leave a diSpofition for ulceration of a different kind from what is peculiar to itfelf. I knew one cafe where they broke out regularly every two months, exact- ly to a day. As they are not venereal their treatment becomes difficult; for the cure confifts more in preventing a return, than in the healing up of the preSent Sores. They require particular attention; Sor although they are not dangerous, they 'are often troubleSome, keeping the mind in fuSpence for months. I have tried a great variety of means, but with little SucceSs, yet they have in general got well in the end. In the follow* ing caSe, the lixivium Saponarium produced a Speedy cure. A gentleman had three Sores broke out on the prepuce,. which had very much the appearance of mild chancres. As I was doubtful of their nature, I waited fome time, and only or- dered them to be kept clean. As they did not get well, feve- ral things were tried. Mercurial dreffings were applied, but they always produced confiderable irritation, and it was necef- Sary to leave them off. The mercurius calcinatus was given by way of trial, and to Secure the conftitution, but the Sores continued the Same. They were eat down with the lunar cau- ftic, which appeared to have a better effeft than any other thing tried; but ftill they were not healed at the end of five months. I ordered Sorty drops of the lixivium Saponarium to be taken cveiy evening and morning in a bafon of broth. After ufing it three days he obServed a confiderable alteration in the Sores, and in fix they were perfectly fkinned over. He had formerly had fuch fores often, which had always been treated as vene- real ; OF CHANCRE. 227 real; but he began to doubt whether they really were So from their getting fo foon well in the prefent inftance by the lixivium. I knew a gentleman who had thefe Sores breaking out and healing again for years. By bathing in the Sea Sor a month or two they healed up and never aSterwards appeared. III. OF A THICKENING AND HARDENING OF THE PARTS. In Some caSes the parts do not ulcerate, but appear to thick- en and become hard or firm ; both the glans and prepuce Seem to Swell, forming a tumor or excrefcence from the end of the penis, in form a good deal like a cauliflower, and, when cut into, Showing radii running from its bafe, or origin, towards the external SurSace, becoming extremely indolent in all its operations. This gives more the idea oSa cancer than the firft, being principally a new-Sormed Subftance. However, it is not always a conSequence of the venereal difeafe; I have known it to arife fpontaneoufly. This diSeaSe appears to be a tumor of fo indolent a kind, that I do not know any medicine that ftands the leaft chance of performing a cure. I have amputated them, and have alfo feen the fame thing done by others, from the idea of their be- ing cancerous, and the remaining part of the penis has heal- ed kindly. , In mofl: of thefe cafes a confiderable part oS the penis muft be removed. Immediately after the amputation, a Suitable ca- theter fhould be introduced into the urethra; for if no fuch precaution is made ufe of, the confequences muft be trouble- fome ; for the firft dreffings become cemented to the orifice by the extravafated blood, and prevent the patient's making water, which muft be attended with obvious inconveniences. This was the cafe with a patient whoSe penis I amputated. IV. OF WARTS. Another diSpofition, which thefe parts acquire from the venereal poifon, is the difpofition to form excrefcences, or cu- taneous tumors, called warts. This difpofition is Strongefl where the chancres were ; and indeed chancres often heal into warts; 228 OF CHANCRE. warts ; but perhaps the parts acquire this diSpofition from the venereal matter having been long in contaft with their furfaces; Sor it often happens after gonorrhoeas, where there had been no chancres ; and probably it is only in thofe cafes where the venereal matter had produced the venereal ftimulus upon the glans and prepuce, forming there what may be called an in- fenfible gonorrhcea. A wart appears to be an excrefcence Srom the cutis, or a tumor Sorming upon it, by which means it becomes covered with a cuticle, which like all other cuticles, is either Strong and hard, or thin and Soft, juft as the cuticle is which covers the parts from whence they arife. They are radiated from their bafis to the circumSerence, the radii appearing at the Sur- Sace pointed or granulated, much like granulations that are healthy, except that they are harder, and riSe above the Sur- face. It would appear that the Surface, on which each is form- ed, has only the difpofition to form"one, becauSe the Surround- ing and connecting Surface docs not go into the like Subftance; thus a wart once begun does not increafe in its bafis, but riSes higher and higher. They have an increafing power within themfelves ; for, after rifing above the Surface of the Skin, on which they are not allowed to increaSe in breadth at the bafis, they Swell out into a round thick Subftance, which becomes rougher and rougher. This ftrufture often makes them liable to be hurt by bodies rubbing againft them ; and often from fuch a caufe they bleed very profufely, and are very painful. Thefe excrefcences are eonfidered by many not as Simply a conSequence of the venereal poiSon, but as poffeffed of its fpe- cific difpofition, and therefore they have recourfe to mercury for the cure of them ; and it is afferted that Such treatment oSten removes them. Such an effeft of mercury I have never Seen, although given in Such a quantity as to cure in the Same perSon recent chancres, and Sometimes a pox. As theSe Subftances are excreScences Srom the body, they are not to be eonfidered as truly a part of the animal, not be- ing endowed with the common or natural animal powers, by which means the cure becomes eafier. They are fq little of the true animal, and So much of a difeafe, that many trifling circumftances make them decay ; an inflammation in the natu- ral and Sound parts round the wart will give it a diSpofition to decay ; OF CHANCRE. 229 idecay; many ftimuli applied to the furface will often make them die. Electricity will produce aftion in them which they are not able to fupport; an inflammation is excited round them, and they drop off. From this view of them, the knife and efcharotics muft ap- pear not always neceffary, although thefe modes will aft more quickly than any other in many cafes, efpecially if the neck is Small. In fuch formed warts perhaps a pair of fciffars is the beft inftrument; but where cutting inftruments of any kind are -horrible to the patient, a Silk thread tied round their neck will do very well ; but in whichsoever way it is Separated, it will be in general neceffary to touch the bafe with cauftic. EScharotics aft upon warts in two different ways, namely by deadening a part and ftimulating the remainder ; So that by the application of efcharotic after efcharotic, the whole decays tolerably Salt; and it is Seldom neceffary to eat them down to the very root, as the bafis or root oSten Separates and is thrown off. This however is not always the cafe, for we find that the root does not always Separate, and that it will grow again; therefore in Such cafes it is neceffary to eat down lower than the general furface to remove the root. Any of the cauftics, fuch as the lapis fepticus, as alfo the metallic Salts, Such as the lunar cauftic, blue vitroil, &c. have this power. The ruft of copper and favine leaves mixed are one of the beft ftimulants. After they have been to appearance Sufficiently deftroyed, they oSten rife anew, not Srom any part being leSt, but from the furface of the cutis having the fame diSpofition as before. This requires a repetition of the fame praftice, So as to take off that Surface of the cutis. V. OF EXCORIATIONS OF THE GLANS AND PREPUCE. It very often happens that the Surface of the glans and in- fide of the prepuce excoriate, becoming extremely tender, and then a matter oozes out. The prepuce in fuch cafes often be- comes a little thickened, and fometimes contracts in its orifice, both which circumftances render the inverfion of it difficult and painful. Whether this complaint ever ariSes from a venereal caufe •330 OF CHANCRE. cauSe is not certain, as it oSten takes place where there never has been any venereal taint. This diSeaSe is in the cutis; and under Such a diSpofition it has no power of forming a good cuticle. It is very fimilar to a gonorrhcea in this part, but is not venereal. Drawing the prepuce back, and fteeping the parts in a Solu- tion of lead, often takes off the irritation, and a found cuticle is formed. Spirits diluted often produce the fame effeft ; the unguentum citrinum of the Edinburgh Difpenfatory, lowered by mixing with it equal parts of hogs-lard, is often of Singular fervice in fuch cafes; but there are cafes which bid defiance to all our applications, in which I have fucceeded by defiring ihe perfon to leave the glans uncovered, which produced the ftimulus of neceffity for the formation of a natural cuticle. PART t *3» 3 PART V. CHAPTER I. OF BUBO. A KNOWLEDGE of the abforbing fyftem, as it is now eftablifhed, gives us confiderable information refpefting many of the effefts of poifons, and illuftrates feveral fymptoms of the venereal diSeaSe, in particular the Sormation oS buboes* Prior to this knowledge we find writers at a loSs how to give a true and confiftent explanation of many of the fymptoms of this difeafe. The difcovery of the lymphatics being a fyfterr* of abforbenfs, has thrown more light on many diSeaSes than the diScovery oS the circulation oS the blood ; it leads in many caSes direftly to the cauSe of the difeafe. The immediate confequence of the local difeafes, gonorrhoea and chancre, which is called bubo, as alfo the remote or lues venerea, arife Srom the abSorption of recent venereal matter from Some Surface where it has either been applied or formed. Although this muft have been allowed in general ever fince the knowledge of the diSeaSe and of abforption, yet a true Solution of the formation of bubo could not be given till we had ac- quired the knowledge of the lymphatics being the only abforb- ents. Upon the old opinion of abforption being performed by the veins, the lues venerea could have eafily been accounted for, becauSe it could as readily be produced by the abforbing power of the veins, if they had fuch, as by the lymphatics; but the difficulty was to fay how the bubo was formed. Ther* they feemed to be at a lofs to account Sor this diSeaSe, yet they fometimes expreffed themSelves as if they had Some idea of it, although at the Same time they could have no clear notions of what they advanced ; nor could they demonftrate what they Said from the knowledge of the parts and their ufes. Buboes are by fome imputed to the flopping of a gonorrhcea, or as they expreffed it, driving it to the glands of the groin, conformably to the idea they had of the caufe of the fwelling of the tefticle. But this is not juft, for we know of no fuch power 232 OF BUBO. power as repulfion ; and iS it was driven there it could not be by flopping the formation of matter, but by increafing the ab- forption, of which they had no Idea. When we examine the opinion of authors concerning the formation of bubo, prior to the knowledge of the power of ab- forption in the lymphatics, we fhall find them making ufe of terms which they could not poffibly underftand. For inftance, Heifter fays, " They are of two kinds, one venereal, and the other not;" but he does not fay that the venereal ariSes only from impure coition. Aftruc fays, page 326, that fome buboes arife immediately from impure coition, and thefe he calls effential; others' from fuppreffed gonorrhcea, or a fmall difcharge, or from chancres' of the penis, and thefe he calls fymptomatic ; laftly, that they arife fpontaneoufly without any immediate previous coition, and are a pathognomonic fign of a hidden pox. In page 327 he Shows the impoffibility of this laft happen- ing from what we now call or underftand by a lues venerea ; but in page 328 he explains what he calls a latent lues venerea, which is local affeftion produced as he fuppofes Srom a lues ve- nerea ; but which moft probably never yet happened ; and if ever they had ariSen Srom Such a cauSe, even the abSorption of their matter could not produce a venereal bubo, as will be ex- plained. In Short, as he underftood not the true abSorbing Syftem, his ideas are become now unintelligible*. We find Cowper, Drake, and Boerhaave, as well as Aftruc, Speaking of the vitiated lymph not paffing the glands, therefore inflaming them ; alfo of the infpiffated lymph paffing either by the circulation of the blood, that is, from the conftitution to thefe glands, (an opinion held by fome to this day) or by a Shorter courfe, viz. The lymphatic veffels which go to the in- guinal glands. They alfo Speak of the fwelling of the in- guinal glands, or venereal buboes, from the contagion being communicated by the reforbent lymphatics. Drake even Speaks more pointedly, and iS we confider him no further, he would almoft make us believe that he knew that the lym- phatics were the abforbents; but as he has no fuch ideas when treating of thofe veffels expreSsly, we are not to give him credit for it. His words are, " The venereal bubo may very likely * The above extracts are from the EnglMi edJtioji, publifheJ in the year 1754, page 326, OF BUBO. 233 likely take its rife from fome parts of the contagious matter of claps fucked up by the lymphatic of the penis, and thence im- ported to the inguinal glands where they depofit their liquor ; and thence it well behoves the Surgeon to be as early as may be in the opening of fuch tumors, before, by the exporting vef- Sels of that clafs, the poifon is carried further into the blood, ■which very probably may be the cafe where fuch tumor arifeth immediately upon the flopping of a gonorrhcea, as does the hernia humoralis; but when the fame appears fome months af- ter that was removed, we are to SuppoSe as in caSes of other poifons laying hold of the blood, by the ftrength of Nature it is thrown forth, either by means of the lymphatics of the blood-veffels themSelves, if not fpewed out of the nervous tubes, as Wharton SurmiSed, and depofited in theSe emunftories." Here he compares it to the Sormation of a hernia humora- lis, which plainly fliows that he underftood neither of them. Even fo late as the year 1748, we do not find any new ideas on this fubjeft : Freke fays, " By Sealing up the mouths of the glands of the urethra, the poifon is thence by the dufts lead- ing to the inguinal glands conveyed to them." In the year 1754, eight years after Dr. Hunter having pub- licly taught his opinion of the lymphatics being a fyftem of abSorbents, we find a treatiSe on this diSeaSe by Mr. Gataker, where as little new is advanced on this Subject, as in any of the former. When we come fo low down as the year 1770, in an abridge- ment of Aftruc by Dr. Chapman, (Second edition) in which he introduces his own knowledge and ideas, we find the abSorbing power of the lymphatics brought in as a cauSe of the formation of buboes; but by this time the knowledge of the lymphatics being the fyftem of abforbents was in this country generally diffufed. The doctrine of abSorption being now perfeftly underftood, we have only to explain the different modes in which it may take place. The venereal matter is taken up by the abSorbents of the part in which it is placed ; and although the abforption of the mat- ter and the effefts aSter abforption are the Same, whether Srom the matter of the gonorrhcea or chancre, yet I fhall divide the abforption into three kinds, according to the three different H h furfaces 234 OF BUBO. furfaces from which the matter may be abfoibed, beginning with the leaft frequent. The firft and moft fimple is where the matter either of a gonorrhcea or chancre has only been applied to fome found fur- face, without having produced any local effeft on the part, but has been abforbed immediately upon its application. Inftances of this I have Seen in men, and Such are perhaps the only in- ftances that can be depended upon ; for it is uncertain in many cafes, whether a woman has a gonorrhcea or not. I think however I nay venture to affirm that I have feen it in women, or at leaft there was every reafon to believe that they had nei- ther chancre, nor gonorrhcea preceding, as there was no local, appearance of it, nor did they communicate it to others who had conneftion with them. It muft be allowed that this mode of abforption is very rare; and if we were to examine the parts very carefully, or inquire of the patient very Strictly, probably a fmall chancre might be discovered to have; been the cauSe, Which I have more than once Seen. For when we confider how rarely it happens Srom a gonorrhcea, in which the mode of abforption is fimilar, we can hardly SuppoSe it probable that it fhould here ariSe from fimple contaft, the time of the application of the venereal mat- ter being commonly fo very fhort. We might indeed fuppoSe the frequency to make up for the length of time, which we can hardly allow, for the fame Srequency Should give the chance of producing it locally. Therefore very particular at- tention fhould be paid to all the circumftances attending fuch cafes. There is however no great reafon why it fhould not happen, and the poffibility of it leffens the faith that is to be put in the fuppofition, that the difeafe may be years in the conftitution before it appears ; for whenever it does appear in a lues vene- rea, its date is always carried back to the laft local affeftion, whether gonorrhcea or chancre, and the latter connections are never regarded. The Second mode of abforption of this matter Is more fre- quent than the former, and it is when the matter applied has produced a gonorrhoea; and it may happen while the complaint is going; on, either under a cure or not. Some of the matter Secreted by the inflamed Surfaces having been acforbed and car- ried into the circulation, produces the fame complaints as in OF BUBO. *35 the former cafe, by which means a perfon gives himSelf the lues venerea. The third mode is the abSorption of the matter from an ui- cer, which may either be a chancre or a bubo. This mode is by much the moft frequent; which, with many other proofs, would fcow that a fore, or ulcer, is the Surface moft favour- able for abforption. Whether ulcers in every part of the body have an equal power of abforption I have not been able to de- termine ; but I fufpeft that an ulcer on the glans is not fo €ood a furface for abforption as one on the prepuce, although I have feen both buboes and the lues venerea arife from the former, but not fo often as from the latter. To thefe three methods may be added a fourth, abforption from a wound; which 1 have already remarked is, perhaps, not fo frequent as any of the former. As the venereal poifon has the power of contaminating whatever part of the body it comes in contaft with, it conta- minates the abforbent fyftem, producing in it local venereal complaints. It is hardly neceffary to obServe, that what is now commonly underftood by a bubo is a Swelling taking place in the abSorbing Syftem, eSpecially in the glands, arifing Srom the abSorption of fome poiSon, or other irritating matter ; and when Such Swellings take place in. the groin, they are called buboes, whether from abSorption or not, but are moft com- monly SuppoSed to be venereal, even although there has been no vifible preceding cauSe. This has been So much the caSe, that ail Swellings in this part have been SuSpefted to be of this nature ; femoral ruptures, and aneuryfms of the femoral arte- ry have been mistaken for venereal buboes. I fhall call every abfeefs in the abSorbing Syftem, whether in the veffels or the glands, arifing in conSequence of the ab- forption of venereal matter, a bubo. This matter when abforbed from either of< the four different furfaces, which are common furfaces, wounds, inflamed fur- faces, and ulcers, is carried along the abSorbent veffels to the common circulation, and in its paffage often produces the Spe- cific inflammation in theSe veffels ; the conSequence of which is the formation of buboes, which are venereal abfceffes, ex- actly fimilar in their nature and effefts to a chancre ; the on- ly difference being in fize. As the abSorbents with the glands are immediately irritated by the Same Specific matter which has undergone 236 OF BUBO. undergone no change in its paffage, the conScquent inflamma- tion muft therefore have the fame fpecific quality, and the matter Secreted in them be venereal*. " As this Syftem of veffels may be divided into two claffes, the veffels themfelves, and their ramifications and convoluti- ons, called the lymphatic glands, I fhall follow the fame divi- sion in treating of their inflammations. Inflammation of the veffels is not nearly fo frequent as that of the glands. In men, fuch inflammations, in conSequence of chancres upon the glans or prepuce, generally appear like a chord leading along the back of the penis from the chancres. Sometimes they arife from the thickening of the prepuce in gonorrhoeas, that part in fuch cafes being generally in a ftate of excoriation, as was defcribed when I treated of that form of the difeafe. Thefe chords often terminate infenfibly on the penis, near its root, or near the pubes; at other times they extend further, paffing to a lymphatic gland in the groin: this chord can be eafily pinched up between the finger and thumb, and it oSten gives a thickneSs to the prepuce, making it So fliff at this part as to make the inverfion of it difficult, it not im- poffible, producing a kind of phymofis. I think I have obferved this appearance to arife as frequent- ly from the gonorrhcea, when attended with the before-men- tioned inflammation and tumefaftion of the prepuce, as from chancres ; which, if my obfervation is juft, is not eafily ac- counted for. I have obfeived that abSorption is more com- mon to ulcers than inflamed SurSaces ; or at leaft the Sormation of a bubo in the gland, and its effefts in the conftitution, are more common Srom an ulcer ; but it may be remarked, that the infide of the prepuce, from whence this chord appears to arife, is in an excoriated ftate. It is poffible that this effeft may ariSe from the lymphatics Sympathifing with the inflamma- tion of the urethra ; but I believe the affeftion is truly vene- real ; or it is poffible that even the abforption of the coagula- ble lymph, which was produced from the venereal inflamma- tion, and which is the caufe of the tumefaftion, may have the power of contamination, as appears to be the cafe in the cancer. The * I do not know how far this reafoning will hold good in all cafes of poifons; for I .very much fufperl that the bubo, that is fometimes formed in confequence of inoculation of the fmall pox, does not produce variolous matter. The natural i..'ifer.=, in p:oducn» t-ooes, certainty dp not form a poifcr. limiid* t-j thcmfel\e>. OF BUBO. 237 The thickening, or the formation of this hard chord, pro- bably arifes from the thickening of the coats of the abforbents, joined with the extravafation of coagulable lymph, thrown in upon its inner furface, as in inflamed veins. This chord often inflames fo much as to Suppurate, and fometimes in more places than one, forming one, two, or three buboes, or fmall abfceffes in the body of the penis. When this is going on, we find in Some parts of this chord a circumScribed hardneSs; then Suppuration takes place in the centre, the fkin begins to inflarrie, the matter comes nearer to it, and the abSceSs opens like any other abSceSs. I have Seen a chain of thefe buboes, or little abfceffes, along ihe upper part of the penis through its whole length. This may be SuppoSed to be exaftly fimilar to the inflam- mation and Suppuration of a vein after being wounded and ex- pofed. Inflammation of the glands is much more frequent than the former, and arifes Srom the venereal matter being carried on to the lymphatic glands ; the ftrufture of which appears to be no more than the ramifications and reunion of the abforbent veffels, by which means they form thefe bodies. From this ftrufture we may reafonably SuppoSe that the fluid abSorbed is in Some meaSure d tained in theSe bodies, and thereby has a greater opportunity of communicating the diSeaSe to them than to the diftinft veffels, where its courSe is perhaps more rapid; which may account Sor the glands being more fre- quently contaminated. Swellings of thefe glands are common to other difeafes, and fhould be carefully diftinguifhed from thofe that arife from the venereal poifon. The firft inquiry fhould be into the caufe, to fee if there is any venereal complaint at Some greater diftance from the heart, as chancres on the penis, or any preceding dif- eafe on the penis; to learn if mercurial ointment has been at all applied to the legs and thighs of that fide ; Sor mercury ap- plied to thoSe parts, Sor the cure of a chancre, will fometimes tumefy the glands, which has been fuppofed to be venereal. We fhould further obferve, if there be no preceding difeafe in the conftitution, fuch as a cold, fever, &c. the progrefs of the fwelling with regard to quicknefs is alSo to be attended to, as alSo to diftinguifh it from a rupture, lumber abfeefs, or aneuryfm of the crural artery. Perhaps uS8 OF BUBO. Perhaps thefe bodies are more irritable, or more fufceptible of ftimuli than the veffels. They are certainly more fufcepti- ble of fympathy ; however we arc not yet Sufficiently acquaint- ed with the ufe of thefe glands to be able to account Satisfacto- rily for this difference. It would appear in fome cafes, that it is fome time after the abforption of the venereal matter before it produces its effefts upon the glands ; in fome it has been fix days at leaft. This could only be known by the chancres being healed fix days be- fore the bubo began to appear ; and in Such caSes it is more than probable that the matter bad been abSorbed a much longer time before ; for the laft matter of a chancre moft probably is not venereal; and indeed it is natural to SuppoSe that the poi- fon may be as long before it produces an aftion on the parts, when applied in this way, as it is either in the urethra, or in forming a chancre ; which I have fhown to be fometimes fix or feven weeks. The glands, neareft to the feat of abforption, are in general the only ones that are attacked, as thofe in the groin, when the matter has been taken up from the penis in men. In the groin, between the labia and thigh, and the round ligaments, when abforbed from the vulva, in women. I think there is commonly but one gland at a time that is affefted by the ab- forption of venereal matter, which if fo, becomes in fome fort a diftinguifhing mark between venereal buboes and other dif- eafes of thefe bodies. We never find the lymphatic veffels, or glajids, that are Second in order, affefted ; as thoSe along- the iliac veffels, or back ; and I have alSo Seen when the diS- eaSe has been contrafted by a Sore, or cut upon the finger, the bubo come on a little above the bend of the arm, upon the in- fide of the biceps mufcle ; and in fuch where the bubo ha« come in that part none has Sormed in the arm-pit, which is the moft common place for the glands to be affefted by abSorption. But this is not univerSal, although common, Sor I was in- formed by a gentleman who contrafted the diSeaSe in the be- fore-mentioned way, that he had buboes both on the biceps muScle, and in the arm-pit. Another caSe of this kind I have heard of fince ; why it is not more common is perhaps not ea- ■fily explained. It might be fuppofed that the matter was weakened, or much diluted by the abforptions from other parts by the time it OF BUBO. n$ St gets through thefe neareft ramifications, and therefore has not power to contaminate thoSe which are beyond them ; but it is moft probable that there are other reafons- for this. I once fufpefted that the nature of the poiSon was altered in theSe glands as it paffed through them, which was the reafon why it did not contaminate the fecond or third Series of glands; and alfo why it did not affeft the conftitution in the Same way as it did the parts to which it was firft applied ; but this expla- nation will not account for the next order of glands to Suppu- rating buboes not being affefted by the abSorption of venereal matter. It appears to me that the internal fituation of the other glands prevents the venereal irritation from taking place in them ; and this opinion is ftrengthened by obferving wher* one of thefe external glands fuppurates and forms a bubo, which is to be eonfidered as a large venereal fore or chancre, that the abSorption from it, which muft be great, does not contaminate the lymphatics or glands next in order, by the venereal matter going direftly through them. If this be true, then the fkin would feem to be the caufe of "the fufceptibility of the abforbents to receive the irritation. Whether the fkin bas the power inherent in itfelf, or acquires it from fome other circumftances, as air, cold, or. fenfe of touch, is not eafily afcertained ; but whichever it be, it fhows that the venereal matter of itfelf is not capable'of irritating, and that it requires a fecond principle to complete its full effect, that is, a combination of the nature of the poiSon and the in- fluence of the Skin, and that influence muft be by Sympathy, and therefore weaker than if acting in the fame part, that is, the fkin itSelf; which perhaps is the reafon why the venereal matter does not always affeft thofe veffels and glands, while it always-does the fkin, if inferted into it. The fituation of buboes arifing from the veneread difeafe in the penis, are in men, in the abforbent glands of the groin : if a gonorrhcea is the caufe of a bubo, one groin is not exempt- ed more than the other, both may be affefted ; but if a bubo arifes in confequence'of a chancre, then the groin may be ge- nerally determined by the feat of the chancre; for if the chancre is on one fide of the penis, then the bubo will commonly be on that fide ; however, this is not univerSally the caSe, for I have known inftances, although but few, where a chancre on one fide of the prepuce, or penis, has been the caufe of a bu- bo 240 OF BUBO. bo on the oppofite fide, which, if arifing from that chancre, is a proof that the abforbents eitiier anaftomofe, or decuffate each other. If the chancre be on the fraenum, or on the middle of the penis, between the two fides, then it is uncertain which fide will be affefted. The fituation of the glands of the groin is not always the fame, and therefore the courfe of the abforbent veffels will vary accordingly. I have Seen a venereal bubo which aroSe from a chancre on the penis, a confiderable way down the thigh ; on the contrary, I have feen it often as high as the lower part of the bellv, before Poupart's ligament, and fometimes near the pubes, all of which three Situations may lead to Some variations in the method of cure, therefore it may be proper to attend to them. As the difeafe moft commonly arifes from copulation, the Situations of buboes are generally in the groin ; but as no part of the body, under certain circumftances, is exempt from this difeafe, we find the neareft external glands between the part of abSorption, and the heart, every where in the body fhare the lame fate with thofe of the groin, efpecially if external. CHAPTER II. OF BUBOES IN WOMEN. THE fame difeafes in the abforbents in conSequence of the abforption of the venereal matter, take place in this Sex as well as in men. I never Saw but one caSe where the abSor- bent veffels were diSeaSed ; but this is nearly in the Same pro- portion as in men, when 1 confider the proportion the number of the one Sex bears to that of the other who apply to me for a cure of the venereal difeafe in any form. The cafe was a gonorrhcea with violent itching and SoreneSs when the patient fat or walked ; but She had very little pain in making water. When I examined the parts, I could See no difference between them and Sound parts, excepting that the left labium was fwel- led, or fuller than the other, and a hard chord paffed from the centre of that labium upwards to the os pubis, and paffed on to OF BUBO. 241 to the groin of the Same fide, and was loft in a gland as high as Poupart's ligament. It was not to be felt but by preffing the parts with fome force, and it gave confiderable p«in upon preffure. ' The fwelling of the labium appeared to be Somewhat Similar to the Swelling oS the prepuce in fimilar caSes in men, So that they would appear to ariSe Srom the Same cauSe. One would naturally SuppoSe that what has been Said of this complaint in the lymphatic glands in men, would be wholly ap- plicable to women ; and alSo that nothing peculiar to women could take place ; but the feat of abforption is more extenfive in this fex, and the courSe of fome of the abforbents is alfo differ- ent, Srom whence there are three fituations of buboes in wo- men, two of which are totally different from thofe in men, and thefe I fufpeft to be in the abforbents. The third fituation of buboes in this fex is fimilar to that in men, and thereSore they may be divided into three, as in men. When buboes ariSe in women where there is no chancre, it is more' difficult to know whether they are venereal or not than in men; for when they arife in men without any local complaint, it is known that no fuch complaint exifts, and therefore the bubo cannot be venereal, excepting by immedi- ate abforption ; but in women it is often difficult to know whether there be any infeftion prefent or not; and therefore in order to afcertain the nature oS the bubo, attention muft be paid to its manner oS coming on, progreSs, and other cir- cumftances. When chancres are fituated forwards, near to the meatus urinarius, nymphae, clitoris, labia, or mons veneris, then we find that the matter