ARMY MEDICAL LIBRARY WASHINGTON Foimxiecl 1836 Section.- Number / 3 (= v5".%„ Fokm 113c, W. D., S. G. O. ipo 3—10543 (Revised June 13, 1936) * *7 Jt^M^- THE PATHOLOGY AND TREATMENT YENEREAL DISEASES: INCLUDING THE RESULTS OF RECENT INVESTIGATIONS UPON THE SUBJECT. BY FEEEMAN J. BUMSTEAD, M.D., LECTURER ON VENEREAL DISEASES AT THE COLLEGE OF PHYSICIANS AND SURGEONS, NEW TORE; LATE SURGEON TO ST. LUKE'S HOSPITAL; SURGEON TO THE NEW TORE EYE AND EAR INFIRMARY. A NEW AND REVISED EDITION. WITH ILLUSTEATIONS. PHILADELPHIA: BLANCHARD AND LEA. 1864. WCf\ Entered a«cording to Act of Congress, in the year 1861, by BLANCHARD AND LEA, in the Of&ce of the Clerk of the District Court of the United States in and for the Eastern District of the State of Pennsylvania. PHILADELPHIA : COLLINS, PRINTER. PREFACE TO THE FIRST EDITION. The object in tbe preparation of this work has been to furnish the student with a full and comprehensive treatise upon Yenereal Diseases, and the practitioner with a plain and practical guide to their treatment. In carrying out this design, theoretical discussions have been made subordinate to practical details; and, in the belief that the success of treatment depends quite as much upon the manner of its execution as upon the general principles upon which it is based, no minutiae, calculated to assist the surgeon or benefit the patient, have been regarded as unworthy of notice. The additions to our knowledge of Venereal, during the last ten years, have been numerous, and in the highest degree important. Among the most remarkable may be mentioned the distinct nature of the chancroid and syphilis; the innocuousness of the secretion of the chancre when applied to the person bearing it, or to any indi- vidual affected with the syphilitic diathesis; the removal of certain obstacles to a general belief in the contagiousness of secondary lesions; the fact that syphilis pursues the same course whether derived from a primary or secondary symptom, commencing, in either case, with a chancre at the point- where the virus enters tbe system; the definite period of incubation of the true chancre, and of general manifestations; the inefficacy of the abortive treatment of syphilis; and the phenomena of " syphilization," improperly so- called, and their correct interpretation. Several of these topics are entirely new within the period mentioned, and upon others much clearer views have been obtained; so that our present knowledge (Hi) iv PREFACE TO THE FIRST EDITION. of Venereal Diseases may be regarded as far more complete and satisfactory than at any previous time. As yet, however, these results and the investigations which have led to them are, for tbe most part, scattered through the pages of medical periodical litera- ture, in our own and foreign languages. To collect them into one volume, and thus render them more accessible to the American reader, has also entered into the purpose of the author. New York, July, 1861. PREFACE TO THE SECOND EDITION. The first edition of this work, the author is now free to confess, was published with many misgivings as to the reception it would receive. Presenting views directly at variance, in many respects, with those which were almost universally taught in our medical schools, and, with few exceptions, entertained by the profession at large throughout this country, it was natural to expect that it would meet with severe criticism and decided opposition; with confidence, however, in tbe truth of the opinions advanced, the venture was made. Its success thus far has surpassed the most sanguine expectations of the writer. During a time of civil war, when communication with a considerable portion of our country has been suspended, and medical literature, except on military subjects, has been almost stagnant, a little more than two years sufficed to exhaust a large edition. The reviews of it, which have appeared both at home and abroad, have been in the highest degree gratifying. It has been thought worthy of translation and publication in Italy. Above all, the views set forth have steadily grown in favor; their accuracy has been confirmed by time; and they are now adopted by the chief authorities upon Venereal throughout the world. Of the credit of this success the author would gladly appropriate to himself the share of having presented in an acceptable manner (v) vi PREFACE TO THE SECOND EDITION. to American readers the results of modern investigations relative to Venereal, and of having thus assisted in producing in this country the same remarkable and radical revolution of opinion that, within the last few years, has elsewhere taken place. To more than this, however, he would lay no claim. It was his good fortune to be the first writer, at least in English—and, it is believed, in any language — to embody the results referred to in a comprehensive treatise. A gap existed in medical literature, which it was impossible should long remain unfilled. Others undoubtedly would soon have accom- plished what he hopes to have done. He is well aware that by far the greater portion of the success of the work has been due to the original investigators, whose views are here given, and who have brought order out of the chaos that had for centuries prevailed. The truth, once indicated, was so plain and simple that every mind was ready to receive it, and to wonder that it bad not been dis- covered before. The most noticeable change in the present edition will be found in the division of the work. From a certain deference to the opinions at that time generally received, the chancroid and its com- plications were, in the first edition, discussed in connection with syphilis. They have now been assigned, as is their due, to separate portions of the work. This change has necessitated a complete reconstruction of the second part of the first edition, and its division into two — a change which, it is hoped, will impress still more strongly upon the mind of the student the distinct nature of the two diseases referred to. The same object has been had in view in abandoning the terms "soft," "hard," "simple," and "infecting chancre," and in applying, in accordance with logical accuracy, the term chancre exclusively to the initial lesion of syphilis, and that of chancroid to the contagious ulcer of the genitals. The practical portion of the work has also undergone important alterations on various topics, among which may be mentioned the treatment of PREFACE TO THE SECOND EDITION. vii stricture by the " immediate plan" of Mr. Holt; the abandonment of specific remedies in most cases of tbe initial lesion of syphilis; the preference given to the external rather than the internal use of mercury in secondary and tertiary syphilis; and the necessity of trusting to nature, aided by hygienic influences, and not to treat- ment indefinitely prolonged after the disappearance of all syphilitic manifestations, to eliminate the virus from the system. Numerous emendations and additions of a minor character have been made; every portion of the work has been carefully revised; a number of chapters have been rewritten; several new illustrations have been added ; and no effort has been spared to render the present edition a complete treatise upon the subject of Venereal, thoroughly on a level with the most advanced state of our knowledge. It will be observed that by an increase in the size of the page, these additions have been accommodated without increasing the bulk of the volume. New York, May, 1864. CONTENTS. PAGE Introduction............17 PART I. GONORRHCEA AND ITS COMPLICATIONS. CHAPTER I. Urethral Gonorrhoea in the Male........57 Preliminary considerations ......... 57 Symptoms............ 59 Causes and nature of gonorrhoea ........ 64 Treatment............73 Abortive treatment .......... 74 Treatment of the acute stage ........ 78 Treatment of the stage of decline.......82 Copaiba and cubebs ......... 89 Obstacles to success ......... 96 Treatment of special symptoms ....... 98 CHAPTER II. Gleet.....'.........101 Symptoms............102 Pathology............103 Treatment ....... ..... 105 Bougies.............108 Injections ...........110 Deep urethral injections .........112 Blisters............113 Separation of the affected surfaces • . . . . 114 CHAPTER III. Balanitis.............116 Causes.............11(5 Symptoms . . ........ . 117 Treatment . . . . .......117 (ix) X CONTENTS. CHAPTER IV. PAGE _ ion Phymosis............. 121 Symptoms ......«••••' 199 Treatment............*■" 124 Circumcision........... CHAPTER V. Paraphymosis..........■ • 1 CHAPTER VI. Swelled Testicle..........."1 Causes.............132 Seat.............134 Symptoms............13/ Pathological anatomy..........144 Treatment............I46 CHAPTER VII. Inflammation of the Prostate........ . 153 Acute prostatitis ........... 153 Treatment .......•••• 155 Chronic prostatitis.......... 156 Treatment...........158 CHAPTER VIII. Inflammation of the Bladder.........161 Treatment............163 CHAPTER IX. GONORRHCEA IN WOMEN...........165 Causes.............165 Symptoms............168 Gonorrhoea of the vulva.........169 Gonorrhoea of the vagina........172 Gonorrhoea of the urethra . . . . . . . . 175 Complications...........177 Diagnosis............178 Treatment............179 CHAPTER X. Gonorrheal Ophthalmia..........190 Frequency............191 Causes.............192 Symptoms............194 Diagnosis ............ 197 Treatment............198 CONTENTS. xi CHAPTER XI. PAGE Gonorrheal Rheumatism..........207 Causes.............209 Seat......... 211 Symptoms ............213 Diagnosis ............ 224 Nature.............225 Treatment............227 CHAPTER XII. Vegetations.............230 Treatment............232 CHAPTER XIII. Stricture of the Urethra......... 234 Anatomical considerations.........234 Transitory strictures..........251 Permanent or organic strictures........254 Seat ............257 Number............260 Form............261 Degree of contraction ......... 262 Pathology of stricture..........265 Abscess and fistula .......... 266 Lesions of the bladder.........268 Lesions of the ureters and kidneys.......269 Lesions of the genital organs ........ 269 Constitutional effects of stricture.......270 Symptoms of stricture..........271 Causes of stricture.......... 276 Diagnosis of stricture..........281 Exploration of the urethra.........281 Introduction of the catheter........285 Model bougies..........288 Treatment............289 Constitutional means......... 289 Dilatation......... 291 Continuous dilatation........295 Rapid dilatation......... 296 Expansion..........298 Rupture............298 Caustics............301 Incisions ........... 304 Internal division......... 305 Perineal section.........310 Consequences of operations upon stricture......319 xii CONTENTS. PAGE Treatment of retention of urine ...••••• 327 Puncture by the rectum ....••••* 330 Opening of the urethra ....••••• 331 Puncture above the pubes........ 331 Puncture through the symphysis....... Treatment of extravasation of urine ...•••• "6" Treatment of urinary abscess and fistula ....•• rf°^ PART II. THE CHANCROID AND ITS COMPLICATIONS. CHAPTER I. The Chancroid............335 Frequency............ 33o Seat.............336 Contagion............338 Inoculation............ 341 Symptoms............34- Diagnosis............ 345 Treatment............347 CHAPTER II. Special Indications from the Seat of Chancroids.....356 Chancroids upon the integument of the penis ..... 356 Chancroids of the frsenum.........356 Urethral chancroids.......... 357 Chancroids of the female genital organs......358 Chancroids of the anus and rectum.......359 CHAPTER III. The Chancroid complicated with Excessive Inflammation and with Phagedena ...... ..... 360 Inflammatory or gangrenous chancroid...... . 360 Phagedenic chancroids.......... 361 CHAPTER IV. The Chancroid complicated with Syphilis......367 CHAPTER V. Buboes..............372 Simple inflammatory bubo.........373 Virulent bubo...........375 Indolent bubo.......... 377 CONTENTS. xiii PAGE Treatment of buboes..........379 General treatment..........379 Counter-irritants..........380 Compression...........381 Methods of opening buboes........381 Treatment of difficult cases........385 CHAPTER VI. Lymphangitis............388 PART III. SYPHILIS. CHAPTER I. Introductory Remarks..........391 Syphilitic virus...........391 Syphilis commonly occurs but once in the same person . . . 392 Exceptions to this law ......... 393 Syphilis possesses a period of incubation......395 The order of evolution of syphilitic symptoms and the classification founded thereon........ . . 396 CHAPTER II. The Initial Lesion of Syphilis, or Chancre......403 Period of incubation..........404 Symptoms............407 Diagnosis............416 Urethral chancre..........418 Buccal chancre..........418 Treatment............419 CHAPTER III. Induration of the Ganglia and of the Lymphatics .... 424 Induration of the ganglia ......... 424 Induration of the lymphatics........ 430 Treatment............431 CHAPTER IV. General Syphilis. — Introductory Remarks......432 General syphilis always follows a chancre ...... 432 Period of incubation......... 434 Some of the symptoms of general syphilis are contagious . . . 441 What general symptoms are contagious ?.....456 Syphilis pursues essentially the same course, whether derived from a primary or secondary symptom; in the latter case, as in the former, the initial lesion is a chancre........459 XIV CONTENTS. CHAPTER V. PAGE Prognosis of Syphilis.......... CHAPTER VI. Treatment of Syphilis..........4'^ Hygiene and tonics . . . . • • • • • • ' Mercurials . ........• • • 4/" Fumigation...........4°1 Inunction.........• • 4°4 Salivation...........485 Duration of treatment . •......• • ^89 Iodine and its compounds .......•• 492 Vegetable decoctions and infusions.......500 Nitric acid............501 CHAPTER VII. Treatment of Syphilis by Repeated Inoculation ..... 502 CHAPTER VIII. Syphilitic Fever; State of the Blood; Engorgement of the Lymphatic Ganglia............509 Syphilitic fever...........509 State of the blood...........511 Engorgement of the cervical ganglia . . . . . . . 511 CHAPTER IX. Syphilitic Affections of the Skin........514 Syphilitic erythema........ 518 Syphilitic papules........... 520 Syphilitic squamae........... 521 Syphilitic vesicles........... 523 Syphilitic bullae.......... 524 Pemphigus.......... . 524 Rupia............525 Syphilitic pustules .......... 526 Acne............526 Impetigo ............ 527 Ecthyma...........528 Syphilitic tubercles..........530 Ulcers.............534 Treatment............534 CHAPTER X. Syphilitic Affections of the Appendages of the Skin .... 537 Alopecia............537 Onychia............539 Whitlow............540 ' CONTENTS. XV CHAPTER XI. PAGE Mucous Patches............541 Treatment............547 CHAPTER XII. Gummy Tumors............548 CHAPTER XIII. Syphilitic Affections of Mucous Membranes......551 Erythema ............ 551 Ulcers ............. 552 Tubercles of the tongue..........555 Treatment of the affections of the mouth and throat .... 556 Stricture of the oesophagus.........558 < Affections of the stomach and intestines......560 Affections of the nasal passages........561 Affections of the larynx and trachea.......562 Aphonia............562 Laryngitis...........563 CHAPTER XIV. Syphilitic Affections of the Eyes........568 Affections of the bones of the orbit....... 568 Affections of the lachrymal passages.......569 Affections of the eyelids.........571 Affections of the conjunctiva.........572 Affections of the cornea.........573 Iritis.............574 Infantile iritis ..........584 Retinitis and choroiditis.........585 Atrophy of optic nerve..........587 Hyperopia ............ 587 Paralysis of the motor nerves........588 CHAPTER XV. Syphilitic Affections of the Ear........590 CHAPTER XVI. Syphilitic Orchitis...........693 Diagnosis............ 595 Treatment............597 CHAPTER XVII. Syphilitic Affections of the Muscles and Tendons .... 599 Muscular pains...........599 Muscular contraction .......... 599 Muscular tumors.....;.....601 Xvi CONTENTS. ' CHAPTER XVIII. PAGE Syphilitic Affections of the Nervous System....."04 CHAPTER XIX. Syphilitic Affections of the Periosteum and Bones .... 609 Osteocopic pains .......•••• 610 Nodes ..........••• "11 Caries and necrosis..........614 CHAPTER XX. Congenital Syphilis...........616 Etiology..........• 616 Transmissibility........... 618 Abortion............620 Period of development.......... 621 Symptoms ............ 625 General aspect of syphilitic infants ...... 625 Coryza............ 626 Affections of the skin and mucous membranes .... 626 Onychia............628 Suppuration of the thymus gland.......628 Changes in the lungs.........628 Changes in the liver.........629 Peritonitis...........631 Affections of the periosteum and bones ...... 631 Hydrocephalus......... . 632 Affections of the supra-renal capsules and pancreas . . . 632 Prognosis............ 632 Treatment............633 VENEREAL DISEASES. INTRODUCTION. There are three diseases, which, from their origin in sexual intercourse, have been denominated Venereal, viz.: Gonorrhoea ; the Contagious Ulcer of the Genitals, or Chancroid; and Syphilis. These three affections, for a long period confounded, have been, since the commencement of the present century, gradu- ally resuming the relations which they held to each other nearly four hundred years ago. The medical mind has been travelling in a circle, and having completed the round, is now where it stood in the last part of the fifteenth and the first of the sixteenth century. The distinction between the above-named diseases which is now admitted—certainly by a very considerable number of our profes- sion, unsurpassed in intelligence, learning, and experience, and including names which have long been acknowledged as the highest authority—was fully recognized for twenty or thirty years after Columbus discovered the new world. The earlier history of venereal diseases has recently been very thoroughly investigated, especially by Bassereau,1 Langlebert,2 Cha- balier,3 and Rollet/ and the conclusions which have uniformly been attained, startling as they may in some respects appear, are yet sup- ported by such an amount of proof drawn from the original sources, 1 Affections de la Peau Symptomatiques de la Syphilis, Paris, 1852. 2 Re'cherches Historiques sur la Doctrine Moderne des Maladies Ve'ne'riennes, l'Union Me"d. 1855. 3 Preuves Historiques de la Plurality des Affections dites Ve'ne'riennes, These de Paris, 1860 (No. 52). I am indebted to M. Chabalier's very able thesis for many of the following facts relating to the history of venereal diseases. 4 Recherches sur la Syphilis, etc., Paris, 1861. 18 INTRODUCTION. that they cannot be called in question; at all events, they have not been disproved, although Bassereau's work has been for eleven years before the profession. I propose as briefly and concisely as possible to state what is at present known upon this subject. EARLY HISTORY OF GONORRHOEA. Gonorrhoea has existed among all nations, and from the earliest times of which we have any record. It is clearly referred to by Moses in the 15th chapter of Leviticus, where he lays down rules for the government of those who are affected with " a running issue out of the flesh." Among the Greeks and Romans, gonorrhoea appears tG have been less common than among the Hebrews; still, unquestionable traces of it are found. Hippocrates describes five kinds of leucorrhcea, in addition to discharges dependent upon inflammation of the womb, which are mentioned separately. Herodotus states that "the Scythians made an irruption into Palestine and pillaged the temple of Venus Urania. The angry Goddess sent upon them and their posterity the woman's disease, which is characterized by a running from the penis. Those attacked by it are looked upon as accursed."1 Celsus2 was also acquainted with balanitis and gonorrhoea; the lat- ter dependent, as he supposed, upon an ulcer within the urethra; and Cicero says that " incontinence gives rise to dysuria, in the same manner that high living causes diarrhoea." At subsequent periods, this disease, and, in many instances, its complications of swelled testicle and cystitis, were described with more or less detail by Mesue3 in 90-1; by Halli Abbas,4 one of tbe Persian magi, who followed the doctrines of Zoroaster and wrote in 980; by Rhazis,5 a learned Arabian physician, born in Chorosana in 852 ; by Albucasa,6 another Arabian of the eleventh century; by Constantine of Carthage ;7 by Michael Scott8 in 1214; by Gariopon- tus of Salerno; by Rogerius, John Gaddesden9 of England (com- mencement of fourteenth century); John de Concoregio,10 John i Clio, lib. I. 2 De Medicina, book vi., chap. 18. 3 Summ. III., part 4, sect. i. * De Virgae Passionibus, Causis eorum et Signis, book ix., chap. 28. B Rhazis, book X., chap. 3. 6 Theoric. nee non Practic, tract, xxi., fol. 92 et 93. 