abforbed is carried along one 01 both ot the round ligaments, and the buboes are formed in thofe liga- ments juft before they enter the abdomen, without, 1 believe, ever going further. Thefe buboes I fufpeft not to be glandu- lar, but inflamed abforbents ; and if So, it ftrengthens the idea that it is only an external part that can be affefted m this way. W hen the chancres are fituated Sar back, near the perinaeum, or in it, the matter abforbed is carried forwards along the an- gle, between the labium and the thigh, to the glands in the groin, and often in this courfe there are formed fmall buboes in the abforbents, fimilar to thoSe on the penis in men • and 1 i whcu 242 OF BUBO. when the effefts of the poifon do not reft here, it often p»o* duces a bubo in the groin as in men. CHAPTER III. OF THE INFLAMMATION OF BUBOES, AND THE MARKS THAT DISTINGUISH THEM FROM OTHER SWELLINGS OF THE GLANDS. THE bubo commonly begins with a fenfe of pain, which leads the patient to examine the part, where a Small hard tumor is to be felt*. This increafes like every other inflamma- tion that has a tendency to Suppuration ; and, if not prevented,. goes on to fuppuration and ulceration, the matter coming faft to the fkin. But we find cafes, where they are Slow in their progreSs, which I SuSpeft either ariSes Srom the inflammatory procefs be- ing kept back by mercury, or other means; or being retarded by a fcrofulous tendency, fuch a difpofition in the parts not fo readily admitting the true venereal aftion. At firft the inflammation is confined to the gland, which is movable in the cellular membrane ; but as it increafes in fize, or as the inflammation, and more efpecially the fuppuration, advances, which in all cafes produce rather a common than a fpecific effeft, the fpecific diftance is exceeded ; the furround- ing cellular membrane becomes more inflamed ; and the tumor is more diffufed. Some buboes become erifypelatous, by which means they are rendered more diffufed and cedematous, and do not readily fuppurate, a circumftance often attending the eri- fypelatous inflammation. To afcertain what a difeafe is, is the firft Step in the cure; and when two or more caufes produce fimilar effefts, great at- tention * It muft be remarked here* that whenever a perfon has either agonorrhoea or a chan- cre, he becomes apprehenfive of a bubo ; and as there are in the gonorrhcea, and fome- Srmed from a belief that, he has no fuch parts naturally. OF BUBO. 243 tention is neceffary to diftinguifh one effeft from another, fo as to come at the true caufe of each. The glands of the groin, from their fituation, are liable to fufpicion, for befides being fubjeft to the common difeaSes, they become expoSed to others by allowing whatever is absorb- ed to paSs through them ; and as the rout of the venereal poi- fon to the conftitution is principally through them, and being oftener ill from this caufe than any other, they often are Sufi. pefted of this diSeaSe without foundation. To diftinguifh, with certainty, the true venereal bubo from fwellings of thofe glands arifing from other cauSes, may be ve- ry difficult. We mull, however, examine all circumftances, to afcertain in what the bubo differs from the common dif- eafes of thofe glands, whether in the groin or elfewhere ; in which examination the apparent cauSes are not to be neglected. I have already given the character of the venereal bubo in ge- neral terms; but I Shall now be more particular, as the two are to be contrafted. The true venereal bubo, in conSequence of a chancre, is moft commonly confined to one gland. It keeps nearly its fpecific diftance till Suppuration has taken place, and then be- comes more diffUSed*. It is rapid in its progrefs from inflam- mation to fuppuration and ulceration. The fuppuration is commonly large for the fize of the gland, and but one abfeefs. The pain is very acute. The colour of the fkin where the in- flammation attacks is of a florid red. It may be obferved, that the buboes in conSequence of the firfl mode of abSorption, viz. where no local diSeaSe has been produced, will always be attended with a greater uncertainty of the nature of the diSeaSe than thoSe attended or preceded by a diSeaSe in the penis; becauSe a fimple inflammation and Sup- puration of thefe glands are not fufficient to mark it to be ve- nereal ; but as we always have this difeafe in view when the glands of the groin are the feat of the difeafe, the patient runs but little rifk of not being cured, if it fhould be venereal; but I am afraid that patients have often undergone a mercurial courfe when there has been no occafion Sor it. It will perhaps be difficult to find out the Specific difference in the diSeaSes themSelves; but I think that Such buboes as ariSe without * It may be obferved here, that the glands and furrounding parts being diffimilar, in- flammation, does net fo readily become diffufed as when it uk.e.» place in a common p-it. 244 0F BUBO. without any vifible cauSe are of two kinds, one fimilar to thofe arifing from chancres or gonorrhcea; that is, inflaming and Sup- purating brifkly. TheSe I have always SuSpefted to be venere- al ; for although there is no proof of their being fo, yet from thefe ciicumftances there is a ftrong preSumption that they are. The Second are generally preceded and attended with flight Sever, or the common Symptoms of a cold, and they are gene- rally indolent and flow in their progrefs. If they are more quick than ordinary, they become more diffuSed than the vene- real, and may not be confined to one gland. When very flow they give but little SenSation; but when more quick the Sen- Sation is more acute, though not So fharp as in thoSe that are ve- nereal ; and moft commonly they do not Suppurate, but often become ftationary. When they do fuppurate it is flowly, and often in more glands than onej the inflammation being more diffufed, and commonly fmall in proportion to the fwelling. The matter comes flowly to the fkin, not attended with much pain, and the colour is different from that of the other, being more of the purple. Sometimes the fuppurations are very con- fiderable but not painful. Now let us fee what other caufes there are for the fwelling of theSe glands befides venereal infeftion, to which I have afcrib- ed one of the modes of fwelling; for there muft be other cauSes to account Sor the other modes of it. The firft thing to be attended to is, whether or not there are any venereal complaints; and iS not, this becomes a ftrong preSumptive proof that they may not be venereal, but proceed from Some Unknown cauSe. If the fwelling is only in one gland, very flow in its progrefs, and gives but little or no pain, it is probably merely Scrofulous ; but if the fwelling is confi- derable, diffuSed and attended with Some inflammation and pain, then it is mofl probable that there is a conftitutional aftion con- Sifting in flight fever, the fymptoms of which are laffitude, loSs of appetite, want of fleep, fmall quick pulfe, and an appear- ance of approaching heftic. Such fwellings are flow in their < ure, and do not feem to be affected by mercury, even when tcry early applied. A gentleman had all the Symptoms of a flight fever ; the pulfe a little quick and hard, lofs of appetite, and of courfe lofs of flefh ; a liltleffnefs and a Sallow look. While he was in this ftate, a Swelling took place in the glands of one of the groins. OF BUBO, *45 groins. He immediately Sent Sor me, becauSe he imagined it to be venereal. From the hiftory of the cafe I gave it as my firm opinion it was not; in this he had not much faith. The fwellings were not very painful ; and, after having acquired a confiderable Size, they became ftationary. To pleaSe him, I gave him a box of mercurial ointment, to be rubbed on the leg and thigh only of the fide affefted, that it might have a fuf- ficient local effeft, and as little go into the conftitution as pof- fible ; but it did not appear to be of any fervice to the fwel- lings in the groin, they remaining ftationary, and almoft with- out pain. His friends became uneafy, and fent their furgeons to him, who, without knowing he was my patient, and of courfe without knowing my opinion, imagined that the difeafe was venereal, and talked of giving mercury. With refpeft to the cure, I thought he fhould go to the fea and bathe. Allowing the chance of the difeaSe being venereal or not venereal, to be equal, I reaSoned upon that ground. His pre- fent want of health could not be fuppofed to arife from any ve- nereal caufe, as it was prior to the fwelling in the groin, and therefore though the fwelling might be venereal, he was not at prefent in a condition to take mercury, as a fufficient quan- tity of that medicine, for the cure, might kill him ; and if it fhould not be venereal, that ftill a greater quantity of mercury muft be given than what was neceffary if it were venereal; be- caufe its not giving way readily would naturally make the fur- geon pufh the mercury further ; and, befides this diSagreeable circumftance, the diSeaSe in the groin might be rendered more difficult of cure. But by going to the fea, his conftitutiuh would be reftored ; and if the difeafe in the groin proved to be venereal, he would be in a proper condition to go through a mercurial courfe, and by that means get rid of both difeafes by the two methods. But if I fhould be right in my opinion, that there was nothing venereal in the cafe, then he would get well by the Sea-bathing alone. TheSe arguments had the defired effeft; he went direftly to the Sea, and began to recover almoft immediately. About a fortnight after a fmall fuppuration took place in one of the glands. I direfted that a poultice fhould be made with fea- water and applied; and, in cafe of the breaking of the abfeefs, that it fhould not be further opened, but poulticed till healed. In fix weeks he came back- perfeftly recovered in every refpeft. t4« OF BUBO. The above-mentioned appearance, with the conftitutional affections, I have Seen take place when there were chancres ; and I have been pfJrzzled to determine whether it was Sympa- thetic, from a derangement of the conftitution, or from the abforption of matter. I have long fufpefted a mixed cafe; and I am now certain that Such exifts. I have Seen cafes where the venereal matter, like a cold or Sever, has only irritated the glands to difeafe, producing in them fcrofula, to which they were predifpoSed. In Such caSes the Swellings commonly arife flowly, give but little pain, and Seem to be rather haftened in their progrefs if mercury is given to deftroy the venereal diSpofition. Some come to Suppuration while under this reSolving courSe ; and others, which probably had a venereal taint at firft, become So indolent that mercury has no effeft upon them, and in the end get well either of themSelves or by other means ; which, I imagine, may have induced Some to think that buboes are ne- ver venereal. Such cafes require great attention, that we may be able to determine them properly ; and I believe, this re- quires in many caSes So nice a judgment, that we fhall be oSt- en liable to miflakes. Buboes are undoubtedly local complaints, as has been ex- plained. How far the lymphatic glands are to be Considered as guards againfl the further progrefs of this or any other difeafe caught by abforption, is not eafily determined. We muft however allow that they Cannot prevent the poiSon from entering the conftitution, in caSes where it produce's buboes ; for whenever it affefts thefe glands in its courSe, it produces the Same diS- eaSe in them which is capable of furnifhing the conftitution, with an increaSed quantity of the Same kind of poifon. CHAPTER C 247 3 CHAPTER IV. GENERAL REFLECTIONS ON THE CURE OF BUBOES. FROM what has been offered on the hiftory of buboes, i* will be needlefs here to enter into a difcuffion of the opi- nion of their being a depofit from the conftitution, and of the conclufion drawn from this opinion, that they ought not to be difperfed ; for, according to this theory, to difperfe them would be to throw the venereal matter upon the conftitution. But if this were really the cafe, then there would be no occa- fjon for the ufe of mercury, provided that the bubo be allowed to proceed, as it would prove its own cure ; but even thofe who were of this opinion, were not fatisfied with the cure; which they fuppofed Nature had pointed out, but gave mercu- ry, and in very large quantities. From the fame hiftory of a bubo I have alfo endeavoured to Show that there are feveral buboes which are not in the leaft venereal, but fcrofulous; and*that there are alfo buboes which appear to be only in part, venereal; or perhaps only a gland diSpoSed to Scrofula brought into aftion by the venereal irritation, Similar to what happens often from the matter of the fmall pox in inoculation. There- fore, prior to the fpeaking of the method of cure, the true ve- nereal bubo is to be diflinguiftied from the others, if poffible. When it is well afcertained to be venereal, refolution is cer- tainly to be attempted, if the bubo be in a ftate of inflamma- tion only. The propriety of the attempt depends on the pro- grefs which the difeafe has made. If it be very large, and Suppuration appears to be near at hand, it is probable that re- folution cannot be effefted; and if fuppuration has taken place, I fhould very much doubt the probability of fuccefs, and art attempt might now poffibly only retard the Suppuration, and protraft the cure. The refolution of thofe inflammations depends principally upon mercury, and almoft abfolutely upon the quantity that can be made to pafs through them ; and the cure of them, if allowed to come to fuppuration, depends upon the fame cir- cumftances. The quantity of mercury, that can be made to pafs 248 OF BUBO. paSs through a bubo, depends principally upon the quantity of external SurSace Sor abSorption beyond the bubo. Mercury Is to be applied in the moft advantageous manner, that is, to thoSe furfaces by an abSorption Srom which it may paSs through the diSeaSed gland : for the difeafes there being de- ftroyed, the conftitution has lefs chance of being contaminated. The powers of mercury may often be increafed from the man- ner in which it is applied. In the cure of buboes, it fhould always be made to pafs into the conftitution by the fame way through which the habit received the poifon ; and therefore to effeft this, it muft be applied to the mouths of thofe lymphatics which pafs through the diSeaSed part, and which will always be placed on a Surface beyond the difeafe. But the Situation of many buboes is fuch as not to have much furSace beyond them, and thereby not to allow of a Sufficient quantity of mercury being taken in in this way; as for in- ftance, thofe buboes on the body of the penis arifing Srom chancres on the glans or prepuce. TheSe two Surfaces are not fufficient to take in the neceffary quantity to cure thofe buboes in its paffage through them ; therefore whenever the firft fymptoms of a bubo appear, its fituation is well to be eonfidered, with a.view to determine if there be a fufficient furface to effeft a cure, without our hav- ing recourfe to other means. It is firft to be obferved, whe- ther the abforbent veffels, on the body of the penis, are affect- ed, or the glands in the groin. If the difeafe be in the groin, it muft be obferved in which of the three Situations oS the bubo, before taken notice of, it is; whether on the upper part of the thigh and groin, on the lower part of the belly before Pou- part's ligament, or near to the pubes. If they are on the body of the penis, this Shows that the abSorbents, leading direftly from the furSace of abSorption, are themSelves diSeaSed. If in the groin, and on the upper part of the thigh, or perhaps a little lower down than what is commonly called the groin, then vre may SuppoSe it is in the glands common to the penis and thigh. If high up, or on the lower part of the belly, before Poupart's ligament, then it is to be fuppofed that thofe abforb- ents, that arife from about the groin, lower part of the belly, and pubes, pafs through the bubo ; and if far forwards, then it is moft probable that only the abforbents of the penis and fkin about the pubes, paSs that way. The knowledge of thefe Situations OF BUBO. *4& HtUatiohs Is very neceffary Sor the application of mercury Sor the cure by refolution, and Sor the cure after fuppuration has taken place. The propriety of this practice muft appear at once, when we confider that the medicine cannot paSs to the common circula- tion without going through the diSeaSed parts; and it muft pro- mote the cure in its paffage through them; while at the fame time it prevents the matter, which has already paffed, and is ftill continuing to pafs into the conftitution from acting there, fo that the bubo is cured and the conftitution preferved. But this praftice alone is not always fufficient; there are many cafes in which mercury by itfelf cannot cure. Mercury can only cure the fpecific difpofition of the inflammation ; and we know that this difeafe is often attended with other kinds of inflammation befides the venereal. Sometimes the common inflammation is carried to a great height, at other times the inflammation is erlfypelatous, and, I SuSpeft, oSten Scrofulous. We mull, therefore, have recourfe to other methodsi Where the inflammation riSes very high, bleeding, purging, and fomenting, are generally recommended. Thefe will cer- tainly leffen the active power of the veffels, and render the in- flammation more languid ; but they can never leffen the Speci- fic effefts of this poifon, which were the firft caufe, and are ftill in Some degree the Support of the inflammation. Their effefts are only Secondary ; and if they reduce the inflamma- tion within the bounds of the fpecific, it is all the fervice they can perform. If the inflammation be of the erifyplatous kind, perhaps bark is the beft medicine that can be given ; or if it be fufpefted to be ScroSulous, hemlock, and poultices made with Sea-water may be of Service. Vomits have been of fervice in refolving buboes, even af- ter matter has been Sormed in them, and after they have been nearly ready to burft ; this afts upon the principle of one irri- tation deftroying another ; and fickneSs and the aft of vomiting perhaps give a difpofition for abforption. A remarkable in- ftance of this kind happened in an officer who had a bubo at Lifbon. It came to Sair Suppuration, and was almoft ready to burft. The fkin was thin and inflamed; and a plain fluctuation felt. I Intended to open it, but as he was going on board a fhip Sor England on the day following, I thought it better to defer it. K k When a$o OF BUBO. When he went on board, he Set Sail immediately ; and the wind blew So very hard that nothing could be done for fome days, all which time he was very fick, and vomited a good deal; when the ficknefs went off, be found the bubo had disap- peared, and it never afterwards appeared. When he came to England, he went through a regular courfe of mercury. I. OF RESOLUTION OF THE INFLAMMATION Of THE ABSORBENTS ON THE PENIS. The furface beyond the feat of the difeafe-m this cafe, that is all that part of the penis before the bubo, is not large enough to take in a quantity of mercury fufficient to prevent the effefts of abforption, and therefore recourfe is to be had to othtr means ; yet this application ihould by no means be neglected, and this SurSace, Small as it is, Should be con flan tly covered with mercurial ointment, which will aflift in the cure of the local difeafe. It may be difputed whether any medicine can pafs through difeafed lymphatics, fo as to have any effeft op- on them, but I judge from experience that it certainly can. As this Surface is too Small, and as it is neceffary that a larger quantity fhould be taken in, it becomes proper to give it either by the mouth, or by friction on fome larger furface; rhis is ne- ceffary to prevent the lues venerea, as well as to cure the parts themfelves. The quantity cannot be determined ; that muft be left to the furgeon, who muft be direfted by the appearances of the original complaint, and the readinefs with which the diSeaSe gives way. The fame method is to be followed in women; but as there is a larger furface in this Sex, more mercury may pdflibly be abSorbed ; and there Should be a conftant application of oint- ment to the infide, and outfide of the labia. II. OF THE RESOLUTION OF BUBOES IN THE GROIN. The inflammation of the glands is to be treated exactly up- on the Same principle with the other ; but we have in general a larger Surface of abforption, fo that we can make a greater quantity of mercury pafs through the difeafed parts. It OF BUBO. 251 It will be proper to apply the mercury according to the fitu- ation of the inflamed gland. If the bubo be in the groin, ac- cording to our firft fituation, then it is neceffary to rub the mercurial ointment upon the thigh. This Surface will in ge- neral abforb as much mercury as will be Sufficient to reSolve the bubo, and to preServe the conftitution from being contami- nated by the poifon that may get into it; but if refolution does not readily take place, then we may increaSe the Surface of friftion, by rubbing the ointment upon the leg. But if the bubo be on the lower part of the belly, that is, in the fecond fituation, then the ointment Should be rubbed alSo upon the penis, Scrotum, and belly ; and the Same, if the bubo fhould be ftill further forwards; for probably thofe glands receive the lymphatics from all the furfaces mentioned as well as from the thigh and leg. The length of time for continuing the frictions muft be de- termined by circumftances. If the bubo gives way, they muft be continued till it has entirely fubfided, and perhaps longer, on account of the caufe of it, a chancre, which may not yield fo foon as the bubo. If it ftill goes on to fuppuration, the frictions may, or may not be continued; for I do not know for certain if any thing is to be gained by their continuance in this ftate. The quantity, here recommended, may affeft the mouth ; and this effeft muft alfo be regulated according to circumftances. III. OF THE RESOLUTION OF BUBOES IN WOMEN. When treating on the feat of buboes in women, I obferved that two fituations were peculiar to them, the others fimilar to thoSe in men. In the treatment of buboes in women fome attention fhould be paid to their fituation, for on that depends, in fome degree, the method of refolution and cure when they fuppurate. The firft was in the round ligament, the fecond between the labi- um and thigh, and the third in the groin. In the firft and fecond fituations, efpecially the firft, the fur- face of abforption, beyond the bubo, is by much too fmall to be depended upon for receiving a fufficient quantity of mercu- ry to produce refolution ; but in the fecond, that is, between the labia and thigh, the mercury may be rubbed in all about 2,58 OF BUBO. the anus and buttock, as all the abforbents of thofe parts "pro* bably paSs that way ; we know at leaft that they do not paSs into the pelvis by the anus, but go by the groin. Other means of introducing mercury muft be recurred to, as is recommend- ed in the cafe of men ; but ftill it will be proper to rub in on thefe Surfaces as much as poffible. In the Situations common to both Sexes, we have a larger field ; yet, as they are divifible into three, the fame obferva, tions hold good, and a Similar mode of praftice is to be foh lowed in women as in men, IV. OF BUBOES IN OTHER PARTS. As venereal buboes arife from other'modes of application of the poiSon befides coition, they are to be found in different parts of the body; but more frequently in the hands. They arife in the arm-pit from wounds in the hands or fingers being contaminated by venereal matter, and reduced to a chancre. In fuch cafes it becomes neceffary that the ointment fhould be rubbed on the arm and Sore-arm ; but this Surface may not be fufficient, therefore we muft apply it in another way, or to other parts, to produce its effefts upon the conftitution. I have feen a true venereal chancre, on the middle of the lower lip, produce a bubo on each fide of the neck under the lower jaw, juft upon the maxillary gland. By applying ftrong mercurial ointment to the under lip, chin, and fwellings, they have been refolved. V. OF THE QUANTITY OF MERCURY NECESSA, RY FOR THE RESOLUTION OF A BUBO. The quantity of mercury, neceffary Sor the reSolution of a bubo, muft be proportioned to the obilinacy of the bubo; but care muft be taken to ftop fliort of certain effefts upon the con- stitution. If it be in the firft Situation, and yields readily to the ufe of half a dram of mercurial ointment, made of equal parts of quickfilver and hogs-lard, every night, and the mouth does not become Sore, or at moft only tender, then it will be fufficient to purfue this courSe till the gland is reduced to its natural Size ; and this probably wifl be a good Security for the conflitution, provided the chancre, which may have been the caufe OF BUBO, fi,53 caufe of the bubo, heals at the fame time. If the mouth is not affefted in fix or eight days, and the gland does not readily refolve, then two fcruples, or a dram, may be applied every night; 'and iS there be no amendment, then more muft be rub- bed in ; in Shoit, if the reduction is obftinate, the mercury rnuft be pufhed as far as can be done without a falivation. If there be a bubo on each fide, then there cannot be So much mercury applied locally to each; Sor the conftitution moft probably could not bear double the quantity which is ne- ceffary for the refolution of one. But in fuch cafes we muft not fo much attend to the SoreneSs of the mouth as when there is but one ; however, we muft allow the buboes to go on to fuppuration, rather than affeft the conftitution too much by the quantity of mercury ; and therefore, when there are two buboes, they are more likely to fuppurate than where there is only one. In the fecond and third fituation of buboes, if we find that moft probably a fufficient quantity of mercury does not pafs through them for their refolution, it may be continued to be thrown in by the leg and thigh to aft upon the conftitution, as has been already obferved. The quantity admitted in this way muft be greater than would be neceffary if the whole could be made to pafs through the bubo. The mouth muft be affefted, and that in proportion to the ftate and progrefs of the bubo. This method of refolving buboes occurred to me at Bellifle, jn the year 1761, where I had good opportunities of trying it upon the foldiers; and I can fay with truth, that only three buboes have fuppurated under my care fince that time, and two of thefe were in one perfon, where a fmall quantity of mercury had confiderable effefts on the conftitution, and there- fore a fufficient quantity could not be Sent through the two groins Sor their reSolution ; but in both caSes the Suppurations were Small in comparison to what they threatened to be. Many buboes, after every attempt, remain fwelled without either coming to refolution or fuppuration, but rather become hard and fcirrhous. Such, I apprehend, were either fcrofu- lous at firft, or became fo when the venereal difpofition was removed. The cure of them fhould be attempted by hemlock, fea-water poultices, and Sea-bathing, as will be Surther taken notice of. _ VI. OF »54 OF BUBO. VI. OF THE TREATMENT OF BUBOES WHEN* THEY SUPPURATE. After every known method has been ufed, buboes can- not in all cafes be reSolved, but come to Suppuration. They then become more an object oS Surgery, and are to be treated in Some reSpefts like any other abScefs. If it be thought pro- per to open a bubo, it fhould be allowed to go on thinning the parts as much as pofftble. The great advantage arifing from this is, that thefe parts having become very thin, lofe the dif- pofition to heal, which gives the bottom of the abfeefs a better chance of healing along with the fuperficial parts ; by this means too, a large opening is avoided, and the different modes made ufe of for keeping the fkin from healing, till the bottom is healed, become unneceffary. It may admit of difpute, whether the application of mer- cury fhould be continued or not through the whole Suppura- tion. I Should be inclined to continue it, but in a Smaller quantity ; Sor although the parts cannot Set about a cure till opeqed, yet I do imagine that they may be better diSpoSed to it; and I think that I have Seen caSes where Suppuration took place although under the above-mentioned practice, that were very large in their inflammation, but very Small in their Sup- puration, which I imputed to the patient's having taken mer- cury in the before-mentioned way, both before and while fup- puration was going on. It has been diSputed more in this kind of abSceSs than in others, whether it fhould be opened or allowed to burft of it- felf; and likewife whether the opening fliould be made by in- cifion or Cauftic. There appears to be nothing in a venereal abSceSs different from any other to recommend one praftice more than another. The furgeon fhould in fome degree be guided by the patient. Some patients are afraid of cauftic, others have a horror of cutting instruments ; but when it is leSt wholly to the furgeon, and the bubo k but Small, I SuppoSe, a flit with a lancet will be Sufficient; in this way no fkin is loft. But when a bubo is very large, in which caSe there is a large quantity of looSe Skin, perhaps the cauftic will anSwer bet- ter, both on account of its destroying fome Skin, and becauSe the OF BUBO, S55 the deftruftion is attended with leSs inflammation than what at- tends incifion. If done by a cauftic, the lapis fepticus is the befl*; but it is not neceffary to open every bubo, and perhaps it may be difficult to point out thoSe where opening would be of ter vice or neceffary. The bubo is to be drefled afterwards according to the nature of the difeafe, which, I have already obferved, is often fo com- plicated as to baffle all our Skill. The,conftitution at the Same time is to be attacked with mercury, either by applying it in- ternally or externally ; if externally, it fhould be applied to that fide, and beyond where the bubo is, as before direfted in treating of the refolution of buboes; for it may have fome in- fluence on the diSeaSe in its paffing through the part. Mercury, in theSe cafes, anfwers two purpofes; it affifts the external applications to cure the buboes, and it prevents the effefts of the conftant abforption of the venereal matter from the fore. How far it is neceffary to purfue the mercurial courSe with a view to prevention, it is not poffible to determine ; but it may be* SuppoSed that it is neceffary to give the Same quantity to prevent a diSeafe that would cure one that has already taken place. It will be neceffary to continue the courfe till the bubo- is healed, or till it has for fome time loft its venereal appear- ance ; but it may be difficult to aScertain this laft Saft ; there- fore we muft have recourfe to experience, not theory, and con- tinue the courfe in general till the whole is healed, and even longer, efpecially if the bubo heals very readily ; for we find in many cafes that the conftitution fhall be ftill tainted after all ; however, fome reftriftions are here neceffary ; for I have already obferved, that it often happens, that buboes affume other diSpofitions befides the venereal, which mercury cannot cure, but will even make worSe. It is thereSore very neceffary to aScertain the diftinftion ; which will be taken notice of. CHAPTER • * I once opened two buboes in the fame perfon, one immediately after the other. The firft was with the lapis infemalis, which gave him confiderable pain, and therefore he would have the other .opened with a lancet, as the pain would only be momentary. But it was great, and the forenefs continued long, while there was no pain in trie other, deadened by the* cauftic, after it bad done Us bufineis. *S$ OF BtJBO. CHAPTER V. OF SOME OF THE CONSEQUENCES OF BUBOES. I FORMERLY obferved, that the venereal difeaSe is ca» pable of bringing latent difpofitions or fufceptibilities intb aftion. This is remarkably the caSe with buboes ; and I be- lieve the diSpofition is more of the fcrofulous kind than any other. Whether this arifes from the buboes being formed in lymphatic glands, or not, is probably not eafily determined. It fometimes happens, that thefe fores, when lofing, or en- tirely deprived of the venereal difpofition, form into a fore of another kind, and moft probably of various kinds. How far it is a diSeaSe arifing Srom a venereal taint, and the effefts of a mercurial courSe jointly, is not certain ; but moft probably theSe two have Some fhare in Sorming the diSeaSe. If this idea of it were juft, it would become a fpecific difeafe, and be re- duceable to one method of cure ; but I fhould fufpeft that ei- ther the conftitution or the part hath fome, if not the princi- pal, Share in it; that is, the parts fall into a peculiar difeaSe independent of the conftitutional difeafe or method of cure; for if it arofe out of the two firft entirely, we might expect to meet with it oftener. So far as the conftitution or the part has a fhare in forming this difeaSe, it becomes more uncertain what the diSeaSe is, becauSe it muft in Some degree partake of the conftitution or nature of the part. Such difeafes make the cure of the venereal affeftion much more uncertain, becauSe when the Sore becomes ftationary, or the mercury begins to diSagree, we are ready to SuSpeft, that the virus is gone ; but this is not always the caSe ; the virus is perhaps only leSs powerful than the new-formed difeafe, and as it were lies dormant, or ceafes to aft, and when the other be- comes weaker, the venereal influence begins to Show itSelf again. The proper treatment, in Such caSes, is to attack the pre- dominant diSeaSe ; but ftill the difficulty is to find out the diS- eaSe, and to know when it is or is not venereal. The follow- ing caSe explains this difficulty very well. A gen- OF BUBO. s3y A gentleman had a very large venereal bubo, which was opened. He took a great deal of mercury for about two months, but, I fufpeft, not in fufficient dofes, which produced a mer- curial habit. The bubo had no difpofition to heal, and I was confulted. From the account he gave me, I fufpefted that he had then too much of a mercurial habit to receive at this time any further good from that medicine. I therefore advifed him to ufe a good nourifhing diet for near a month ; after that I put him upon a brifk mercurial courSe by Sriftion ; and the parts put on a better appearance. This courSe he continued for near two months, and then the Sore, although much mend- ed, began to be ftationary, I did now conceive that the vene- real aftion was deftroyed, and therefore immediately left off the mercurial courfe and put him upon a milk diet, and fent him into the country; But not gaining much ground, he had a ftrong decoftion of the farfaparilla with mezereon given him, which, although continued for above a month, produced little or no effeft. I alfo gave him the cicuta as much as he could bear, with the bark almoft the whole time, without effeft: new SinuSes formed, which were opened, and the fore became ex- tremely irritablej with thickened lip?. The dreffings were poultices made with the juice of hemlock Sea-water, opium, and a gentle Solution of lunar cauftic ; but nothing feemed to affeft it; I fufpefted fcrofula, and therefore propofed he fliould bathe in the fea ; but this then could not be done. Thefe dif- ferent treatments, after mercury had been left off, took up about four months without the leaft benefit. Being doubtful whe- ther there might not be ftill Something venereal in the fore, efpecially as appearances were growing worfe, and it was now four months fince he had taken any mercury, I was inclined to try it once more, and Sent him two portions of ointment, half an ounce each, to rub in in two nights. He had caught a little cold, and therefore did not rub in the mercury the two evenings as ordered; and called upon me the third day and told me he was much better ; the fore now became eafy, the watry or tranSparent inflammation began to Subfide ; the lips became flatter and thinner ; and the edges of the fore began to heal. I then defired him not to rub in the ointment, but wait a lit- tle. In eight or ten days the Sore had contrafted to three quarter? of its former fize, and had all the appearance of a heal- ing Sore. L 1 Query ; 258 OF BUBO. Query: What conclufions fhould be drawn from this caSe? I think the Sollowing ; that the virus may be gone, although the Sore has no diSpofition to heal : therefore we are not to look upon the not healing of a bubo as a Sign of the prefence of the original diSeaSe. Secondly; that the SarSaparilla, meze- reon, cicuta, and the bark, will not Succeed in all Such caSes; and thirdly, that Some of thefe difeafes are capable of wearing out the unhealthy diSpofition of themfelves, and that we fhould not be too ready to attribute cures to our treatment; for if the mercury had been rubbed in, and the fame effefts had ftill tak- en place, I fhould then have certainly purSued the mercury with vigor, and attributed the cure to it; but I Should not have refled here: I fhould have related the caSe, as an inftance of the diSeaSe continuing after repeated courSes of mercury, and fliould have contended that it is neceffary in Such caSes, where the mercury appeared to loSe its power, and even do harm, to wait, and SeaSon the conftitution to ftrength, and the loSs of the mercurial habit; and that even Sour months are Sometiraei neceffary for this purpofe; after which we muft begin again to give mercury. A gentleman had a common gonorrhcea, which was Severe. I gave him an injection of a grain of corrofive Sublimate in eight ounces of water, with a few mercurial pills. After hav- ing continued the injeftion for ten, or twelve days, without any vifible benefit, I gave it as my opinion that it would be of no Service to continue it any longer; and thereSore defired he would be quiet Sor a little time. About this time a Swelling in each groin took place, and Suppofing them to be venereal, I ordered mercurial ointment to be rubbed into both the legs and thighs to refolve them if poffible. He appeared to be leSs un- eaSy about the buboes than he was about the gonorrhcea; but I told him that the cure of that complaint would be infenfibly involved in the reSolution oS the buboes. I Spoke too confi- dently oS my power, with reSpeft to the reSolution of the bu- boes, for they both Suppurated ; although the Suppuration was Small in comparison to the magnitude of the buboes when they firft inflamed. The frictions were left off. While we were attempting to refolve the buboes, he got well of the gonorrhcea. The Skin, covering the buboes, be- came thin ; they were both opened, one with a cauftic, the other with a lancet; he then was ordered to rub in mercury again OF BUBO. 2,59 again >in the thighs and legs for their cure. They began Soon to look well, and to cloSe faft, but when about half healed they became ftationary. I fufpefted that a new difeaSe was Sorming. On continuing the frictions a little longer, they began to in- flame and fwell anew, and a fuppuration took place about half an inch above each of the firft fuppurations, which broke into the firfl. I left off the mercury immediately upon their in- flaming, and faid that now a new diSeaSe had formed. I or- dered poultices made with fea-water to be applied, and alfo a decoction of farfaparilla to be taken; but this appeared not to be fufficient for the cure of this new difeaSe. I then ordered him to go into the tepid Sea-bath every evening, the heat of the water to be about ninety degrees. By the time he had been in the bath four times, the inflammation and fwelling had very much abated, and the firft fores, or original buboes, were beginning to heal. He went on with the bathing every everting for about three weeks, when the fores rather began to look worfe; I then fuSpefted that the venereal diSpofition was become predominant; and I ordered the friftion as before. In about a fortnight the firft bubbes healed, but the fecond fuppurations were not yet healed ; then I fuppofed it to be entirely the new-formed dif- eaSe, and he went into the country, where I defired he might go into the open Sea every day, as he then could have an op- portunity, which he did, and got perfeftly well, and has con- tinued So. This cafe plainly Shows that there was another diSpofition formed befides the venereal, and which was put into aftion by the venereal irritation. I have feen Some buboes mofl exceedingly painful and ten- der to almoft every thing that touched them, and the more mild that the dreffings were, the more painful the part* became. In fome the fkin Seems only to admit the diSeaSe ; ulcera- tion going on in the Surrounding fkin, while a new fkin forms in the centre, and keeps pace with the ulceration, Sorming an irregular Sore like a worm-eaten groove all round. This, like the eriSypelatous inflammation, as alSo Some others, appears to have only the power of contaminating the parts that have not yet come into action : and thofe that have already taken it feem to lofe the diSeaSed diSpofition, and heal readily. In Some they Spread to an amazing extent, as the following eafe fliows, the circumftances of which are Very remarkable. A young 260 OF BUBO. A young gentleman, aged eighteen years, in confcqrence of a venereal infeftion, had two buboes, which were both opened. They were treated in the ufual manner, and at firft put on a favourable appearance; but, when they were nearly healed, they began to ulcerate at their edges, and fpread in all di- rections, rifing above the pubes almoft to the navel, anddeScend- ing upon each thigh. His nights became reftlefs, and his ge, neral health was affefted. A great variety of medicines were tried, particularly mercury in different Sorms, with little or no effeft. Extract of hemlock did more good than any thing elfe, and was taken in unuSual quantities. An ounce was Swallow-, » ' ed in the courSe of the day for fome time, which was afterward* v» increafed to an ounce and an half, two ounces, and even two ounces and an half. It produced indiftinft vifion and blind- neSs, loSs of the voice, falling of the lower jaw, a temporary palfy of the extremities, and once or twice a lofs of fenfation; and notwithflanding he was almoft every night in a ftate, as it were, of complete intoxication from the hemlock, his general health did not fuffer, but, on the contrary, kept pace in its. improvement with the ulcers. They could not however be healed by the hemlock; and among many other things, --Ethi-, ops mineral, and Plummer's pill were liberally given, Seeming- ly with advantage, RecourSe was had to the hemlock Srom time to time. A great many different kinds of dreffings were made trial of, none of which were found to exceed dry lint, The ulcers were nearly all healed, after having tormented him upwards of three years, when committing fome irregularities in diet, and the fores getting worfe, he returned to the extract of hemlock, which he had for fome time laid afide, and of himSelf fwallowed in the courfe of the morning ten drams. This quantity was only the half of what he had formerly taken in twenty-four hours, but his conftitution had been gradually habituated to the medicine. The ten drams produced great reftleffnefs and anxiety; he dropt infenfible from his chair, fell into convulsions, and expired in two hours. To return to the cure pf buboes: where they only become Stationary and appear to have but little difpofition to fpread, (which is moft common) and where perhaps a Sinus or two may be found running into them from fome other gland, I have often feen them give way to hemlock, and fooner than to any thing I am acquainted with, efpecially if joined to the bark. O F B U B O. l6% Jf the hemlock is applied both internally and externally it an- fwers better. Sarfaparilla is often of Singular Service here, as well as in other caSes arifing Seemingly from the fame caufe ; and I have feen Sea-bathing of great Service, as alSo Sea-water poultice. At the Lock HoSpital they uSe goldrefiners water as an ap- plication, which is of fervice in fome cafes. Dr. Fordyce re- commends the juice of oranges to be drunk in large quantities, which I have feen good effefts from in Some cafes. Th* me- gereon is in fome inftances of Singular ufe, PART [ 6fo ] PART VL CHAPTER I. OF THE LUES VENEREA. THE lues venerea, I have already obServed, arifes in con- Sequence of the poiSonous matter being abforbed and car- ried into the common circulation. This form of the difeafe, which I have called the conftitutional*, would appear to be much more complicated, both in the different ways in which it may be caught, and in its effefts when caught, than either a gonorrhcea or chancre. It generally arifes from the local complaints, before taken notice of, the matter being abforbed and carried into the conftitution. The matter, however, ap- pears to be capable of being taken into the conftitution by Sim- ple application, without firft having produced either of the be- fore-mentioned local effefts, as I obferved in treating of the formation of the bubo; but this feems to be only when it is applied to fome particular parts of our body, fuch as may be called a half internal furface, as the glans penis. I think it is not capable of being received by the abforbents of the found ftin ; but this is matter only of opinion. It may likewife be received into the conftitution by being applied to common ulcers, although not neceffarily rendering thefe ulcers themfelves venereal; alfo by wounds, as has been obferved ; but, I believe, always previoufly producing ulcera- tion in the wound. Many other modes of infeftion have been fuppofed, but, I believe, erroneoufly ; fuch fuppofitions moft probably having taken * The term eon/litutional is, perhaps, not ftriftly a proper term; for by conftitutional aifeafe ftriftly, I would underftand that, in which every part of the body is afting in one way, as in fevers of all kinds, either fympathetic or original; but the venereal poifon ap- pears to be only diffufed through the circulating fluids, and, as it were, to force certain parts of the body to affume the venereal aftion, which aftion is perfeftly local, and takes place in different parts in regular fucceffion of fiifceptibiliries ; ther« are but few parts therefore afting at the fame time; and a perfon may be conftitutionally affefted in this way, and yet almoft every funftion may be perfect. OF THE LUES VENEREA. tfy taken their rife from ignorance or deceit, two great Sources of error in this difeaSe. It is moft likely that contamination takes place about the beginning of the local complaints, efpecially when that is a chancre ; Sor there is in moft caSes leSs chance of its happening afterwards, becauSe the patient commonly flies to medicine, which generally becomes a prevention of contamination. For if it could take place through the whole time of the cure, wft fhould have the parts contaminated at different periods, com- ing into aftion at different times, each according to its ftated time, although in fimilar parts both in their nature and other circumftances; but as theSe fimilar parts do not vary much in the time of coming into aftion, it is reafonable to SuppoSe that they were contaminated at, or near, the Same time, and there- fore that no contamination takes place in the time oS the cure, although we may SuppoSe that the power of abSorption is equal- ly ftrong then as at any other time. In cafes oS contamination Srom a gonorrhoea, where no mer- cury has been taken, we might expect this irregularity in fi- milar Structures ; but as contamination So Seldom takes place in this way, we have not a chance of great variety from fuch; however, it would be worth while to aScertain the matter, which, from a great many cafes, might be done. Without being very exaft in ascertaining the different pro- portions in thoSe who have the lues venerea originating from the three Several modes above-deScribed, I think we may ven- ture to Say from general praftice or experience, that where one contrafts it from the firft caufe, that is, where no local effefts have been produced, an hundred have it from the Se- cond, or gonorrhoea; and where one has it Srom the fecond, an hundred have it Srom the third, or chancre; and, perhaps, not one in five hundred who have connection with venereal women, have it in the firft way, and not one in an hundred have it from the fecond ; while not one in an hundred would efcape it Srom the third, if the means of prevention were not made ufe of in the Qommqn method of cure of the chancre. I. OF &6i 6F-THE LUES VENEREA. I. OF THE NATURE OF THE SORES OF ULCERS PROCEEDING FROM THE LUES VENEREA. In cohfequence of the blood being contaminated with real Tenereal pus, it might naturally be fuppofed. that the local effefts arifing thereform would be the fame with the original which produced them ; but from obfervation and experiment I have reafon to believe that this is not So. In confiderirtg this Subjeft* we may firft obServe, that local effefts, from the conftitution, are all of one fpecies, that is ulcers, let the furface upon which they appear be what it will, whether the throat or common fkin ; which is not the cafe in the local application of the matter in gonorrhcea and chancre; for there I obferved, that it produced effefts according to the nature of the furfaces. Now if the matter, when in the con- stitution, were to aft upon the fame fpecific principles with that which is applied^ we fhould have gonorrhoeas when it attacks a canal; fores or chancres when it attacks other Surfaces ; but it has never been yet known to produce a gonorrhcea from the conftitution, though this has indeed been fufpefted. For fome gonorrhoeas* the origin of which has not been clear, and which have not eafily given way to the common methods of cure, have been fuppofed to have arifen from the conftitution. Whenever the diSeaSe affefts the mouth and nofe, it has always been looked upon as producing a true chancre ; yet even here I find that fuch ulcers in their firft appearance are very diffe- rent Srom chancres. The true chancre, I obServed, produces confiderable inflammation, which of courfe brings on quickly fuppuration, attended often with a great deal of pain ; but the local effefts, Srom the constitution, are flow in their progrefs, attended with little inflammation, and are Seldom or ever pain- ful, except in particular parts. However, this SluggifhneSs in the effefts of the poiSon is more or leSs according to the na- ture of the parts which become diSeaSed; Sor when the tonfils, uvula, or noSe, are affefted, its progreSs is rapid, and the Sores have more of the chancre in their appearance than when it af- fefts the fkin ; yet I do not think that the inflammation is fo great in them as in chancres that are ulcerating equally faft. It has been fuppofed that even all the fecretions from the con- taminated blood could be affefted fo as to produce a like poiSon in OF THE LUES VENEREA. 265 in them ; and as the parts of generation are thrown in the way of receiving it, when frefh contrafted, fo they ftill lie under the cenfure of having it returned upon them from the confti- tution. Hence it has been SuppoSed that the tefticles and vi- ficulae Seminales may be affefted by the diSeaSe ; that the Semen may become venereal, may communicate the difeaSe to others, and, after impregnation, may even grow into a pocky child : but all this is without Soundation ; otherways, when a perSon has the lues venerea, no Secreting Surface could be free from the ftate of a gonorrhoea, nor could any fore be other than venereal. Contrary to all which, the Secretions are the Same as before ; and if a fore is produced by any other means in a found part, that fore is not venereal, nor the matter poifonous, although formed from the fame blood. The faliva in the cafe of a mad dog, being a natural Secre- tion rendered poiSonous, may be brought as an argument in contradiftion to this theory ; yet it is eafily accounted Sor, and might be produced rather as an argument in Support of it. In the dog, there is an irritation peculiar to the hydrophobia in the Salivary glands ; but the other and natural Secretions of the fame dog are not capable of giving this infeftion, becaufe thev are not fufceptible of the fame Specific irritation. The breath and Sweat are SuppoSed to carry along with them contagion. The milk of the breaft is fuppofed to be capable of containing venereal poifon, and of affefting the child who fucks it; but there are Several reaSons which overturn theSe opinions. Firft, we find that no Secretion is affefted by this poiSon, excepting where the Secreting organs have been pre- vioufly affefted by venereal inflammation or irritation, or its fpecific mode of aftion. Again, If they were contaminated So as to produce matter fimilar to that of an ulcer in the throat, fuch matter would not be poifonous, nor poffefs a power of communicating the diSeaSe, as will be explained more fully hereafter. Further, true venereal matter, even when taken into the ftomach, does not affeft either the ftomach or confti- tution, but is digeflcd ; as was evident in the two following cafes. A gentleman, who had chancres which difcharged largely, ufed to wafli the parts with milk in a tea-cup with fome lint, and generally let the lint lie in the cup with the milk. A lit- tle boy in the houfc ftole the milk and drank it: but whether M m or a*36 OF THE LUES VENEREA. or not he fwallowed the lint was not known. No notice wai taken of this by the gentleman, either to the family or the boy; and attention, unknown the family, was paid to the boy even for years, but nothing happened that could give the leaft fuf- picion of his having been affected either locally in the ftomach or conflitutionally. A gentleman had a moft violent gonorrhcea, in which both the inflammation and the difcharge were remarkably great. He had alfo a chordee, which was very troublefome at night. In order to cool the p.uts, and keep them clean, lie had a Small bafon of milk by the bed-fide, in which, when the chor- dee was troubieSome, he got up and dipped or waflied the pe- ris. This operation he frequently repeated in the night. Un- der fuch complaints he allowed a young lady to Sleep with him. Her cuftom was to have by her bed-fide a baSon of tea to drink in the morning before flie got up ; but unfortunately Sor the lady, fhe dr;;nk one morning the milk inftead of the tea. This was not known till fhe got up, which was five or fix hours afterwards. I was Sent for direftly, and in the meaB time fhe endeavoured to vomit, but could not. I ordered ipe- cuanha, which proved flow in its operation. She vomited, but it w^s more than eight hours after drinking the milk and water, and what came up was nothing but flime, mucus, or water, the milk being digefted. I was attentive to what might follow ; but nothing uncommon happened, at leaft Sor many months. It is alSo SuppoSed, that a foetus, in the womb of a pocky mo- ther, may be infected by her. This I fhould doubt very much, both from what may be obferved of the Secretions, and from finding that even the matter from fuch conftitutional inflamma- tion is not capable of communicating the difeafe. However, one can conceive the bare poffibility of a child being affefted in the womb of a pocky mother, not indeed from the difeafe of the mother, but from a part of the Same matter which con- taminated the mother and was abforbed by her; and whether irritating her Solids to aftion or not, may poffibly be conveyed to the child, pure as abforbed ; and if fo it may affeft the child exactly in the fame way it did or might have done the mother. This idea has been carried fti!', funhcr ; for it has been SuppoS- ed that fuch a contaminated dild tould contaminate the breafts cf a clean woman by Sucking her; the prfhbility of which will be , OF THE LUES VENEREA. 25; be eonfidered prefently. We may obServe, that even the blood of a pocky perfon has no power of contaminating, «nd is not capable of giving the difeafe to another even by inoculation; for if it were capable of irritating a found Sore to a venereal inflammation, no perSon that has this matter circulating, or has the lues venerea, .could efcape having a venereal fore when- ever he is bled or receives a Scratch with a pin, the part So wounded turning into a chancre. For if venereal matter had been on the point of the lancet, or pn the point of the pin, the punftures muft become chancres. II. OF THE MATTER FROM SORES IN THE LUES VENEREA COMPARED WITH THAT FROM CHANCRES AND BUBOES. When* the matter has affefted the conftitution, it from thence produces many local effefts on different parts of the bo- dy, which are in general a kind of inflammation, or at leaft an increafed aftion occafioning a fuppuration of its own kind. It is fuppofed, that the matter, produced in confequence of thefe inflammations, fimilar to the matter from a gonorrhcea or chancre, is alfo venereal and poifonous. This I believe till now has never been denied ; and, upon the firft view of the Sub- ject, one would be inclined to SuppoSe that it reallyfhould be ve- nereal ; for firft the venereal matter is the cauSe ; and again the fame treatment cures both diSeaSes; thus mercury cures both a chancre and a lues venerea; however this is no decifive proof, as mercury cures many diSeaSes befides the venereal. On the other hand there are many ftrong reaSons Sor believing that the matter is not venereal. There is one curious ^aft which Shows it is either not venereal, or if it be, that it is not capa- ble of afting in fome reSpefts on the Same body or Same ftate of conftitution as that matter does, which is produced from a chancre or gonorrhcea. The pus from thefe latter, when ab- sorbed, generally produces a bubo, as has been deScribed ; but we never find a bubo from the abforption of matter from a pocky fore ; for inftance, when there is a venereal ulcer in the throat, we have no buboes in the glands of the neck; wlua there are venereal fores on the arms, or even Suppurating nodes on the ulna, there are no Swellings of the glands of the arm-pit ; although fuch will take place if frefh venereal matter £68 OF THE LUES VENEREA. is applied to a common Sore on the arm, hand, or fingers. No Swelling takes place in the glands of the groin from either nodes or blotches on the legs and thighs. It may be SuppoS- ed that there is no abSorption Srom Such Sores ; but I think we , have no grounds Sor Such Suppofition. Its mode of irritation, or the aftion of the parts affefted is very different from what happens in the chancre, gonorrhcea or bubo, being hardly at- tended with inflammation, which in them is generally violent. It might be SuppoSed that a conflitution truly and univerfal- ly pocky, is not to be affefted locally by the fame fpecies of matter ; but Srom the Sollowing experiments it would appear that matter from a gonorrhcea or chancre is capable of affect- ing a man locally that is already poxed; and that matter from pockv Soies, arifing Srom the conftitution, has not that power. A man had been affefted with the venereal difeafe a long time, and had been feveral times Salivated, but the diSeaSe ftill broke out anew. He was taken into St. George's HoSpital, affefted with a number of pocky fores ; and before I put him under a mercurial courfe, I made the following experiment: I took fome matter from one of the fores upon the point of a lancet, and made three fmall wounds upon the back where the fkin was Smooth and Sound, deep enough to draw blood. I made a wound fimilar to the other three, with a clean lancet, the four wounds making a quadrangle ; but all the wounds heal- ed up and none of them ever appeared afterwards. This experiment I have repeated more than once, and with the fame refult. It fhows that a' pockv perfon cannot be af- fefted locally with the matter proceeding from the fores pro- duced by the lues venerea. But to fee how far real venereal matter was capable of producing chancres on a pocky perfon, I made the following experiment. A man, who had venereal blotches on many parts of his fkin, was inoculated in found parts with matter Srom a chan- cre, and alSo with matter from his own fores. The wounds inoculated with the matter from the chancres became chancres; but the others healed up. Here then was a venereal conftitu- tion capable of being affefted locally with frefh venereal mat- ter. This experiment I have likewife repeated more than once, and always with the fame effeft. I ordered a perfon, at St. George's Hofpital, to be inocu- UteJ with the matter taken from a well marked venereal ulcer on OF THE LUES VENEREA. 26*9 on the tonfil, and alfo with matter from a gonorrhcea, which produced the fame effefts as in the preceding experiment; that is, the matter from a gonorrhcea produced a chancre, but that from the tonfil had no effeft. A woman, aged twenty-five, came into St. George's HoS- pital, Auguft 21, 1782, with Sores on her legs, and blotches over her body. Her hufband gave her the venereal diSeaSe, December 1781. Her Symptoms then were a diScharge from the vagina, and a fmall fwelling of the glands of the groin, which were painful. She had taken fome pills, fuppofed to be mercurial. February 1782, about three months after being infected, the difcharge ftopped ; but the fwelling, wdiich had been gradually increafing ever fince its firft appearance, had now Suppurated. She applied Some ointment to it which was brought to her by her hufband, and in two months it got well, that is, in April 1782. After the bubo got well, a difcharge from the vagina came on, for which fhe took more of the fame pills fhe had taken before. After this dme blotches came out over her whole body ; fome about her legs, under her arms, and upon her nipples, ulcerated. Twins, which fhe brought forth at eight months, in March 1782, at the time the bubo was healing, had blotches upon them at their birth, and died foon after. Another girl, about two years old, whom fhe fuckled, was alfo covered with blotches when fhe came to the hofpital. To afcertain whether her Secondary ulcers were infectious, that is, whether the matter of them would have the fpecific ef- fefts of venereal matter, flie was inoculated with Some matter Srom one of her own ulcers, and with fome matter of a bubo of another perSon where mercury had not been uSed. This was done, September 18, 1782. September 19, the punfture, where fhe was inoculated with her own matter, gave her pain three hours Srom the time of inoculation, and the day follow- ing inflamed a little. The other had not then inflamed at all. September 20, both the punftures had Suppurated and had the appearance of a fmall-pox puftule; they fpread confiderably, arid were attended with much inflammation. That Srom her own matter healed with common poultices, and ointments without mercury ; but the other, although treated in a Similar way, continued in the Same ftate, attended with much pain and inflammation. September 27o OF THE LUES VENEREA. September 22, the child was inoculated with fome matter from one of its own ulcers, and with fome common pus. The punftures both inflamed in a Small degree, but neither of them Suppurated. The mother and the child went into the ward appropriated to falivation, Oftober 21, 1782. The child took no mercury. It was fuppofed that its gums became a little fore; and the blotches got well. During the time that the mother was ufing mercury, the ulcer Srom inoculation began to get well, and all her venereal Symptoms disappeared. What fhall we Say to this caSe ? Were the blotches venereal ? There was every leading circumftance to make us think So ; and our opinion was ftrengthened by the method of cure. If they were venereal, my opinion that the conftitutional appearances of the diSeaSe do not produce matter of the fame fpecies that produced them, is confirmed. If they were not venereal, then we have no abSolute rule by which to judge in Such caSes. It has been SuppoSed and afferted from obfervation, that ul- cers in the mouths of children from a conftitutional diSeafi^. which conftittuional diSeaSe has been SuppoSed to be derived from the parent, have produced the Same difeaSe upon the nip- ples of women who had been fucked by them ; that is, th« children were contaminated either by their mothers or Sathers having the diSeaSe in form of a lues venerea, of which I hav« endeavoured to Show the impossibility. If, however, it were poffible to contaminate once in this way, it would be poffible to contaminate for ever. How far the obfervations, upon which the before-mention- ed opinion is hmnded, have been made with fufficient accuracy to overturn thofe which I made with a view to aScertain the truth, I know not. But, from a more accurate inveftigation of fome of thofe cafes, which were by moft of the faculty call- ed venereal, they appeared evidently not to be Such. To Say what they were, would lead us into the consideration of other diSeaSes. The Sollowing caSe may leffen our faith in the hifto- ries of fuch as have been fuppofed to be venereal. Before I defer ihe the cafe, I fhall firft mention fome of the circumftances leading to it. A child was Suppcfed to have infefted its nurfe with the ve- aer'eal diSeaSe. The parents had been married about twelve years, OF THE LUES VENEREA. tjt years, when this child was born. The Sather was a very fond hufband, and the mother a mild and moft affectionate woman. The father had a venereal gonorrhcea two years before he mar- ried, that is, fourteen years before the birth of the child. About nine months after marriage they had a child, and afterwards a fecond, both of which were extremely healthy at birth, and ftill continue fo. The mother fell into a weakly ftate of health and mifcarried of her third child at the end of five months. The fourth child was born at Seven months, but was puny, weak, and had hardly any cuticle when born. It was imme- diately after birth attacked with a violent dySentery. It died in a few days and was opened by me. The whole Skin was almoft one excoriated Surface. The inteftines were much in- flamed and thickened. With her fifth child, from great care, fhe went eight months* and it was now hoped that fhe might go the full time, and alfo that this child might be more healthy than the former. When She was delivered, the child was very thin, but Sree from any vifible diSeaSe. , Some days after birth it became bliftered in a vafl number of places on its body, which blifters were filled with a kind of matter, and, when they broke, difcharged a thlnnifh pus. The infide of the mouth was in the Same condition. Bark was given to the nurSe. Bark, in milk, was given to the child by the mouth ; and it was fomented with a decoftion of bark ; but, in about three weeks after birth, it died. Some weeks after the death of the child, the nurfe's nipple, and the ring around the nipple, inflamed, and Sores or ulcers were formed with a circumfcribed bafe*. They were poulticed, but without benefit. She alfo complained of a fore throat; but the SenSation, fhe complained of, was So low in the throat that no diSeaSe could be Seen. A Swelling took place in the glands of the arm-pit but they did not fuppurate. She applied to a phyfician, and according to the account which fhe gave, he pronounced that her diSeaSe was venereal, and that fhe had given Suck to a foul child; and he ordered ten boxes of mer- curial ointment to be rubbed in on her legs and thighs, eight of which had been ufed, when I faw her; and then her mouth was become extremely fore. TheSe * She had but tne breaft that gave milk, &yz OF THE LUES VENEREA. Thefe circumftances carre to the ears of the family, and an alarm took place. The hufband went Srom