1 Constantinus Africanus. De Morborum Cognitione et Curationo, lib. v. 8 Michael Scott, De Procreat. Horn. Physion., Cap. vi. 9 John Gaddesden. Rosa Anglica, Practica Medicinse, a Capite ad Pedes, lib. ii. c. xvii., fol. 107. 10 Practica nova Medicinse. Lucidur, tract, iv., fol. 66. INTRODUCTION. 19 Arculanus, Guy de Chauliac,1 Valescus de Tarento, John Ardern/2 settled at London in 1371; and by many others. Since the close of the fifteenth century, when the study of venereal diseases received new impulse from the irruption of syphilis into Europe, it is hardly necessary to state that every medical writer has been familiar with the existence of gonorrhoea. EARLY HISTORY OF THE CONTAGIOUS ULCER OF THE GENITALS. The history of the contagious ulcer of the genitals is essentially the same. Ulcers of the genital organs and suppurating buboes are described by nearly all the Greek, Latin, and Arabian writers on medicine. Hippocrates gives very minute directions for the treat- ment of abscesses in the groin, dependent upon ulcerations of the womb and of the genitals. Celsus is still more explicit, and clearly describes the simple, phagedenic, serpiginous, and gangrenous vene- real ulcers, which are recognized at the present day. It would be difficult, for instance, to draw up a more faithful description of the phagedenic chancroid than the following: "Ulcus latius atque altius serpit.....solet etiam interdum ad nervos ulcus descen- dere; profluitque pituita multa, sanies tenuis malique odoris, non coacta, et aquae similis in qua caro lota est; doloresque is locus et punctiones habet." He also alludes to the danger of destruction of the prepuce when the ulcer is complicated with phymosis, and, under such circumstances, advises circumcision. Many other names might be quoted, but it is unnecessary to adduce farther evidence upon this subject, since it is generally admitted that ulcers of the genital organs dependent upon contagion in sexual intercourse, have been known from a very remote antiquity. The only point in dis- pute relates to their nature. It is maintained by some authors, and especially by Cazenave, that these were instances of primary syphilis, and not chancroids, as I have here assumed; and they have been supposed to furnish evi- dence of the existence of syphilis in Europe prior to the close of the fifteenth century. This idea is inadmissible for several reasons. One argument against it is the frequency of suppurating buboes with which these ulcers are said to have been attended; since in the 1 Cyrurgia Guidonis de Chauliaco, tract, vi., doct. ii. 2 Becket, Philosoph. Trans., vol. xxx., p. 839. Most of the above texts have been derived from a learned work written in the last century by Gruner, and entitled: Aphrodisiacus sive de Lue Venerea in duas Partes divisus, quarum altera continet ejus Vestigia in Veterum Auctorum Monumentis obvia, altera quos Aloysius Luisinus temere omisit Scriptores, Jena, 1789. 20 INTRODUCTION. great majority of true chancres the inguinal ganglia which become indurated remain entirely passive; while the chancroid, on tbe con- trary, is frequently accompanied by an inflammatory bubo termi- nating in suppuration. This consideration, however, will have no weight with those who do not allow, in cases of venereal sores, any prognostic value to suppuration of the inguinal ganglia; but we can well afford to waive it and base our argument upon tbe fact that there is no record in history of the existence of general symptoms prior to the year 1494; that the ulcer of tbe genitals known to the ancients was always a local affection, and never followed by general manifestations at a distance from the point of contagion; that re- peated outbreaks of the disease when once apparently cured did not occur; that hereditary syphilis was unknown;1 and finally, that the physicians who lived at the close of the fifteenth century, and who were perfectly familiar with the ulcers in question, were struck with horror and amazement at the appearance at this time of a disease which is now known to have been syphilis; confessed that they had never seen its like before, and that they were ignorant of its nature and treatment; and in their treatises upon venereal for nearly thirty years afterwards, described this and the former disease in separate and distinct chapters, thus showing that they did not entertain the least idea of their identity. EARLY HISTORY OF SYPHILIS. According to the most reliable contemporary authors, syphilis was first known to European nations from its appearance in Italy in the latter part of the year 1494, about the time that Charles VIIL, King of France, at the head of a large army, entered that country for the purpose of taking possession of the kingdom of Naples, to which he laid claim by right of inheritance. In this expedition, which was at first favored by the Neapolitans themselves, Charles left Rome on his way to Naples Jan. 28, and was received in the latter city Feb. 21, 1495.2 The Neapolitans soon became restive under the yoke of their new master, and, assisted by tbe forces of Ferdinand of Aragon, under the leadership of Gonsalvo of Cordova, the great captain, endeavored to expel the French from Italy. Now, although the new disease probably had no necessary con- nection with the events just mentioned, yet the latter doubtless favored the extension and exacerbation of the former throuo-h the license and debauch attending large bodies of troops, and subse- 1 Syphilis in infants at the breast is first mentioned by Gaspard Torello (1498). 2 Guicciakdini, lib. i. cap. iv. INTRODUCTION. 21 quently led to mutual recrimination between the natives and the invaders respecting the origin of the malady; the French calling it " Mai de Naples," because it was to them unknown before the Nea- politan expedition, and the Italians ascribing its origin to the French, and calling it the " French disease." It is often asserted that the subsequent extension of syphilis was due to its conveyance to their homes after the close of the war by the troops which had been collected upon Italian soil. This could not, however, have been the sole, nor even the chief mode of its transmission; since the French, on their return from Naples, fought the battle of Fornovo, July 6,1495,1 and a decree of Emperor Maxi- milian I., " Contra Blaspbemos," promulgated at the Diet of "Worms, Aug. 7, of tbe same year, includes among the evils sent as a punish- ment against the prevailing vice of blasphemy, "praesertim novus ille et gravissimus hominum morbus, nostris diebus exortus, quern vulgo Malum Francicum vocant, post hominum memoriam inauditus, sseve grassatur,2 thus showing that syphilis had already spread so widely in Germany as to attract general attention about the time that the French left Italy. Joseph Grunbeck, a German physician, writing in 1496, also de- scribes the disease as it appeared in his own person, evidently at a considerable period prior to the date of his work. This author states, as quoted by Chabalier, that he was a happy man until this new pestilence found its way into Germany; but that one pleasant day while walking in the fields, he found himself attacked with it; " et primam venenosam sagittam in glandem Priapi ista fcetidas de- fixit, quae ex vulnere tumefacta, utrisque manibus vix comprehendi potuisset." Sad and dejected he returned home, undecided whether he should make known his condition to his friends; but the change in his countenance, his silence and despondency, made them suspect that some misfortune had occurred to him, and he was obliged at last to confess that he was attacked by the French disease, and to exhibit the evidences of it in his person. His dearest friends at once turned their backs upon him, and fled as if they had seen an enemy's sword suspended over their heads. Grunbeck's sadness was increased, and, retiring into solitude, he gave himself up to gloomy thoughts upon the vanity of earthly things and the ingratitude and perfidy of men. Meanwhile his disease extended, and a "thousand" ulcers appeared upon his penis and testicles and "vomited forth" bloody matter. After suffering in this manner for four months, he placed himself under the care of a celebrated empiric, who healed his sores by the 1 Guicciardini, lib. ii. cap. iv. 2 Goldast. Const. Imp. II. 110. 22 INTRODUCTION. application of a powder which gave him much pain. The disease disappeared from the penis, but soon returned upon the skin, where it assumed the form of tubercles. "Pestifera qualitas ex hoc suppu- rato et arcto loco retrocessit, atque in multis aliis verrucas passim in cutis superficiem elisit." The skill of the most celebrated physicians was unable to dissipate these new symptoms. Temporary relief was obtained from frictions with an ointment containing mercury, which was recommended by a charlatan, but several relapses subsequently occurred. The testimony of other authors also concurs in showing that syphi- lis rapidly extended in tbe course of a few years over the greater part of Europe, and pervaded every rank of society. As stated by John Lemaire, a poet of that period:— II n' espargnoit ne couronne ne crosse. A large amount of evidence is adduced by Bassereau and Chaba- lier in support of the fact already mentioned that syphilis was en- tirely unknown prior to the year 1494. Its connection with sexual intercourse was not at first recognized, and many attributed it to the evil influences of the stars; and although a few endeavored to assi- milate it to certain diseases of ancient times, as, for instance, to the " asaphati" of the Persians, the mentagra which prevailed at Rome under Tiberius, to psoriasis, elephantiasis, and lepra, yet the greater portion of the writers of that period declared that it was entirely new in the world's history, and all confessed that, so far as their own experience went, they had never seen anything like it. For instance, Philip Beroald, who died in 1505, says that he can neither affirm nor deny the truth of the supposition that it has pre- viously existed; all that he knows with certainty is that this " French disease, characterized by enormous prominent spots, by pustules giving the face and body a hideous aspect, sometimes painless, at other times causing the most excruciating suffering in the joints, and depriving the patient of rest and sleep at night, slowly consumes the body; that it can be cured by no remedy; that it was unknown to his ancestors; that whatever others may name it, he desires to call it morbum pestiferum diuturnum; that he prays, Dii, prohibite mi- nas! Dii, talem avertite pestem! May this disease, more destructive than any pestilence, depart and return to the gulf of hell whence it came." James Cataneus de Lacu-Marcino, a Genoese, in bis treatise de Morbo Oallico, written in 1505, states that in the year 1494, under the pontificate of Alexander VI., and during the invasion of Naples by Charles VIII., King of France, there appeared in Italy a terrible INTRODUCTION. 23 disease, which was never before known in any age; which was new to the whole world; which did not resemble the asaphati nor any other serpiginous and fetid ulcer, and which could not be regarded as epidemic; but which spreading over tbe world was due to the vengeance of God, who desires to punish fornication and adultery, which, though forbidden by law, are practised by men, who live like wild beasts.1 The testimony of many other writers is equally conclusive. The contagious ulcers of the genitals which were known prior to the latter part of the fifteenth century, were called " caries," " caroli," and " taroli," and the first of these terms was afterwards applied to the new disease, which, however, was distinguished as the " caries gallica." Moreover, in the works of Marcellus Cumanus, Alexander Benedictus, Leonicenus, Gaspar Torella, John de Vigo, and other au- thors who wrote within thirty years after the appearance of syphilis, these two affections were described in separate chapters with many of the distinguishing features that are recognized at the present day. Thus, John de Vigo mentions the induration of those ulcers which are followed by constitutional symptoms: " Cum calositate eas cir- cumdante;" and none of the writers of this early period, when speak- ing of the French disease, make any allusion to suppurating buboes, which are described apart and referred to the " caries non gallica" known in ancient times. An exceedingly accurate description is also given of the cutaneous eruptions, the nocturnal pains, the bony tumors, and other general symptoms of syphilis; and notice is taken of the fact that a cure is in most cases only temporary, and that the disease often returns. Moreover, the early writers on syphilis be- lieved in the contagiousness of general symptoms, and even of the blood of infected persons, which has recently been demonstrated by actual experiment. ORIGIN OF SYPHILIS UNKNOWN. None of the theories which have been advanced to account for the appearance of syphilis in Europe near the close of the fifteenth century, rest upon sufficient data to entitle them to full credence. We cannot suppose that it was of the nature of an epidemic and due to atmospheric influences, since it is expressly stated by those who witnessed its advent that it did not suddenly affect large numbers of persons of all ages, but spread from one to another, chiefly attacking the middle-aged (the very class most exposed in sexual intercourse), and sparing old men ar\d infants, and the inhabitants of cloisters, and 1 Chabalier, op. cit., p. 87. 24 INTRODUCTION. that it advanced from Italy as a centre, and occupied several years in extending to the more remote countries of Europe. Moreover, our present knowledge of the disease enables us to state with confi- dence that it never appears except as the result of contagion. The theory which has met with the most favor, refers the origin of syphilis to America, whence Columbus returning from his first voyage, landed at Barcelona, in Spain, in 1493, only a year before the appearance of the disease in Italy. According to Chabalier, it was stated by John Baptist Fulgosus, Doge of Venice, as early as 1509, that a new disease, communicated only by coitus, and first af- fecting the genital organs, had broken out in Spain, and had thence been transported to Italy, and also that it came into Spain from Africa: " Quae pestis primo ex Hispania in Italiam allata, ad Hispa- nos ex ^Ethiopia, brevi totum terrarum orbem comprehendit." The idea, that syphilis was brought to Europe from America by the sailors under Columbus was first advanced by Leonard Schmans, in 1518, Ulrich von Hutten in 1519, and Fracastori in 1521, with what evi- dence I shall proceed to show. There can be no doubt that syphilis existed in the colony founded by Columbus during his second voyage, but whether indigenous to the West Indies, or brought there by the Spaniards, is unknown. Washington Irving, in his Life and Voyages of Columbus,1 says, when speaking of the colony at Isabella: " Many of the Spaniards suffered also under the torments of a disease hitherto unknown among them, the scourge, as was supposed, of their licentious inter- course with the Indian females; but the origin of which, whether American or European, has been a subject of great dispute." Cha- balier also adds the following testimony:— Peter Martyr, Governor of Castile in 1492, states in a work2 writ- ten in 1500: " They have in this island (Hayti) a peculiar disease, characterized by large pustules occupying the body and eating into the extremities, because they are too much addicted to luxury. This disease is contracted by cohabitation with men and women who are already infected." Francisco Lopez de Gomare, almoner of Fernando Cortez, states that nearly all the Indians were affected with syphilis: "Los de aquesta isla Espannola son tudos bubosas, i como los Espannoles dormian con las Indias." Rodericus Diacius Insulanus, who was physician at Barcelona at the time syphilis made its appearance, is confident that it was brought to that city in 1493 by Columbus; that the companions of Columbus i Vol. i., book vi., chap. xi. » De Navigatione et Terris de Novo Repertis INTRODUCTION. 25 ascribed their disease to the privations and fatigue of tbe voyage; and that at Barcelona they infected the entire city, whence the dis- ease was transported to Naples. When Charles VIII. arrived in Italy the following year, the opposing forces included a number of Spaniards affected with the disease, with regard to the nature of which they were ignorant, and which they attributed to atmospheric influences. Laying aside all American partialities, I have thus endeavored to give a truthful statement of the evidence upon this subject; which, as the reader will observe, contains no statement from those who took part in the discovery of the new world, that they found syphilis there on their arrival. Its existence in the Indies during the second voyage of Columbus may readily be explained by its transportation thither by the Europeans, who may be supposed to have been quite willing to ascribe their disease to the natives. It is unnecessary, however, to enter into a farther discussion of this point, since I think I can assert with truth that those authors of the present day who have paid the. most attention to this subject, regard the testimony in favor of the supposed American origin of syphilis as far from conclusive. Indeed, if credence is to be placed in a recent writer,1 Chinese medical literature affords evidence of the existence of syphilis in that country and of its treatment by mercury, many centuries before the birth of Christ. The origin of syphilis, however, is enveloped in so much obscurity that we may well say, with Voltaire, "la verole est comme les beaux-arts, on ignore quel en a ete l'inventeur." AGE OF CONFUSION IN VENEREAL. The views that were entertained by those who witnessed the first appearance of syphilis in Europe, and which in many respects coincided to a remarkable degree with those which have recently been advanced in the middle of the nineteenth century, gradually lost their hold upon succeeding generations, and were followed by the utmost confusion of ideas respecting this subject. A most admirable history of this " age of confusion in venereal," as it has been called, is given by Bassereau, which should be read by every one who would understand the origin of those errors from which the medical mind has but recently commenced to free itself, and which yet finds advocates among the profession. In justice to M. Bassereau, who was the first to discover the evidence afforded 1 La Medecine chez les Chinois, par le Capitaine Dabrt, Consul de France en Chine, etc., Paris, 1863. 26 INTRODUCTION. by history in favor of the duality of the chancrous virus, I prefer to give the following extended extract from his remarks instead of a mere abridgment; and this course is the more desirable since the original discoverer is but little known in this country, and others have had the credit of his labors.1 " In the first part of the sixteenth century, a tendency to confound the various venereal diseases appeared. Thus, George Vella (A. D. 1508) attributed them all to the same cause. The following is his line of argument: It is conceded, he says, that before the existence of the French disease, certain women communicated to men by coitus, ulcers which were never followed by that assemblage of symptoms which make up the new disease. But it is also certain that the latter commences with ulcers upon the genitals, which are contracted in the same manner from diseased women, and have the same objective symptoms (quoad sensum visus) as the ulcers of the penis anterior to the appearance of the French disease, so that the most skilful physicians cannot distinguish them. If, then, these ulcers are contracted in the same manner, have the same aspect, and cannot be distinguished from each other, why not refer them to the same principle ? Vella admits that it may be objected that a new effect presupposes a new cause, and that since the French disease was never observed before, it must be produced by some other cause than the one to which we refer the contagious ulcers of the genitals which have been known in all ages. In answer to this objection, he replies, that the causes of disease may at times assume a greater activity, just as we see pestilential fevers produce greater ravages at certain periods than at others, while yet the cause remains the same. "It may also be objected, he says, that the necessity of new remedies indicates a difference in the nature of the disease. He replies, that it is indeed true that the remedies employed to cure the ulcers anterior to the French disease, are insufficient for the new disease, but that the means which are efficacious in the latter, will also cure the former. This is equivalent to saying that the remedy of a severe disease is generally sufficient for a light disease, while the remedy of a light disease is not always the one required for a grave disease. 