Surgeon to Surge- on, and from phvfician to phyfician, to learn, if it was poffible for him to have the diSeaSe for fourteen years, and never to have perceived a Single Symptom of it in all that time : or if it was poffible he could get children with the difeafe now, when the two firft were healthy* Fie alfo wanted to know, if it was pof- fible for his wife to have caught the difeafe from him under Such circumftances; and alSo, if fhe could breed children with : this difeafe, although She herSelf never had a Single Symptom of it. If we take all the above-mentioned circumftances as fafts, the conclufion is, that it was impoffible there could be any thing venereal in the caSe ; but as they could not be ab- solutely proved to be fafts, there muft remain a doubt in the mind, a Something ftill to be proved. Now let us confider the reSult of the cafe. The nurSe's mouth was become extremely Sore Srom the mercury when I firft faw her. I defired that Mr. Pott might See her along with me ; and it was the opinion of us both, that the Sores on the nipple, and around it, were not venereal ; but it was alledged, that, as She had taken mercury, their not having a ve- nereal appearance now was owing to that cauSe. The bark was given, as alSo the SarSaparilla, but the Sores did not heal, nor did they become worSe ; nor was the mouth better by leaving off the mercury. I ordered the hemlock, but that appeared to have no effeft. In the mean time eruptions broke out on the fkin. The Skin of the hands and fingers peeled off; the nails of both fingers and toes Separated ; and Sores Sormed about their roots, which were all SuppoSed (by many) to be venereal. But Some of them appearing, while the conftitution was full of mercury, and others disappearing without any fur- ther uSe oS that medicine, I judged that thev were not venereal. We fuSpefted that her mode of living was Such as contributed greatly to the continuance of her firft complaint, and gave rife to the new ones; for fhe looked dejefted and fallow. She was defired to go into an hoSpital, which fhe did. As foon as fhe got into a warm bed, and had good wholeSome food, fhe began to mend, and in about five or fix weeks fhe had become fat and almoft well ; the fore only about the root of the nail of the great toe had not healed ; but that appeared now to be owing to the root of the nail being detached, therefore afting as an OF THE. LUES VENEREA. *73 an extraneous body. She came out of the hofpital before this toe had got well; and, returning to her old poor mode of liv- ing, fhe had a return of the forenefs in the mouth ; however, fhe mended at laft without the uSe of more mercury. This cafe I fhall further confider when on diSeaSes reSem- bling the venereal. The following cafe will further prove that we often fufpeft complaints to be venereal when they really are not. A gentleman had for fome time blotches on his fkin. The face, arms, legs and thighs, were in many places covered with them ; and they were in their different ftages of violence. In this fituation he applied to me; and I muff own they had a very fufpicious appearance. I afked him what he SuppoSed thefe blotches were ? he Said he SuppoSed them to be venereal. I afked him when he had a recent venereal complaint? he told me not Sor above twelve months. I then afked him how long he had had the blotches ? and the anSwer was, above fix months. As this was a Sufficient time Sor making observations upon tbem that might afcertain better than the mere appear- ance what they were, I afked him iS any oS the blotches, that came firft, had disappeared in that time? and he Said many ; I fifthly, in the parts, that come firft into aftion, the difeaSe goes on increafing without wearing itSelf out, while thofe that •re fecond in time follow the fame courfe. Sixthly, mercury hinders a difpofition Srom Sorming, or in other words, prevents contamination. Seventhly, mercury does not deftroy a diSpofition already formed. Eighthly, mereury hinders the action from taking place al- though the difpofition be formed. Ninthly, mercury cures the aftion. Thefe principles being eftablifhed, the fafts refpefting the Cure are eafily accounted for. CHAPTER II. OF THE SYMPTOMS OF THE LUES VENEREA. HEN the venereal matter has affefted the conftitution in any of the ways before-mentioned, it has the whole body to work upon, and fhows itSelS in a variety of Shapes; many of which putting on the appearance of a different difeafe, we are often obliged to have recourfe to the preceding hiftory of the cafe before we can form any judgment of it. Probably the varieties in the appearances may be referred to the three following circumftances ; the different kinds of conftitutions ; the different kinds of folids affefted ; and the different diSpo- fitions which the Solids are in at the time : Sor I can eafily conceive, that a peculiarity of conftitution may make a very material difference in the appearance of the fame fpecific com- plaint; and I am certain, that the Solids, according to their different natures, produce a very different appearance when at- tacked with this difeafe ; and I can alfo eafily conceive, that a different diSpofition, Srom the common, in the Solids at the time, may make a confiderable difference in the appearances. The difference of the conftitution, and of the fame parts at different times, may have confiderable effefts in the difeaSe P p with w e9o OF THE LUES VENEREA. with refpeft to its appearing fooner, or later. This I am cer* tain of, that the different parts of the body produce a very confiderable difference in the times of appearance of this difeafe. That it appears much fooner in fome parts than in others, is beft feen where different parts are affefted in the fame perfon ; for I have already endeavoured to fhow that it is moft probable all the parts affefted are contaminated near- ly at the fame time. This difference in the times is either ow- ing to fome parts being naturally put into aftion more eafily by the poifon than others, or they are naturally more active in themfelves, and therefore probably will admit more quickly the aftion of every difeafe that is capable of affefting them. When on the general hiftory of the lues venerea, I divided the parts into two orders, according to the time of their ap- pearance ; I alfo obServed that the firft were commonly the external parts, as the fkin, noSe, tonfils; and that the Second were more internal, as the bones, periofteum, faScise, and tendons. The time, neceffary for its appearance, or for producing its local effefts in the feveral parts of the body, moft readily affefted, after it has got into the conftitution, is uncertain; but in general it is about fix weeks; In many cafes, however, it is much later, and in others much fooner. In fome caSes it appears to pro- duce its local effefts within a fortnight after the poffibility of the abSorption of the matter. In one cafe a gentleman had a chancre, and a Swelling in the groin came on, and within the before-mentioned time he had venereal eruptions all over the body. He could not impute this to any former complaint, yet there is a poffibility of its having arifen from the firft mode of catching the difeafe, by fimple contaft, at the time he got the local or chancre, which might extend the time to a week or more, although this is not probable. In another cafe, three weeks after the healing of a chancre, eruptions broke out all ^ver the body, and this happened only a fortnight after leaving off the courfe of mercury that cured the chancre. The effefts on other parts of the body, that are lefs SuSceptible of this irri- tation, or are flower in their aftion, are of courfe much later in appearing; and in thofe cafes where both orders of parts are contaminated, it is in general not till after the firfl has made its appearance for a confiderable time, and even pefhaps after it has been cured; for while the parts firft in order of aftion were contaminate! OF THE LUES VENEREA. 291 contaminated and under cure, the Second in order are only ifl a ftate of contamination, and go on with the difeafe afterwards, although it may naver again appear in the firft. From this circumftance of the part6, fecond in Order, com- ing later into aftion, we can plainly fee the reafon why it fhall appear in them, although the firft in order may have been cur- ed; Sor if the external parts, or firft in order, have been cured, and the internal, or Second, Such as the tendons, bones, peri- ofteum, &c. have not been cured, then it becomes confined folely to thefe parts. The order of parts may fometimes be in- verted ; for I have Seen caSes where the periofteum, or bone, was affefted prior to any other part; whether in the Same caSe it might in the end have affefted the Skin, or throat, I will not pretend to Say, as it was not allowed to go on; but it is poffible that the Second order of parts may be affefted without the firfl; having ever been contaminated. Its effefts on the deeper Seated parts are not like thofe pro- duced in the external, and the difference is fo remarkable as to give the appearance of another difeafe; and a perfon accuftom- ed to fee it in the firft parts only, would be entirely at a lofs about the Second. The parts which come firfl into aftion go on with it, pro- bably on the Same principle, much quicker than the others; and this ariSes Srom the nature oS the parts, as has already been obServed. Each Succeeding part, that becomes affefted, is flower and flower in its progrefs, and more fixed in its Symptoms when produced ; this ariSes alfo from the natural difpofition of fuch parts, all their aftions being Slow, which indolent aftion may be aflifted by the abSence of the great difpofing caufe, that is cold. I fhould, however, fufpeft that warmth did not contri- bute much to their indolence of aftion, for if it did, it would affifl in the cure, which it appears not to do, thefe parts being as flow in their operations of reftoration as they are in their aftions of difeafe. We may alfo obferve, that fimilar parts come Sooner into aftion, and appear to go on more rapidly with it,- as they are nearer the fource of the circulation. It ap- pears earlier on the face, head, ftioulders, and breaft, than on the legs, and the eruptions come fooner to fuppuration in the before-mentioned parts*. Ths * See Introduction. .492 OF THE LUES VENEREA. The circumflance of its being very late in appearing in fome parts, wrfien it had been only cured in its firft appearances, as mentioned, has made many fuppofe that the poiSon lurked Some- where in the Solids; and others, that it kept circulating in the blood for years. It is not, however, eafy to determine this point; but there can be no good reafon for the firft hypothefis, as the lurking diSpofition never takes place prior to its firfl appearance ; for inftance, we never find that a man had a chancre a twelve- month ago, and that it broke out after in venereal fcnrfs upon the fkin, or ulcers in the throat. The flowneSs of its pro- grefs is only when the parts, lefs SuSceptible of its irritation, have been affefted by it. I. OF THE SYMPTOMS OF THE FIRST STAGE OF THE LUES VENEREA. The firft fymptoms of the difeafe, after abforption, appesrf either on the fkin, throat, or mouth. TheSe differ Srom one another according to the nature of the parts affefted. I fhall therefore divide them into two kinds, although there appears to be no difference in the nature of the difeafe itfelf. The appearance on the fkin I fhall call the firfl, although it is not always the firft appearance; for that in the throat hv often as early a fymptom as any. The appearances upon the Skin generally fhow themfelves in every part of the body, no part being more fufceptible than another, firft in difcoloura- tions, making the fkin appear mot'.led, many of them difap- pearing, whilft others continue, and increafe with the difeafe*. In others it will come on in diftinft blotches, often not ob- ferved till fcurfs are Sorming ; at other times they appear in fmall diftinft inflammations, containing matter and refembling pimples, but not So pyramidal, nor So red at the baSe. Venereal blotches, at their firft coming out, are often at* tended with inflammation, which gives them a degree of tranfi patency, which I think is generally greater in the Summer^ than in the winter, eSpecially if the patient be kept warm. In a little time this inflammation difappears, and the cuticle peels off in the form of a fcurf. This fometimes mifleads the pa.lent, and the Surgeon, who look upon this dying away of the inflam- mation * This is not peculiar to this difeafc, itoften takes place in the fmall. jox. OF THE LUES VENEREA. **3 iriation as a decay of the difeafe, till a SucceSfion of fcurfs un- deceives them. Thefe difcolourations of the cuticle arife from the venereal irritation, and are feldom to be reckoned a true inflammation, for they feldom have any of its charafteriftics, Such as tume- faftion and pain ; but this is true only on thoSe parts moft ex- poSed ; Sor in parts well covered, and in parts conftantly in contaft with* other parts there is more of the true inflammatory appearance, efpecially about the anus. The appearance of the parts themfelves next begins to alter, forming a copper coloured, dry, inelaftic cuticle, called a Scurf; this is thrown off, and new ones are formed. Thefe appear- ances fpread to the breadth of a Sixpence or Shilling, but Sel- dom broader, at leaft for a confiderable time, every Succeed- ing fcurf becoming thicker and thicker, till at laft it becomes a common fcab, and the diSpofition for the formation of mat- ter takes place in the cutis under the fcab, fo that at laft it turns out a true ulcer, in which ftate it commonly Spreads, al- though but flowly. TheSe appearances ariSe firft Srom the gradual loSs of the true Sound cuticle; the diSeaSed cutis having loft the diSpofi- tion to form one; and, as a kind of fubftitute for this want of cuticle, an exudation takes place, forming a Scale, and after- ward becoming thicker, and the matter acquiring more con- fiftence, it at laft forms a fcab; but before it has arrived at this ftage, the cutis has given way, and ulcerated, after which the diScharge becomes more oS a true pus. When it attacks the palms of the hands and the foles of the feet, where thfc cuticle is thick, a Separation of the cuticle takes place, and it peels off, a new one is immediately formed, which alfo Sepa- rates, So that a Series of new cuticles takes place from its not So readily Sorming ScurSs as on the common fkin. If the difi- eaSe is confined to thoSe parts, it becomes more difficult to de- termine whether or not it be venereal; for moft difeafes of the cutis of thefe parts produce a Separation of the cuticle at* tended with the Same appearances in all, and having nothing charafteriftic of the venereal difeafe. Such appearances are peculiar to that part of the common Skin of the body which is uSually expofed ; but when the fkin is oppofed by another fkin, which keeps it in Some degree more moift, as between the nates, about the anus, or between the Scrotum 2^4 OF THE LU£S VENEREA.' fcrotum and the thigh, or in the angle between the two thigh*, or upon the prolabiumof the mouth, and in the arm-pits, the eruptions never acquire the above-defcribed appearances, and, inftead of fcurfs and Scabs, we have the Skin elevated, or, as it were, tumefied by the extravaSated lymph into a white, Soft, moift, flat furface, which difcharges a white matter. This may perhaps arife from there being more warmth, more perfpirati- on, and lefs evaporation, as well as from- the Skin being thin- ner in Such places. What ftrengthens this idea ftill more is, that in many venereal patients I have Seen an approach towards fuch appearances on the common fkin of the body ; but this has been on fuch parts as were covered with the clothes; for on thofe parts of the fkin, that were not covered, there was only the flat Scurf; theSe, however, were redder than the above-deScribed appearances, but hardly So high. How Sar this is peculiar to the venereal diSeaSe, I know not. It may take place in mofl: Scurvy eruptions of the fkin. From a fuppofition of this not being venereal, I have deftroyed them at the fide of ihe anus with cauftic, and the patient has got well ; however, from my idea of the difeafe that every effect from the conftitution is truly local, and therefore may be cured locally ; a cure effefted by this treatment does not determine the queflion. This difeaSe, on its firft appearance, often attacks that part of the fingers upon which the nail is formed, making that fur- face red which is feen fhining through the nail ; and, if allow- ed to continue, a Separation of the nail takes place, fimilar to the cuticle in the before-defcribed Symptoms ; but here there cannot be that regular Succeffion of nails as there is of cuticle. It alfo attacks the Superficies of the body which is covered with hair, producing a Separation of the hair. A prevention of the growth of young hair is alfo the conSequence while the diSeaSe lafts. The Second part, in which it appears, is moft commonly the throat, Sometimes the mouth and tongue. In the throat, ton- fils, and infide oS the mouth, the difeafe generally fhows itfelf atonce in the form of an ulcer without much previous tume- faftion, fo that the tonfils are not much enlarged ; Sor when the venereal inflammation attacks thefe parts, it appears to be always upon the furSace, and it very Soon terminates in an ulcer. TheSe OF THE LUES VENEREA. zg$ TheSe ulcers in the throat are to be carefully dlflinguifhedl from all others of the fame parts. It is to be remarked, that this difeafe when it attacks the throat, always, I believe, pro- duces an ulcer; although this is not commonly underftood j for I have feen cafes where no ulceration had taken place, call- ed, by miftake, venereal. It is therefore only this ulcer that is to be diftinguifhed from other ulcers of thefe parts. This fpecies of ulcer is generally tolerably well marked, yet it is per- haps in all caSes not to be diftinguifhed from others that attack this part, for fome have the appearance of being venereal, and what are really venereal refemble thofe that are not. We have feveral difeafes of this part which do not produce ulceration on the furface, one of which is common inflammation of the ton- fils, which often fuppurates in the centre, forming an abfeefs, which burfts by a fmall opening, but never looks like an ulcer begun upon the furface as in the true, venereal; this cafe is always attended with too much inflammation, pain, and tume- Saftion of the pans to be venereal; and'if it fuppurates and burfts, it fubfides direftly, and it is generally attended with other inflammatory fymptoms in the conftitution. There is another difeafe of thefe parts, which is an indolent tumefaction of the tonfils, and is peculiar to many people whofe conftitutions have Something of the Scrofula in rhem, producing a thicknefs in the Speech. Sometimes the coagulable lymph is thrown out on the SurSace, and called by Some ulcers, by others floughs, and Such are often called putrid fore throats. ThoSe commonly Swell to too large a Size Sor the venereal; and this appearance is eafily diftinguifhed Srom an ulcer or loSs of fubftance; however, where it is not plain at firft fight, it will be right to endeavour to remove fome of it; and if the furface of the tonfil is not ulcerated, then we may be Sure it is not venereal. I have Seen a chink filled with this, appearing very much like an ulcer ; but upon removing the coagulable lymph, the tonfil has appeared perfeftly found. 1 have feen caSes of a fwelled tonfil where a flough formed in its centre, and that flough has opened a paffage out for itfelf; and when it has been as it were flicking in this paffage it has appeared like a foul ulcer. The moft puzzling ftage of the complaint is, when the flough is come out, for then it has moft of the characters of the*ve- nereal ulcer ; but when I have feen the d;.« afe in its firfl ftag^s, 1 have $9J& OF THE LUES VENEREA. I have always treated it as of the erifypelatous kind, or as fbmething of the nature of a carbuncle. When I have feen them in their Second Stage only, I have been apt to SuppoSe them venereal ; however, no man will be fo rafh as to pronounce what a diSeaSe is Srom the eye only, but will make inquiries into all the circumftances before he forms a judgment. IS there have been no preceding local Symp- toms within the proper date, he will SuSpend his judgment and wait a little to See how Sar Nature is able to relieve herSelf. If there has been any preceding fever, it will be Still leSs probable that it is venereal. However, I will not Say of what nature ftich cafes are, but only that they are not venereal, as they are often believed to be. I have Seen a Sore throat oS this kind miftaken Sor venereal, and mercury given till it fhould affeft the month, which when it did, it brought on a mortification on all the parts concerned in the firft diSeaSe. It would there- fore appear that this Species of the fore throat is aggravated by mercury. There is another complaint of thofe parts which is oSten ta- ken for venereal, which is an ulcerous excoriation, where the ulceration or excoriations run along the furface of the parts, becoming very broad and Sometimes Soul, having a regular termination, but never going deep into the Subftance of the parts as the venereal ulcer does. There is no part of the in. fide of the mouth exempted from this ulcerous excoriation ; but I think it is moft frequent about the root of the uvula, aid fpreads forwards along the palatum molle. That fuch are not venereal, is evident from their not giving way in general to mercury ; and I have feen them continue for weeks without altering, and a true veneraal ulcer appear upon the centre of the excoriated part. The difference between the two is So ftrong that there can be no miftake ; patients have gone through a courSe of mercury which has perfeftly cured the venereal ulcers, but has had no ef. foci upon the others, which have afterwards been cured by bark. The true venereal ulcer in the throat is perhaps the leaft li- able to be miftaken of any of the forms of the difeafe. It is a fair lofs of fubftance, part being dug out as it were from the body of the tonfil, with a determined edge, and is commonly very foul, having thick white matter adhering to it like a flough, which cannot be wajiied away. Ulcers OF THE LUES VENEREA. 297 Ulcers in Such fituations are always kept moift, the matter not being allowed to dry and form Scabs, as in tbofeupon the fkin ; the matter is carried off the ulcers by deglutition, or the motion of the parts, fo that no fucceffion of Scurfs or Scabs can take place, as on the fkin. Their progreSs is alSo much more rapid than on the common Skin, ulceration taking place very faft. Like molt other Spreading ulcers, they are generally very foul, and for the moft part have thickened or bordered edges, which is very common to venereal or cancerous fores, and in- deed to moft Sores which have no diSpofition to heal, whatever the Specific diSeafe may be. When it attacks the tongue it fometimes produces a thicken- ing and hardnefs in the part ; but this is not always the cafe, for it very often ulcerates as in the other parts of the mouth. They are generally more painful than thofe of the fkin ; al- though not fo much So as common Sore throats arifing from inflamed tonfils. They oblige the perSon to Speak thick, or as if his tongue was too large for his mouth, with a fmall degree of fnuffling. Thefe are the moft common fymptoms of this ftage of the difeafe ; but it is perhaps impoffible to know all the fymptoms this poifon produces when in the conftitution. I knew a gen- tleman who had a teafing cough, which he imputed to it ; Sor it came on with the Symptomatic fever and continued with it, and by ufing mercury both difappeared. There are inflammations of the eyes which are fuppofed to be venereal ; for after the tifual remedies againft inflammation have been tried in vain, mercury has been given on the Sup- position of the cafe being venereal, and Sometimes with SucceSs, which has tended to eftablifh this opinion. But if fuch cafes are venereal, the difeafe is very different Srom what it is when attacking other parts, from the conftitution, for the inflamma- tion is more painful than in venereal inflammation proceeding from the conflitution ; and I have never feen fuch cafes attend- ed with ulceration, as in the mouth, throat and tongue, which makes me doubt much of their being venereal. Qq II. EX- 298 OF THE LUES VENEREA, II. EXPERIMENTS MADE TO ASCERTAIN THE PROGRESS AND EFFECTS OF THE VENE- REAL POISON. To afcertain Several fafts relative to the venereal diSeaSe, the following experiments were made. They were begun in May 1767. Two punftures were made on the penis with a lancet dipped in venereal matter from a gonorrhoea ; one punfture was on the glans, the other on the prepuce. This was on a Friday ; on the Sunday following there waj a teafing itching in thofe parts which lafted till the Tuefday following. In the mean time, thefe parts being often examin- ed, there feemed to be a greater rednefs and moifture than ufu- al, which was imputed to the parts being rubbed. Upon the Tuefday morning, the parts of the prepnce where the punfture had been made were redder, thickened, and had formed a Speck; by the Tuefday following, the fpeck had increafed and discharg- ed Some matter, and there Seemed to be a little pouting of the Jips of the urethra, alfo a SenSation in it in making water, So that a diScharge was expected from it- The fpeck was now touched with lunar cauftic, and afterwards dreffed with calomel ointment. On Saturday morning, the flough came off; and it was again touched, and another flough came off on the Mon- day Sollowing. The preceding night the glans had itched a good deal, and on Tuefday a white fpeck was obferved where the punfture had been made; this fpeck, when examined, was found to be a pimple full of yellowifh matter. This was novr touched with the cauftic, and dreffed as the former. On the Wednefday, the fore on the prepuce was yellow, and therefore was again touched with cauftic. On the Friday both floughi came off; and the fore on the prepuce looked red, and its bafis not So hard ; but on the Saturday it did not look quite So well, and was touched again ; and, when that went off, it was al- lowed to heal up, as alSo the other, which left a dent in the glans. This dent on the glans filled up in fome months, but for a confiderable time it had a bluifh caft. Four months afterwards the chancre on the prepuce broke out again ; and very Stimulating applications were tried ; but thefe feemed not to agree with it, and nothing being applied, it OF THE LUES VENEREA. £99 it healed up. This it did feveral times afterwards, but always healed up without any application to it. That on the glans never did break out; and herein alfo it differed from the other. While the fores remained on the prepuce and glans, a fwel- ling took place in one of the glands of the right groin. I had for Some time conceived an idea that the moft effectual way to put back a bubo was to rub in mercury on that leg and thigh, that thus a current of mercury would pafs through the inflam- ed gland. There was a good opportunity of making the ex- periment. I had often fucceeded in this way, but now want- ed to pat it more critically to the teft*. The fores upon the penis were healed before the reduction of the bubo was attempt- ed. A few days after beginning the mercury in this method, the gland fubfided confiderably. It was then left off; for the intention was not to cure it completely at prefent. The gland fome time after began to fwell again, and as much mercury was rubbed in as appeared to be fufficient for the entire reduc- tion of the gland ; but it was meant to do no more than to cure the gland locally, without giving enough to prevent the con- ftitution from being contaminated. About two months after the lafl attack of the bubo, a little ifharp pricking pain was felt in one of the tonfils in Swallowing anything; and, on infpeftion, a fmall ulcer was found, which was allowed to go on till the nature of it was afcertained, and then recourfe was had to mercury. The mercury was thrown in by the fame leg and thigh as before, to fecure the gland more •effectually, although that was not now probably neceffary. As Soon as the ulcer was fkinned over, the mercury was left off, it not being intended to deftroy the poifon, but to obServe what parts it would next affeft. About three months after, copper coloured blotches broke out on the fkin, and the form- er ulcer returned in the tonfil. Mercury was now applied the fecond time for thofe effefts of the poifon from the conftitution, but ftill only with a view to palliate. It was left off a fecond time, and the attention was given to mark where it would break out next, but it returned again in the fame parts. It not appearing that any further knowledge was to be procured by only palliating the difeafe a fourth time in • The practice ia 1767, was to apply a mercurial plaifter on the part, or to rub in Bicrcurial oir-tment on the part, which could hardly aft by any other power than fympathy. «-5oo OF THE LUES VENEREA. in the tonfil, and a third time in the fkin, mercury was now taken in a fufficient quantity, and for a proper time, to com- plete the cure. The time the experiments took up, from the firft infertion to the complete cure, was about three years. The above cafe is only uncommon in the mode of contract- ing the difeafe, and the particular views with which fome parts of the treatment were direfted; but, as it was meant to prove many things, which, though not uncommon, are yet not at- tended to, attention was paid to all the circumftances. It proves many things, and opens a field for further conjeftures. It proves firft, that matter from a gonorrhcea will produce chancres. It makes it probable that the glans does not admit the vene- real irritation fo quickly as the prepuce. The chancre, on the prepuce, inflamed and fuppurated in fomewhat more than three days, and that on the glans in about ten. This is probably the reafon why the glans did not throw off its floughs So Soon. It renders it highly probable, that to apply mercury to the legs and thighs, is the beft method of refolving a bubo ; and therefore alfo the beft method of applying mercury to affift in the cure, even when the bubo Suppurates. It alfo fhows that buboes may be refolved in this way, and vet the conftitution not fafe ; and therefore that more mercury fhould be thrown in, efpecially in cafes of eafy refolution, than what fimply reSolves the bubo. It fhows that parts may be contaminated, and may have the poiSon kept dormant in them while under a courSe of mercury for other fymptoms, but break out afterwards. It alfo fhows that the poiSon, having originally only conta- minated certain parts, when not completely cured, can break out again only in thoSe parts. III. OF THE SYMPTOMS OF THE SECOND STAGE OF THE LUES VENEREA. This ftage of the difeaSe is not So well marked as the former; and, as it is of more importance, ir requires all our discern- ment to determine what the diSeaSe is. The parts leSs SuSceptible of this irritation are fuch as are more out of the way of the great exciting caufe, which is the exter- nal OF THE LUES VENEREA. nal air, as has been before-related. And they begin to take on the venereal aftion whether it may or it may not have produced its local effects upon the external or expoSed Surfaces; and they even go on with the aftion, in many cafes, after thefe furfaces firft affefted have taken on the aftion and have been cured, as has been already obferved. Thefe deeper feat- ed parts are, the periofteum, tendons, fafciae, and ligaments ; however, what the parts affefted may be when the diSeaSe is in this ftage, is not always certain ; I have known it produce to- tal deafnefs, and fome of thofe cafes to end in fuppuration, at- tended with great pain in the ear, and fide of the head. Such cafes are generally fuppofed to arife from fome other caufe; and nothing but fome particular circumftance in the hiftory of the cafe, or fome fymptom attending it, can lead the furgeon to the nature of the complaint. When thefe deeper Seated parts become irritated by this poi- fon, the progiefs is more gradual than In the firft; they have very much the character oS ScroSulous Swellings, or chronic ■ rheumatiSm, only in this diSeaSe the joints are not So Subject to it as they are in the rheumatiSm. We fhall find a fwelling come upon a bone when there has been no poffible means of catching the infeftion for many months, and it will be of fome fize before it is taken notice of, from having given but little pain. On the other hand, there fhall be great pain, and pro- bably no fwelling to be obferved till fome time after. The fame observations are applicable to the Swelling of tendons, and fafciae. As thefe fwellings increafe by flow degrees, they Show but little figns of inflammation. When they attack the periofte- um, the fwelling has all the appearance of a fwelling of the bone, by being firm and clofely connected with it. The inflammation, produced in thefe later flages of the dif- eafe, can hardly get beyond the adhefive, in which ftate it con- tinues growing worfe and worfe, and when matter is formed it is not true pus, but a flimy matter. This may ariSe in Some degree Srom the nature of the parts not being in themfelves eafily made to Suppurate ; and, when they do Suppurate, the Same languidneSs ftill continues, in So much that this matter is not capable of giving the extraneous ftimulus, fo as to excite true Suppuration or ulceration, even after the conftitution is cleared go* OF THE LUES VENEREA. cleared of the original cauSe, and then the diSeafe is probably fcrofulous. Some nodes, either in the tendons or bones, laft for years before they form any matter at all; and in this cafe it is doubtful whether they are venereal or not, although com- monly fuppofed to be fo. I have already obferved, that the pain in the firft flages of this difeafe is much lefs than might be expefted, considering the effefts produced by the poiSon. The diSeaSe being very flow and gradual in its progreSs, its giving little pain may be accounted for. An ulcer in the throat cauSes no great pain; and the Same may be Said of blotches on the fkin, even when they become large fores. When the periofteum and bones become affected, the pain is fometimes very confiderable, and at other times there is hard- ly any. It is not perhaps eafy to account for this. We know alfo that the tendinous parts, when inflamed, give in fome caSes very confiderable pain, and that of the heavy kind, while in others they will fwell confiderably without giving any pain. TheSe pains are commonly periodical, or have their exacer- bations, being commonly worft in the night. This is common to other aches or pains, eSpecially of the rheumatic kind, which the venereal pains refemble very much. > When the pain is the firft Symptom, it affords no diftinguifh- ing mark of the difeafe, it is therefore often taken for the rheumatifm. IV. OF THE EFFECTS OF THE POISON ON THE CONSTITUTION. The poifonous matter, fimply as extraneous matter, pro- duces no change whatever upon the conftitution, and whatever effefts it has depend wholly upon its fpecific quality as a poi- fon. The general effefts of this poiSon on the conftitution are fimilar to other irritations, either local or conftitutional. It produces fever, which w of the flow kind ; and when it conti- nues a confiderable time it produces what is called a heftic difpofition, which is no more than an habitual flow fever arif- ing from a caufe which the conftitution cannot overcome. While this exifts, it is impoffible that any thing falutary can go on in fuch a conftitution. The patient lofes his appetite, or OF THE LUES VENEREA. 3°S or even if his appetite is good, lofes his flefh, becomes reftleSs, loSes his fleep, arrd looks Sallow*. In the firft ftage of this difeafe, before it begins to Show it- felf externally, the patient has generally rigors, hot fits, head- achs, and all the Symptoms of an approaching fever. Thefe fymptoms continuing for Some days, and often for weeks, (how that there is Some irritating cauSe which works ■flowly upon the conftitution. It is then SuppoSed to be what- ever the invention or ingenuity of the practitioner fhall call it; but the venereal eruptions or nodes upon either the periofteum, bones, tendons, or other parts, appearing, Show the cauSe, and in Some degree carry off the Symptoms of fever and relieve the conftitution for a little time, but they Soon recur. TheSe conftitutional complaints, however, are not always to be Sound; the poiSon ftimulating fo flowly as hardly to affeft the conftitution, unlefs it be allowed to remain in it a long jime. There are a number of local appearances, mentioned by au- thors, which I never faw, fuch as the fiffures about the anus, &c. There are alSo a number of diSeaSes, defcribed by author* as venereal, efpecially by Aftruc and his followers, which are almoft endleSs. The cancer, fcrofula, rheumatifm, and gout, have been eonfidered as arifing from it, which may be in fome mcafure true ; but they are with them the difeaSe itSelf, and all their confequences, as confumption, wafting Srom want of nou- rishment, jaundice, and a thoufand other difeafes, which hap- pened many years before the exiftence of the lues venerea, are all attributed to it. There is even at this day hardly any difeafe the practitioner is puzzled about, but the venereal comes immediately into his mind ; and if this became the caufe of careful inveftigation, it would be produftive of good, but with many the idea alone Satisfies the mind. CHAPTER * This kind of look, although aritfng entirely from a harrafled conftitution, is alwayt fuppofed to be peculiar to a venerral one. Thitidea, Wtrcr, dew not arife from the look only, but from the' leading fymptoms. OF THE LUES VENEREA. CHAPTER HI. GENERAL OBSERVATIONS ON THE CURE OF THE LUES VENEREA. IT has been obferved before, that there are three forms of the venereal infection, gonorrhoea, chancre, and the lues venerea, which various forms I have endeavoured to account for. As they all three arife from the fame poifon, and as the two firft depend only on a difference in the nature of the parts, and the lues venerea on another circumftance which has been explained, it would be natural to fuppofe that one medicine, whatever it be, would cure all the forms of this difeaSe. But we find from experience, that this does not hold good ; for one medicine, that is mercury, cures only the chancre and the lues venerea, and the gonorrhcea is not the leaft affefted by it; and what is ftill more remarkable is, that the two, which it cures, are in no refpeft Similar, while the gonorrhcea, which it does not cure, is Similar in Some reSpefts to the chancre, which it does cure. It may be remarked in general, that there is not only a dif- ference in the form of the difeafe, but alfo in the modes of cure, and in the times neceffary Sor the cure oS the different forms of the difeaSe, even when the Same medicines cure. The gonorrhcea, in its cure, is the moft uncertain of the three, the chancre next, and the lues venerea the moft certain, although cured by the fame medicine which cures the chancre. A gonorrhcea in fome cafes fhall be cured in fix days, and in others require as many months; which, with regard to time, is about the proportion of thirty to one. A chancre may be fometimes cured in two weeks, and often requires as many months ; which is in the proportion of four to one. The lu- es venerea in general may be cured in one or two months; which is only two to one. This calculation fhows the regula- rity and irregularity, as to time, in the cure of each form of the difeafe. I have formerly obServed, that indiSpofitions of the body often affeft this difeafe very confiderably, more efpecially the gonorrhoea and the chancre. When OF THE LUES VENEREA: $03 When an increafe of fymptoms takes place in a gonorrhcea, from an indifpofition of body, nothing Should be done for the gonorrhoea, the indifpofition of body being only to be attended to; becauSe we have no,Specific Sor the gonorrhcea, and in time it cures itfelf. But this praftice is perhaps not to be followed in a chancre, or lues venerea. It may be neceffary in thoSe to continue the mercury, although perhaps more gently ; for the mercury is a Specific that cannot be diSpenSed with, becauSe neither the chancre nor lues venerea are cured by themSelves, but always increaSe. This form of the venereal difeafe I have divided into two ftages. When in the parts moft fufceptible of the difeafe, which I have called the firfl order of parts, and which appear to be the fupeificies only ; the lues venerea is perhaps Subject to lefs variety than either the gonorrhcea or chancre, and its mode of cure is of courfe more uniform ; although the difeaSe be lefs eafily aScertained, at leaft for fome time. In the fe- cond order of parts the lues venerea becomes more complicated, and its cure ftill lefs to be depended upon. The cure of this form is much more difficultly aScertained than either of the two former, they being always local, and their effefts vifible,4 become more the object of our fenfes, fo that we are feldom or ever deceived in the cure ; althouph at the fame time the cure is often more tedious and difficult; for whenever the Symptoms oS the gonorrhcea or chancre have en- tirely difiippeared, in general the patient may look upon him- Self as cured of them; but this is not the caSe in the lues ve- nerea. A lues venerea is the effefts of the poifon having circulated in the blood till it has irritated parts fo as to give them a vene- real difpofition, which parts Sooner or later affume the vene*- real aftion, according to the order of their SuSceptibility. When the venereal matter is circulating, I have fuppofe^ that certain ports are irritated by it, and that a vaft number of other parts efcape, as is evidently the cafe with the chancre ; for in the cafe of a chancre the whole glans, prepuce and fkin of the penis, have had the matter applied to them, yet only one or more parts are contaminated or irritated by it, all the others efcaping; and we often See in the lues venerea, that when the parts contaminated affume the aftion, it is confined to them without affefting other parts, although the diSeafe be allowed R r ta» 3C$ OF THE LUES VENEREA. to go on for a confiderable time without any attempt to a cure; i>nd alfo, if thefe parts are imperfectly cured, the difeaSe re- turns only in them ; therefore thefe effefts, although arifing Srom the conftitution, are in themSelves entirely local, Similar to the gonorrhcea and chancre, and like them may be cured locally ; and the perSon may ftill continue to have the lues ve- nerea, although not in theSe, yet in other parts, becauSe there may be many other parts in the Same body that are under the venereal diSpofition, although they may not yet have affumed the venereal aftion. To cure the local and vifible effefts of the diSeaSe we muft attack it through that medium by which it was communicated, that is, the blood, without however con- sidering the blood itfielS as diSeaSed, or containing the poiSon, but as the vehicle oS our medicine, which will be carried by it to every part of the body where the poiSon was carried, and in its courSe it will aft upon the diSeaSed Solids. This praftice muft be continued Some time after all fymptoms have disappeared ; Sor the venereal aftion may to appearance be Stopped, and Symptoms diSappear, and yet all return again, the venereal aftion not being completely deftroyed. If the medi- cine were alfo a cure Sor the diSpofition in the parts Second in order, and could prevent their coming into aftion, it would be neceffary to continue it Somewhat longer on their account; but this is not the caSe, Sor the vifible effefts, Symptoms, or appearances, in the firft order of Darts, give way to the treat- ment, while the parts that have only acquired the difpofition, and are ftill inaftive, afterwards affume the aftion and conti- nue the diSeaSe. This deceives the Surgeon and leaves the ground-work Sor a Second Set of local effefts in the parts Se- cond in order ; but I have afferted, that what will cure an ac- tion will not cure a diSpofition; iS So, we Should pufh our medicine no Surther than the cure oS the vifible effects of the poifon, and allow whatever parts may be contaminated to come into aftion afterwards. The parts that firft affume the venereal aftion are eafieft of cure ; and I have SuSpefted that thoSe effefts of the difeaSe be- ing external, were in Some degree affifted in their cure by the local aftion of the medicine, which evidently paffes off through thofe parts. Wnen the difeaSe has attacked the parts Second in order of SuSceptibility, it generally happens that they are more difficult of OF THE LUES VENEREA. '307 of cure than the former; therefore, when they are affefted at the fame time with the former, and are cured, we may be fure that the firft will be alSo cured. From hence, as it would ap- pear that the parts moft SuSceptible of the difeaSe are alSo eafieft of cure, it follows that the parts leaft fufceptible of the difeafe are alfo moft difficult of cure ; and I believe that this is feldom or ever reverfed, therefore, thofe fecond in order of fufcepti- bility have this advantage, that we have the local complaints for our guide to judge of the whole ; and in fuch we have on- ly to continue the treatment till they all vanifh, being certain that the cure of the firft, if there are any, will be involved in thofe of the fecond. As the fecond are attended with more tumeSaftion or Swel- ling than the firft, it becomes a queflion, whether the mercu- rial courSe fhould be continued till the whole has Subfided. But I believe it is not neceffary to continue the method of cure till the whole tumefaftion disappears; for as thofe local complaints cannot contaminate the conftitution by reabforption, and as the venereal difpofition and aftion from the conftituti- on can be cured while the local effefts ftill remain, even where the tumefaftion forming nodes on the bones, fafciae, &c. is carried the length of fuppuration, there can be no occafion Sor continuing the courSe longer than the deftruftion of the vene- real aftion. But this effeft of our medicine is not eafily known, therefore it will be neceffary to purfue the method of cure till the appearances become ftationary, and probably a little longer to deftroy the whole aftion of the difeaSe. From theSe circum- ftances it would appear that the venereal irritation, when in this ftage of the difeaSe, is eafier of cure than the effefts of that irritation, Such as the tumefaftion. I. OF THE USE OF MERCURY IN THE CURE OF THE LUES VENEREA. Mercury in the lues venerea, as In the chancre, is the great fpecific, and hardly any thing elSe is to be depended up- on. It is neceffary that we fhould always confider well the effefts of this medicine, both on the conftitution at large, and the difeafe for which it is given. The effefts of mercury on a conftitution will always be as the quantity of mercury in that conftitution; and when the fame quantity affefts one conftitu- tion 308 6t THfe LUfeS VENEREA. ♦ion more than another, it is in the proportion of the irritabi- lity of that conftitution, to the powers of mercury, entirely in- dependent of any particular preparation, or any particular mode of giving it. With regard to the preparations of the medicine, and the modes of applying it, we are to confider two things; firft, the preparation and mode that is attended with the leaft trouble or inconvenience to the patient; and Second, the preparation and mode of adminiftering it that moft readily conveys the neceffa- ry quantity into the conftitution. Nothing can fhow more the ungrateful ^or unfettled mind of man, than his treatment of this medicine. If there is fuch a thing as a fpecific, mercury is one for the venereal difeafe in two of its forms; yet mankind are in purfuit of other fpecifics for the difeaSe, as if Specifics weie more common than dif- eafes ; while at the fame time they are too often contented with the common mode of treating many other diffeafes for which they have no fpecific ; and thtfe prejudices are Supported by the Public, who have in their minds a dread of this medicine; arifing from the want of knowledge of our predeceffors in ad- miniftering it; and many of the prefent age, who are equally ignorant, take the advantage of this weaknefs. Mercury in the conftitution afts on all parts of the machine, cures thofe which are diSeaSed, affefting but little thoSe that are Sound. Mercury is carried into the conftitution in the Same way as other SubStances, either externally by the fkin, or in- ternally by the mouth : it cannot, however, in all caSes, be taken into the conftitution in both ways; for Sometimes it hap- pens that the abSorbents on the fkin will not readily receive it, at leaft no effeft will be produced, either on the difeaSe or con- ftitution, from Such application ; when this is the caSe it is to be eonfidered as a misfortune, for then it muSt be given inter- nally by the mouth, although poffibly this mode may be very improper in other refpefts, and often inconvenient. On the other hand it Sometimes happens that the internal abSorbents will not tike up this medicine, or at leaft no effeft is produc- ed either upon the difeafe Or conftitution ; in fuch cafes it is right to try all the different preparaiions of the medicine; for it will fometimes happen that one preparation will Succeed when another will not. I have never Seen a caSe where neither ex- ternal OF THE LUES VENEREA. 3*9 ternal nor internal applications of mercury were n6t abSorbed; fuch a cafe muft be miSerable indeed. I mav jufl obferve here, that many furfaces appear to ab- forb this medicine better than others ; and mofl probably all internal furfaces and fores are of this kind ; for when we find that thirtv grains of calomel rubbed in on the fkin has no more effeft than three or four taken b> the mouth, it becomes a kind of proof that the bowels abforb it beft; alfo, when dreffing a fm-ll Soie with red (..recipitate produces a Salivation, it fliows that Sores are good abSorbing Surfaces, eSpecially too when we know that the lues venerea geneiaily ariSes Srom a chancre. A patient with a flump which produced too much granula- tions, was dreffed with ointment containing a large proportion of red precipitate; the Sore was about the fize of a crown piece. It very nearly brought on a Salivation, and the patient wai obliged to leave it off. A mulatto woman had upon her leg a very bad ulcer, which was about the breadth of two palms ; it was dreffed with red precipitate mixed with common ointment, which Soon lhrevfr her into a violent Salivation. A lady, in the month of December 1782, was burnt oveT the whole breaft, neck, and ftioulders, as alfo between her Shoulders, on which parts deep floughs were formed. The fores at firfl healed nearly up, and tolerably well for burns ; but they broke out anew and then became more obftinate. Se- ven months after the accident flie came to London, with very large fores extending acroSs the breaft, and upon each fide t6 the Shoulders; they were extremely tender and painful. They continued to heal for fome time after She came to London; but fhe became ill, having been "affected with extreme irritabi- lity, lofs of appetite, fickneSs, and throwing up of her food and medicines. At this time the fores again began to Spread, and became very large. After having been two months in town with little advantage, I tried warmer dreffings, as bafili- con to Some parts, to See if any advantage- would arife from Such treatment, and it was Sound that thefe parts healed rathe* Safter than the others; but the forenefs was So great, even from the mildeft dreffings, that they could only be nfed in part. I next tried red precipitate mixed with the diVTtmcfit; and, that it might increafe the pain as little as poffible, I ordered 6nly ten trains to two ounces of the ointment. This appeared td agree &iP OF THE LUES VENEREA. agree better with the fores than the ointment alone ; and we were happy in having found a dreffing which both haftened on the cure, and was eafier than the Sormer. But about the fourth or fifth dreffing from beginning the ufe of the precipitate, fhe began to complain of her gums ; the next day began to fpit, and by the feventh or eighth day the mouth was fo fore, and the fpitting fo confiderable, that upon confidering the caSe we began to SuSpeft that it might proceed Srom the red precipitate in the dreffing. The gums, infide of the cheeks, and the breath, were truly mercurial. We immediately left off this dreffing, except to a fmall corner, and had recourfe to the former dreffings. In a few days the effefts of the mercury abated, and the fores looked more healthy than ever, and we again began to drefs part of the fores with the ointment containing preci- pitate, which ftill agreed with them. When the mouth firft became affefted, She had not uSed much above one half of the ointment; and by the time we had discovered the cauSe, about three fourths of it had been expended ih dreffings, fo that there was not quite ten grains of precipitate applied ; and although this took up Seven or eight days, and the ointment muft have been Soon ^removed Srom the Sore by the diScharge, yet a con- fiderable fpitting was produced, which lafted above a month. It is hardly to be conceived that above a grain or two could really be taken into the conftitution ; for when we confider the particles of precipitate were covered with ointment, and a vaft difcharge of matter, So as Soon to remove this fmall quantity from the Sore, we can hardly admit the poffibility of more be- ing abforbed ; if this idea of the quantity taken in Is juft, to what muft we attribute the great fufceptibility to the effefts of the medicine ? Was it the irritable ftate of the patient at the time ? For the ftate of the conftitution appeared to me to be that in which the locked jaw often takes place ; and I often had this difeafe in my mind. The patient afterwards got well by the ufe of an ointment in which pitch was an ingredient. All this tends to Show that Sores and internal Surfaces abforb better than the fkin. Befides the practicability of getting the medicine into the conftitution in either way, it is proper to confider the eafieft for the patient, each mode having its convenience and inconveni- ence, which arifes from the nature of the conftitution of the parts to which it is applied, or from certain Situations of life of the OF THE LUES VENEREA: V* the patient at the time. It is therefore proper to give it in that way which Suits theSe circumftanres beft. To explain this further, we find that in many patients the bowels can hardly bear mercury at all, therefore it is to be giv- en in the mildeft form poffible; alfo joined with Such other medicines as will leffen or correct its violent local effefts, al- though not its Specific ones on the conftitution at large. When it can be thrown into the conftitution with propriety by the external method, it is preferable to the internal, becaufe the fkin is not nearly So effential to life as the ftomach, and therefore is capable in itfelf of bearing much more than the Sto- mach ; it alfo affefts the conftitution much leSs; many courSes of mercury, which are abfolutely neceffary, would kill the pa- tient if taken by the ftomach, proving hurtful both to the fto- mach and inteftines, even when given in any form, and join- ed with the greateft correftors : on the other hand, the way of life will often not allow it to be applied externally. It is not every one that can find convenience to rub in mercury, there- fore they muft take it by the mouth if poffible. To obviate the inconvenience often arifing Srom the vifible effefts of mercury, many preparations have been invented; but any preparation of mercury producing an effeft different from the Simple effefts of mercury in that conftitution, Such as Sweating, or an increaS- ed diScharge of urine, muft be fuppofed either not to aft as mercury, or the fubftance with which it is compounded pro- duces this effeft; but if its peculiar effefts are leSs than ufual, I fhould very much SuSpeft that the mercury is afting in pars as a compound, and not entirely as mercury. Mercury, like many other medicines, has two effefts, one upon the conftitution and particular parts, which is according to its mode of irritation, independent of any difeafe whatever. The other is its fpecific effefts upon a difeafed aftion of the whole body, or of parts, whatever the difeafe be, and which effefts are only known by the difeafe gradually disappearing. The firft becomes an object of confideration for the furgeon, as it is in fome meafure by them he is to be guided in giving this medicine So as to have its Specific effefts Sufficient for the cure of the difeaSe. Whatever injury mercury may do to the conftitution it is by its vifible effefts, and thence the pretended art in avoiding thofe vifible effefts has been too much the caufe of great impofition. The * 8i3 OF THE LUES VENEREA. The part upon which its effefts are moft likely to fall, is trie part that :& in moft caSes attempted to be avoided, or guarded againft, and that is the mouth. I believe that we are not poS- feffed of an, means of either driving the mercury to the mouth, or of preventing it from attacking that part. Cold and warmth are the two great agents mentioned by authors ; we find them recommending the avoiding of cold, Sor fear the mercury fhould fjy to the mouth, as if warmth was a prevention ; while others, and even the fame authors, when talking of bringing the mer- cury to the mouth, recommend warmth, as if cold were a pre- ventive. Tnis being the cafe, we may reafonably fuppofe that neither the one nor the oilier have any material effeft. In giving mercury in the venereal difeafe, the firft attention Should be to the quantity, and its vifible effefts in a given time ; which when brought to a proper pitch, are only to be kept up, and the decline of the difeafe to be watched; for by this w« judge of the invifible or Specific effefts of the medicine, which will often inform us that Some variation in the quantity may be neceiTary. The vifible effefts of mercury are of two kinds, the one on the conftitution, the other on fome parts capable of Secretion. In the firfl it appears to produce univeiSal irritability, making it more SuSceptible of all impreffions ; it quickens the pulfe, alfo increafes its hardnefs, producing a kind of temporary fe- ver ; but in many conftitutions it exceeds this, afting as it were as a poifon. In Some it produces a kind of heftic fever, that is, a fmall quick pulfe, loSs of appetite, reftleffneSs, want of Sleep, and a Sallow complexion, with a number of confequent fymptoms; but by the patient being a little accuftomed to the uSe of it, thefe conftitutional effefts commonly become lefs, of which the following cafes are ftrong inftances. A gentleman rubbed in mercurial ointment for the reducti- on of two buboes. He had only rubbed in a few times when it affefted his conftitution fo much that it was neceffary to leave it off. He was Seized with Severifli complaints of the heftic kind, a fmall quick pulfe, debility, loSs of appetite, no fleep, and night Sweats. He took the bark, with James's powder, and affes milk, and got gradually rid of thefe complaints. As the buboes were advancing, it was neceffary to have recourSe to mercury again ; and I told him that now it would not pro- duce tfte Same effefts So quickly, nor So violently as before. He OF THE LUES VENEREA. 313 He rubbed in a confiderable quantity without his conftitution Or mouth being affefted ; but the buboes Suppurating, I order- ed it to be left off a fecond time ; and when they were opened he had recourfe to the ointment again for the third time, and without producing any difagreeable effefts. The buboes took on a healing diSpofition for a while and then became ftationary, fliowing that a new difpofition was forming. He was direfted to leave off the ointment and to bathe in the fea, which he did, and the buboes began to heal. In about three weeks, how- ever, it was thought neceffary to ufe more friftion, and when he began, which was the fourth time, it had almoft an imme- diateand violent, effect upon his mouth; he left off again till his mouth became a little better, and then returned to the mercury a fifth time, and was able to go on with it. A flout healthy man ufed mercurial friftion for a bubo till it affefted his mouth ; it further brought on very difagreeable conftitutional complaints, Such as loSs of appetite, watchfulnefs, fallow complexion, laffitude from the leaft exercife, and fwell- ed legs; and although various means were ufed to reconcile •the conftitution to it, yet it continued to aft as a poifon. Mercury often produces pains like thofe of the rheumatifm, and alfo nodes which are of a fcrofulous nature, from thence it has been accufed of affefting the bones, " lurking in them," as authors have expreffed it. . It may be fuppofed to be unneceffary to mention in the pre- fent ftate of our knowledge, that it never gets into the bones in the form of a metal, although this has been afferted by men of eminence and authority in the profeffion ; and even the defec- tions of dead bodies have been brought in proof of it; but my experience in anatomy has convinced me that fuch appearances never occur. Thofe authors have been quoted by others; imaginary cafes of difeafe have been increafed ; the credulous and' ignorant practitioner milled, and patients rendered mi- Serable. II OF THE QUANTITY OF MERCURY NECESSARY TO BE GIVEN. The quantity of mercury to be thrown into the conftitution for the cure of any venereal complaint, muft be proportioned to the violence of the difeafe. Two circumftances are, how- S s «vcr» 3r4 OF THE LUES VENEREA. ever, to be ftriftly attended to in the administration of this me- dicine ; which are, the time in which any given quantity is to be thrown in, and the effefts it has on fome parts of the body, as the Salivary glands, fkin, or inteftines. Thefe two circum- ftances, taken together, are to guide us in the cure of n.e dif- eaSe ; Sor mercury may be thrown into the Same conftitution in very different quantities So as to produce the Same ultimate ' effect; but the two very different quantities muft be alSo in dif- ferent times ; for inftance, one ounce of mercurial ointment, wfeeVin two days, will have more effect upon the conftitution than two ounces ufed in ten -r and to produce the fame effeft in the ten days, it may perhaps be seceffary to ufe three ounce* ©r more. ■j-.vEJhe effefts, on the conftitution, of one ounce, ufed in two daysy-Me confiderable, and alSo its effefts upon the diSeaSed partsV^ereSore a much lefs quantity in fuch a way, will have greater effefts; but if thefe effefts are principally local, that i», upon the glands of the mouth, the conftitution at large not being equally Stimulated, the effeft upon the diSeaSed parts muft alSo be leSs, which is to be determined by the local diSeaSe not giving way in proportion to the effefts>o£ the mercury on fome particular parts. If it is given in very fmall quantities, and increafed gradu- ally fo as to Ileal infenfibly on the conftitution, its vifible ef- fefts are lefs, and it is hardly conceivable how much may at laft be thrown fn, without having any vifible effeft at all*. Thefe circumftances being known, it makes mercury a much more efficacious, manageable, and faSe medicine, than formerly it was thought to be; but unluckily its vifible effefts upon Some particular parts, Such as the mouth, and the intef- tines, are Sometimes much more violent than its general effect upon the conftitution at large ; thereSore a certain degree of caution is neceffary, not to Stimulate theSe parts too quickly, as that will prevent the neceffary quantity being given. The conftitution, or parts, are more SuSceptible of mercury 'at firft than afterwards; if the mouth is made fore, and allow- ed to recover, a much greater quantity may be thrown in a fe- cond *. To give an idea of this, ten grains of the ointment ufed every day, during ten dayt, .affefted a gentleman's mouth. The ointment was of equal parts ot mercury and h*g«- hrd. But by means of omitting the ointment occafionally, and returning to the ufe of ir, he at laft rubbed in eighty grains every night for a month* without having his-rrwuth, •i any of the fecretions vifibly affc&ed. OF THE LUES VENEREA. 315 cond time, before the fame forenefs is produced ; and indeed I have feen cafes where it could not be reproduced by as much mercury as poffibly could be thrown in. Upon a renewal of the courfe of mercury therefore, the fame precautions are not neceffary as at firft. We are, however, every now and then deceived by this medicine, it being hardly poffible to produce vifible effects at one time; and afterwards the mouth, and in- teftines, fhall all at once be affefted. Mercury, when it Sails on the mouth, produces in many conftitutions violent inflammation, which Sometimes terminates in mortification. The conftitutions, in which this happen*, I SuSpeft are of the erifypelatous kind, or what are called the putrid; therefore in fuch, greater caution is neceffary. Mercury in general, that is, where it only produces its common effefts, feldom or never does any injury to the conflitution. It fhould feem only to aft for the time, and to leave the con- ftitution in an healthy ftate. But this k not always the cafe, for probably mercury can be made to affeft every conftitution very materially, being capable of producing local difeafes, as has been mentioned; and alfo capable of retarding the cure of chancres, buboes, and certain effects of the lues venerea, after ihe poifon has been deftroyed. III. OF THE SENSIBLE EFFECTS OF MERCURY UPON PARTS. The fenfible effefts of mercury are generally an increafe of Tome of the Secretions, a Swelling in the Salivaiy glands, and increaSe of Saliva ; and increaSe of the fecretion of the bow- els, which produces purging, and an increafe of the fecretion of the Skin, producing Sweat, alSo often an increaSe of the Se- cretion of urine. Sometimes one of thefe fecretions only is affefted, fometimes more, and Sometimes all of them together. But the effefts upon the mouth are the moft frequent. Mercury often produces headaches, and alfo coftiveneGs, when its aftion on other parts become fenfible, efpecially up- on the glands of the mouth. When the mercury falls upon the mouth, it does not affeft all parts of it equally, fometimes attacking the gums, at other times the cheeks, which become thickened, and ulcerate, while the 3to OF THE LUES VENEREA. the gums are not in the leaft affefted, as appears by the pati- ent being capable of biting any thing hard. Mercury, when it falls upon the mouth, and parts belong- ing to the mouth, not only increafes the difcharge of thofe parts, but it brings on great tumefaftion, which is not of the true inflammatory kind, where coagulable lymph is thrown out, but rather refembling erifypelatous tumefaftion. The tongue, cheeks, and gums fwell, and the teeth become looSe; all which effefts are in proportion to the quantity of mercury given, and fufceptibility of the parts for fuch irritation. It produces great weaknefs in the parts, in which ulceration eafily takes place, efpecially if they are in the leaft irritated, which is often done by the teeth, and even mortification fometimes enfues. How Sar it produces Similar effefts when it Sails on other parts, I do not know. The Saliva, in Such caSes, is generally ropy, as if principally from the glands affefted. The breath acquires a particular Smell. As mercury generally produces evacuations, it was natural- ly imagined that it was by this means it effefted a cure of the venereal diSeaSe ; but experience has taught us, that in curing the venereal diSeaSe by this medicine, evacuations of any kind, produced by it, are not at all neceffary ; and this might have been fuppofed, as fimilar evacuations, produced by other me- dicines, are of no fervice; therefore it was reafonable to ima- gine that thefe evacuations, when produced by mercury, were alfo of no fervice; except when we could SuppoSe the evacua- tion, produced by the mercury, was not the Same with that pro- duced by other medicines, but that it was a Specific evacuation; that is to Say, a diScharge carrying off the venereal poiSon by its union with the mercury ; and therefore the fafter the mer- cury went off, the fooner would the poiSon be carried out of the conftitution. But this Is not Sound to be the caSe in prac- tice ; on the contrary, evacuations produced by the medicine retard the cure, eSpecially if the fecretory organs are too fuf- ceptible of this Stimulus ; for then the quantity which is necef- fary, or fufficient for the cure of the difeafe, cannot be taken in, the effefts of the medicine upon particular parts being great- er than the patient can bear; and the quantity of mercury to be thrown into the conftitution muft be limited and regulated according to the quantity of evacuation, and not according U the extent of the difeafe. On the other hand, if it is given with OF THE LUES VENEREA. 