1 In conversations with American physicians, I have been surprised to find many who were entirely unacquainted with the name of M. Bassereau, and who attributed the honor of producing the first proof in favor of the distinct nature of the chancroid and syphilis to M. Clerc, whose views, differing from Bassereau's and now known to be incorrect, were published two years later than those of the last mentioned author. INTRODUCTION. 27 " George Vella, therefore, very clearly establishes the fact, which we have seen to be apparent in the writings of Alexander Bene- dictus, Marcellus Cumanus, and John de Vigo, viz., the existence of contagious ulcers, the effects of which were confined to the genital organs, before the year 1495, and the appearance about this period of a new disease, which commenced upon the private parts in the form of ulcers, which were soon followed by general cutaneous eruptions, pains in the joints, etc. In addition to this — and the idea is entirely his own — he endeavors to show that these two affections are dependent upon the same cause. " It was not irrational nor inconsistent with pathology in Vella, to consider the new ulcers of the genitals which affect the whole system, as of the same nature as tbe local ulcers which were known in all ages, and to suppose that the latter had suddenly assumed an unusual activity under the influence of some peculiar state of the constitution. Unfortunately, his theory rests only upon two very contestable facts: 1. The identity in their mode of transmission. 2. Their striking resemblance and the impossibility of distinguishing between them. But it is evident that the same mode of communica- tion in two diseases does not prove their nature to be the same; and Vella's supposed similarity in the appearance of all chancres had already been refuted by his predecessors. In fact, most preceding authors had agreed in their statements, that the ulcer which was fol- lowed by general symptoms, could be recognized by its livid aspect and its hard and indurated base; and this ulcer appeared to them so different from the ordinary venereal sore that in their works upon venereal, they described it in separate books or chapters. " The writers on syphilis, whose testimony I have adduced in op- position to Vella's, did not say that the ulcer of the French disease always presented decided special symptoms; nor do I myself attempt to sustain this opinion. In one of the preceding sections, I have shown that the characteristic induration is wanting in a number of venereal sores, followed by syphilitic erythema. " The doctrines professed by George Vella induced neglect of the study of the special symptoms of venereal ulcers, and greatly con- tributed to introduce confusion with regard to them. This confu- sion, however, was especially the work of those physicians, who had commenced the practice of their art subsequent to the year 1495, and who, therefore, were unable to compare the new disease with the venereal affections which had prevailed from time immemorial, before the close of the fifteenth century. In following the change which took place, we find that the first step was to make no distinc- 28 INTRODUCTION. tion in their writings between the old and new ulcer, and to include in their descriptions of syphilis certain complications which belong almost exclusively to the ancient variety. Thus Nicholas Massa (1532), the author of a celebrated treatise on the French disease, includes among the unequivocal symptoms of this affection, suppu- rating buboes, which attend almost exclusively the ulcer of the ancients. Yet it had not escaped the observing mind of Massa, that sores followed by suppurating buboes are rarely succeeded by cutaneous eruptions and other general symptoms; so that, after speaking of these buboes as a symptom of true syphilis, he is obliged to confess that patients who have them are generally exempt from the eruptions and pains which constitute the French disease. ' Et sequuntur apostemata inguinum quae si suppurantur removent aegritudinem.' Matthiolus (1535) also includes suppurating buboes among the symptoms of the French disease. Antony Lecoq (A.D. 1540) speaks of them in the same terms as Nicholas Massa; whilst Fracastorius (A.D. 1530) and Sebastian Montius, both witnesses of the appearance and progress of syphilis, continue to describe this disease (the former in a special treatise, the latter in his 'Dialexeon' published in 1537, when he was eighty years old), as was done by Marcellus Cumanus, Benedictus, Leonicenus, Gaspar Torella, and many others, without including suppurating buboes among its symptoms. " As the venereal ulcers of the ancients, and its attendant suppu- rating bubo, began to be included among the symptoms of syphilis, treatises on surgery ceased to contain those special chapters in which contagious ulcers of the genital organs and inguinal abscesses bad heretofore been described. Discharges from the urethra were also included among the symptoms of syphilis, and still farther modified the tableau. Finally, in the descriptions given of the French dis- ease, not only were symptoms inserted which were completely foreign to syphilis, but the regular course of this affection was entirely forgotten. " This confusion was rendered complete by Anthony Musa Bras- savolus. This physician, who was a laborious student rather than a sagacious observer, seems to have made it an object of his treatise upon the French disease, published in 1551, to collect together all the errors of the writers upon syphilis of this period, and to add others of his own invention. Not only did he include all venereal affections under the head of syphilis, but, as described by him, this affection lost its characteristic physiognomy, and was a mere collec- tion of symptoms succeeding each other without order or reo-ularitv. INTRODUCTION. 29 According to this author, buboes may appear before chancres upon tbe penis; syphilis may commence indifferently as an exostosis, an eruption upon the skin, pains in the bones, or falling out of the hair and teeth. He goes so far as to admit eight primary symptoms, which he calls the simple forms of the disease, and which by their union in various ways may give rise to an infinite variety of com- binations, which he terms the compound forms of syphilis, and limits to two hundred and thirty-four in number. " Brassavolus, it is true, did not escape severe criticism. Gabriel Fallopius, his pupil, called his views ' futile inventions,' and Joseph Scaliger did not hesitate to say that Brassavolus was the echo of the vulgar herd of physicians of his day: ' Cymbalum ineptae medicorum plebis.' But error, especially when sanctioned by a great name, is a source of great danger, since many minds are wont to accept the opinions of others without criticism, and to study books rather than nature. The doctrines of Brassavolus, therefore, were not without influence; and if we except the excellent treatises of Fernel and Leonard Botal, most of the works upon syphilis that appeared during the two following centuries, were more or less tainted with these doctrines. Even at the present day, since the publication of the writings of Hunter, and his annotators, we have still a school of Brassavolus. To be convinced of this fact, it is only necessary to read what has been published on syphilis since the commencement of the nineteenth century. "Yet, after the time of Brassavolus, the syphilitic ulcer, on account of the induration of its base, was still considered by some writers as distinct from the ulcer which is not succeeded by general symptoms. Thus Fallopius (A. D. 1555) devotes the eighty-first chapter of his treatise upon the French disease to the purpose of showing that there are several species of venereal sores; that there is a great difference between the ' caries gallica' and the ' caries non gallica;' that the former precedes the French disease, and has no connection with the latter, which is described in the writings of ancient and also in those of modern physicians prior to the year 1495. "After Fallopius, Antonius Fracantianus (1564), a celebrated pro- fessor at Bologna, also says that the sore which precedes general syphilis, may always be distinguished with ease from the one the action of which is local. ' Siquis carie afficiatur norunt non tantum chirurgi, sed et inepti tonsores, num caries ilia gallica sit nee ne; hoc vero non nisi ab exustione et sorditie, quas livido vel nigro colore, et ex callositate innotescit.' "Again, Nicholas de Blegny, in 1673, speaks of the indurated 30 INTRODUCTION. chancre; but, unlike preceding authors, does not regard it as a distinct species, but as an indication that the general symptoms of syphilis are likely to follow; and, in this respect, his views agree with those of Ricord at the present day." [As the reader is probably aware, Ricord has since adopted the distinct nature of the two species of venereal ulcers.] "After the venereal affections which had been known in ancient times had thus been confounded with the disease which appeared at the close of the fifteenth century, and after the natural history of syphilis had been completely lost sight of under the supposition that the variations in the symptoms produced for the most part by treatment were really modifications in the course of the disease, an incident occurred which is worthy of attention, and does not require comment. Physicians perceived that the recent descriptions of syphilis did not coincide with those given by the authors who had witnessed the earliest appearance of the disease in Europe; and as it was impossible to suspect that the earlier writers had omitted gonorrhoea and suppurating buboes, which were now regarded as the most frequent and positive indications of syphilis, they supposed that the type of the disease had changed, and that since its first appearance new symptoms had been added. Thus Brassavolus says that gonorrhoea was not a symptom of the French disease until about 1520; and Gabriel Fallopius, writing in 1555, that the same disease appeared fifteen years before as a new symptom of syphilis, the Protean nature of which is thus apparent. ' Ultimum signum est gonorrhoea gallica, signum incipientis morbi quae nobis indicat istius Protaei naturam.' Yet Alexander Benedictus had written more than fifty years before, that gonorrhoea, which had been known in every age, had become as it were epidemic since the appearance of the French disease; still, the assertion of Brassavolus and Fallopius prevailed, and, repeated by most succeeding writers on syphilis, became, so to speak, a classic dogma. " Buboes were also considered of more recent date than the other symptoms of syphilis, and their origin was referred to the year 1514, because at that time they were first included among the manifesta- tions of the French disease by Nicholas Massa. " These pretended changes in the disease were the foundation of the fabulous 'periods' or 'epochs' of syphilis, invented by Astruc (A. D. 1736), and composed of various elements, among which are found: 1. The symptoms of those venereal affections which existed prior to syphilis and were successively annexed to it • 2. Certain symptoms belonging to syphilis, as the late form of alopecia and INTRODUCTION. 31 exostoses, which generally appear several years after infection, and which consequently did not figure in the early descriptions of the French disease which were written before the close of the fifteenth century; 3. Certain symptoms, as pustular eruptions, which were very prominent on account of their frequency and intensity for some years, but which were afterwards supplanted in a measure by other manifestations of the disease which at an early period were quite uncommon, but which subsequently acquired a great degree of im- portance ; I refer to gummy tumors, which, according to Fracastorius, were very frequent about the year 1540. " In all these ' periods' of Astruc, only one fact is supported by medical tradition, and that is the gradual diminution in the intensity of syphilitic symptoms, which is attested by many reliable authors, and which is evident to any one who compares the frightful descrip- tions of this disease which were written in the latter part of the fifteenth century, with those which appeared twenty years later, or with others which have been published in our own day. " The modifications of the doctrines professed by those who wit- nessed the first appearance of syphilis in Europe, could not fail to affect the treatment of venereal diseases. Before the year 1495, ulcers of the genital organs, the suppurating buboes dependent upon them, the various forms of vegetations and discharges from the urethra, were considered as purely local affections, and treated by means of local remedies. As soon as the French disease appeared, the insufficiency of all topical applications in the treatment of the new disease was manifest; but human ingenuity, never more fertile in resources than under circumstances of great necessity, soon dis- covered in mercury a powerful modifier of the new complaint. For several years this remedy was employed in the form of frictions, and only in case the patient had broken out with an eruption fol- lowing a sore upon the genital organs; but it soon became the custom to resort to mercurial inunction immediately after contagion and during the existence of the primary sore, with a view of pre- venting the appearance of general symptoms. This practice was first recommended by James Cataneus, who thought that the same remedy which cured the pustular eruption would also prevent it. ' Haec enim onctio, absque dubio, tale destruit virus quod enim unam sanat aegritudinem, ab e&dem praeservat.' " This wise precept, to employ mercurial medication during the existence of the primary sore for the purpose of preventing a gene- ral eruption, soon gave rise to the most serious errors; for, about the time that it was given, physicians began to ignore the distinction 32 INTRODUCTION. between the two species of ulcers, and were consequently led to treat them all indiscriminately with mercury. This injurious, not to say barbarous practice, has been continued to tbe present day, and has led to an exaggerated estimate of the powers of mercury, which, for three centuries, has been given to a multitude of patients, who have been supposed to be preserved through its influence from symptoms of which they stood in no danger. " Hence we may explain the success of all those modes of treat- ment which charlatans have endeavored to substitute for mercury when given during the existence of supposed primary symptoms, as a prophylactic against secondary manifestations; since, if the same treatment, no matter what, be applied without distinction to patients with gonorrhoea, ulcerations, and buboes, there will always be a large proportion who will escape farther trouble, for the simple reason that their symptoms do not belong to the disease which first appeared in the fifteenth century, and are, therefore, incapable of infecting the general system." Probably no cause contributed more powerfully to the production and continuance during three centuries of confused ideas respecting venereal diseases than the fact that they are usually transmitted in the same manner, viz., by sexual intercourse. As already seen, this was a strong argument with George Vella in favor of their dependence upon one and the same poison; and it may well be doubted if it has entirely lost its weight at the present time. And yet it requires but a moment's thought to be convinced that this is the shallowest possible foundation upon which to build a theory as to the nature of any disease; for if identity in the mode of commu- nication proves identity of species, we must regard all those affec- tions which are conveyed through the medium of the air, or, in other words, the whole tribe of epidemics, as constituting one dis- ease ; those which are communicated by contact, as the itch, favus, etc., another; and so on, making as many species as there are ways of transmission. As Rollet has ably shown,1 the communication of gonorrhoea, the chancroid, and the initial lesion of syphilis in the sexual act is merely an accidental circumstance, and due to the fact that these diseases are capable of affecting the genital organs which are brought into such frequent and intimate contact. The conditions i De la Plurality des Maladies VSneriennes, Gaz. MeU de Lyon, No. 7, Apr. 1, 1860. It is probable after all that the yaws and radzyge, as well as a number of' other contagious diseases hitherto supposed to be peculiar to certain localities, are nothing but syphilis. See Rollet, Recherches sur la Syphilis, etc., Paris, 1861. INTRODUCTION. 33 during coitus are in the highest degree favorable for contagion to take place; and all contagious diseases, the active principle of which is fixed and not volatile, which find their natural habitat in man, and which are capable of affecting the genital organs in the two sexes, are frequently transmitted in this manner. The only diseases of this latitude which fulfil these requirements are gonorrhoea, the chancroid, and syphilis; while " in those countries in which other contagious affections, as the yaws and radzyge, foreign to our own climate, exist, they also are communicated in sexual intercourse, and are, strictly speaking, venereal." Scarlet fever, variola, measles, and other contagious diseases dependent upon a volatile poison, are naturally transmitted by way of the respiratory organs. Hydro- phobia, glanders, vaccinia, etc., are not natural to man; and those contagious diseases which depend upon the presence of a parasite, as tbe itch, favus, and herpes tonsurans, are incapable of affecting mucous surfaces. This is not the only mode of transmission of veneral diseases, since gonorrhoeal inflammation is not unfrequently communicated from one eye to another through the medium of the conjunctival discharge conveyed upon towels and other articles in common use; and the secretion of the chancroid and of the lesions of true syphilis, whether primary or secondary, is contagious when properly applied, by whatever means, to any part of the body. In infants, the frequent and intimate contact of nursing takes the place of that during coitus, and the most common mode of transmission of venereal diseases is through the medium of the breast; while even in adults syphilis is not unfrequently contracted from a primary or secondary lesion situated upon the mucous membrane of the mouth, tongue, or fauces. GONORRHCEA AND SYPHILIS DISTINCT. Our review of the history of venereal diseases has incidentally furnished us with proof that gonorrhoea and syphilis are not dependent upon the same poison by showing that they have origi- nated at different periods, the former being known in all ages, the latter only since the close of the fifteenth century; but the chief evidence of the distinct nature of these affections, like that of all other diseases, is to be found in clinical observation. We infer that intermittent fever is different from whooping-cough, the smallpox from rheumatism, phthisis from the measles, etc., because the symp- toms, course, termination and susceptibility to the action of remedies, in each, are different. And yet, in none of the diseases mentioned, is the difference greater than between gonorrhoea and syphilis; the 3 34 INTRODUCTION. former being characterized by the symptoms of catarrhal inflamma- tion common to mucous membranes, not infecting the general sys- tem, exposed to complications which are for the most part seated in organs which hold direct communication with the urethra through the medium of a mucous surface — as, for instance, the testicle, bladder and prostate, amenable to local treatment, and terminating in resolution and a complete restoration to health; the latter disease commencing with an ulcer followed by a long category of general symptoms, its complications usually seated in the lymphatic system, mercury and iodine its chief remedies, its effect upon the constitu- tion, if not permanent, at least of long duration. And let it not be objected to this argument, that the premises assume what it is attempted to prove. Nothing has been assumed, but a simple statement given of the results of clinical observation. The differences which I have mentioned characterize the two dis- eases in the great majority of cases, as every one will admit; and the general testimony afforded by the symptoms, course, and termi- nation is, in all diseases, considered sufficient to establish their distinctive character. In the exceptional cases, in which one dis- ease appears to run into another, we seek and are generally able to find an adequate explanation, although in some instances we fail; but we do not, therefore, infer that the line of demarcation between them should be entirely effaced. Let any one follow out a series of cases of gonorrhoea from their commencement, assuring himself that the constitution is not already infected with syphilis from previous exposure, making a careful examination for the purpose of ascertaining that no chancre is present upon any part of the body, and keeping the patient under observation, in order to be sure that no primary sore is subsequently contracted, and it may safely be asserted that the investigation will satisfy any candid mind of the distinct nature of gonorrhoea. In all the reported cases, with scarcely an exception, which have ap- peared to favor a belief in the identity of gonorrhoea and syphilis, the mode of investigation has been exactly the reverse of the above. The patient has not been seen by the surgeon until general symp- toms have appeared, and the only knowledge of his previous historv has been derived from his own lips. Now, such cases are entirely valueless, for the simple reason that a patient is an incompetent witness upon a subject with regard to which, unless a medical man he is necessarily ignorant. He may state, with perfect honesty, that his only previous symptom has been an attack of gonorrhoea and yet he may, without knowing it, have had a chancre within the INTRODUCTION. 35 urethra, or even upon the external surface of the genitals (since the superficial form which a chancre most frequently assumes, may be attended by such slight symptoms as entirely to escape observation), or a primary sore may have been situated upon some remote part of the body, and, consequently, its character not have been suspected, and, in many instances, careful inquiry and examination will show that one of these suppositions is true. There are also other sources of error too numerous to dilate upon here, but which will receive due consideration hereafter. Now, with these facts before us, and even granting, in some cases of general syphilis, apparently com- mencing with a discharge from the urethra without appreciable ulceration, that no plausible explanation can be discovered, which is the more probable; that such explanation really exists, or that nature in disease belies herself by contradicting in a few rare instances what she is constantly teaching in unmistakable terms in the overwhelming majority? Ricord thought to find additional proof of the distinct nature of gonorrhoea and syphilis in artificial inoculation. He inoculated the discharge of the former upon the patient and the result was nega- tive ; the same experiment, performed, as he supposed, with the secretion of a chancre, was successful; whence he concluded that artificial inoculation upon the person affected, would enable us to distinguish between the urethral discharge of gonorrhoea and that from a concealed chancre. He has since discovered that a true chancre is not auto-inoculable, and, consequently, that his successful inoculations upon the individuals from whom the matter was taken must have been performed with the virus of the chancroid. It fol- lows, therefore, in respect to capability of inoculation upon the patient himself, that a chancre is precisely upon the same footing as gonorrhoea; neither one nor the other is auto-inoculable; and hence this test, at one time much insisted upon by Ricord, though not original with him, is proved fallacious. For all practical purposes, the idea that gonorrhoea is identical with syphilis is exploded; for although, in some works upon vene- real, this error still retains the form and proportions which it assumed for three centuries, it is a corpse without life; since, how- ever its friends may preach, it would be difficult to find one among them who puts his principles in practice, and treats gonorrhoea with mercury. Diday * has adduced the testimony of three of the Internes of the Hopital du Midi in proof of the fact that Vidal, one of the 1 Nouvelles Doctrines sur la Syphilis, p. 100. 36 INTRODUCTION. strongest advocates among recent writers of the syphilitic nature of gonorrhoea, invariably treated this disease as a simple inflammation without mercury. THE CHANCROID AND SYPHILIS DISTINCT. The separation of gonorrhoea from syphilis had for many years been received as beyond dispute, while the contagious ulcer of the genitals and that constitutional disease which was first known in Europe about the year 1494, were still confounded under the name of syphilis and regarded as modifications of one and the same affec- tion. In 1852, however, the discovery was announced that the latter diseases are as radically distinct as the former, and that they bear no resemblance to each other except in their most frequent mode of transmission by sexual intercourse. The great revolution in medical belief upon this subject which, in the few years that have since elapsed, has been constantly gaining adherents, and which even now, I do not hesitate to say, is supported by the greater weight of authority throughout the world, requires more than a passing notice. We may first, however, with both interest and profit, recall some of the glimmerings of this truth which had already crossed the minds of certain careful observers. It had for a long period been a matter of common observation that some venereal ulcers, even when not subjected to treatment, were limited in their action to the part upon which they were situ- ated and its immediate neighborhood; while others were attended by infection of the general system. Mr. A., for instance, would have a sore upon the penis and a suppurating bubo in the groin, but, after these were healed, no further trouble; while Mr. B. would contract an ulcer, which would be followed by a train of general symptoms, extending over a period of years, and perhaps affecting his offspring. This remarkable difference was explained on the ground of a diversity in the constitutions of the two individuals. The seed was supposed to be the same in both cases, but some pecu- liarity of soil in which it was implanted produced a different mode of germination. There was an unknown something in the system of Mr. A. which protected him from constitutional infection, while the absence of the same in Mr. B. exposed him to it. If either of these men should communicate his disease to a woman, her sore it was thought, would be attended by systemic syphilis or not, according to her peculiar idiosyncrasy, and independently of the source from which the virus came. The unsatisfactory nature of these views had attracted attention INTRODUCTION. 37 and awakened doubts of their correctness in the minds of several surgeons. Hunter devotes Part VII. of his work on Venereal to a consideration of "Diseases resembling the Lues Venerea, which have been mistaken for it," and which he is often evidently at a loss to classify. But although frequent misgivings as to the correctness of his views are to be found in his writings, he still maintained that "there is no difference in the kind of matter, and no variation can arise in the disease from the matters being of different degrees of strength; the variations of the symptoms in different persons de- pend upon the constitution and habit of the patient at the time."1 Abernethy was also at a loss to account for many syphilitic phe- nomena, and especially for the development or non-development of general syphilis after venereal ulcers which closely resemble each other. In his work entitled " Surgical Diseases resembling Syphilis," when speaking of venereal ulcers, he says: " It is from their effects upon the constitution alone that we can judge whether they are syphilitic or not." (p. 59.) CarmichaeV in 1814, took a decided stand in favor of a plurality of poisons, of which he admitted four, but he believed that they were all capable of affecting the constitution, though some were susceptible of spontaneous cure without mercury. The distinctions which he drew were grounded more upon the character of the erup- tion than upon the appearances of the ulcer, as will appear from the following summary:— " 1. The scaly eruption which appears under the form of lepra and psoriasis, and terminates in ulceration, is alone produced by the syphilitic primary ulcer, characterized by its slow progress, and its indurated edge and base; and we find that both local and constitu- tional symptoms yield with almost invariable certainty and celerity to the action of mercury. " 2. The papular eruption which terminates in exfoliation of the cuticle may either be occasioned by the smooth superficial ulcer, without induration or ulcerated edges, or by a purulent discharge from the surface of the glans and prepuce (balanitis); or, thirdly, by a gonorrhoea virulenta; and we have found that these different species of the same disease are alike capable of a spontaneous cure, or of being removed by external astringent applications; and that the constitutional disease they produce, is, like the primary, also capable of a spontaneous cure, which is promoted by antimony and decoctions of the woods. 1 Ricokd and Hunter on Venereal, 2d edition, p. 47. 1 Essay on the Venereal Diseases which have been confounded with Syphilis. 38 INTRODUCTION. " 3. The pustular eruption which terminates in ulcers, covered by crusts, is either occasioned by the phagedenic or sloughing ulcers. These distinctive venereal complaints, in their primary stage, are best treated by such means as subdue inflammation and sympto- matic fever, and by anodyne medicines, such as cicuta and opium. In their secondary stages, the decoctions of the woods, antimony, and mercurial salts, in alterative doses, are the means most to be depended upon; but change of air, and such measures as may tend to strengthen the constitution, are also of unquestionable moment. "4. The tubercular eruption which terminates in deep, irregular ulcers, has been traced, in one instance only, to a primary sore, which from the manner it undermines the skin, has been named the bur- rowing ulcer. But until other cases concur to demonstrate this connection, it would be premature to conclude that the one always occasions the other. The treatment is the same as for the phage- denic ulcer. "5. The diseases likely to be confounded with syphilis, which arise spontaneously from a disordered state of the constitution, fre- quently assume the form of the tubercular eruption. But after ulceration, the sores do not continue so extensive, jagged, and obstinate, and particularly under the means recommended, as those of venereal origin. Treatment: nitrous acid, the woods, and altera- tive doses of mercury." These views were never generally adopted, even in Dublin, where Carmichael resided, and after a brief notoriety were almost entirely forgotten. But Ricord appears to have had the clearest anticipations of the discovery which was destined to emanate from his "school," or from among his pupils and followers. In the absence of proof to the con- trary, this surgeon advocated, in general, the unity of the syphilitic virus, and explained its different effects on the ground of constitu- tional differences already referred to; but Mr. Victor de Meric1 states that Ricord remarked to him many years ago: "You may rest assured that some day distinct origins will be found for the infecting and non-infecting chancres;" and in the first edition of his Letters on Syphilis, published in 1851 (p. 257), when referring to the fact that in experiments upon syphilization, inoculation of the matter of chancroids had always produced chancroids, while in the single instance that pus from a true chancre had been employed, a true chancre was the result, this author says: "If these results were Lettsomian Lectures, 1858, p. 9. INTRODUCTION. 39 constantly obtained, we should be forced to conclude, that there are differences in syphilis which do not depend alone upon the condition of the individual upon whom the cause acts, but upon differences in the cause itself." With this brief history of opinion regarding this important ques- tion, we come down to the year 1852, when the first successful assault was made on the old doctrine of idiosyncrasies and temperaments, and led to its final overthrow and the establishment of the duality of the chancrous virus. At this time, M. Bassereau, a former pupil of Ricord, published his " Traite des Affections de la Peau, Sympto- matiques de la Syphilis," a work characterized throughout by such originality of thought and accuracy of investigation that its perusal is essential to every one who would be thoroughly informed on venereal diseases. Although nominally a treatise upon syphilitic eruptions alone, many other subjects connected with syphilis are discussed, and among them the unity or duality of the virus, hitherto regarded as one. Justice to the author, the intrinsic and historical interest of his remarks, the manly and cogent style of his reasoning, and the absence, so far as I am aware, in the English language, of any suitable exposition of his views expressed at this early day, demand a somewhat extended quotation, which I shall give in the form of a free translation, with such abridgment as my limits as to space require. It is necessary to premise that this question is discussed by M. Bassereau in his chapter on syphilitic erythema, which, being one of the earliest symptoms of general syphilis, affords a better opportunity for tracing the connection between primary and secondary lesions than any other. The cases of erythema, to which frequent reference is made, number 170, if we exclude twenty-eight in which the absence of information regarding the primary ulcer precluded any comparison. In the tenth section of the chapter upon this subject, entitled: " Recherche des causes qui ont pu determiner le developpement de l'erytheme, c'est-a-dire la generalization des symptomes syphilitiques dans l'economie," M. Bassereau says:— "There can be no question of the fact that there are venereal ulcers which may be treated by the most simple remedies without the employment of any mercury whatsoever, and yet never be followed by the symptoms of general syphilis. Any one may convince himself of this truth by inquiring of old men, many of whom will state that they had venereal ulcers several times in their youth, which were treated with simple cerate, lint, or other means to INTRODUCTION. destitute of specific action, and, though they have never taken mercurials, there has not been tbe slightest appearance of constitu- tional syphilis during the thirty or forty years which have since elapsed. Many persons also will repeatedly have ulcers and escape infection, but will finally contract another which will be followed by a syphilitic eruption. Why this difference ? What should limit the action of the sore in the one case and in the other extend it to the whole system? This is an interesting problem, and I will proceed to give the results of my attempts to solve it. Let no one who is wont to pay respect to opinions which have received the stamp of authority take umbrage at the novelty of the propositions which I am about to present, or be hasty in rejecting them. The question at issue is so important that it deserves serious examination. It is not to be decided by an appeal to the vague impressions left on the mind by former experience, or by the doctrines of this school or that; it can only be settled by new investigations undertaken for the very purpose. I ask therefore of unbiassed men to devote the necessary time to verify the facts which I am about to present, and to give them their most scrupulous attention. "Among the causes which I have investigated, I have endeavored to ascertain if age has any influence upon the infection of the system by syphilis, and I have satisfied myself that it has none. From birth to the most advanced years, men may have sores which, at any age, may be followed by general syphilis; and though infec- tion is more common among the young, it is simply because they are more exposed. Sex is equally devoid of influence. Ricord states that venereal ulcers are less frequently indurated in women than in men, which is equivalent to saying that women are less liable to syphilis, since it can be easily shown that infection attends in most cases indurated chancres. I do not believe, however, that Ricord carries the induction thus far. For my own part, I think that the rarity of induration in women is only apparent. Indeed, in an examination of the same number of venereal ulcers in the two sexes, I have found nearly the same proportion indurated in the one as in the other; with this difference, that the induration was generally poorly marked on the vulva, while it was very decided upon the penis. Just as the skin of various parts of the body is not equally susceptible of the development of induration, so this symptom is less frequent upon the genital organs in women than in men. But women are not on this account less exposed to syphilis. Though fewer persons of this sex are affected with this disease it is because the number who are addicted to debauch is incomparably INTRODUCTION. 41 less than of men; whence venereal affections of all kinds, syphilis included, are less common among them, and the difference cannot be attributed merely to sex. "Again, idiosyncrasy will not explain the fact that a sore is only local in its effect in one person, while in another the system at large is contaminated. This is proved by the number of persons who, after having numerous simple ulcers, contract another which becomes indurated and is followed by general manifestations. " Can such different results from two acts of contagion by a virus reputed the same be accounted for by the changes which frequently take place in the constitution, and by virtue of which a man is not affected in the same manner by the same agent at times very nearly approximated? Doubtless such dissimilar effects might depend upon the particular disposition existing at the time of contagion; but this explanation is admissible only in default of a better, espe- cially as it is opposed to what we know of the action of specific causes, which always tend to produce the same results. "I have carefully studied the temperament and constitution of persons affected with syphilitic erythema, in order to discover if any one of these organic modifications of the system might not influence the development of syphilis, but such inquiry has led to no positive result. I have found all temperaments affected in nearly equal proportion; none can therefore be regarded as peculiarly con- ducive to the extension of the virus throughout the economy; and the same may be said of difference of constitution. " An insufficient amount or the bad quality of food, which is a powerful aggravating cause of syphilitic symptoms, has been so rarely observed in the cases of erythema which have come under my notice, that it is impossible to ascribe to it the development of general syphilis. The abuse of alcoholic stimulants, changes of temperature, and intercurrent diseases appear to have had no more effect. I have merely noticed that chancres contracted during warm weather are more rapidly followed by syphilis than during cold. " The above remarks clearly show that neither age, sex, idiosyn- crasy, temperament, constitution, hygienic influences, nor coexisting diseases which might be supposed to have depressed the system at the time contagion took place, can, each by itself, be regarded as the determining cause of infection; and if we group them all together instead of considering each singly, my statistics will show that they will not account for one-third of the cases of constitutional disease. The better to appreciate the etiological value of these influences, I have examined the condition of those persons whose ulcers, in spite 42 INTRODUCTION. of the absence of all treatment capable of retarding or destroying a tendency to secondary symptoms, have not been followed by gene- ral syphilis. I have compared one hundred such cases with an equal number of patients affected with syphilitic erythema, and have found in each nearly the same proportion of lymphatic tem- peraments, feeble constitutions, bad hygienic influences, etc., thus confirming my opinion of the necessity of searching for other than physiological and hygienic causes of the generalization of syphilitic manifestations. " I have also sought for the solution of this question in tbe sore itself. I have endeavored to ascertain if repeated acts of contagion might not favor the appearance of secondary symptoms. On exam- ination of the cases cited, I found that in 112 cases the eruption appeared after several successive ulcerations, and in 86 after a single one. Notwithstanding the predominance of the former, it cannot, I think, be admitted that repeated attacks are the cause of constitu- tional infection. The idea that the action of a virus must be accu- mulated to produce its utmost effect is but little in accordance with the medical knowledge we already possess. In a number of my cases, also, there was so long an interval between the ulcers that it appears to me difficult to attribute to the first contagion any influ- ence whatever in the production of the syphilitic manifestations which followed the last exposure. "Again, I have inquired if individuals affected with several ulcers at one time, were not more exposed to constitutional infec- tion than those having only one, and who consequently bore upon their persons a smaller surface secreting contagious matter; but I found this could not be the case, for of the 170 instances of syphi- litic erythema, 141 had had but one, and only 29 multiple ulcers; whence I conclude that neither the plurality of the sores nor the extent of the secreting surface can be regarded as the cause of the constitutional manifestations which sometimes appear. These results are analogous to those obtained by Kirkpatrick, Dimsdale, and Gatti in experiments with the virus of variola, from which it ap- pears that there is no connection between the number of inoculated points and the copiousness of the consecutive eruption. Girot even observed that the eruption of variola was milder and more discrete after inoculating in six places than when only two punctures were made. "An analysis of these cases of syphilitic erythema also shows that the development of general syphilis is not affected by the situa- INTRODUCTION. 