317 wilh care, fo as to avoid violent evacuation, any quantity may be thrown in Sufficient for the cure of the difeafe. Certain evacuations may be fuppofed to be a mark of the conftitutional effefts of mercury; but they are not to be entire- ly depended upon, the fecretions being only a proof of the fuf- ceptibility of fome parts to fuch a ftimulus; however, it is pro- bable that in general they are a good gauge of its conftitution- al effefts. Some have gone fo far as to fuppofe that quantity of mercury alone, without any fenfible effefts, is Sufficient for the cure of the diSeaSe; and this is in Some degree the caSe, but not completely So, for we have no good proof of its affefting the conftitution but by its producing an increafe of fome of the fecretions. IV. OF THE ACTION OF MERCURY. Mercury can have but two modes of aftion, one on the poifon, the other on the conftitution ; we can hardly fuppofe it to aft both ways. If mercury afted upon the poifon only, it might be fuppofed to be in two ways, either by deftroying its qualities by decompofing it, or by attracting it and carrying it out of the conftitution. If the firft were the aftion of mer- cury, then we might reafonably SuppoSe that quantity alone would be the thing to be depended upon ; if the fecond, that the quantity of evacuation would be the principal circumftance. But if it aft upon the principle of deftroying the difeaSed aftion of the living parts^ counterafting the venereal irritation by producing another of a different kind, then neither quanti- ty alone, nor evacuation, will avail much; but it will be quan- tity joined with fenfible effefts that will produce the quickefl cure, which from experience we find to be the cafe. But al- though the effefts, that mercury has upon the venereal difeafe, are in fome degree in proportion to its local effefts on Some of. . the glands, or particular part of the body, as the mouth, fkin, kidneys, and inteftines, yet it is not exaftly in this proporti- on, as has been mentioned. When mercury difagrees as it were conftitutionally, producing great irritability and heftic fymptoms, this aftion or irritation is not a counter irritation to the venereal diSeaSe, but is a conftitutional irritation, hav- ing no effeft on the diSeaSe, which continues to increaSe. Mercury, loofing it* effefts upon the diSeafe by uSe, gives a proof $iS OE THE LUES VENEREA. proof that it neither afts chemically, nor by carrying off the poiSon by evacuation, but by its ftimulating power. The effefts will always be in proportion to the quantity in a given time, joined with the fufceptibility of the conftitution to the mercurial irritation. Thefe circumftances require the mi- nuteft attention; and in order to procure its greateft aftion with fafety, and to procure this in the moft effectual way, it muft be given till it produces local effefts fomewhere, but not too quickly, that we may be able to throw in a proper quantity; for local effefts produced too quickly prevent the fufficient quantity being thrown in for counteracting the venereal irrita- tion at large. I have feen cafes where the mercury very rea- dily acted locally, and yet the conftitution was hardly affefted by it, for the difeaSe did not give way. A gentleman had a chancre which he deftroyed with cau- ftic, and dreffed the fore with mercurial ointment. He had al- fo a fmall uneafineSs in one of his groins, which went no fur- ther, but which Showed an abSorption oS the poiSon. The chancre Soon healed, and he rubbed in about two ounces of mercurial ointment. He began this courSe with fmall quan- tities, that is, a Scruple at each rubbing, and increaSed it; however it Soon affefted his mouth, and he Spit Sor about a month. Two months after he had a venereal ulcer in one of his tonfils. Here was a confiderable fenfible effeft from a fmall quantity of mercury, which proved ineffectual, becaufe its Spe- cific effefts, as I apprehend, were not in proportion to its Sen- fible effefts; the Salivary glands baing too fufceptible of the mercurial irritation. On the otherliand, I have feen cafes, where quantity dir| not anfwer till it was given fo quickly as to affeft the conflitu- tion in Such a manner as to produce local irritation, and con- sequently Senfible evacuations, which is a proof that the local effefts are often the fign of its fpecific effefts on the conflitution at large, and Shows the fuSceptibility of the diSeaSed parts, to be affefted by the medicine, is in proportion to the effefts of it upon the mouth. Its effects are not to be imputed to evacua- tion, but to its irritation, therefore mercury Should be given, if poffible, So as to produce Senfible effefts upon Some parts of the body, and in the largeft quantity of mercury that can be giv- en to produce thefe effefts within certain bounds ; and that thefe Senfible effefts Should be the means of determining how far . OF THE LUES VENEREA. far the medicine may be pufhed, in order to have its beft effefts upon the difeafe without endangering the conflitution. The praftice here muft vary according to circumftances; and if the difeafe is in a violent degree, lefs regard muft be had to the conftitution, and the mercury is to be thrown in in larger quan- tities ; but if the difeafe be mild, it is not neceffary to go be- yond that rule, although it is better to keep up to it on pur- poSe to cure the difeafe the fooner. If the difeafe is in the firft order of parts, a lefs quantity of mercury is neceSSary than if it were in the fecond order of parts, and had been of long ftanding, with its firft appearances only cured, and the venereal difpofition ftill remaining in the Secondary parts- To cure the difeafe, whether in chancre, bu- bo, or lues venerea, probably the fame quantity of mercury is neceffary ; for one fore requires as much mercury as fifty fores in the fame perfon, and a Small fore as much as a large one; the only difference, if there is any,, muft depend upon the na- ture of the parts affefted, whether naturally active or indolent. If there be any material difference between the recent and con- ftitutional, which, I apprehend, there is, it may make a differ- ence in the quantity. I do conceive that the recent are up- on the whole more difficult to cure; at leafl they commonly re- quire longer time, although not always. Having thus far premifed thefe general rules and observati- ons, I Shall now give the different methods of achniniftering mercury. V. OF THE DIFFERENT METHODS OF GIVING MERCURY EXTERNALLY—INTERNALLY. Previously to the giving of mercury, it is very proper to underftand, as much as poffible, the conftitution of the pa- tient with regard to this medicine, which can only be known in thofe who have already gone through a mercurial courSe j but as many of our patients are obliged to undergo this treat- ment more than once, it becomes no vague inquiry ; for as there are many who can bear this medicine much better than others, it is very proper that this fhould be known, as it will be a diieftion for our prefent praftice. I think that few con- ftitutions alter in this difpofition ; although I knew one cafe which admitted of a confiderable quantity at one time without being $20 OF THE LU&S VENEREA. being vlfibly affefted ; but about a twelve month after, the pa« tient was affefted with a very little! When mercury is given to cure" the lues venerea, whatever length we mean to go in the fenfible effefts of it, we fhould get to that length if poffible, and we fhould keep up to it. For we fhall find it difficult to bring its effefts to that flandard again if we allow it to get below it. If the mercurv fhould get be- yond what we intended, we fliould be very n.uch upon our guard in lowering it; and fhould probably begin to give it again before its effefts are reduced to the intended flandard : for the fame quantity now will not operate So powerfully as before ; infomuch that what at firft produced greater effefts than was intended, will not be Sufficient afterwards. Mercury is beft applied externally in form of an ointment. Unftuous Subftances keep it divided, attach it to furfaces, and do not dry ; it may alfo be SuppoSed that they become a vehicle for the mercury, and carry it through the abSorbents to the ge- neral circulation ; Sor it is probable that oil is as eaSy of ab- forption as watry Subftances. If the fymptoms are mild in the firft order of parts, and the patient not accuftomed to mercury, or it is known that he can- not bear the medicine In great quantity, and it is intended to conduct the cure by almoft infenfible means, it is proper to begin with fmall quantities. One Scruple, or half a dram, of an ointment made of equal parts of quickfilver and hogs-lard, rubbed in every night Sor Sour or Six nights will be Sufficient to begin with. If the mouth is not affefted, the quantity may be gradually increafed till two or three drams are rubbed in at each time ; but if the firfl quantity has affefted the mouth, wc may be almoft certain that the glands of the mouth are very fufceptible of the mercurial ftimulus ; therefore it will be pro- per to wait two or three days till that effeft begins to go off. When we begin the fecond time, the quantity may be gra* dually increafed, at leaft a fcruple every time, till two drams or more are rubbed in each night, which may be done with- out affefting the patient very confiderably a Second time, as hai been already obServed. If all the fymptoms gradually difappear, there is no more to be done but continue this praftice for a fortnight longer by way of Security. This OF THE LUES VENEREA. - 32 i This method, fteadily purSued, will cure moft recent caSes of lues venerea ; but it is not Sufficient if the difeafe has been merely kept under by flight courfes of mercury ; a greater quantity becomes neceffary, Srom a kind of habit the conftitu- tion has acquired, by which it is rendered lefs SuSceptible of the mercurial ftimulus. If the difeafe fhould return in the fecond order of parts, we may be certain the fame quantity of mercury will not be fuffi- cient to cure them, their aftion being flow under the venereal irritation, therefore require more than what had been firft given. I may be allowed to remark, that where the venereal fymp- toms have been ulcers in the moUth or throat, I have fufpeft- ed that the mercury being brought to the mouth, and the faliva being impregnated with it, and afting as a mercurial gargle, cured thofe parts locally ; and that the conftitution has remain- ed ftill tainted ; the mercurial aftion in it having been much inferior to what it was in the mouth. Perhaps Something Simi- lar may take place in eruptions of the fkin where the mercury paffes off by Sweat; Sor we know that Sulphur will cure the itch by paffing off in perSpiration. If thefe are fafts, then it may in fome degree account for the local fymptoms in the firft order of parts being eafier of cure than thofe in the Second. The manner of living under a mercurial courSe need not be altered from the common, becaufe mercury has no aftion upon the difeaSe which is more favoured by one way of life than an- other. Let me afk any one what effeft eating a hearty dinner, and drinking a bottle of wine can have over the aftion of mer- cury upon a venereal fore, either to make it affeft any part fenfibly, as Sailing upon the glands of the mouth, or prevent its effeft upon the venereal irritation ? In Short, I do not fee why mercury Should not cure the venereal diSeaSe under any mode whatever oS regimen or diet. I own, however, that I can conceive cold affefting the ope- rations of mercury upon the venereal difeafe ; it is poffible that cold may be favourable to the venereal irritation, and' there- fore contrary to that produced by mercury ; and there is forno fhow of reafon for fuppofing this ; for I have before afferted that cold was an encourager of the venereal irritation ; and therefore keeping the patient warm may diminilh the powers of the difeafe while under the cure. T t M-rcury, OF THE LUES VENEREA. Mercury, given internally, is in many cafes fufficient, af, though in general it is not fo much to be depended on as the external application ; thereSore I would not recommend it, or give it in caSes where the diSeaSe has not been Sufficiently cured by Sormer courSes of mercury. It is the moft convenient way of giving this medicine ; for many will Swallow a pill who do not chooSe to rub the body with the ointment; indeed there are many circumftances in life which make this mode of in- troducing it into the conftitution the moft convenient; but, on the other hand, there are many conftitutions that cannot bear mercury given internally. When thefe two circumftances meet in the fame patient it is unfortunate. Mercury taken internally, often produces very difagreeable effefts upon the ftomach and inteftines, caufing fickneSs in the one, and griping and purging in the other. If it be found neceffary to give it internally, and it diSagree either with the ftomach or inteftines, or both, even in the mofl fimple preparation, its effefts, whatever they are, muft be cor- rected or prevented, by joining with the mercury other medi- cines. If it affeft the ftomach only, the mercury may be join- ed with fmall quantities of the effential oils, as the effential oil of cloves, or camomile flowers, which will in many cafes take off that effeft. If it difagree both with the ftomach and bow- els, which I believe arifes either from the mercury meeting with an acid in the ftomach, by which part of it is diffolved, Sorming a Salt, or Srom being given in the form of a fait, hotb of which will generally purge and become the caufe of their own expulfion. There are two ways of obviating thefe effefts; the firfl is, by preventing the fait from forming ; the fecond, by mitigating its effefts on the inteftines if forming, by taking off their irritability. To prevent the fait from forming, the beft way is to join the mercury with alkaline fubftances, either Salts, or earths; and when given in a Saline ftate, it may be joined with opium, or Some of'the effential oils. To prevent the formation of the Salt, take of the preparati- ons of mercury, fuch as mercurius calcinatus, mercurius fufxuj, or calomel, forming them into pills, with the addition of a fmall quantity of foft foap, or any of the alkaline falts; the alkaline fait alfo prevents the pill from drying: or inftead of thefe a calcareous earth may be joined with the mercury, fuch as chalk or crabs eyes : upon this p:i:::.iplc is the mercurius alkaiizatus, 1 which OF THE LUES VENEREA. "3*3 Which is crude mercury rubbed down with crabs-eyes. But thefe Subftances add confiderably to the bulk of the medicine, no lefs than twenty grains being neceffary for a dofe ; which contains Seven grains and a half of crude mercury. The mer- curius calcinatus, rubbed with a fmall proportion of opium, makes an efficacious pill, and in general agrees well both with the ftomach and bowels. Opium has long been joined with mercury to cure the venereal difeafe. By fome as much has been attributed to the opium as the mercury ; however, opium fliould be given with care, for it is not every conftitution with which it agrees, often producing irritability, in fome laffitude and debility, in others SpaSms. If the mercury is not given in the above manner, but, in the form of a fall, or the falts are allowed to form, then it Should be joined with one third of opium, and a drop of the oil of cloves, or camomile, which will make it agree with the ftomach, and prevent its purging; or, if it is found ftill to difagree both with the ftomach and bowels, compound it ftill further, by joining with the mercury the alkaline falts, the opium, and fome effential oil. A grain of mercurius calcinatus made into a pill, with the addition of fuch medicines as the ftomach or bowels may re- quire, may be given every night for a week ; and if in that time it has not affefted the mouth, it may be repeated evening and morning; and after the patient has been accuftomed to the medicine, and it is found not to fall much upon the mouth, it may be increafed to two grains in the evening, and one in the morning. The fame directions hold equally good either with the mer- curius fufcus, or calomel; but it requires more of thefe laft preparations of mercury to have the fame medicinal effeft upon the difeafe, than of the before-mentioned; perhaps the propor- tion of their effefts are about two, or three, to one. Why this fhould be the cafe is probably not eafily accounted for, the quantity of mercury being very nearly the fame in a given weight in both, for in eight grains of calomel there are feven grains of crude mercury. Three grains of thefe preparations appear only equal to one of the mercurius calcinatus. The crude mercury given in the fame quantities with either of the former appears the leaft efficacious of all; for fifteen grains of 334 OF THE LUES VENEREA. crude mercury rubbed down with any mucilage, Seems only equal to one or two of the mercurius calcinatus. The corrofive Sublimate, which is a Salt capable of Stimulat- ing violently, isgeneially given in Solution in common water, brandy, or fome of the Simple waters, and has been uSed with fhe appearance of confiderable SucceSs. It would appear that it removes ulcers in the mouth, as Soon, if not fooner than any of the other preparations ; but this I fufpeft arifes from its application to thefe parts in its paffage to the ftomach, afting upon them locally as a gargle; however, from experience, it appears not to have Sufficient powers over the venereal irrita- tion ; in recent caSes only removing the vifible local effefts, without entirely deftroying the venereal aftion; for many more have been found to relapfe aSter having taken this preparation, than Srom many oS the others; which is owing to its paffing ve- ry readily off by the fkin. Befides, it diSagrees much more with the ftomach and inteftines, than any of the other preparations. A grain of this medicine diffolved in about an ounce oS Some fluid, is generally the dofe, and increaSed according as it agrees with the bowels, and according to its effefts upon the mouth, and difeafe. As corrofive Sublimate contains an acid, and as you muft be guided by the effefts of the acid on the bowels, the quantity of mercury you can give in this form is neceffarily Smaller than in the other preparations. Ward's drop, containing leSs acid, can be given in larger quantity, and is more efficacious on that account. Perhaps any of thefe preparations united with a Scru- ple of gum guaiacum may have more effeft than when given alone ; fince guaiacum is Sound to have confiderable effefts on the venereal diSeaSe. This praftice, continued Sor two months, will in general cure a common lues venerea ; but here it is not meant that any time fhould be Specified. After all the fymptoms of the dif- eafe have difappearcd, this courfe Should be continued at le«ft n Sortnight longer; but if the Symptoms diSappear very Sudden- ly, as they often do, perhaps within eight or ten days, proba- bly from the medicine going off by thoSe Surfaces where the diSeaSe appears, the medicine fliould be continued three weeks, or perhaps a month longer, and the doSe increaSed. In Such cafes the vifible local effefts appeared to be cured, while a ve- nereal diSpofition remains in the parts. Various OF THE LUES VENEREA. 325 Various are the preparations of mercury recommended for internal ufe, while practitioners have generally been Satisfied. with but one for external application. Every practitioner finds fome one of the preparations anfwering better to appearance in Some one caSe than another, which call the balance in favour of that medicine in his mind; or others finding the bad eff fts of a particular preparation at fome one time, have geneially condemned that preparation ; not to mention that deceit is oft- en praftifed in the cure of this difeafe. One would naturally SuppoSe that the fimpleft preparation is the beft, that which is eafieft diffolved in the animal juices, does leaft mifchief to the ftomach, or general health, and is leaft difturbed or hinder- ed in its operations ; for we can hardly fuppofe that any fub- ftance joined with mercury, which alters eithei its chemical or mechanical properties out of the body, can add to its power in the body, except a fubftance which had a fimilar power when afting alone. The preference generally, given to the ointment fhows this ; and if we could find a preparation ftill more fim- ple than the ointment, that preparation fhould be ufed in pre- ference to the crude mercury. VI OF THE CURE OF THE DISEASE IN THE SECOND OR THIRD STAGE. In the more advanced flages of the difeaSe the mercurial courfe muft be pufhed further. The greateft quantity of that medi- cine that the patient can bear at a time, is to be thrown in and continued with fteadinefs till there is great reafon to SuppoSe the difeaSe is deftroyed. It will not be poffible, in Such caSes, to prevent the mouth from being confiderably affefted, the quan- tity of mercury neceffary to be thrown in for the cure of thefe flages of the difeafe being fuch as will in moft cafes produce that effeft. Before the difeafe has advanced fo far, the patient moft pro- bably has taken mercury, and it is proper to inquire how he has been affefted by it, and what quantity of it he can bear, which will in fome degree direft us in the quantity now to be begun with. If the patient has not taken mercury for a confi- derable time, and is eafily affefted by it, which is the cafe that admits of the leaft quantity, it will be neceffary to begin cau- tioufly, regulating the quantity according to circumftances; 7 but 3a6 OF THE LUES VENEREA. but if "the perfon has taken mercury lately, although eafily af- fefted by it, more freedom may be ufed on returning to it, be- caufe it will have lefs power on his mouth, as alSo on the dif- eafe ; again, if the perfon has been taking mercury very late- ly, and is with difficulty affefted by it, which is the cafe that ad- mits of the greateft quantity, then it may be adminiftered free- ly fo as to affeft the conftitution in the proper time. If the mercury is brought to the mouth in fix or eight days, and a confiderable SoreneSs is produced in twelve, it will in general be a good beginning. In Such caSes the conftitution is if poffible to be Surprized by the medicine So as to produce its greateft eS- Scfts, but with Such caution as to be able to keep up theSe ef- fects by quantity. Mercurial friftion will anfwer better than mercury given in- ternally ; Sor in this way we are Surer of throwing in a larger quantity in a given time, than could be taken internally with. out hurting the ftomach. The quantity of mercury applied in this way fhould be un- der certain circumftances, in an inverfe proportion to the fur- face on which it is applied, and tire Surface Should be complete- ly covered with the ointment ; for half an ounce of mercurial ointment rubbed in upon a given Surface, will have nearly the fame effeft as one ounce rubbed in on the Came furface ; there- fore one ounce to have double the effeft fhould have double the furSace. The quantity of ointment muft therefore be adapted to the quantity of Surface, for on a certain extent of furface no more than a determined qaantity of ointment can be applied So as to be abSorbed ; and applying a greater quantity would be> uSeleSs ; and if the quantity of Surface is greater, the fame pro- portion of ointment cannot be diffuSed So as to employ fully all the abSorbents, Every Surface which is ufed may therefore have its full quantity of ointment, but certainly Should not have more, if we are to attribute the effefts of the mercury to the quantity. It has mofl probably been always the praftice to rub the mercary well in, as it is termed ; but I SuSpeft that this aroSe rathqr from an idea of the furface being porous like a fponge, than of abforption being performed by the aftion of veffels; and if is probable that this aftion in the veffels producing abforp- tion may be rather difturbcd than excited by friction. How OF THE LUES VENEREA. 327 How long the courfe is to be followed is not to be exactly aScertained, it may be thought proper to continue it till the lo- cal appearances, as nodes, have Subfided ; but I SuSpeft that this is hardly neceffary, except they give way readily ; for in fuch cafes the local complaints, or tumefaftion, &c. generally re- quire a longer time to be removed than the venereal aftion ; and local applications muft be of fervice, efpecially if fuch tu- mefactions are obftinate. The manner of living under fuch a fevere courfe, which is in every refpeft weakening, is to be particularly attended to ; the patient muft be fupported, and the local effefts of the me- dicine in the mouth preventing his taking many kinds of nou- rifhment, efpecially fuch as are of a folid form ; fluids mufl form his only nourishment, and thefe Should be Such as will become Solid after they are Swallowed ; milk is of this kind. An egg beat up with a little Sugar, and a little wine; Sago, fa- lep, &c. form a proper diet. In many cafes wine and bark muft be given through the whole courSe. Sugar is perhaps one of the beft reftoratives of any kind we are acquainted with, when a conftitution has been very much debilitated by long fatting, from whatever caufe, whether from the want of food when in health, or in the time of difeaSe, or where the Sood has not been allowed to. anfwer the constitutional wafte, as in a courSe oS mercury, and when the diSeaSe or courSe of mercury is gone, then fugar will reflore fuch conftitution probably bet- ter than any thing elfe. Although it is not a common opinion, and therefore not a common praftice to give Sugar entirely with this view, yet there are Sufficient proofs of its nutritive quality over almoft every other Subftance. It is a well-known laft, that all the negroes in the Sugar-iflands become extremely lufly and fat in the fugar-cane SeaSon ; and they hardly live upon any thing elSe. The horSes and cattle that are allowed to Seed upon them all become Sat. The hair of the tjprfes becomes fine. Birds who Seed upon fruit never eat it till it becomes very ripe, when it has formed the greateft quantity of fugar, and even then only on fuch as furnifh the largeft quantity of fugar. Infects do the fame ; but we cannot have a ftronger inftance of this faft than in the bee. Honey is compofed of fugar, with fome other juices of plants, with a little effential oil; but fugar is the principal ingredient. When we confider that a Swarm of bees 328 OF THE LUES VENEREA. will live a whple winter on a few pounds of honey, keep up a conftant heat about ninety-five or ninety-fix degrees, and the aftions of the animal ceconomy equal to that heat, we mull al- low that fugar contains perhaps more real nourishment than any other known Subftance. We See too that whey is extremely Sattening, which is the watry part of the milk, containing neither the oil nor the co. agulable matter; this ariSes principally Srom the Sugar it con- tains ; for being compofed of the watry part it holds all the fugar of the milk in Solution. If the milk is allowed to be- come Sour it is not So fattening, becauSe it is the Sugar which is become Sour. Although the nutritive qualities of Sugar have not been So generally known as to introduce it into univerSal praftice, yet they have not entirely eScaped the notice of practitioners. Mr. Vaux, from obferving the negroes in the Weft Indies growing fat in the Sugar-SeaSon, has been induced to give it in very large quantities to many oS his patients, and with very good effefts. Honey is perhaps as good a mode of taking this fub- ftance as any; Sweetening every thing that is either eat or drank, whether by Sugar in honey, or Sugar alone, is proba- bly immaterial; yet it is probable that the other ingredients in honey may add to its nutritive quality. VII. OF LOCAL TREATMENT. If the local effefts have gone no Surther than inflammation and Swelling, either of the foft or hard parts, moft probably no local treatment will be neceffary, Sor the treatment of the con- ftitution will, in general, remove them, entirely. It Sometimes, however, happens that the local complaints will not give way, but the parts remain Swelled in an indolent and inactive ftate, even alter there is every reaSon for SuppoS- ing the conftitution is perfectly cured. In Such,caSes the con- ftitutional treatment is to be affifted by local applications of mercury to the part, either In the form of a plafter or oint- ment. The latter is by much the beft mode. If theSe are not Sufficient, as often happens, we muft endeavour to deftroy this diSpofition by producing an inflammation of another kind. I have feen a venereal node which gave excruciating pain, cur- ed by an incifion only being made down to the bene the whole length OF THE LUES VENEREA. 3?rj length of the node ; the pain has ceafed, the fwelling has de- creafed, and the fore healed up kindly, without taking a grain of mercury. Blifters have been applied to nodes with fuccefs; they have removed the pains and diminifhed the fwellings; fo far furnifhing a proof> that local treatment may affilt mercury in many caSes. This treatment has not only been uSed to affift mercury in thoSe caSes where the medicine did not appear to be equal to the diSeaSe, but it has been uSed at the commencement of the cure, and even before mercury had been applied ; but it was ftill thought neceffary to go through the fame mercurial courfe as if nothing had been done to the local complaints. It may be afked, What advantage arifes from the incifion or application of the blifter ? The advantage is immediate relief from violent pains; and as there are two powers afting, it is natural to fuppofe the cure will be more Speedy. After all the above-mentioned trials, it may happen that the local effefts fhall flill remain, forming as it were a new dif- eafe, which mercury may increaSe, and thereSore other me- thods of cure may be tried, as will be deScribed hereafter. VIII. OF ABSCESSES—EXFOLIATION. When an abSceSs forms in a node in the periofteum, the bones are generally affefted and make part of the abfeefs. Great attention fhould be paid to them, for fuppurations in them are not like Suppurations in common abSceffes, they are Seldom produced from the true fuppurative inflammation, and therefore are flow in their progrefs, rarely producing true matter, but a mucus Something reSembling flime, which lies flat upon the bone. This circumflance makes it difficult to deter- mine when Suppuration has taken place ; and in many caSes to detect matter, even where it is formed. Another circumftance, which renders the prefence of matter in fuch cafes doubtful, is, that the progrefs of the difeaSe is generally checked very early by the uSe of mercury. This matter is often reabforbed dur- ing a mercurial courfe ; and it Is proper, particularly in an early ftate of the complaint, to give it this chance ; but if the abforption does not take place, and the complaint is in an ad- vanced ftate, it muft be opened. U u The ^30 OF THE LUES VENEREA; The furgical treatment of the parts under fuch circumftances is the fame as in other difeafes of thefe parts; opening with great freedom is abfolutely neceffary ; for the more parts are expoSed, the more inclinable they are in general to heal, and ftill more So here ; Sor violence aflifts in deftroying the vene- real diSpofition. No fkin covering a bone fhould be removed- from an abfeefs, efpecially in the lower extremities. If the abfeefs is opened freely, and an exfoliation takes place, which is generally the cafe, it is to be treated as any other exfoliation. Exfoliations Succeed much better here than in many other cafes, becaufe the difeafe from which they pro- ceed can generally be corrected, which is not the cafe in ma- ny difeafes of bones where exfoliation takes place. Cafes, however, fometimes occur in which, after the venereal difpo- fition has been correftcd, another difeafe takes place in the | bone, the nature of which will be explained when we (hall confider the effefts remaining after the difeaSe is cured, and the difeafe fometimes produced by the cure. TC OF NODES ON TENDONS, LIGAMENTS, AND FASCI/E. The observations, made on the nodes of the periofleum ] and bones, are applicable to Swellings and Suppurations of the ligaments and faciae ; but it is ftill more difficult to afcertain the preSence of matter in them than in the Sormer. When a thickening only of the ligaments or fafciae is the confequence of the difeaSe, it is very obftinate, as in many cafes the diSeaSed part may be cleared of all venereal taint and ftill the fwellings remain. Blifters may oSten be applied here with fuccefs; but if they fail, then it will be abfolutely neceffary to make an incifion into the part, to excite a more vigorous aftion; Sor although the complaint has nothing venereal in it, nor is any contamination to be Seared from it in future, yet as it leaves often very obftinate and difagreeable Swellings, which neither give way to medicine nor time, it is proper to uSe eve- ry means for their removal. X. OF OF THE LUES VENEREA. 