43 tion,1 degree of ulceration, or duration of the sores. General symp- toms may supervene, on whatever part of the body the sore is situated; and the intensity of the former is not increased when the ulcer is at a distance from the genital organs, as was once supposed by Boerhaave. A decided tendency to extend by ulceration is also innocent of the development of constitutional syphilis; for I have often seen the mildest and most superficial erosions followed by infection, while phagedenic sores proved innocuous. Those ulcers which last for a long period are not more likely to terminate in secondary syphilis than those which cicatrize within a moderate or short space of time, as may also be seen from an examination of these 170 cases. " On the other hand, induration is so frequent a symptom of these ulcers2 that it is impossible not to admit that it bears an intimate relation to the syphilitic erythema which ensued. But even if it could be shown that all chancres are indurated, must we necessarily say that induration is the cause of infection ? By no means; for this would only be avoiding the question instead of solving it, since the cause of the induration would still remain to be discovered. " Finally, in my investigations I have endeavored to ascertain if any relation existed between the symptoms presented by my patients and those of the persons from whom they contracted their disease. Such inquiry is often difficult, for men are frequently infected by women whom they never see but once, and of whose name and address they are ignorant. Some have intercourse with several women within a short time preceding the appearance of the sore, so that the source of the virus is doubtful; others refuse to give any information with regard to the persons with whom they have had connection. In some cases, however, we are able to compare the symptoms in the two sexes. Patients often bring to me for examination the women who infected them, or else put me in the way of visiting them at their homes. Frequently, also, at the Hopital des Veneriens, I have found two or three, or even a larger number of men who contracted their disease from the same woman, either on the same day or at a few days' interval. Finally, in several instances I have seen both a wife and a husband, and even their children, all affected with syphilis which had been introduced into the family through one of its members. 1 At the time this was written, the fact that chancroids are rarely met with upon the head or face was not known. 2 Of the 170 chancres, 157 were known to be indurated; in 13 induration was doubtful. 44 INTRODUCTION. " These repeated confrontations of persons infected by each other — undertaken at first to determine what syphilitic lesions are con- tagious and what are not; to show what symptoms may succeed others, and what modifications the same symptom may undergo by transmission between individuals of different sex and temperament — have led to the discovery of that hitherto mysterious cause by virtue of which venereal ulcers sometimes limit their action to the part on which they are situated and the neighboring ganglia, and at other times extend their effect to the system at large and are followed by general syphilis. The following propositions embody the results obtained from the confrontation of patients affected not only with erythema, but also with other syphilitic eruptions and primary sores, with those persons from whom their disease was derived:— " If we compare persons who have had venereal ulcers followed by general symptoms with those persons who inoculated them, or with those whom they in turn have inoculated, we find that all, without exception, have had constitutional syphilis; never, in any case, has the action of the sore been merely local. " On the other hand, by the comparison of individuals who have had ulcerations which did not result in general manifestations with the individuals who infected them, or with those whom they have infected, we find without exception that the latter, equally with the former, have had sores, the action of which was limited to the part first inoculated. Thus an ulcer followed by constitutional syphilis never gives rise to a merely local ulcer; and a purely local ulcer cannot produce an ulcer which will be followed by the general manifestations of syphilis. The uniformity of the facts which have come under my observation — none but apparent exceptions having ever been met with—fully justifies me in enunciating the following proposition as a law:— "Whenever a person has a chancre and afterwards general syphilis, the generalization of the disease is first of all due to the fact that the person from whom the contagion came had a chancre which was neces- sarily followed by general symptoms. "Of thirty-four cases of syphilitic erythema, in which I have been able to confront the patients with those who infected them, and in some instances with those whom they had afterwards infected, in thirty-one, conformably to the law just enunciated, all the indi- viduals thus confronted presented lesions of the same character; all without exception had ulcers which were followed by general syphilis. In only three, from the absence of symptoms of general infection, did there seem to be any exception, but induration was INTRODUCTION. 45 found at the site of the sore, showing that the exception was only apparent; moreover, the mercury which had been administered for the latter fully accounted for the absence, or delay in the appearance, of general manifestations." The immutability of these two varieties of venereal ulcers being thus established by clinical experience, it is evidently necessary to admit that they constitute two species. The question then remains whether or not they bear any relationship to each other. One of two alternatives must be true: the virus of both must be the same, but of greater intensity in one than in the other; or there must be two poisons totally and radically distinct. Two years after the publication of M. Bassereau's work, the first mentioned supposition was adopted by M. Clerc,1 another pupil of Ricord, who maintained that the virus of the soft was a modification of that of the hard variety; the former bearing the same relation to the latter that varioloid does to variola, and the false to the true vaccine pustule; and in accordance with this view, the name of "chancroid" was given to the first, while the term chancre was exclusively reserved for the second ulcer. This modification, as M. Clerc believed, was produced by the passage of the virus through the system of a person already under the influence of the syphilitic diathesis; the poison, thus materially changed in its nature, was capable of indefinite transmission by contagion, but could never recover its original power of infecting the constitution; just as the false vaccine pustule may sometimes2 (not always) be inoculated from one individual to another without affording protection against variola, or, in other words, without exerting any influence upon the general system. M. Clerc's theory was sufficient to explain all the phenomena hitherto stated in the quotation from M. Bassereau, and it only remained to demonstrate by direct observation whether or not the transmission of the syphilitic virus through a system already infected would produce such modification as was claimed in its nature. At the time M. Clerc's essay appeared, the necessary facts were want- ing to determine this point, but they have since been met with and 1 M6moire du Chancroi'de Syphilitique, Paris, 1854. 1 The theory of M. Clerc appears to be as defective in its analogies as in the ab- sence of direct proof, for the false vaccine pustule is not always perpetuated as such; and there is abundant evidence—cited very fully by M. Fournier (Legons sur le Chancre, p. 168)—to show that varioloid may give rise to variola and vice versa in subjects unprotected by vaccination or previous attacks. The assumed per- manence of these forms of disease, when once established, cannot therefore be sustained. 46 INTRODUCTION. have proved the theory without foundation. In several instances, a man laboring under the symptoms or diathesis of general syphilis has contracted a sore from a woman having a true chancre, and although, under these circumstances, as will be seen hereafter, the ulcer in the male closely resembles a chancroid in appearance, yet if it be communicated to a third person as yet free from constitu- tional taint, the result will be a chancre and general syphilis. We thus have positive proof that no such modification takes place as asserted by M. Clerc; and his theory is at present generally aban- doned, although the term " chancroid" is conveniently retained to distinguish the local ulcer from the true chancre. Bassereau regarded the first alternative above mentioned, of which Clerc's theory is the only representative, as deserving of rejection from the absence of any proof in its favor; and boldly advocated the second, viz., that the virus of the chancroid is radically distinct from that of a chancre. As we have already seen, Bassereau found additional evidence of the correctness of this view in a careful study of the older writers on medicine, from which it appears that simple venereal ulcers have been known from the earliest times of which we have any record; that the true chancre and general symptoms were first observed in the latter part of the fifteenth century, during the Italian epidemic; and that for twenty or thirty years afterwards these two species of ulcer were never confounded; the duality of the chancrous virus is not therefore a modern discovery, but was familiar to those who wit- nessed the first irruption of syphilis into Europe. Adopting Bassereau's own words: "When we read all that ancient and modern authors have written on the diseases of the organs of generation, we find that gonorrhoea, venereal ulcers, buboes, and vegetations are mentioned as late as the last years of the fifteenth century, as diseases requiring only local treatment; up to this time there is not the slightest allusion to any symptoms consecutive to the diseases of the genital organs. The end of the fifteenth century, according to all contemporary authors, was marked by the appearance of a new disease. This disease com- menced by indurated ulcers upon the genital organs, which were speedily followed by pustular eruptions over the whole body, and by frightful pains in the head and limbs. The physicians who were eye-witnesses of the new disease did not at first confound the callous ulcers in which it commenced with the ulcers of the genital organs which had been known for ages. Thus these two species of ulcers occupy in their writings separate chapters, and even separate books. INTRODUCTION. 47 But, twenty or thirty years after the appearance of syphilis in Eu- rope, many physicians not knowing, as those did who witnessed its first ravages, how to distinguish the symptoms by which the new disease commenced from those which had no relation whatever with it, assumed by degrees the habit of submitting to mercurial treat- ment, without distinction, all persons affected with gonorrhoea, ^ulcers and buboes; for it had already become a general practice to admin- ister mercury, not only for the purpose of modifying existing syphi- litic symptoms, but also as a prophylactic agent against future symptoms, as soon as the first signs of contagion began to appear. The confusion which reigned in practice was soon introduced into the works of the day; the writers on syphilis in the middle of the sixteenth century included, one by one, under the name of syphilis all those venereal symptoms which had been known from the earliest antiquity, and which the physicians who exercised their art in the last years of the fifteenth century had taken care to separate from the symptoms of the new disease." The attention of the profession being thus directed anew to the important question of the unity or duality of the chancrous virus, other observers immediately set to work to test the accuracy of M. Bassereau's observations, and new facts soon began to appear, all of which were found to point in the same direction. In 1856, M. Dron1 was able to collect one hundred and eleven instances of con- frontation, including those of Bassereau relating to the initial lesion of syphilis, those of M. Clerc relating to the chancroid, and others relating to both varieties furnished by Diday, Rollet, Rodet, and Fournier, and in all, without exception, the type of the ulcer remained unchanged in passing from one individual to another. Farther investigations, under the supervision of Ricord and with the same result, were made by MM. Fournier and Caby, who availed themselves of the unequalled facilities for such examination afforded by the chief venereal hospitals of Paris—one (du Midi) devoted to men, the other (St. Lazare) to women—and of the vigilance of tbe French police. These observations were published in detail by M. Fournier in his edition of Ricord's Lecons sur le Chancre,2 and also in a pamphlet entitled, Recherches sur la Contagion du Chancre,3 and comprise fifty-nine cases of transmission of chancres, and thirty-nine of chancroids. The value of many of these cases was materially enhanced by the fact that two or more men were contaminated by the same woman, and thus the testimony in favor of the duality of 1 " Du Double Virus Syphilitique," these de Paris, 1856. 2 Paris, 1858 3 paris, 1857. 48 INTRODUCTION. the chancrous virus was multiplied. In one, two friends, who shared the favors of the same woman having a true chancre, caught, each of them, a chancre followed by general symptoms; and the father of one of them, an old man aged seventy-three, had connec- tion with his son's mistress, and met with the same fate. Again, six persons were infected from the same source, and the consequences in all were identical, viz., chancres and general manifestations. So with the chancroid; in several of Fournier's cases, two, three, or four men, bearing chancroids, were found together in the wards of the Hopital du Midi, all of whom ascribed their contagion to the same woman; who, on examination, was proved to have the same species of sore; and in none did general symptoms appear during several months that they were kept under observation. Thus far in our account of Fournier's investigations, we find that they merely confirm the observations of Bassereau, since they all relate to the transmission of venereal sores between persons free from previous syphilitic taint. It remains to be proved what effect, if any, is produced in each species by being communicated to a svstem already under the influence of the syphilitic diathesis. The solution of this question was also undertaken by Fournier, who found, as regards the chancroid, that the sore was in no way modi- fied ; that if, for instance, a woman having a chancroid, communi- cated it to a man whose constitution was already infected with the virus of true syphilis, and he gave the same to a woman free from such taint, the resulting sore would in no respect be changed in consequence of the general infection of the man through whom it had been transmitted. This result might have been predicted before- hand, from a consideration of the distinct nature of the two kinds of virus, neither of which will directly influence the other, any more than syphilis will affect the course of gonorrhoea, or vice versa. With regard to the true chancre the results were more novel and interesting. A sore of this species, communicated to a subject already infected with syphilis, does not present its usual character- istics ; it is either not at all or only imperfectly indurated and is unaccompanied by induration of the neighboring lymphatic gan- glia ; in short, it so closely resembles a chancroid that it cannot be distinguished from it by any outward sign.1 If, however, this sore —in appearance a chancroid, but in reality a chancre, modified by the constitutional infection of the person bearing it—be communi- cated to a third person free from constitutional taint, it will resume 1 This point will receive further consideration hereafter. INTRODUCTION. 49 its normal characteristics, will become indurated, be accompanied by induration of the neighboring lymphatic ganglia, and be followed by the general manifestations of syphilis. The evidence on which the statement just made regarding a chancre is based, is sufficient, though not so great in amount as that relating to the transmission of chancres between individuals free from constitutional infection; since facts capable of solving the question under consideration are necessarily rare. For, in the first place, the syphilitic virus rarely takes effect at all upon a subject already infected; one general attack protecting against even local manifestations of the poison, just as vaccination is without result upon a system once imbued with the vaccine or variolous virus; and, in the second place, supposing contagion to occur, the disease must be again communicated to a person who has always been free from constitutional taint. These numerous and complex require- ments, however, have all been present in seven cases, of which Cullerier,1 Melchior Robert,2 and Diday,3 each observed one, and Fournier and Caby four; and they all concur in showing that, con- trary to M. Clerc's theory, the syphilitic virus is not modified by being communicated to a system already infected, and although it produces a sore apparently identical with a chancroid, its essential attributes are unchanged. Another point to which Fournier directed his attention was whe- ther phagedenic ulceration is due to any peculiarity inherent in the virus—a question which the confrontation of patients answers in the negative. The origin of phagedena is probably complex, being attributable in some cases to noxious principles in the primary pus of contagion, more frequently to constitutional cachexia in the reci- pient, and sometimes to both causes combined; but without entering fully into its etiology, it is sufficient for our present purpose to say that the virus of phagedenic ulcers is not a distinct species, since this form of ulcer may owe its origin either to a chancroid or a true chancre. The results thus far attained by comparison of the symptoms of those giving and those receiving venereal ulcers may be summed up in the following propositions:— 1. Among persons free from previous syphilitic taint, each of the two species of ulcer is transmitted in its kind: the chancroid as a chancroid limited in its action to the neighborhood of its site; the chancre as a chancre, followed by general manifestations. i Fournier, Contagion du Chancre, p. 57. 2 Dron, These, already referred to. 8 Annuaire de la Syphilis, ann^e 1858, p. 277 4 50 INTRODUCTION. 2. A sore with a soft base, and unaccompanied by induration of the neighboring lymphatic ganglia, in a subject already infected with syphilis, will, when communicated to a person free from syphi- litic taint, give rise either to a chancroid or to a chancre, according to the nature of the virus which occasioned the first mentioned ulcer. 3. The virus of a chancroid is a poison distinct from that of a chancre. 4. Phagedenic ulceration of a venereal ulcer does not depend upon a specific difference in the virus. In reviewing the labors, of which a somewhat full account has now been given, we find that the duality of the chancrous virus is established upon the same evidence as naturalists determine the identity of species in the animal and vegetable kingdoms; viz., by the immutability of certain traits in successive generations. The " immutability of species" lies at the foundation of all classification in natural history; it is the groundwork upon which the whole superstructure rests; and although we cannot always expect to fol- low out the same laws in the arrangement of the Protean forms of disease that we do in nature, the simple principle referred to is unquestionably as applicable to one as to the other; nay, when pre- sent in morbid manifestations, it may be regarded as of the greatei value from the very fact of their general inconstancy. The character- istics, the immutability of which is relied upon to establish the duality of the chancrous virus, are the limitation of the power of the ulcer to mere local action on the one hand, and, on the other, its necessary influence upon the general system; and no one will fail to see that, if these can be proved to be constant, they are sufficient to establish a distinction of species. It should be observed that the external appearance of venereal ulcers does not enter as an element into this consideration. The proof would be equally valid, even if it could be shown that the two species are never distinguishable by any outward sign. It is sufficient to establish the fact that the action of the virus in one series of cases is local, and in the other general. Naturalists, in many instances, ground their classification of species upon differ- ences confined to one period of their existence. The young of many forms of animal life closely resemble each other, although the adults are widely different. From the study of embryology alone, Agassiz has derived the most correct system of classification which has ever been advanced. While, therefore, as will hereafter appear, the chancroid and chancre do present, in most cases, differences reco-r- INTRODUCTION. 51 nizable by the sight and touch, these must be regarded as additional, but not essential, evidence of the distinct nature of the two diseases; and their absence, as occurs in some instances, and perhaps in all, when the virus of a chancre is implanted upon a system already infected, does not invalidate the above reasoning. Tbe new doctrine upon this subject, which, as shown by Bassereau, is an old doctrine revived, appears to me to occupy an impregnable position. The confrontations of the observers whose names have been mentioned, alone amount to 137, and among them all, not a single instance of interchange between the two forms of ulcer has been met with. Moreover, as Rollet remarks, this number is but a tithe of the concurrent testimony which we now possess on this point; since, in addition to the confrontations of persons having venereal ulcers reported by the authors now cited, we may rightfully include the hundreds of recorded cases of the communication of syphilis from secondary lesions, either between nurses and infants or between adults; the numerous instances in which the disease has been conveyed by vaccination; those in which the syphilitic virus has been artificially and intentionally inoculated upon persons free from syphilitic taint; and the tens of thousands of inoculations (usually with the virus of the chancroid) employed in the so-called practice of syphilization:—in all of which either syphilis has been the origin of syphilis, or a local contagious ulcer the origin of a local contagious ulcer. Again, upon no other ground than a duality of poisons, can we satisfactorily explain why the same individual should repeatedly contract a local sore and after a short interval incur another contagion resulting in constitutional infection; or why a chancroid and a true chancre should ever coexist upon the same person—instances of which are of almost daily occurrence. Nearly every surgeon has the opportunity to satisfy himself of the truth of this doctrine by personal observation; let him but take note of the not unfrequent cases in which a husband gives a venereal ulcer to a wife whose fidelity cannot be called in question, and he will find that they will both escape, or both incur constitutional infection. Thus, every one can contribute his quota to the statistics on this interesting subject. For myself, in a somewhat extended field of observation during twelve years of practice, I have never seen an instance of interchange of the chancroid and syphilis. In pursuing these investigations, it is of course necessary to guard against all sources of error; the fact should be well established that the person supposed is really the one who gave the disease; it should be ascertained with certainty that neither the man nor woman has 52 INTRODUCTION. been previously infected, otherwise he or she is incapable of receiving a second infection; and the influence of a mercurial course in pre- venting, or more frequently in retarding, general manifestations, should be borne in mind. Nor is mercury the only agent capable of delaying the appearance of secondary symptoms; the same effect may be produced by a course of iodide of potassium, sudorifics, or other medicines which increase the excretions from the body. It is now evident that the local contagious ulcer of the genitals should no longer be described under the head of syphilis, but should be considered apart like gonorrhoea, as was done by writers upon Venereal during the thirty years immediately succeeding the Italian epidemic. With regard to the nomenclature of the contagious ulcer of the genitals and the initial lesion of syphilis, both of which until recently were included under the head of "chancres" or "primary syphilis," no little confusion at present exists. Their distinct nature being recognized, it is of course desirable to designate them by distinct names; but, retaining the term chancre for one of them, to which shall it be applied, and how shall we call the other ? Most French and English writers have seen fit to follow the nomenclature adopted by Clerc, and call the former a " chancroid" and the latter a " chancre;" instead of which Diday calls them " chancrelle " and "chancre," from the analogy of the terms varicella and variola; while the German school of to-day, represented by Hebra, Zeissl,1 Reder,2 Lindwurm,3 and Dr. Elsberg4 among American authorities, apply the name of chancre exclusively to the local ulcer of the ancients, and designate the sore of 1494 by the term " initial lesion of syphilis," or "primary syphilis." 1 Allgemeine Wiener Medizinische Zeitung, January 1862. A translation of a por- tion of this article may be found in the Boston Medical and Surgical Journal, May 15, 1862. Zeissl's clinique is made up of Hebra's venereal patients, and the views of the former surgeon are fully endorsed by the latter. 2 Ueber die Trennung des Schankers von der Syphilis. Medizinische Jahrbucher, Heft I., 1862. 3 Ueber die Verschiedenheit der syphilitischen Krankheiten. * Dr. Elsberg claims to have been the first to propose this nomenclature of venereal ulcers. He says in a letter to the author: " I regret my inability to refer you at this time to any printed article in which I have proposed to limit the term chancre to the local venereal sore, and to call the corresponding initial lesion of syphilis at once by the latter name. The simplicity, logical correctness, and incidental advantages of such a nomenclature, first occurred to me during my visit to Europe in 1858, while privately discussing the general subject. I afterwards publicly stated and advocated it in the Med. Soc. at Frankfort on the Main (by whom it may have been published); again in a letter to Prof. v. Barensprung; before the Medico-Chirurgical College of this city in 1860 ; and again at great length in a discussion, Feb. 13, 1862." INTRODUCTION. 53 Now, much may be said in favor of the German plan, which com- mends itself by its simplicity and its theoretical accuracy. Accord- ing to it, one man contracts a venereal ulcer, local in its character and incapable of infecting the system, and we say he has a chancre; another man contracts the other venereal sore and we say he has syphilis, thus expressing at once the idea that his system is just as much contaminated and that the same general treatment is required as if secondary manifestations had already made their appearance. To be sure he exhibits as yet only the " initial lesion of syphilis," but the mischief is already done; the sore is not and never has been local; it is not the disease itself, but the manifestation or symptom of a disease—which is syphilis. In like manner, when a person breaks out with a pustule succeeding vaccination, we do not say he has a pustule, but that he has vaccinia; and why, it may well be asked, should not the name of the disease upon which the mani- festation depends, be used in the one case as well as in the other ? If, therefore, we could at will arrange our venereal nomenclature de novo, and forget the signification which has for centuries been attached to certain terms, I should not hesitate to adopt the plan referred to; but it appears to me that the idea of syphilis in con- nection with " chancre" is too deeply rooted in the minds of profes- sional readers to render their disseverance practicable without introducing great confusion. Moreover, the German plan has this objection, that it gives one no single word to express "the initial lesion of syphilis," and the inconvenience of resorting to such circum- locution on all occasions will be appreciated, if the reader will notice how often the idea of this sore must be conveyed in the introduction alone of the present work. I believe, also, that the advantages attached to the German nomenclature can be attained in a simpler way; indeed, that they are already well nigh attained, since it is now very generally under- stood among those conversant with modern views of venereal dis- eases, that when a man has a local venereal ulcer he has a " chan- croid" and not syphilis, and that when he has a "chancre" his system is already infected with the syphilitic poison, and that his disease is syphilis. To consummate the desired end, it is only necessary to abolish in toto the illogical terms " soft chancre," " hard chancre," "infecting chancre," etc., and to have it understood that a " chancre" always means the initial lesion of syphilis and nothing else, and that its presence is due to infection of the constitution with the syphilitic virus. The nomenclature adopted in the present edition of this work is in accordance with this view, and I shall designate 54 INTRODUCTION. the local contagious ulcer of the genitals as the chancroid, reserving the term " chancre" exclusively for the initial lesion of syphilis. The distinction which is now drawn between the chancroid and chancre explains in a great measure the variance which has long existed with regard to the treatment of venereal sores between the " mercurialists" and " anti-mercurialists." The former, being a strictly local disease, requires no constitutional remedies, unless, in exceptional cases, as adjuvants to local treatment. Mercury is only of value in cases of syphilis, including its initial lesion or chancre. Since the number of cases of chancroid met with in practice greatly exceeds those of chancre, it is evident that the general results of treatment may be made to sustain either the use or disuse of mer- cury, if exclusively applied to both affections in common. COMPARISON OF THE THREE POISONS OF GONORRHEA, THE CHAN- CROID, AND SYPHILIS. A comparison of the three poisons of gonorrhoea, the chancroid and syphilis, so far as we are at present able to understand their nature, leads to the following conclusions. The only property common to them all is their communication, for the most part, by contact of the genital organs. The poisons of gonorrhoea and of the chancroid are alike in that their action is limited and never extends to the general system; nor does one attack afford the slightest protection against a second. They differ in that the poison of gonorrhoea may arise spontane- ously, while that of the chancroid, so far as we know, never thus originates; that gonorrhoea chiefly affects tbe surface—true ulcera- tion being rarely induced—and, in its complications, most frequently attacks parts connected with the original seat of the disease by a continuous mucous surface, as the prostate, bladder, and testicle; while the chancroid, on the contrary, is an ulcer, involving the whole thickness of the integument or mucous membrane, and its complications are seated in the absorbent vessels and ganglia. It would also appear that the poisons of these two affections are limited to one common vehicle, viz., pus. Van Roosbroeck, on the authority of Rollet, has proved by experiment that if the discharge of gonorrhceal ophthalmia be deprived of its pus-globules by filtra- tion, the remaining fluid is innocuous; and Rollet states that he has obtained like results with the pus of chancroids. If these experi- ments can be relied on, they prove that the virus is not diffused throughout the purulent secretion, but is confined to the pus-globules which it contains. This conclusion is sustained by the fact that INTRODUCTION. 55 neither the poison of gonorrhoea nor that of the chancroid ever reaches the general circulation, and it is well known that pus- globules are not capable of absorption. When the purulent matter of a chancroid enters the absorbent vessels, as occurs in the forma- tion of a virulent bubo, it is arrested by the first chain of lymphatic ganglia, and goes no farther. The paint used in tattooing is some- times conveyed to a ganglion in a similar manner;J but neither in this case nor the former is there complete absorption.2 The syphilitic virus is alone capable of infecting the system at large, and of affording protection by its presence against subsequent attacks. Unlike the poisons of gonorrhoea and the chancroid, it is not limited to purulent matter, but exists in the blood, in the fluids of secondary lesions, in the semen, and probably in other secretions. The secretion of one form of chancre (the superficial variety), as shown by microscopical examination, is often entirely destitute of pus-globules;3 and the presence of the virus in secondary symptoms is proved by their power of contagion, and in the semen by the occurrence of hereditary syphilis in the offspring when the father is alone infected. There is no opposition whatever between these three poisons; they may all coexist in the same person, who may at the same time have gonorrhoea, a chancroid, and a chancre, or other syphilitic lesion; hence we may explain a case related by Acton in which each of three students contracted one of these diseases from inter- course with the same woman on the same day. Two of these poisons may be present in the same fluid, as when the secretion of a chancroid or chancre mingles with that of gonorrhoea; or as in the " mixed chancre " resulting from inoculation of the same part, either at the same time or successively, by the virus of the chancroid and 1 Virchow has given a beautiful plate of the deposit of pigment matter in the axillary gland of an arm, the skin of which had been tattooed, and describes the process of absorption as follows: "A certain number of particles find their way iuto lymphatic vessels, are carried along in spite of their heaviness by the current of lymph, and reach the nearest lymphatic glands, where they are separated by filtration. We never find that any particles are conveyed beyond the lymphatic glands and make their way to more distant points, or that they deposit themselves in any way in the parenchyma of internal organs." {Cellular Pathology, English translation, p. 184.) 2 Rollet, De la Plurality des Maladies Ve'ne'riennes, Gaz. Me"d. de Lyon, No. 8, 1860. 3 Mr. Henry Lee believes that a chancre is always an ulcer affected with specific adhesive inflammation, and, unless irritated, destitute of pus-globules. Of 95 cases examined by the microscope at King's College Hospital, in none was the secretion purulent. (Medico-Chir. Trans, vol. xlii. p. 450.) 56 INTRODUCTION. that of syphilis. The secretion of a chancroid or of a syphilitic lesion may also mingle with the other animal poisons, as the vaccine virus, and each will produce its usual effects unmodified by the pre- sence of the other. DIVISION OF THE PRESENT WORK. Following the natural order suggested by the above considera- tions, I propose to divide the present work into three parts: the First treating of Gonorrhoea and its Complications; the Second of the Local Contagious Ulcer of the Genitals, and its Complications; and the Third of Syphilis. PART I. GONORRHCEA AND ITS COMPLICATIONS. CHAPTER I. URETHRAL GONORRHCEA IN THE MALE. Preliminary Considerations. — By far the most frequent dis- ease originating in sexual intercourse, is an affection of certain mucous membranes, a prominent symptom of which is an increased secretion and discharge from the diseased surface. At various times and places, this disease has received different names, founded on the prevailing ideas of the nature of the secretion referred to. At an early period in the history of Venereal, the discharge was supposed to consist of the semen, and hence the disease was called gonorrhoea, from yovrj, sperm, and f>sw, to flow; a name which is still in use among American and English writers, notwithstanding the incorrectness of the supposition in which it originated.1 The French call the same affection " blennorrhagie," or a flow of mucus, a name which is also erroneous, since the discharge does not consist of mucus alone, but of a mixture of mucus and pus. In popular language it is termed "clap"2 by the English, and "chaude-pisse" by the French. The chief mucous membranes subject to gonorrhoea are those lining the genital organs in the two sexes, and the conjunctiva oculi. Gonorrhoea of the anus, mouth, nose, and external ear are, indeed, mentioned by authors, but the existence of all of them is more or less doubtful. Perhaps there is the least question in ad- 1 Cockburne (The Symptoms, Nature, Cause, and Cure of Gonorrhoea, London, 1757) first established the fact that gonorrhoea is not a flow of semen. 2 The term " clap" is said to be derived from the old French word clnpier, indi- cating the low places where the disease is contracted. '•Old French clapises, public shops kept by prostitutes. Hoblyn ;—clapiers, an old term for houses of ill fame."—Worcester's Dictionary. (57) 58 URETHRAL GONORRHCEA IN THE MALE. mitting gonorrhoea of the anus and rectum, though it is said to be rare even in countries where unnatural practices are frequent; but we can hardly admit under this head those cases in which the anus is simply excoriated by a discharge flowing from the urethra or vulva, without extension of the disease to the rectum. Reported cases of gonorrhoea of the mouth, nose, and external ear are very few in number, and are all of them open to serious question; as, for instance, the supposed case of gonorrhoea of the nose, reported by Mr. Edwards,1 in which it is very doubtful whether the disease was of this origin and not a simple catarrhal affection. M. Diday relates some experiments which will serve to elucidate this point, though we are surprised, in reading them, that any surgeon should presume to make them, or any patient submit to them. M. Diday says: " Frequently (eight or ten times at least), for the purpose of experiment, I have moistened the end of my finger in the urethral discharge of patients with gonorrhoea, when the disease was in its most acute stage, applied it within their nostrils and rubbed it into the nasal mucous membrane, and there has never resulted the slightest degree of inflammation in the part."2 But when we recollect how frequently a disregard of cleanliness must cause the application of gonorrhceal matter to the nostrils and lips, and how readily such applications excite inflammation of the ocular conjunctiva, the great rarity of suspected cases of nasal and buccal gonorrhoea must convince us, without the necessity of such experiments as those above mentioned, that certain mucous mem- branes are more apt to contract gonorrhoea than others; and in this we may find an analogy to an extraordinary fact which at one time excited much attention, viz., that all parts of the body are not equally susceptible of the two species of venereal ulcers; the chan- croid never being met with upon the head or face, although it may be implanted there by artificial inoculation. The reason of the preference of these diseases for certain localities escapes us, but they are not the only instances of the kind met with. The symptoms and the treatment of gonorrhoea vary according as the disease affects the male or female, and according also to the portion of mucous membrane attacked; it will be convenient, there- fore, to consider this affection under corresponding heads. 