33* X. OF CORRECTING SOME OF THE EFFECTS OF MERCURY. Formerly, when the management of mercury was not fo well underftood, nor its effefts in this difeafe fo well known as they are at prefent, it was generally fuppofed to aft by eva- cuation from the Salivary glands, and was thereSore always given till that evacuation took place ; and, as its effefts in the cure were imagined to be in proportion to the quantity of this evacuation, it was pufhed as far as poffible, without endanger- ing fuffocation. From this treatment it often happened in thofe conftitutions which were very fufceptible of the mercu- rial irritation, and in which the medicine produced much more violent effefts on fome particular fecretions than could be wifh- ed, that recourfe was obliged to be had to medicines correct- ing the effefts of mercury ; as thefe effefts were often an hin- drance to its being given in fufficient quantities Sor the cure of the difeafe. I mentioned, when treating of the effefts of mercury, that the fenfible increafe of the fecretions, produced by it, were in the following order: firft of faliva, then fweat, then urine, and often of the mucus of the inteftines, producing purging ; I alfo obferved, that when any of thofe fecretions became too violent, the hand of the furgeon was tied up till they were mo- derated. Attempts have been made to leffen thofe effefts in two ways, either by the deftruftion of its power on the body in general, or by its removal, but neither of thefe means have fucceeded. It never has once been thought neceffary to at- tempt to leffen its powers on the organs of fecretion, So as ftill to retain the Same quantity in the conftitution, or even to throw in more, which, if it could be effefted, would be fome- times of great fervice ; but as we are not yet acquainted with powers fufficient for thefe purpofes, we are obliged to obferve great caution in our mode of giving the medicine. I have endeavoured to ffiow that this medicine need not be given with a view to procure thofe evacuations ; and that it may be given in any quantity without increafing either of thofe Secretions in any evident degree ; however, after every pre- caution, we may ftill be deceived, and the medicine will eve- ry now'and then produce greater effefts than were intended, it 33a OF THE LUES VENEREA. It is very neceffary thereSore to Seek Sor a preventive of the effefts of mercury, when likely to be too violent; or to reme- dy thofe effefts when they have already taken place. The common praftice when mercury produced violent ef- fefts upon the inteftines, was to counteract thefe effefts ; but this was not done with a view to retain the mercury in the con- ftitution, but to relieve the bowels that were fuffering by the aftion of the medicine : whereas the proper praftice would be to ftop its progrefs here, as in every other outlet, that more mercury may be retained in the conftitution. Although thefe increafed fecretions arife from the conftitu- tion's being loaded with mercury, yet there is no danger in Stopping them, Sor they do not ariSe from an univerfal difpofi- tion becoming a local, or critical one; and therefore if fuch an aftion be checked or ftopped in one place, it muft neceffa* rily fall upon fome other ; but it is from the part being more fufceptible of this irritation than any other, and the quantity now in the conftitution being equal to the fuSceptibility of the part; and therefore, though its effefts are ftopped here, it does not break out any where elfe, every other part being capable of Supporting this quantity, and of remaining unaffected till more is thrown in. When the mercury attacked the falivary glands, it increafed that fecretion fo much as in fome cafes to oblige practitioners to adminifter fuch medicines as were thought likely to remove this new complaint. This fuSceptibility of the glands of the mouth, and the mouth in general, to be eafily put into aftion by this medicine, was generally SuppoSed to ariSe Srom a Scorbutic con- ftitution, to which moft complaints of the mouth are attribut- ed. I am of opinion that fcrofulous people, and thofe of a lax and delicate habit, are more fubjeft to have it fall on the mouth than thofe of a contrary temperament. Purges were given upon a fuppofition that mercury could be carried off by the evacuation produced by them, and they were repeated according to the violence of the effefts of the medi- cine, and the ftrength of the patient: but I can hardly Say that I have ever feen the effefts of mercury upon the mouth leffen- ed by purging ; whether it arofe fpontaneoufly, was produced by purging medicines, or even when arifing from the mercury itfelf. As this method was not found fufficient for the remov- al of the complaint, other medicines were tried ; fulphur was fuppofed OF THE LUES VENEREA. 33s fuppofed to be a fpecific for the removal of the effeft of mer- cury. Whether this idea arofe from praftice or reafoning, is not material* ; but I think I have Seen good effefts Srom it in fome cafes. If we can fuppofe purging of any fervice, purg- ing with fulphur would anfwer beft, as it would exert its ef- fefts both as a purge and a Specific. Sulphur certainly enters the circulation as Sulphur, becauSe our Sweat and urine Smell of it; if it does not combine with the mercury and deftroy its properties as mercury, it is poffible, agreeably to the opinion of thofe who firft thought of giving it with this intention, that it may fo combine as to form aethiops mineral, or fomething fimilar; for we know that the aethiops mineral, however formed, does not in general falivate. It is poffible too, that fulphur may aft as a contrary ftimulus to mercury, by counterafting the effefts of it in the conftitution. Sulphur has even been fuppofed to hinder the mercury from entering the circulation. Upon the whole, as thefe prepara- tions of fulphur and mercury are ftill fuppofed to have good effefts, and as I think I have Seen good effefts in other cafes, we muft either allow that they enter the circulation, or that their whole effefts are on the ftomach and inteftines, with which the reft of the body fympathifes, The good effefts from ful- phur in leffening or altering the immediate effefts of mercury, can only take place when that medicine is really in the confti- tution ; therefore a diftinftion is to be made between fuch as arife immediately from mercury, and one continued from habit, after the mercury has been evacuated from the conftitution ; a caSe that Sometimes happens, and which will be taken notice of in its proper place. The tafle in the mouth, from the ufe of mercury, has been known to go off, and not be perceived for a fortnight, and the fame tafle has recurred ; this I am informed has happened twice to one gentleman from the firft quantity of mercury taken. To account for this is not eafy ; in whatever way it happens, it is a curious faft. When the mercury has fallen upon the mouth and throat, wafhing thoSe parts with opium has often good effefts; for opium takes off irritability, and of courSe the SoreneSs, which is one means * Sulphur, united with any of the metals, probably deftroys their WuWity in .he • • V7,lea* their effeas in the circulation; none of the cinnabars »« e.ther as Khur o mercury Crude antimony, which is regulus and fulphur, h* no eft*. Ar& wheTjoia/d with fulphur, hasnoeffca; aorhuwu g34 OF THE LUES VENEREA. means of leffening the Secretion. A dram of tinftura thebaic* to an ounce of water, makes a good wafh, or gargie*. When the mercury falls upon the fkin, it is neither So dif- agreeable nor fo dangerous as when it falls upon the moir.h ; however, it may often happen that it will be proper to check fuch a difcharge, both upon account of its being troublefome and of its leffening the effefts of the medicine in the conltitu- tion by carrying it off. The bark is, perhaps, one of the beft correftors of this increafed fecretion. When the medicine attacks the kidneys and increafes the fecretion of thefe glands, it is not fo troublefome as when it pro- duces fweating, though it is poffible that it may carry off the mercury too foon ; but as we have but few medicines that can leffen that fecretion, in moft cafes it muft be allowed to go on. The bark may in Such caSes be given with advantage. When the mercury falls upon the bowels it proves often more dangerous and troublefome than in any of the former cafes, efpecially the two laft ; but it is, perhaps, moft in our power to prevent or palliate. Opium fhould be given in fuch quan- tities as to overcome the complaint, and I believe will feldom fail of removing all the fymptoms. XI. OF THE FORM OF THE DIFFERENT PREPA- RATIONS OF MERCURY WHEN IN THE CIRCULATION. It would appear from reafon, and many circumftances, that mercury muft be in the ftate of folution in the juices of the body before it can aft upon the venereal difeafe, and indeed before it can aft upon any other difeaSe. That mercury is in a ftate of Solution in our juices and not in the ftate of any preparation of mercury, that we know of, is very probable from the follow- ing fafts. Firft, crude mercury, every Salt of mercury, and calx of mer- cury, Is Soluble in the Spittle, when taken into the mouth, by which means it is rendered fenfible to the tafle ; from thence it muft appear that it is capable of folution in fome of our juices. Secondly, * My ufing opium in this way was from analogy; finding that opium quieted the bowels when a purging came on in confequence of mercury : I tried it by way of gargle to the mouth, and found good efFedts from it, but not equal to thofe which it produced in the bowels. OF THE LUES VENEREA. 33$ Secondly, crude mercury, when divided into fmall parts by gum arabic, &c. fo as to be eafier of folution when taken into the ftomach, generally purges ; but crude mercury taken with- ort fuch divifion has no Such powers, not being So readily dif- folved in the juices of the ftomach. The fimple calx of mer- cury has the Same effefts, purging, and much more violently, from being, I fuppofe, readier of folution in the animal juices ; for if it only purged from its union with the acid which happen- ed to be in the ftomach, it moft probably would not purge more than crude mercury ; although it is very probable that the calx is eafier of folution in a weak acid, than even the crude mer- cury. Thirdly, every preparation of mercury producing the fame effeft in the mouth, and alfo having one and the fame effeft in the conftitution, fhows that they muft all undergo a change, by which they are reduced to one particular form. We can- not fay what that form is, whether it is the calx, the metal, or any other that we are acquainted with ; but it is probable that it is not any of them, but a new folution in the animal juices peculiar to the animal itfelf. This is rendered ftill more probable by this circumftance, that every preparation of mer- cury put into the mouth, undergoes the fame change, and the fpittle has the fame tafle from every one of them. If every different preparation of mercury had the fame properties in the conftitution that it poffeffes out of it, which we muft fuppofe if it enters and continues in the fame Sorm, in that cafe the venereal poifon muft be eradicated in as many different ways as there are preparations. Crude mercury would aft mecha- nically, by increafing the weight and momentum of the blood; the calx would aft like brick-duft, or any other powder that is heavy ; the red precipitate would ftimulate by chemical pro- perties in one way, while the corrofive Sublimate would aft in another, and the mercurius flavus in a third ; this laft would mofl probably vomit as ipecacuanha does, which vomits whe- ther thrown into the ftomach or circulation. Fourthly, all the preparations of mercury, when locally ap- plied, ;.ct always in one way, that is, as mercury ; but fome have alfo another mode of aftion, which is chemical, and which is according to the fpecific nature of the preparation. Tiie red precipitate is a preparation of this kind, and afts in both thefe ways; it is either a ftimulant or an efcharotic. To 336 OF THE LUES VENEREA. To aScertain whether this opinion of mercury being in So-; iution in our juices was juft, I made the following experiments upon myfelt. I put fome crude mercury into my mouth, as a flandard, and let it flay there, working it about, fo as to render it eafier of folution, till I tafted it fenfibly ; I then put into my mouth the mercurius calcinatus, and let it remain till I perceived the tafte oS it, which was exaftly the Same ; but I ObServed that it was eafier of folution than the crude mercury. I tried calomel in the fame way, and alfo corrofive Sublimate, after being diluted with water, and the tafte was ftill the Same. It was Some time before I perceived the tafte of the crude mer- cury in my mouth. I tafted the calx and calomel much loon- ier. The corrofive Sublimate had at firft a mixed tafte, but when the acid was diluted it had exaftly the Same tafte with the former ; all thefe different preparations producing the fame fenfation or tafte in the mouth. From the effefts of thefe experiments it would appear, that the mercury in every one of them was diffolved in the fpittle, and reduced to the fame preparation or folution. To try whether mercury in the conftitution would produce the fame tafte in the mouth, I rubbed in mercurial ointment- upon my thighs till my mouth was affefted, and I could plain- ly tafte the mercury ; and, as far as I could rely upon my memory, the tafte was exaftly the fame as in the former ex- periments. I allowed fome time for my mouth to get perfeftly well and free from the tafte; I then took calomel in pills till it was af- fefted again in the Same way. I afterwards took mercurius calcinatus, and alfo corrofive Sublimate. All theSe experiments were attended with the Same reSult; the mercury in every form producing the fame tafte, which was alfo exaftly the Same as when the Several preparations were put into the mouth. From the above experiments it muft appear, that when mercury produces evacuation by the mouth, it certainly goes off in that diScharge; and from thence we may reafonably con- clude, that when other evacuations are produced from the me- dicine when in the conftitution, as purging, Sweating, or an increaSed flow of urine, that it alfo goes off by thefe evacua- tions, which become outlets to the mercury. From the above experiments it appears to be immaterial what preparation of mercury is ufed in the cure of this diSeaSe, provided Of the lues venerea. 337 provided it is of eafy folution in our juices, the preparations eafieft of folution being always the beft. XII. OF THE OPERATION OF MERCURY ON THE POISON. MercuRy Hnay be SuppoSed to aft in three different ways in curing the venereal diSeaSe. Firft, it may unite with the poiSon chemically, and decompoSe it, by which means its powers of irritation may be deftroyed ; Secondly, it may carry it but of the conftitution by evacuation ; or thirdly, it may produce an irritation in the conftitution which counteracts the venereal and entirely deftroys it. It has been SuppoSed that mercury afts fimply by its weight in the circulating fluids ; but of this we can form no adequate idea ; and if it were fo, other Subftances fhould aft on this diSeaSe in proportion to their weight, and of courfe many of them fhould cure it ; but from experience we find, that Such bodies as have confiderable weight, as moft of the metals, have no effeft on this diSeaSe. We have no proof of mercury aft- ing by a decomposition of the poifon from any of the conco- mitant circumftances. Mercury certainly does not cure the venereal difeafe by uniting with the poifon and producing an evacuation. For n* thofe cafes where mercury is given in fuch a way as to produce confiderable evacuations, or in thofe conftitutions where eva- cuations are eafily excited by mercury, its effefts upon the dif- eafed aftion are the leaft; and the fame evacuations produced by any other means have not the leaft effeft on the difeafe. Whether the mercury be fuppofed to carry off the circulat- ing poifon, or to decompoSe it, in neither way could it pro- duce, when locally applied, any effeft on a venereal inflam- mation or Sore arifing from the conftitution ; for as long as. any of the poifon exifted In the circulation, none of them eould be healed by local applications, the circulation conftant- ly carrying the poiSon to them ; but we find the contrary of this to be true ; for a venereal Sore, arifing Srom the constitu- tion, may be cured locally. The laft or third of our modes of aftion of mercury, SeemS to me the moft probable, and for many reafons. Firft, becaufe the difeafe can in many cafes be cured by railing a violent fti- X x- mulus 33.5 QF THE LUES VENEREA. mulus of another kind ; and perhaps if we could raife Such a conftitutional irritation without danger, as we often can in lo- cal caSes, we might cure the venereal difeafe in the Same man- ner, and in one quarter of the ufual time. Secondly, we find that mercury afts as an univerfal ftimulus, caufing great irrita- bility in the conftitution, making the heart beat fatter, and ren- dering the arteries more rigid, fo as to produce a hard pulSe, as has been already ohServed. It may further be faid to pro- duce a difeafe, or a peculiar or unnatural mode of aftion in a certain degree. The following cafe will illuftrate this. A gentleman had electricity recommended to him Sor Some com- plaint he had. The electricity was applied, but without any vifible effeft. Befides the complaint for which he ufed elec- tricity, lie had a venereal one, for which he was firft put under a courfe of mercury, and while under it, the electricity was applied for the former complaint; but he had become fo irrita- ble, that he could not bear the fhocks of one half their forme? ftrength ; but the moft curious pa«rt of the cafe was, that the Shocks had a much greater effeft on the diSeaSe than what they had before when twice as ftrong, and he now got cured. This gave the furgeon a hint, and having another occafion to ufe eleftncity, alfo without effeft, he put the patient under a gen- tle courSe of mercury, and then found the fame effefts from the electricity as in the former cafe, and the patient alfo got well. The powers of mercury upon the constitution appear to be as the quantity of mercury and the fuSceptibility of the confti- tution to be affefted with it, without any relation to the difeafe itfelf; and we find that the power of mercury upon the difeafe is nearly in the fame proportion. This faft gives us an idea of the irritation of mercury upon the conftitution, and conse- quently an idea of adminiflering it, and of the cure of any difeafe for which it is a remedy. As we find that a given quantity of mercury produces dou- ble effefts in Some conftitutions to what it does in others ; al- fo, that in thole caSes it produces its effefts upon the diSeaSe, we are led to believe that it is this effeft upon the conftitution which cures, the diSeaSe; and thereSore if it did not produce this effeft it would alfo not have pei formed a cure. I have already obferved, that the cure does not go on exaftly in pro- portion to the vifible effefts upon the conflitution, except quantity in the medicine is joined with it; which, if true, would OF THE LUES VENEREA. 339 *?ould incline us to believe that there was Something more than Simply a conftitutional ftimulus, which mofl probably is a peculiar Specific effeft, which is not regulated entirely by its vifible effefts, either conftitutional or local, although they ap- pear to have Some conneftion. This faft being known, obliges us to be more liberal in giv*- ing mercury in thoSe conftitutions where it makes but little im- preffion, than in thoSe which it eafily irritates; although in theSe lafl we muft not be entirely regulated by its local effefts, nor depend upon a commonly Sufficient quantity, but be ruled by the Senfibility of the conftitution, and quantity joined ; for in thofe where the conftitution appears to be very fufceptible of the mercurial irritation, where fmall quantities produce con- siderable local effefts, it is flill neceffary to have quantity, al- though it is not fo neceffary to take the quantity in general that is fuppofed to be fufficient. We muft be guided by the three following circumftances, the disappearance of the difeafe, the quantity of irritation produced, and the quantity of the medi- cine taken. XIII. OF GUM GUAIACUM, AND RADIX SARSA- PAR1LL.E IN THE VENEREAL DISEASE. I have hitherto only recommended mercury in the cure of the venereal difeaSe ; and indeed it is the only medicine to be depended upon. However, as both the guaiacum and SarSapa- rilla have been recommended as powerful remedies in this com- plaint, I took a favourable opportunity of trying their compa- rative powers in the venereal difeaSe upon the Same perSon. The guaiacum* I Sound had confiderable Specific power over ihe diSeaSe, consequently it may be of Service in flight caSes where it may be inconvenient or improper to give mercury on account of fome other difeaSe. Thefe cafes, however, I have wot yet afcertained ; or it may be given in thofe cafes where it is apprehended that the quantity of mercury neceffary to fub- due the difeafe would be too much for the conflitution to bear ; cafes which fometimes occur. The farfaparilla appeared to have no effeft at all. I fhall * The li-num guaici was imported by the Spaniards from Hifpaniola, as a cure for the aereal ilifeV*, in the year 1517. having been given to one of them by a native. 34c OF THE LUES VENEREA. I fhall relate exaftly the caSe in which their comparative powers were tried. A man came into St. George's HoSpital with venereal Sores over almoft his whole body :• there were many excreScent Sores in the arm-pits, Some of which were about the Size of an half-penny ; there were the fame appearances about the anus, between the buttocks, along the perinaeum, be- tween the fcrotum and thigh, where thofe parts come in con- taft with one another. ThoSe upon the fkin in general had the common appearance. I ordered a poultice of the gum guaia- cum to be applied to the fores in the right arm-pit; alfo a poultice of a ftrong decoction of farfaparilla and oatmeal mix- ed, to be applied to the left arm-pit. Thefe poultices were changed every day for a fortnight; the excreScent Sores in the right arm-pit were entirely healed, and become even with the fkin, and covered with a natural Skin, although Somewhat dif- coloured ; the Sores in the left arm-pit, which were poulticed with SarSaparilla, were rather worSe than when the poultice was firfl applied, as indeed were all the Sores, except thoSe in the right arm-pit. I then ordered the poultice of guaiacum to be applied to the left arm-pit, which was done, and the fores there alfo got well in a fortnight. I was now perfeftly convinced that the gum guaiacum had cured thefe eruptions locally. I next wifhed to fee what effeft the gum guaiacum would liave upon the remaining fores when given internally, that is, thofe about the anus, fcrotum, and on the fkin in general. The patient began with half a dram three times every day, which purged him ; but this was prevented by joining it with opium. In about four weeks all the eruptions were cured, and he was allowed to flay in the hoSpital Some time longer, to See if he would continue well; but about a Sortnight after he began to break out anew, and in a very Short time was almoft as bad as ever. I began a Second time the gum guaiacum internally, but it had loft all its powers, or rather the conftitution was no longer affefted by it, He was put under a courSe of mercury, apd cured. CHAPTER C?F-THE LUES VENEREA. 34* CHAPTER IV. OF THE EFFECTS REMAINING AFTER THE DISEASE IS CURED, AND OF THE DISEASES SOMETIMES PRODUC- ED BY THE CURE. IN treating of the local effefts of the venereal difeafe, the go- norrhoea and chancre, as alfo the bubo, 1 obServed that after the virus was deftroyed, there remained in many cafes Some of the Same Symptoms, and particularly after the gonor- rhoea. It was alfo obferved, that, though all the fymptoms were entirely cured, yet they were liable to break out again. .A gleet will appear, fometimes attended with pain, fo as to refemble a gonorrhcea ; after chancres there will be fores re- Sembllng them ; and buboes after the virus is gone, will not heal, but fpread. In the lues venerea, the fame thing often happens, efpecially if the inflammation and fuppuration have been violent in the parts. Thefe cafes puzzle confiderably ; Sor it is difficult to Say when the venereal virus is abfolutely gone. In Such doubtful cafes the treatment to be followed be- comes more undetermined. Such complaints are more common in the tonfils than in any other part ; Sor we oSten find that while a mercurial courSe is going on, and the ulcer on the tonfils healing, or even heal- ed, they fhall Swell, become excoriated, and the excoriations fhall Sometimes Spread over the whole palatum molle, which renders the nature of the difeafe doubtful. I believe thef#ex- coriations, as well as Such other appearances of diSeaSe as come on during the uSe of mercury, are feldom or never venereal. In all fuch cafes I would recommend not to continue the mer- cury longer than what appears fufficient for overcoming the original venereal complaints, not confidering thoSe changes in the caSe as venereal. The bark is often of fervice here, and may be given either with the mercury, or after the mercu- rial courfe is over. It often happens that venereal abfceffes will not heal up, al- though they have gone a certain length towards it; for while the venereal aftion remained in the part, the mercury difpofed that 84* #F THE LUES VENEREAi that part to heal; but under that courfe the conflitution and part had acquired another diSpofition, proceeding from a vene- real and mercurial irritation affefting a particular habit of bo- dy, or part, at tire time, which new difpofition differs from the venereal, mercurial, and natural, being a fourth difpofiti- on arifing out oS all the three. I Sufpeft however that it de- pends chiefly on the conflitution ; becaufe If it was owing to the other two, we fhould always have the fame diSeaSe ; and what makes this opinion more probable is, that it differs in different people, at leaft it is not cured in all by the Same means. The conftitution being prediSpoSed, the other two be- come the immediate cauSes of aftion. As foon as the venereal irritation is deftroyed by the mercury, or becomes weaker than the other tvvo, then the effefts of the others take place. While the venereal aftion prevails, the mercury is of fervice, and the fore continues healing ; but when it is leffened to a certain de- gree, or deftroyed, the mercury not only loSes its powers, but becomes a poiSon to the new diSpofition that is Sormed ; for if mercury is continued, the Sore Spreads, it fliould there- fore be immediately left off. Some of the fores, formed in this way, not only refift all means of cure, but often inflame, ulcerate, and form hard cal- lous baSes, So as to put on the appearance of a cancer, and are often fuppofed really to be fo. We find alfo that new diSeaSes ariSe from the mercury alone. The tonfils Shall Swell where no venereal diSeaSe has been be- fore, the periofteum fhall thicken, and alSo probably the bones, and the parrs over them fhall become cedematous and Sore to the touch ; but as theSe complaints ariSe while under a mercu- rial eourSe, they are not to be reckoned venereal, but a new diSeaSe, although they are too often SuppoSed to be venereal, and on that account the mercury is pufhed as far as poffible. In fuch Cafes if the complaints for which the mercury was giv- en are nearly cured, and the medicine has been continued a fuf- ficient time after to complete the cure of thofe complaints, then of courfe it fliould be left off; and if there be any doubt, it Should be left off rather fooner than if no fuch complaint had taken place, becaufe it is probably producing a worfe difeafe than the venereal ; and if after the cure of thefe complaints from the mercury, the venereal diSeaSe begins again to come into action, mercury muft be given a Second time, and now the .OF THE LUES VENEREA. $& fhe conftitution will be better able to bear it, efpecially if at- tention has been paid to the reftoring the ftrength of it. Thofe difeafes of the tonfils and periofteum, I SuSpeft have Something fcrofulous in them. Befides, local complaints, arifing Srom the combined aftion of the mercury, the diSeaSe, and the conftitution, there is Some- times a conftitutional effeft, which is a weakneSs, or debility, a langour, want of appetite, frequent Sweats threatening hec- tic ; but thefe happen moftly in thofe conftitutions with which mercury disagrees. TheSe complaints, local as well as confti- tutional, arife in Some meaSure from weakneSs. They are dif- ficult of cure, whether arifing from a venereal chancre, bubo, pr the lues venerea. Strengthening medicines are of the moft fervice : the hark is of great ufe, though in general not fuffi- cient, as it can only more or lefs remove the weaknefs, the Specific qualities; ftill remaining. What thefe are, is, 1 believe, not yet known ; but I fufpeft that many partake of the fcnv fula ; and this opinion is flrengthened by their frequently giv- ing way to fea-bathing*. J. GENERAL OBSERVATIONS ON THE MEDI- CINES USUALLY GIVEN FOR THE CURE. A decoction of the woods, among which are common* ly'included guaiacum and farfaparilla, is one of the firft medi- cines in the cure, and many of the cafes yield to it, which give* them the credit of curing the venereal difeafe, while fuch dif- eafes were fuppofed to be venereal. The farfaparilla was often given alone, and was found to produce nearly the fame effeft. The good effects of it in one cafe gave it fome reputation*. A diet-drink difcovered at Lifbon was alfo of confiderable Ser- vice ; and as it cured caSes Similar to thoSe cured by the far- faparilla, it was imagined that the diet-drink confifled princi- pally of a decoction of this root. This was ftill on the fuppo- fition that all thofe cafes were venereal ; but it was obferved at laft that thoSe medicines did not cure this diSeaSe till mercu- ry * In a cafe of an ulcerated rib from a venereal caufe, and five nodes on the fhin-bone, of twelve months ftanding, a deep faliva.tion of fix months ,ras uBdergone, atter fru.tlef* °* f" k " "1 friaion None of the fores were healed by the mercury, and the pa- ss'EKSitS" Jz <* -■*•')- ,rk'In *■" ■" *"r"""" Fordyce. 344 OF THE LUES VENEREA. ry had been given, and in tolerably large quantity. This was fufficient to lead fome thinking minds to doubt whether they iwere venereal, or not; and their being cured by different me- dicines ought to produce a conviftion of their being different •from the venereal difeafe, and that they are themfelves of dif- ferent kinds. The mezereon has alfo been found to be of fervice in fome fymptoms of the lues venerea, fuch as nodes of the bones; but their being venereal was taken for granted. The mezereon is feldom given in venereal ulcers in the throat, or blotches on the fkin, which of all the venereal fymptoms are the moft cer- tain, and the moft eafy of cure ; yet it was conceived that it removed fuch fymptoms as are the moft difficult of cure ; but all thofe cafes in which the mezereon has been given with fuc- cefs, plainly appear not to have been venereal. When the hemlock came into fafhion in this country, it was given in almoft every difeafe, and of courfe was tried in fome of thofe complaints confequent to the venereal difeafe; and fome of thefe it was found to cure, fo that it now ftands upon the lift of remedies. Velno's vegetable firup has had fimilar effefts in fome of thefe cafes ; and opium appears alSo to have many advocates. Opium, like the SarSaparilla, and mezereon, was SuppoSed by its firfl introducers to cure the lu- es venerea*, but, like the SarSaparilla, it appears to have no effeft till mercury has done its beft, or its worftt. It has cer- tainly confiderable effefts in many diSeaSes, both in Such as are conSequent to the venereal diSeaSe, and others arifing Srom other caufes. It has been long a favourite medicine of mine, not only as relieving pain, for that is its common effeft, but as a medicine capable of altering difeafed aftions, and producing healthy ones. In all fores attended with irritability, a decoction of poppy- heads, made into a poultice, is an excellent application. Bleed- ing fores that do not ariSe from weaknefs, but from irritability, have the bleeding ftopped immediately by this application. Mr. Pott is, I believe, the firft who fliowed the world its uSe irr mortifications. My firft mode of applying it for the cure of difeafes was locally, in which I found it had moft falutary ef- fefts in fome cafes, and it was ordered afterwards internally upon * S-? Medical Communications, vol. i, page 3;7, + See a pamphlet pu'oiiihed by Mr. Grant. OF THE LUES VENEREA. 