1 London Lancet, Am. ed, June. 1857. 3 Annuaire de la Syphilis, ann6e 1858. SYMPTOMS. 59 URETHRAL GONORRHOEA IN THE MALE. Men are more liable to contract gonorrhoea than women; and of a given number of cases of this disease in the former, in a large proportion it is the urethra which is affected. Cases of urethral discharge in the male outnumber all other forms of gonorrhoea in the two sexes combined. The explanation of this fact will appear when we come to consider the causes and nature of gonorrhoea. Symptoms.—The symptoms of urethral gonorrhoea in the male first appear, as a general rule, between the second and fifth day after exposure; though, in exceptional cases, as late as the seventh, tenth, or fourteenth day; but their occurrence after this time, as alleged by some authors, is, I believe, to be explained on the ground that the earliest manifestations of the disease have been overlooked. At first, the symptoms are very slight, consisting only of an uneasy or ticklish sensation at the mouth of the canal, which, on examina- tion, is found more florid than natural, and moistened with a small quantity of colorless and viscid fluid, which glues the lips of the meatus together. This moisture of the canal gradually increases in amount, until on pressure a drop may be made to appear at the orifice; at the same time it begins to lose its clear watery appear- ance, and assumes a milky hue. Examined under the microscope, it is found to consist of mucus with the addition of pus-globules; the number of the latter being proportioned to the depth of color of the discharge. Meanwhile, some smarting is felt by the patient in the anterior portion of the canal during the passage of the urine. Such are the symptoms of the early stage of gonorrhoea. The exciting cause of the disease has been applied to that portion of the canal which lies near the orifice of the meatus and which was chiefly exposed to contagion, and the ensuing inflammation is gradually lighted up in this part, and has not yet extended beyond that por- tion of the urethra known as the fossa navicularis. This early stage of gonorrhoea is often called "the stage of incubation," a name which is objectionable because the inflammatory process is doubtless set up at the time of the application of the exciting cause. Time is required for it to produce its full effect, and the earliest symptoms are but slowly and gradually ushered in. A more appro- priate name is the first or preparatory stage. It is important to recollect the symptoms of this stage and the fact that the disease is as yet confined to the external portion of the urethra, since, as we 60 URETHRAL GONORRHOEA IN THE MALE. shall see hereafter, a more rapid method of cure may now be resorted to than is admissible in the subsequent stages. The first stage of gonorrhoea usually lasts from two to four days. The symptoms gradually increase in intensity, until, in about a week after exposure, the second or inflammatory stage may be said to commence. If we examine the penis during this stage, we find the mucous membrane covering the glans, reddened and with an angry look. The whole extremity of the organ is swollen so that the prepuce fits more tightly than natural. In some cases the latter is puffed out by oedema in the cellular tissue, and phymosis may exist, rendering it impossible to uncover the glans. The inflamma- tory blush is especially marked in the neighborhood of the meatus, the lips of which are swollen so as to contract the calibre of the orifice. The discharge has now become copious, so much so in some instances as to drop from the meatus as the patient stands before you. It is thick, of a yellowish cream color, and not unfre- quently tinged with green. This greenish hue, as in the sputa of pneumonia, is due to the admixture of blood-corpuscles, which may be sufficiently numerous to produce the characteristic color of blood. The penis generally, and especially upon the under surface over the course of the canal, is sensitive and tender on pressure. While passing his urine, the patient complains of intense pain which is now not confined to the auterior part of the canal, but is felt in all that portion of the organ anterior to the scrotum, or is even more deeply seated. The severity of the suffering during the act is in some instances very great. The pain is compared to the sensation of a hot iron introduced within the canal, and the popular name, chaude-pisse, given to the disease by the French, is fully justified. This pain is excited in part by the irritation produced upon an abnormally sensitive membrane by the salts contained in the urine, but chiefly, I am inclined to think, by the distention of the contracted and sensitive canal by the passage of the stream. Hence, during the act, the patient involuntarily relaxes the abdomi- nal walls, forces the air from his lungs, and keeps the diaphragm elevated, in order to diminish the pressure upon the bladder and lessen the size and force of the stream of urine. In consequence also of the urethra being contracted and more or less obstructed by the discharge, the stream is forked or otherwise irregular. Another source of suffering in this stage of gonorrhoea is the nocturnal erections, which are apt to come on after the patient is warm in bed. The genital organs are in a highly sensitive condi- tion, and are readily excited by lascivious dreams, the contact of SYMPTOMS. 61 the bedclothes, or a distended bladder; or, independently of such exciting cause, they assume a state of erection which even in health is more apt to occur during sleep. When thus excited, it will often be found that the penis is bent in the form of an arc with its concavity downward. This condition is known as chordee. Its explanation is very simple. The urethra, the chief seat of the inflammation, runs along the under surface of the penis. Plastic lymph is effused around the canal, gluing the tissues together and rendering this portion of the penis less extensible than the remain- ing portion composed of the corpora cavernosa. Hence, in a state of erection, the corpus spongiosum surrounding the urethra, not being able to yield to the distention, acts like the string of a bow, and chordee is produced. The stretching of the parts thus ad- hering together excites pain, which is often very severe. The sufferer, awaking from sleep, instinctively grasps the penis in his hand, and bends it in a still smaller curve, so as to remove the strain from the under surface and thus ease the pain. I have been in the habit in my lectures of illustrating the mechanism of chordee by gluing a piece of tape along the surface of an india rubber condom, and then distending it with air or water. It not unfre- quently happens that during one of these attacks of chordee, the mucous membrane of the urethra becomes lacerated, and hemor- rhage takes place from the canal. In this way nature may produce local depletion, and if the flow be not excessive, the effect is often beneficial. The above explanation of the mechanism of chordee is the one usually received, though it is proper to state that it is rejected by Mr. Milton, who believes that chordee is due to spasm of the mus- cular fibres, which Kblliker and Mr. Hancock have shown to exist around the whole course of the urethra.1 Milton's explanation is opposed by the fact that bending the penis so as to increase the curve of the arc affords partial ease to the pain of chordee, and I am not convinced that the generally received opinion should thus be laid aside, though it is highly probable that spasmodic muscular action plays some part in the production of the frequent erections and chordee which take place in gonorrhoea. During the inflammatory stage of gonorrhoea abscesses sometimes form in the cellular tissue covering the urethra, either anteriorly to the scrotum, or in the perineum; and may attain a very con- siderable size. If left to themselves, they are liable to break 1 Milton on Gonorrhoea, p. 75. 62 URETHRAL GONORRHOEA IN THE MALE. internally within the canal and give rise to urinary abscess and fistula. It is chiefly during the second stage of gonorrhoea that buboes are met with, if they occur at all; for they are rare compared with the number of patients afflicted with this disease. According to the statistics of the Antiquaille Hospital at Lyons, an attendant bubo is met with in one out of every fourteen cases of gonorrhoea.1 They are at once recognized by the physician and patient by the enlargement and tenderness of one or more glands in the groin, occasioning considerable pain and uneasiness in walking and stand- ing. Buboes attendant upon gonorrhoea, uncomplicated with chan- croid, are sympathetic buboes; of which a fuller description will be given hereafter, when speaking of buboes in general. They may generally be made to disappear in a few days by keeping the patient quiet and producing a little counter-irritation by painting the skin over them daily with tincture of iodine. It is only in scrofulous subjects, or in consequence of violence, excessive fatigue or general depressing influences, that they ever exhibit a tendency to suppu- rate. I have known of one instance of a man suffering from gonor- rhoea, who after exposure to great hardship upon a wreck, had a suppurating bubo that confined him to his bed for six months. Inflammation of the lymphatic vessels running along the dorsum of the penis is still another complication of the acute stage of gonorrhoea, and one which is also met with in connection with chancroids. It is to be carefully distinguished, as we shall see here- after, from the induration of these vessels which often attends an indurated chancre. "It occupies the same vessels and the same situation, and presents the same forms as the latter; but is distin- guished from it in several ways: 1. By its feel, which is like that of an hypertrophied cord, elastic but not cartilaginous. 2. By the fact that the cellular tissue uniting the vessels generally participates in the inflammation, and thus binds together in a large cord the dorsal vein, the lymphatics and the artery, rendering it difficult to distinguish the inflamed lymphatics from the bloodvessels. 3. Bv the pain, generally severe, which it excites, and by the swelling and redness visible over the course of the inflamed vessels, caused by the extension of the inflammation to the skin."2 This inflammation of the lymphatics on the dorsum of the penis sometimes gives rise to chordee, with the concavity of the arc looking upward. The second stage of gonorrhoea, which we have now described, is i Gaz. des Hopitaux, No. 141, 1861. - Basserkau: Affections de la Peau Symptomatiques de la Syphilis p. 160. SYMPTOMS. 63 variable in its duration in different subjects. As a general rule, it lasts from one to three weeks, being influenced by the constitution of the individual, his mode of life and the number of his previous attacks. It is succeeded by the third stage or stage of decline. This final stage of acute gonorrhoea is marked by no peculiar symp- toms, and is characterized only by the disappearance of the more acute symptoms and a gradual return to a condition of health. The discharge runs through the same phases, in an inverse order, which it did at the outset of the attack. It gradually becomes less and less purulent, and finally is almost wholly mucous, before completely disappearing. Perhaps the most valuable indication of the ushering in of this stage of gonorrhoea is the marked diminution or entire cessation of the pain in passing water. The painful erections and chordee may continue after the acute inflammation has subsided, since it takes time for the plastic matter effused around the urethra to be ab- sorbed. We have reason to believe that in the course of an attack of gonorrhoea, the disease gradually extends from the outer to the deeper portions of the canal, and it is in this latter situation that it is prone to lurk for an indefinite period. After the discharge has lasted for several weeks, we may evacuate the whole of the spongy portion by pressure from behind forward in front of the scrotum. and then, when no further discharge can be made to appear, we can still produce it by the exercise of similar pressure on the perineum. In some instances, the inflammation extends to the mucous mem- brane of the bladder. The duration of the final stage of gonorrhoea is, as a general rule, longer than either of the preceding. It may be cut short by treat- ment, but, if left to itself, commonly lasts for weeks or even months. Gonorrhoea is a disease which, independently of treatment, rarely terminates in less than three months. Thus far I have said nothing of the reaction of this disease upon the general system. This varies greatly in different individuals and in different attacks in the same person. In some rare cases there is considerable febrile excitement during the inflammatory stage, marked by the usual symptoms of headache, dry skin, full pulse, furred tongue, etc. As a general rule, however, there is but little constitutional disturbance, and after the acute symptoms have passed, the invariable tendency of the disease is to depress the general health. This fact should be remembered in the treatment. A first attack of gonorrhoea is usually more acute than subsequent 64 URETHRAL GONORRHOEA IN THE MALE. ones; the latter often being subacute or chronic from the first. They are also more difficult to be influenced by remedies, and show a decided tendency to run into gleet. Cases of gonorrhoea have been reported, in which it has been said there was no discharge whatever—all the other symptoms of gonor- rhoea being present, and the disease following impure coitus. These have been called cases of dry gonorrhoea. I doubt whether there be a total absence of all secretion in these cases throughout their whole course, but can readily conceive of an inflammation of the mucous membrane of the urethra, resembling that of erysipelas upon the skin, in which the secretion is for a time but slight, and incapable of detection except by a careful examination of the urine. As the inflammation subsides, however, I should expect to find dis- tinct traces of a discharge. We have analogous symptoms occa- sionally in inflammations of the pituitary membrane of the nose. Two cases of this variety of gonorrhoea are reported by Dr. Beadle in the New York Journal of Medicine and Surgery, for October, 1840. Causes and Nature of Gonorrhoea.—Every one is aware that urethral gonorrhoea in the male often proceeds from direct conta- gion, or, in other words, from intercourse with a woman affected with the same disease. But there is another mode of origin, ad- mitted by nearly every writer, as of at least occasional occurrence, but with regard to the frequency of which some difference of opinion has been expressed. I refer to gonorrhoea originating in coitus just before, after, or during the menstrual period, or with a woman suffer- ing from leucorrhcea, and, in a few instances, when nothing whatever abnormal can be discovered in the female genital organs, and the disease in the male can only be attributed to the irritant character of the vaginal or uterine secretions. I have been convinced, by a somewhat extended observation, that gonorrhoea originating in this mode is of very frequent occurrence. Of one thing I am absolutely certain, that gonorrhoea in the male may proceed from intercourse with a woman with whom coitus has for months, or even years, been practised with safety, and this, too, without any change in the condition of her genital organs, percepti- ble upon the most minute examination with the speculum. I am constantly meeting with cases in which one or more men have cohabited with impunity with a woman both before and after the time when she has occasioned gonorrhoea in another person • or, less frequently, in which the same man, after visiting a woman for a long period with safety, is attacked with gonorrhoea without any disease CAUSES AND NATURE OF GONORRHOEA. 65 appearing in her, and after recovery resumes his intercourse with her and experiences no farther trouble. The frequency of such cases leaves no doubt in my mind, that gonorrhoea is often due to accidental causes, and not to direct contagion. In many of the instances referred to, the woman is suffering from a frequent combination of symptoms met with in practice, viz., general debility, engorgement of the cervix uteri, and more or less leucorrhcea; but her previous history, and the impunity with which her favors have been bestowed for a long period, preclude the idea that her discharge is the remains of a previous attack of gonorrhoea to which it owes its contagious property. Moreover, such an expla- nation fails to cover other instances, in which there is no appearance whatever of leucorrhoea, and the genital organs, so far as we can discover, are in a state of perfect health; although intercourse about the time of the menstrual period has given rise to gonorrhoea in the male. An attempt is sometimes made to evade the issue of this question, by asserting that in the cases referred to, the disease has been con- tracted from another source than the one alleged, and the proverbial mendacity of venereal patients is appealed to in support of this assumption. Argument is of course useless with any one assuming this ground; but to a candid mind, the opinion of such men as Ricord, Diday, and others, who fully sustain the position above assumed, and who are certainly not ignorant of the sources of error surrounding the etiology of venereal diseases, is sufficient to carry great weight, and lead to an impartial investigation of facts which, I believe, can be followed but by one conclusion. For my own part, I desire to state that while pursuing the investigation which has led me to believe in the frequency of gonorrhoea independent of contagion, I have not entertained a single case in which the moral grounds of certainty have not been irresistible; and that a number of my patients have been medical men, and intimate acquaintances, whose sins against morality were fully known to me, who could therefore have had no motive for concealment, and with whom mistake or deceit has been either in the highest degree impro- bable, or, in repeated instances, well nigh impossible. Moreover, it is a mistake to suppose that in investigations of this nature we are entirely at the mercy of the patient's honor and truthfulness, since to one practising in a large city there are a thousand sources of circumstantial evidence and remarkable coincidences in the testi- mony of persons wholly unknown to each other, which in many cases preclude all possibility of error. 5 66 URETHRAL GONORRHOEA IN THE MALE. The greatest obstacle to the admission of gonorrhoea independent of contagion appears to be the rarity of urethritis in married men compared with the frequency of leucorrhceal discharges in their wives. As proved by unquestionable cases occurring in my own practice and in that of my medical friends, husbands do not always escape. That they are not more frequently affected is sufficiently explained by the immunity conferred against all simple irritants by constant and repeated exposure, whereby "acclimation"—to use a term adopted by the French—is acquired. The same fact is observed when neither the church nor the state has sanctioned marital rela- tions ; since it is not generally the habitual attendant upon a kept mistress affected with leucorrhoea who suffers, but some fresh comer who shares her favors for the first time. My friend, Dr. B. Fordyce Barker, whose extensive experience with female diseases is well known, and who has thus had the op- portunity of studying this subject from an opposite standpoint to my own, tells me that he has noticed a peculiar form of inflamma- tion of the lining membrane of the uterus, in which the uterine discharge loses its alkaline reaction, becomes decidedly acid and acrid, and irritates and excoriates the mucous membrane of the vagina and the surface of the vulva. He adds, that, in numerous instances in married life, he has known this discbarge to excite urethritis in the male between parties whose fidelity was unques- tionable ; and he has related to me a number in detail which I would gladly repeat, if space permitted. Most cases of gonorrhoea from leucorrhcea or the menstrual fluid present no characteristic symptoms by which they can be distin- guished from those originating in contagion. The contrary is frequently asserted, and it is said that the former class may be recognized by the mildness of the symptoms, the short duration of the disease, and the absence of contagious properties. I am familiar with the slight urethral discharge unattended by symptoms of acute inflammation, and disappearing spontaneously in a few days, which sometimes follows intercourse with women affected with leucorrhcea; but such instances are far less frequent than those in which the dis- ease is equally as persistent and as exposed to complications as any case of gonorrhoea from contagion. Some of the most obstinate cases of urethritis I have ever met with have been of leucorrhceal origin, and have terminated in gleet of many months' duration. Diday has even set apart those cases of urethritis which originate in the menstrual fluid as constituting a distinct class, characterized CAUSES AND NATURE OF GONORRHOEA. 