345 Upon the fame principle, and it was alfo found to have falutary effefts in this mode. In two cafes that had been long fuSpefted to be venereal, its effefts were very remarkable ; and, by its having cured them, it confirmed me in my opinion that they were not. But when I was informed that they cured the vene- real difeafe in the army in America by opium, I then began to queftion myfelf, whether I had formed a right judgment of the nature of thofe two cafes which were cured by opium. To af- certain whether opium would cure the lues venerea or not, I made the following trial at St. George's Hofpital. A woman was taken into the hofpital with blotches on her Skin, which had arrived to the ftate of fcabs, with well-mark- ed venereal ulcers on both tonfils. A grain of opium was or- dered to be taken the firft night, two the fecond, and fo on, increafing a grain every night, unleSs Something fliould arife to forbid it. This was clofely followed till the nineteenth night, when fhe was ordered a dofe of phyfic as Ihe had become coftive, and the opium was omitted. On the 20th fhe began again, and continued increafing the dofe, as before, till it amounted to thirty grains, no alteration being produced in the fores, except what aroSe from the lofs of time, whereby they were rather worfe. I concluded, that if flie had taken mercury to affeft the conftitution as much as the opium did, the venereal difeafe muft have been nearly cured, or at leaft much leffened ; but as that was not the cafe, it convinced me that the opium had no effeft whatever on the venereal difeafe. I then put her under a courfe of mercury, by friftion, and in a Short time it affefted her mouth; the Sores Soon began to look better, and they went on healing without interruption, till the diSeaSe was cured. I may juft obferve, the inconvenience from the opium was not confiderable ; for although it kept her quieT, fhe was not conftantly dofing. Luke Ward was admitted into St. Bartholomew's Hofpital, January 12, 1785 ; his complaint was an ulcer in the throat of three months ftanding, which, both from its appearance, and the fymptoms which preceded it, feemed to be venereal. He was ordered two grains of opium twice a day, which he took a few days, without any other effeft than that of Sleeping better at night than ufua), when the dofe was increafed to two grains three times a day. His throat now gave him lefs pain ; bui upon infpeftion was not found to he at all mended. Alter two 34b OF THE LUES VENEREA. days the dofe was increafed to three grains thrice a day ; from this quantity he hit little or no inconvenience : he complained of being a little drowfy ; his eyes were rather inflamed, and his face rather flufhed. He continued to take this quantity for five days, and then it was increafed to three grains four times a day. Next morning the rednefs and heat of his face was much increafed, and had extended over his whole fkin ; he complained of pain in his head. His pulfe was full and ftrong; he was bound in his body, and his belly was tenfe and painful. The opium was omitted, and fuch remedies as the prefent fymp- toms feemed to require were given, but without effeft ; all his Symptoms continuing to increafe till he died, which was on the fourth day after ; during this time the ulcer increafed much, and the difcharge of faliva was fo great as to referable a flight Salivation. This cafe proves, in the fiift place, that the opium had no effeft upon the ulcer in the throat; and, in the next that it is a medicine capable of producing very violent effefts on the fkin, requiring therefore great caution in the mode of adminifter- ing it. John Morgan was admitted into St. Bartholomew's Hofpital with an ulcerated leg. The common applications were tried for {'even weeks, at the end of which time he was in every re- fpeft worfe, having no Sleep from conftant pain, and he was Sinking very faft. Two grains of opium were given every two hours, for twenty-thVee days ; it made him hot and coflive, and his pulfe became ftrong and full, but without fleep or abate- ment of pain. The dofe was increafed to four grains every two hours in the day, and eight grains every two hours during the night. The effefts \vere cofliveneSs, retention of urine, lofs of appetite, an inflammatory difpofition, no fleep, with- out any amendment of the ulcer. On the third day of taking the laft mentioned quantities, he awoke from a fliort fleep, de- lirious, and continued So for twelve hours, when it left him very weak, Sick at his ftomach, and with a low pulfe. In three or four hours the delirium returned and continued forty- ciaclcara U/a!Unct Sculp!; EXPLANATION OF THE P L A T E S. PLATE I. FIGURE I. THE penis, Slit open, Showing a Stricture in the urethra, about two inches from the glans. The ftrifture is but flight. AA. The cut Surface of the corpus SpongioSum urethrae. BB. The canal of the urethra, in which may be obferved the orifices oS the lacunae. C. The ftrifture. FIGURE II. The penis Slit open Sor about three inches, to fhow the la- cunae, which become occasionally an obftruftion to the^fliftge of the bougie. ** " AA. The corpus SpongioSum urethra. BB. The internal furface of the canal of the urethra, pointing to the orifice of two of the lacunae. C. A briftle introduced into a lucuna. D. The end of the bougie introduced into the remaining part of the urethra. PLATE II. FIGURE I. THE urethra opened in two different places, one before the ftrifture, the other behind: the one before, is through the body of the penis ; the other behind, is upon the anterior furface of the membraneous part, and a bougie paffes from the one opening to the other. AA. The crura penis and bulbous part of the urethra all blended together by inflammation and fuppuration, which has taken place in many parts. BB. The proftate gland in a difeafed ftate. CC. The cut edges of the bladder. D. The urethra behind the ftrifture very much enlarged ; ir- regular on the furface in confequence of ulceration. EE. The cut furface of the corpus cavernofum penis. FF. The cut SurSace oS the corpus SpongioSum urethrae. GG. The bougie paffing from the found to the unfound part of the urethra. H. A fmall bougie in the new paffage, Two cannulas, for applying cauftic to ftriftures in the urethra. FIGURE II. A ftraight Silver cannula, with the plug projefting beyond the termination oS the cannula, making a rounded end ; at the other end of the wire is a Small portcrayon in which is repre- sented a piece of cauftic. FIGURE III. A flexible cannula, for applying the cauftic to ftriftures in the bend of the urethra. The wire, with the Small portcrayon is pufhed out beyond its end. FIGURE IV. A piece of Silver wire, with the plug at the end, to be in- troduced into the cannula, as in Figure II. PLATE III. THE bladder and penis of a perfon who died of a mortifica- tion of the bladder in confequence of a ftrifture and ftone in the urethra. In this plate not only the ftrifture is re- prefented, but the thickened coats and fafciculated inner fur- face of the bladder; as alfo the fmall ftone which afted as a valve, or plug; befides which, a cannula is introduced Srom the glans down to the ftrifture, Showing the practicability of deftroying it with cauftic. AA. The bladder, cut open, Showing its coats a little thick- ened, and its inner SurSace SaSciculated. B. The body of the penis. CC. The corpus SpongioSum urethra, cut open through its whole length expofing the urethra. D. The proftate gland divided. E. A Silver cannula introduced into the urethra, through which the cauftic is paffed on to the ftrifture. F. Points out the ftrifture, with the ftone laying above, fo as entirely to prevent the paffage of urine. Flak ir. I &mJutr. c. Calculous matter frequently attaches itfelf to the ends of bougies, when left in the blad- der, 124. Frequently fills up the cavity of the catheter, when kept a long time in the bladder, 176. Camphor; its ufe in chordee, 82. Caruncles in the urethra, 1C3. Their cure, 154. Cafe of a child under inoculation attacked with the meafies, 3. Of a gentleman, prov- ing that a gonorrhoea may produce a lues venerea, 15. Of a young woman from the . Magdalen Hofpital, fhowing that a gonorrhcea may continue two years, 36. Of a gentleman, where a gonorrhcea continued a length of time without loving its virulence, ibid. Of a gentleman, proving the fame, 37. Of a man, where the cuticle of the glans came off, 39. Of a young gentleman, where the gonorrhoea was confined to the glans, 40. Of a gentleman, Chawing how the venereal matter is communicated to the urethra, 47. Of a woman having a fluor albus, and communicating a difeafe fimilar to gonorrhcea, 37. Of a, gentleman cured of a gonorrhoea almoft immediately by tak- ing ten grains of calomel, 67. Of a gentleman under a, courfe of mercury contracting a gonorrhoea, 69. Of a gentleman, fhowing the ufe of blifters applied to the perinae- um in removing difagreeable fenfations which remain after the cure of a gonorrhcea, 89. Qf a gentte roan's fervant, Showing the fame, 90. Of a chimney-fweeper cured of a ftrifture by the application of lunar cauftic, 118. Of a gentleman relieved in a ftrifture by a gonorrhcea, 123. Of a gentleman, (hewing the fame, ibid. Ofafol- dier, where a new paffage was made along the fide of the urethra by a bougie, 129. Its treatment and cure, 129, 130. Of a gentleman where a mortification took place in the cellular membrane of-the penis from urine diffufed into it, 13 5. Of a man in St. George's Hofpital, fhowing that keeping extraneous bodies in the urethra prevents wounds made into that canal from healing, 148. Of a roan in St. George's Hofpital, eured of a paralyfis of the urethra, 153. Of John Doby, a poor peafkmor in the Charter-Houfe, who died from a fupprefTion of urine occafioned by a fwelled proftate gland, 156. Of a gentleman, fhowing the inconveniences arifing from a fwelling of the proftate gland, 1^8. Of a gentleman, fhowing the ufe of blifters applied to the perinaeum in fpafmodic affeftions of the urethra accompanied with a paralyfis of the bladder, 168. Of a total fuppreffion of urine relieved by a punfture in the bladder through the reftum, 171. Two inftance* of thefarae, 17*, 173. Of a fa i lor, where the urine paffed from the bladder into the rectum, 174. Of a gentleman, who was impotent with relped to one woman only, 185. Of a young man cured of a feminal weaknefs by opium, 188. Of a gentleman, where the femen paged into the bladder i.t the time of emiffion, 189. Of a gentleman, where one of the tefticles wafted en- tirely, 191. Of a jentfein^n, (homing the fame, '^id. Another inftance of the fame, tyz. Of a gentleman, where feven weeks elapfed between the application of f.c-venereal poifon and fhe appearance of a chancre, 198. Of a gentleman, where the penis was Lent to one fide at the time of erection, 2C4. Of a gentleman, fhowing that mercury! 1 fictions fometimes oc«afion ulcers on the tonfils which have the ar- peararicr «f v*r.o nl u'-.-ert, 220. Ar.ot'icr . afe, fhowing the fame, 221. Ofaeen- t.einau, with a fF..-0;i:;^ ^v«. of t'.e u^-,., < , u.cd by fea-batbing, 325. Of a ?en- tlcnus INDEX. : tleman cured of ulcerations refembling chancres, by the lixivium faponarium, 226. Of a gentleman, who had a fwelling in the groin fufpefted to be venereal, 244. Of an officer at Lifbon, where a bubo was refolved, though it contained matter, by fea- ficknefs, 249. Of a gentleman, where a bubo degenerated into a fore of the fcrofu- lous kind, 257. Of a gentleman, who had a gonorrhcea and two buboes, where a new difpofition formed befides the venerea!, 258. Of a boy who fwallowed fome ve- nereal matter without any ill confequences, 265. Of a lady who met with the fame accident, 266. Of a child who was fuppofed to infect its nurfe with the lues venerea, a7o. Of a gentleman, proving that venereal complaints are often fuppofed toexiit when they really do not, 273. Of a man having the lues venerea, fhowing that th;: fuperficial parts, or thofe firft in order, may come into aftion and be cured ; while thofe parts which are fecond in order have only the difpofition ; but that they after- wards may come into aftion and be cured as thofe firft in order were, 284. Of a gen- tleman, fhowing the fame, 286. Of a hdy who was falivated by a fmall quantity of red precipitate applied to fores, 309/ Of a gentleman, fhowing the effefts of mercury on the conftitution, 312. Another inftance of the fame, 313. Of a gentleman, mow- ing that the effefts of mercury on the conftitution are not fufficient for the cure of the lues venerea, it requiring its fpecific effefts on the poifon, as well as its fenfible effefts on the conftitution, 318. Of a gentleman, (howing that the efficacy of electricity ini the cure of difeafes may be increafed by mercury, 338. Of a man in St. George's Hofpital having the lues venerea, where a comparative trial was made of the effefts of guaiacum and farfaparilla, 340. Of a woman in St. George's Hofpital having the lues venerea, where the cure was attempted by opium, but without fuccefs, 345., Of Luke Ward, in St. Bartholomew's Hofpital, fhowing the inefficacy of opium in the lues ve- nerea, and that it may fometimes act as a poifon, ibid. Of J. Morgan, in the fame hofpital, fhowing the ufe of opium in the cure of an ulcerated leg, 346. Of a woman,^ ' Where hemlock was of ufe in venereal fores which had put on a cancerous appearance, ' 347. Of a~gentleman infefted with the yaws, 353. Of a gentleman having a, difeafe refembling the lues venerea, 355. Of a gentleman having a fimilar complaint, 356. Of a lady infefted with a difeafe fimilar to the lues venerea, by the tranfplanting of a tooth, 362. Another inftance in a young lady, 363. Another in a gentleman, ibid. Cafes of a lady, two children and a wet nurfe, infefted with a difeafe refembling the lues venerea, 357. Of three children and three wet nurfes having fimilar complaints, 358. Of difeafes refembling the venereal difeafe, from tranfplanted teeth, 362, 363, 364, Catheter in the urethra; mode of fixing it, 146. Obfervations on the ufe of the, ibid. How introduced into the bladder when the proftate gland is enlarged, 157. Of allow- ' ing it to remain in the urethra and bladder, 175. Cauftic; its ufe and application in ftrifture, 1-16, 117, 118, 143. Defcription of an inftrument for conveying it to ftriftures in the urethra, 119. Ks in the lues venerea will not affeft a perfon locally who has the lues venerea; but that matter from a gonorrhoea or chancre will, 268. Made to afcertain the progrefs and effefts of the venereal poifon, 298. Conclusions drawn from thofe experiments, 300. ^fade to prove that mercury and its preparations are dif&lved in the animal juices, 336, Fermentation ; the venereal poifon does not arife from, 17. Fever, fymptomatic; of, 1. Heftic; of, ibid. No two different fevers can exift at • the fame time* 2. Suppurative fometimes takes place in a gonorrhoea, 63. lis ef- fects on gonorrhoea, 78. Brings the lues venerea into aftion, 284. Fiftula in perinaeo; its caufe, 144. The occafion of agHift* complaints, ibid. Its cure, ibid. Defcription of the operation for, 145. Fluor albus foraetimcs commufticates a ckifeafe fimilar to- the gonorrhcea, 5 7. Fcetus in utero, may be JrifSfted with the h+es venerea by the matter which infefted the mother, 266. But not from the effects of tha* matter upon the mothe*, 279* G. Glands, abforbent; fwellings of, from fympathy, 54. Affefted fingly by the venereal poifon, 23 8. Thofe which are fecond in Order are not affefted by the venereal porfon ; the reafon of this, 239. SwelHngs of, how diftinguifhed from buboes, 242. Gland, proftate; fwelling of, 154, 155. Its effects on the canal of the urethra, 155, 1 >6. Sometimes prevents a ftone in the bladder being reft, 1 c 5. Mode of detecting; it, 156. Its treatment, 160. The ufe of hemlock in, ibid. The ufe of burnt fponge in, ibid. Of the difcharge of the fecretion of, x8o. Mucus of;, the diftinclrron be- tween it and femen, 181, Glands INDEX. Glands of the groin affefted by fympathy in a gonorrhcea, 48, 54, 55. Of fhe urethra ^ their fuppuration, how treated, 42, 82. Of the groin affected fympathetically by the ufe of bougies, 124, 125, 131. Gleet; its caufe, 91. Its cure, 93. Balfams; their ufe in, ibid. Injeftions to be ufed in, 95. The ufe of blifters in, 97. The ufe of electricity in, ibid. Its treat- ment in women, ibid. Attends upon ftrifture, 103, 131. In confequence of a ftric- ture, its cure, 121. Cured by a chancre; an inftance of, 200. Gonorrhcea may produce a lues venerea, 15. Does not arife from ulcers in the urethra, 27. Appears fometimes the day after receiving the infeftion, 29. May be cured without mercury, 29, 67. Virulent and fimple; difficult to diftinguifti them, 30. Frequently cures itfelf, 33, G4, 71. Cannot be increafed by the application of frefh matter, 34. The firft the fevereft; the fucceeding ones generally milder ; fafts feem- ing to prove this, 35. Frequently continues a long time without lofing itg virulence, 36,86. Its feat in both fexes, 38. Often confined to the glans, 39. Its fymptoms, 41. Affefts Cowper's glands, 43. Of the difcharge in, 44. A variety of fymptoms produced by fympathy in, 48. Uncommon fymptoms in, 50. Its effects on the con- ftitution in both fexes, 62. Itseure,63. No fpecific medicine for, 63, 64. Dif- ferent modes of praftice in, 67. As foon cured without mercury as with, 68. May be contrafted by a perfon under a courfe of mercury, 69. How affected by fever, 7%. Treatment of occafional fymptoms of, 81. And gleet; the diftinftion between them not yet afcertained, 86. Symptoms of, remaining after the difeafe is fubdued, 87, Suppofed confequences of, 100. Does npt in general occafion rhifture, 105. Some- times relieves a ftrifture, 123. May be produced by a chancre fympathetically, 200. Gonorrhoea in women, 58. Not eafily diftinguilhed from fluor albus, ibid. The parts affefted, 59. Uncommon fymptoms in, 60. Wears itfelf out in women as well as men, 61. Proofs of its exiftence in women, ibid. Its continuance, ibid. May ex- ift without the patient knowing it, 62. Its cure, 76. Guaiacum; its ufe in the lues venerea, 343,347, Gum guaiacum, its effects in the lyes venerea, 339,347. H. Haemorrhage, from chancre; the ufe of oil of turpentine in, 213. Hemlock ; its ufe in fwellings of the pftftate gland, 160. In what is called a feminal weaknefs, 182'. In fpreading ulcers of the prepuce, 225. An inftance of.its being taken in very large quantities, z6o. Its ufe in buboes, ibid. In lues venerea, 344, 347- Hernia humoralis; fymptoms of, 52. Hydrophobia; obfervations on that difeafe, 20,265, I. Talap ; its effefts on the ftomach when thrown into the veins, 210. Impotence; its caufes, 182. Depending on the mind, the caufe of, 183. From a wan.t of proper correfpondence between the actions of the different organs, 185. Infection, venereal; the mode of, 21. . Inflammation, of, 6. Divifion of, into adhefive, fuppurative, and ulcerative, ibid. Pro- duces matter without ulceration, 27. How it attacks the urethra in gonorrhoea, 47. A cafe fhowing this, ibid. Venereal; obferves a fpecific diftance, or extent, 48. Ir- ritable ; what it is, 65. In the parts furrounding the urethra ; its treatment, 139, 141 'in the perinaeum and fcrotum, its effefts on the conftitution, 143. Injections; different kinds of, ufed in gonorrhoea, 70. To be uled very often, .71. Their effefts, 72. In what cafes they are improper, ibid. To be ufed in gleet, 95. Inftrument; defcription of one for conveying cauftic to ftriftures in the urethra, 119. Inoculation ; queries relative to that operation, 3. Cafe of a child under inoculation attacked with the meafies, ibid. Ipecacuanha; its effefts on the ftomach when thrown into the veins, 210. Irritation, fpecific; produced by the venereal poifon, 19. Venereal, can be kept up but a certain time in gonorrhcea, 33> M- Venereal parts become fo habituated to, as hardly to be affefted by it, 3 6. Venereal, takes place more-ceadily in thofe parts ex- pofed to cold, 282, L, I N D E X. L. lead; its ufe in ™:iorrhcea, 7;. In gleet, 95. In the bladder how removed, 107. , Living ; mode of, under a courfe of mercury, 321, 327. Lixivium faponarium ; its ufe in ulcerations refembling chancres, 226. Lues venerea ; never combined with the itch or fcurvy, 2. And fmall-pox may appear at the fame time, but not in the fame parts, ibid. Produced by a gonorrhoea, 15, The caufe of other difeafes, 24. The different ways in which it is communicated, 262. Of the nature of the fores or ulcers proceeding from the, 264. Does not con- taminate the different fecretions, 264, 265. Sores in the ; the matter from, compared with that from chancres and buboes, 267. Sores in the ; the matter of, not venereal, ibid. A perfon having the, may be affefted locally by the application of matter from a. gonorrhoea or chancre, 268, Of the local effects arifing from the, eonfidered as critical, 274. Of the fymptomatic fever in the, ibid. Of the local and conftitution- al forms of the difeafe never interfering with one another, 278. Of its fuppofed ter- mination in other difeafes, 277. Of the fpecific diftance of the venereal inflammati- on in the, 278. Of the parts moft fufceptible of the, 279. Of the time and manner jn which the parts are affifted in the, ibid. Summary of the doftrine on the, ibid. Parts affefted in the, are divided into two orders, namely, firft in order of parts and fecond in order of parts, 280, 305. Takes place more readily in thofe parts which are expofed to coll, 282. Is brought into aftion by fiver, 284. Symptoms of the, 289. Of the time neceffary for its appearance, 290. Of the fymptoms of the firft ftage of, 292. Of the fymptoms of the fecond ftage of, 300. Of the effefts of the poifon, on the conftitution in the, 302. General obfervations on the cure of the, 304'. The poifon in the, circulates with the blood ; but its effefts are local and may be cared locally, 30^, 306. The parts firft in order are eafier of cure than thofe fecond in order, 306. Oi continuing mercury while the fwelling of the parts fecond in order ftill continues, 307. Of the ufe of mercury in the cure of, ibid. Preparation of mercury and mode of applying it in the, 308. Of the quantity of mercury neceffary to be given in the cure of the, 313. Of the length of time mercury fhould be conti- nued for the cine of the, 324. Of the cure of the, in the fecond or third ftage, 325. Of the local tieatment in the, 328. Of the effefts remaining after its cure, and of the difeafes fometimes produced by the cure, 341. General obfervations on the me- cj'tines ufually given for the cure cf, 343. Of the continuance of the fpitting in, 34S'. Of difeafes refembling the, which have been miftaken for it, 350. Suppofed to be communicated by the tranfplanting of a tooth, ibid. Lymphatics; difeafes of in gonorrhcea, 56. • Matter of a fore, not pernicious to that fore, 34. Venereal, may be taken into the fto- mach without producing any bad confequences, 265, 266. Mercury, unneceffary in the cure of a gonorrhoea, 67. Combined with mucilage preferr able to oily fubftances when ufed externally, 210. Sometimes produces ulcers on the tonfils, which are taken for venereal, 220. When rubbed into the thigh for the cure of a chancre fometimes occafions fwelling of the glands of the groin, 221. How to be ufed in the refolution of buboes, 248, 2.5 1. Of the quantity neceffary for the refolur tion of buboes, 252. To be ufed during the fuppuration of buboes, 254. Appears fometimes to lofe its power on the body, 257. Of the ufe of, in the cure of lues ve- nerea, 307. Preparation of, and mode of applying it in the lues venerea, 308. The moft convenient way of introducing it into the conftitution, 310. Its aftion, 3 11, 3 17. Its effefts on the conftitution, and parts capable of fecretion, 3 12, 338. Ne- vrr g^:ts into the bones in the form of a metal, 3 13. Of the quantity neceffary to be p'.ven for the cure of the lues venerea, 3 13, 3 18, 326. Its effefts on the mouth, 3 1 5. «>f its fenfible effefts upon parts, ibid. Docs not aft by evacuation, 3 16, 337. Of tSe different methods of giving mercury externally and internally, 319, 322. When mixed with the feliva may aft as a gargle upen ulcers in the throat, 321. Mode of Jiving under a courfe of, ibid. Of the different preparations of, and theircombinat'.on "ith other medicines, 322, 325. Of the length of time it ihould be continued for the cure of the lues venerea, 324. Of correcting feme of the effefts of, 331. Of the form «f the different preparations of, when in the circulation, 314. Is diffolved in ihe fnimal juices, 335. Of the operation of, on the venereal poifon, 33-7. Increafesthe efficacy of electricity in fhe cure of difeafes, 338. Mercurius INDEX. Mercurius calcinatus; its ufe in preventing a lues venerea from a gonorrhcea, 80. In the lues venerea, 322. Mezereon; its ufe in the lues venerea, 344. Mortification takes place in the extremities of tall people, and why, 4. Of two kinds, 7. Its caufe, ibid. Its treatment hitherto in part improper, ibid. _ Its cure, ibid. The ufe of the bark in, 8. The ufe of opium in, ibid. In confequence of the diffu- sion of urine into the cellular membrane of the fcrotum; its treatment, 135. N. Nails; feparation of the, a fymptom of the lues venerea, 294. Nodes, venereal; defcription of, 30*. Treatment of, 328. The ufe of blifters in, 329. Of abfceffes in confequence of, ibid. Of exfoliation in confequence of, 330. On tendons, ligaments, and fafciae ; their treatment, ibid. Kurfes, who fuckle children, fuppofed to have the lues venerea; how affefted, 270. o. Onanifm ; how far pernicious to the conftitution, 182. Opium; its ufe in mortifications, 8. In priapifm, 43. In gonorrhcea, 73. In chor- dee, 82. In ftrifture, 108.' In fpafmodic affeftions of the urethra, 151. In fimple irritability of the bladder, 178. Its ufe in feminal weaknefs, 188. In phymofis, 217, In the luds venerea, 323, 344. In forenefs of the mouth from mercury, 333, An inftance of its being given in very large quantities, .346. P. Paralyfis of the urethra, 152. Its cure, 153. Of the bladder from obftruftion to the paffage of the urine, 164. Of the bladder; its cure when it arifes from obftruftion owing to preffure or fpafm, 167. Of the acceleratores urinse ; its cure, 179. Paraphymofis; its caufe, 201. Natural; defcription of, ibid. 202. From difeafe ; de- fcription of, 203. From chancres;-the treatment of, 217. Operation for, 218. Phymofis; its caufe, 201. Natural; defcription of, ibid. 202. From difeafe; de- fcription of, 203. Its treatment when produced by or attended with chancre, 211. • Produced by chancres; the common operation for, 214. Of the conftitutional treat- ment of, 216. Poifon, venereal; its origin doubtful, 9. Began in the human race, and in the parts of generation, 10. Its nature, ir. Its effefts, ibid. Propagated by matter, 12-, 63. Its aftion, 12. Its greater or lefs acrimony, ibid. It affefts very differently differ- ent people, 13. Tlie fame in gonorrhcea as in chancre, ibid. How communicated to the inhabitants of the South Sea iflands, ibid. Produces different forms of the dif- eafe ; how this happens, 16. The caufe of its poifonous quality, 17. Does not arife from fermentation, ibid. Its effefts arife from a fpecific irritation, 19. Affefts the body in two different ways, locally and conftitutionally, 22. Of the time between the application and effeft, 29. Applied to a fore will often produce the venereal ir- ritation, 34. May be abforbed in three different ways, 233. When abforbed may affeft the lymphatics themfelves, or the lymphatic glands, forming buboes in each, 23 5. Of the time between its application and the formation of a bubo, 238. Af- fefts but one gland at a time, ibid. ' Never affefts the glands which are fecond in or- der- the reafon of this, 239. Sometimes only irritates the glands to difeafe, produc- ing in them fcrofula, 246. Experiments made to afcertain the progrefs and effefts of the, 298. Of its effefts on the conftitution in the lues venerea; 302. Circulates with the blood in the lues venerea ; but its effefts are local and may be cured locally, 305, 306. Of the operation of mercury on the, 337. Poifons, morbid; divided into fimple and compound, g.» New, are rifing up every flay, 358. Prepuce ; contraftion of the, operation for, 213. Mortification of; its treatment, 2*6. Tumefaftion and elongation of, after the cure of chancre ; its treatment, 223. Ex- coriations of the prepuce and glans ; their treatment, 229. Friapifm; its effefts in a dog, 43. The ufe'of opium in, 44. Its caufe, 187. Its cure. ibiJ. s. INDEX, S. Salivation, pccafioned by a fore being dreffed with red precipitate, 399. SarfapariHa; its nfe in fpreading ulcers of the prepuce, 225. Infcuboes, 261. In the lues venerea, 339, 343, 347. Scrofula; obfervations on, 24,25,88,91. Scrotum; relaxation of the; the caufe of, 18$. Sirup ; Velno's vegetable ; its ufe in the lues venerea, 344. Skin, feems to be the caufe of the fufceptibility of the abforbents to receive venereal ir- ritation, 239. Small-pox; matter immaterial from what fubjeft taken, 13. The reafon why a perfon cannot be infefted twke with the, 274. South Sea iflands; inhabitants of, how infected with the lues venerea, 13. Strangury; the ufe of blifters in, 90. Its caufe, 149. Strifture ; different kinds of, 102, Permanent; defcription of, 103. Affected hjr cold, 104, Its caufe, 105. Common to moft paffages in the body, ibid. In gene- ral not the effeft of venereal complaints, ibid. Its cure by dilatation, 108. Ufe of bougies in, ibid. Frequently attended with fpafms, 109. Its cure by ulceration, 112. Occafions an increafe in the ftrength of the bladder, 115. The ufe and appli- cation of cauftic to, 116,143. In women ; obfervations on, 120. In women ; its cure, 121. Attended with fpafmodic affeftion, 122. Sometimes relieved by a go- norrhoea, 123. Spafmodic; its treatment, ibid. Permanent; difeafes in confe- rence of, 13 j. Bad effefts of travelling in, 150. Sugar ; one of the beft reftoratives of any kind we are acquainted with, 327. Sulphur; its ufe in currc€ting fome of the effefts of mercury, 332, 333. Suppreffion of urine ; how relic™!, ,6.,. Op*iati*m Cm the cure of, 168. Suppuration; of its not anfwering the common final intention in a gonorrhcea, 28. Surfaces ; fecreting and non-fecreting, what they are, 16. Of the beft, for abforption* 3°9- Sympathy; divjfion of, into univerfal and partial, 1. Partial, divided into remote, contiguous, and continuous, 2. Between the urethra and the cutting of a tooth ; an inftance of it, 3 j", Occafions a variety of fymptoms in gonorrhcea, 48. In gonor- rhcea occafions fwellings in the tefticles., 50,, 84; and in the abforbent glands, 54. Sometimes cures a fleet, 96. Occafions affeftions of many parts during the ufe of bougies, 125, 131. Between the (kin and deeper feated parts of the body when col4 is applied to the former, 2S3. Syftem, abforbent, affefted in-two ways; by irritation and the abforption of matter, 54. Difcoveryof; its ufe in medicine, 231. T. Teeth; tranfphmfing of, fuppofed to communicate the lues venerea, 350. Of difeafe* fuppofed to be venereal produced by, 362. Produces a difeafe which fometimes is more difficult of cure than the venereal, 368. Tefticle; fwelling of the, arifes from fympathy in gonorrhcea, 50,84,200. Swelled; fymptoms of, ibid- Swelling of, is not venereal, 53, $4. Swelling of, fometimes produced by the gout, 53. Swelled; its treatment, 83, 84. The ufe of vomits in, 84. Affefted fympathetically from the ufe of bougies, 125, 131. Of the decay of the, 190. Tongue; ulcers of the, are feldom venereal, 281. Tonfils, venereal; ulcers of the; defcription of, 295. Tumefaftion of, ibid. Exco- riation of, 296, 341. Turpentine, oil of; its ufe in haemorrhage from chancre, 213. V. Veficulse feminales; their ufe, 45. Are feldom difeafed, 160. Of the difcharge of the fecretion of, 180. Mucus of; the diftinftion between it and femen, 181. Viper ; an obfervation on its poifon, 34. Vomits; their ufe ia a fwelled tefticle, 84. In refelving buboes, 249. u. INDEX. U. Ulcers, venereal; of the nature of, 264. Of the tonfils; defcription of, 295. Ureter and kidney, affefted in a gonorrhcea, 50. Of the diftenfion of the ureters, 177. Urethra ; ulcers in the, not produced in a gonorrhcea, 27, 106. A fhort hiftory relative? to that fubjeft, 29. An inftance of its fympathifing with the cutting of a tooth, 31. Is fometimes the feat of the gout and rheumatifm, ibid. Its aftion, 43. What parts of the, furnifh the matter in a gonorrhcea, 45. Bleeding of, 46. How affefted by inflammation, 47. Bleedings from ; their treatment, 81. Suppuration of its glands; how treated, 82. Obfervations on its ufes, 101. Obftruftions of; the different kinds of, 102. Parts of the, moft fubjeft to ftrifture, 104. Lacunae of, a bougie frequently ftops in them, 111. Different kinds of obftruftions which take place in that canal, 116. Sometimes a new paflage is made along the fide of the urethra by bougies; the treatment and cure of that accident, 127. Enlargement of, 13 2. In- flammation of the parts furrounding the; treatment of, 139, 141. Abfceffes near the; their treatment, 139, 140. Spafmodic affeftions of the, 149. Their caufe, ibid. Their cure, 150. Paralyfis of, 152; its cure, 153; the ufe of cantharides in, ibid. And bladder contraft and relax alternately, 162. Inconveniences which arife when thefe aftions do not take place regularly, 163. Their treatment, 164. Mucus of; of the difcharge of, 180. Urine; a new paffage formed for the, 132. The mifchief it occafions by being diffufed into the cellular membrane of the fcrotum and neighbouring parts, 133. Defcription of an operation to prevent it, 134, 135. To be drawn off frequently in fupprefliona of, 135, 168. Suppreflion of; how relieved, 165. Suppreflion of; operations for the cure of, 168. Suppreflion of ; the ufe of calomel and opium in, 172. Should never be retained a length of time in the bladder* 179. w. Warts, venereal; their treatment, 229. Weaknefs, feminal; its caufe, 188. The ufe of opium in, ibid. Its cure, 190. Y. Yaws; cafe of a gentleman infefted with the, 3 53. Defcription of the, 354. ^-7 0 nil iv ■ ■ * ■■ *" '. ' ' i I r '• .'*i<3