67 by their greater persistency and obstinacy under treatment than cases of gonorrhoea from contagion.1 Those who maintain the non-contagious character of urethral dis- charges of leucorrhceal origin have failed to adduce the slightest proof in favor of their assumption, and it may safely be asserted that none of them would venture to make a practical application of their principles. The contagious character of the leucorrhceal secre- tion is already proved by the existence of the disease in the male; why should not the same property be continued another, still another, and any number of removes from its origin ? This suppo- sition is sustained by analogy, since no fact is better established than that catarrhal conjunctivitis may be communicated from one person to another until all the members of a family, school, or asylum have become affected. At our public institutions for dis- eases of the eye such instances are very common, and the physicians of our children's asylums are well aware of the difficulty of eradi- cating muco-purulent conjunctivitis which has once sprung up among the inmates. At an orphan asylum, under the charge of my friend, Dr. Learning, this disease was introduced by a single child, brought from Randall's Island, and spread to twenty-two others before it could be arrested. Again, the leucorrhcea of pregnancy is sufficient to give rise to ophthalmia neonatorum: would any one, presuming upon its leucorrhceal origin, dare to apply a drop from the infant's eyes to his own? Several instances are recorded in which physicians have lost the sight of an eye with which the dis- charge of ophthalmia neonatorum has inadvertently been brought in contact. The views which I have here advocated relative to the frequency of gonorrhoea independent of contagion, are by no means novel, and are entertained by many of our most eminent authorities, espe- cially among the French, who possess unequalled advantages for investigating the etiology of venereal diseases. The importance of the subject will fully justify me in making the following quotations from other authors. Ricord says: " If we investigate with the greatest care the exciting , causes of gonorrhoea—and I am now speaking of the most charac- teristic cases of the disease—we cannot help admitting that a gonorrhceal virus is absent in the majority of cases. Nothing is more common than to find women who have occasioned gonorrhoea unsurpassed in intensity and persistency, and attended by the most i Arch. Gen. de MeU, Oct., 1861. 68 URETHRAL GONORRHOEA IN THE MALE. serious complications, and who are yet only affected with uterine catarrh which is sometimes hardly purulent. In many cases, inter- course during the menstrual period appears to be the only cause of the disease; while, in a large number, we can discover nothing, unless perhaps errors in diet, fatigue, excessive sexual congress, the use of certain drinks, as beer, or of certain articles of food, as asparagus. Hence the frequent belief of patients, which is very often correct, that they have contracted their gonorrhoea from a perfectly sound woman. " I am most assuredly familiar with all the sources of error in such investigations, and I will presume to say that no one is more guarded than I am against the various forms of deceit which are strown in the path of the observer; yet I confidently maintain the following proposition: Gonorrhoea often arises from intercourse with women who themselves have not the disease. Any one who studies gonorrhoea without preconceived notions, is forced to admit that it often originates from the same causes that give rise to inflammation of other mucous membranes."1 The "preconceived notions" that Ricord here speaks of, have been the greatest obstacle to the admission of the truth in question. To a surgeon making up his mind beforehand that every patient utters a falsehood who says that he has contracted his gonorrhoea from a woman in whom no evidences of disease can be found, any amount of proof is valueless. Diday, in speaking of the prophylaxis of venereal diseases, says: "A man should never forget that gonorrhoea may be contracted from any woman; and I say any woman, and not any prostitute, for I do not except from this uncivil remark, any member of the gentler sex. No matter how great her cleanliness, her apparent health, her supposed or real virtue, or even her virginity, or how recently she has been examined, a woman may, from some cause or other, have the whites—often of a very innocent character, as from metritis, chlorosis, dysmenorrhoea, catarrhal inflammation, or as a result of confinement, and also, on the other hand, from a gonorrhoea which she has contracted; and from the very fact that she has a discharge- no matter what its origin—she is liable to give a discharge to a man."2 * Fournier arrives at the same result from an investigation relative to the classes of women from whom gonorrhoea is derived. It ap- pears from his statistics that gonorrhoea was contracted from inter- course with— 1 Lettres sur la Syphilis, 2d ed., p. 29. - Nouvelles Doctrines sur la Syphilis, p. 515. The italics are in the original. CAUSES AND NATURE OF GONORRHOEA. 69 Cases. 12 44 138 126 41 26 Total 387 Fournier adds: " This result is easily explained, and might even have been predicted. In fact, gonorrhoea is, I think, much less frequently contracted from contagion than from excessive coitus, repeated or prolonged sexual congress, or peculiar excitement during the act; and in most cases of intercourse with public women, all these causes are absent, and intercourse is generally very short, without much excitement, and not frequently repeated."1 Again, Mr. Henry Thompson says: " It is a fact too well estab- lished to render it necessary to adduce evidence respecting it here, that urethritis in the male is sometimes caused by contact with the other sex, from discharges which are not venereal in their origin."2 Finally, from many other writers whose testimony is equally strong in favor of the leucorrhceal and menstrual origin of gonor- rhoea in many cases, I will quote the remarks of Mr. Skey:— " I cannot entertain a doubt that a very considerable proportion of cases of gonorrhoea are not the product of a specific poison. The opinions I entertain on this subject are not the product of mere speculation, and still less of a desire to differ with other and more experienced authorities. They are deduced from, what appeared to my judgment, positive facts, and those by no means few or far be- tween. I may venture to say it is notorious that leucorrhoea will produce gonorrhoeal discharge; and if a poison be essential to gonorrhoea, whence comes it? Leucorrhoea is not supposed to contain the elements of gonorrhoeal poison. Again, gonorrhoea is by no means an infrequent result from intercourse about the period of menstruation; and it also follows intercourse with women under circumstances of mechanical violence."3 The importance of the truth laid before the reader in the above remarks and quotations, whenever a physician in the exercise of his profession incurs the fearful responsibility of passing judgment upon the virtue of a woman, and thus affecting her reputation and 1 De la Contagion Syphilitique, p. 118. 2 Stricture of the Urethra, p. 120. 3 Lectures on the Venereal Disease, Lonlon Medical Gazette, vol. xxiii. (1838-9), p. 439. Women of the town Clandestine prostitutes . Kept women, actresses, etc, Working girls Domestics Married women 70 URETHRAL GONORRHOEA IN THE MALE. happiness (and often that of many others with whom she is con- nected) for life, cannot be overrated. In all such cases, the accused should receive the benefit of any doubt which may exist; and the physician who withholds it from her out of a morbid fear that he may be imposed upon,1 and thus runs the risk of convicting an inno- cent person, is unworthy of his calling. His province is to decide from the symptoms taken in connection with the known facts of the case, and unless these are sufficient to establish guilt beyond the shadow of a doubt, humanity demands at least a verdict of "not proven." The following cases will illustrate this point:— Case 1. A gentleman of the city, six weeks after marriage, applied to his physician to be treated for gonorrhoea, which he solemnly declared he had contracted from his wife, and his known probity was such as to render his statement in the highest degree probable. Under the supposition that his disease could only have arisen from contagion, he had already accused his wife of unchastity, her friends * had been informed of the charge, and a separation and action for divorce were imminent. His physician examined the wife, whom he found perfectly healthy, and ascertained, on farther inquiry, that the disease in the husband was due to the continuance of coitus during a menstrual period. Case 2. The following case is reported in a work entitled " Sur la Non-existence de la Maladie Venerienne," which was published in Paris in 1826 :— A young man became attached to a young female friend, " a peine sortie de l'enfance," and married her after some years of mutual attachment. Some months after this " hymen fortune!" the young man was compelled to take a journey to some distance, and, while travelling, he experienced pain in making water, and shortly per- ceived a discharge from the urethra. On arriving at a town, he con- sulted an eminent surgeon, who assured him he had a gonorrhoea. " Mais, monsieur, je suis nouvellement maris," and he assured the learned surgeon, that he had never known any woman but his wife from the hour of his birth. " Comment," repond le chirurgien, en souriant, " vous voudrez me cacher la cause de votre mal: de quel pays etes-vous ? Vos jeunes gens rougiroient; je vous certifie, mon- sieur, que vous avez une belle et bonne ehaude-pisse." The youth continued to protest his innocence. Some days after the testicle swelled. The surgeon now assured him that if his wife were vir- tuous, he must have had " une affaire" with another woman, and that i In a discussion upon the origin of gonorrhoea independent of contagion, which I once held with the writer of a work on venereal, the final argument of my oppo- nent was, " I do not like to feel that I am imposed upon by patients." CAUSES AND NATURE OF GONORRHOEA. 71 the pox remained in his blood from that period. Between the two alternatives of his own or his wife's purity, of course he could not entertain a doubt. He wrote to her an indignant and passionate letter, and then blew out his brains. The unfortunate woman sub- mitted to an examination, which proved her free from disease, never uttered another word—shortly miscarried, and died. So much for the honor of our noble profession ! * Case 3. A few years since, in one of the New England States, a clergyman came very near being deposed from the ministry, and convicted of adultery, on the testimony of his physician, that a urethral discharge for which he had treated him could only have arisen from impure intercourse! Other causes, in addition to those already mentioned, may give rise to urethral gonorrhoea in the male. Thus, unquestionable instances are reported in which a gouty or rheumatic diathesis without exposure in sexual intercourse has occasioned a discharge from the urethra. Ricord relates a remarkable case of tubercular deposit in differ- ent portions of the urethra of a strumous subject with symptomatic urethral discharge;2 and a scrofulous diathesis is generally a strong predisposing, if not an active cause of inflammation of the urethra as well as other mucous canals. Mr. Harrison reports the case of a medical practitioner who suf- fered from a puriform discharge, heat and pain along the course of the urethra, attended with frequent micturition, chordee, and sympa- thetic fever, after eating largely of asparagus.3 Among other causes of urethritis are free indulgence in fermented liquors, terebinthinate medicines, 'paraplegia inducing changes in the urine, the use of bougies, stricture, masturbation, prolonged excitement of the genitals, cancer of the womb, vegetations within the urethra, ascarides in the rectum, dentition, epidemic influences, etc. The internal use of cantharides is peculiarly liable to excite gonorrhoea, which, in this case, commences in the deeper portion of the canal. M. Latour, editor of the Union Medicate, vouches for the truth of the following story: A physician, thirty years of age, had been continent for more than six weeks, when he passed an entire day in the presence of a woman whose virtue he vainly attempted to overcome, but who resisted all his approaches. From ten o'clock 1 Quoted by Mr. Skkt. loc. cit. 2 Bulletin de l'Acad. de M6d., vol. xv., p. 565. 3 London Lancet, Am. ed., Jan., 1860. 72 URETHRAL GONORRHOEA IN THE MALE. in the morning until seven in the evening, his genital organs were in a constant state of excitement. Three days afterwards he was seized with a very severe attack of gonorrhoea, which lasted for forty days. A chancre within the urethra is attended with more or less thin and often bloody discharge, which will be more particularly de- scribed in a subsequent portion of this work. I will merely remark at present that inoculation of the secretion upon the person affected cannot determine the presence of an ulcer, unless it be a chancroid, since a chancre is not auto-inoculable. Again, urethral discharges are sometimes due to changes in the mucous membrane lining the canal, induced by infection of the constitution with the syphilitic virus. In several instances I have observed a muco-purulent discharge coinciding with the first out- break or a relapse of secondary symptoms, and so long after the last sexual act that it could not be attributed to the ordinary causes of gonorrhoea. Bassereau speaks of similar cases.1 There is no more frequent seat of early general manifestations than the mucous membranes in general; and in the cases referred to changes probably take place in the urethral walls similar to the erythema, mucous patches, and superficial ulcerations which are found within the buccal and nasal cavities. These cases are very rare, and can only be distinguished from ordinary gonorrhoea by the previous history and coexisting symptoms of the patient. For instance, if there has been no exposure for a long period, and especially if secondary- symptoms have recently made their appearance upon other mucous membranes, the urethral discharge is probably symptomatic of the constitutional disease. Since the secretions of secondary lesions are now known to be contagious, the discharge in these cases is doubtless so, also; it is not susceptible of inoculation upon the person from whom it is derived nor upon any other affected with syphilis, but, if communicated to a healthy individual under the requisite conditions, will give rise to a chancre. The inferences from what has now been said of the etiology of gonorrhoea relative to its nature, are so obvious that they require little more than mere mention. If in a large proportion of cases the disease can be traced to no other cause than leucorrhcea, the menstrual fluid, or, in less frequent instances, to excessive coitus, intercourse under circumstances of special excitement, inattention to cleanliness, the abuse of stimulants, etc., and if, when thus ori- Affections Syphilitiques de la Peau, p. 356. TREATMENT. 73 ginating, it is undistinguishable either by its symptoms, course, complications, or termination, from the same affection due to con- tagion, it is evident that it should be ranked among the ordinary catarrhal inflammations of mucous membranes, or, in other words, that it is a simple urethritis, the connection of which with sexual intercourse is a merely accidental, or at all events, not a necessary circumstance. But—it may be asserted—the possibility of contagion proves the presence of a poison. Granted: but it does not follow that it is a specific poison, or one incapable of being produced by simple inflam- mation. Such a conclusion would be contrary to the facts adduced in the preceding pages, and, moreover, is not required by the analogy of inflammations of other mucous membranes; since, in muco-puru- lent conjunctivitis—the true analogue of gonorrhoea—we have pre- cisely the same order of events, viz., inflammation originating in simple causes, and giving rise to a secretion which is contagious and capable of transmission through an indefinite series of indivi- duals. The discharge from the two mucous surfaces just mentioned would even appear to be transferable, since that from the urethra applied to the eye gives rise to purulent ophthalmia, the secretion of which, if we may rely uppn a few experiments by Thiry, of Brussels, will, when brought in contact with the lining membrane of the urethra, produce urethritis. I have no space to discuss the untenable theory of a "granular virus" of gonorrhoea advanced by M. Thiry, according to which, the presence of granulations upon the mucous membrane is neces- sary to render the discharge contagious.1 Treatment.—The treatment of gonorrhoea must be adapted to the general condition of the patient, and especially to the stage of his disease. In the great majority of cases met with in practice, acute inflammatory symptoms have already set in at the time the patient first applies to the surgeon; but in those exceptional cases which are seen at an early period, and in those only, we may often succeed in cutting short the disease by means of the treatment termed abortive. Abortive Treatment of the First Stage.—During the first few days after exposure, varying in number from one to five in different cases, before the symptoms have become acute, when the discharge is but slight and chiefly mucous, and while as yet there is no severe 1 M. Thiry's views have been published in a series of lectures in the Presse Me"d. Beige, and are also advocated by Guyomar, These de Paris, 1858 (No. 282). 74 URETHRAL GONORRHOEA IN THE MALE. scalding in passing water, we may resort to caustic injections with a view of exciting artificial inflammation which will tend to subside in a few days, and supplanting the existing morbid action which is liable to continue for an indefinite period and is exposed to various complications. This is known as the " substitutive," or more com- monly as the "abortive treatment" of gonorrhoea. This method has been inordinately praised and as violently attacked; its true merit is probably to be found between these two extremes. It is certainly liable to be greatly abused, and, if so, is both unsuccessful and capable of producing the most unpleasant consequences; but when limited to the early stage of gonorrhoea and used with proper caution, it is a highly valuable method of treatment, unattended with danger, and undeserving the censure sometimes cast upon it. In employing the abortive treatment, there are several points which it is important to recollect: 1. The disease, in the stage to which this treatment is applicable, is limited to the anterior portion of the urethra, known as the fossa navicularis, or extends but a short distance beyond it; it is not necessary, therefore, that the injection should reach the deeper portions of the canal. 2. For the treatment to be successful, the whole diseased surface should receive a thorough application of the injection, for if any portion remain untouched, it will secrete matter that will again light up the disease. 3. When once a sufficient degree of artificial inflammation is ex- cited, the caustic has accomplished all that can be expected of it, and should be suspended. Since a solution of nitrate of silver, which is commonly used in the abortive treatment, is readily decomposed by contact with metallic substances, metal syringes should be avoided. Glass syr- inges, if well made, answer every purpose; but as found in the shops, they are apt to be unequal in calibre in different parts of the cylinder, the wadding of the piston contracts in drying, and a portion of the fluid fails to be thrown out, as is seen by its overflow when the syringe is filled a second time. For these reasons, I never advise a patient to purchase a glass syringe, knowing that it will probably give him much annoyance, and perhaps prevent his deriving benefit from treatment. Fortunately, we have a very excellent substitute in the hard-rubber syringes which can be obtained at the druggists'.1 i An excellent series of urethral syringes is manufactured by the American Hard Rubber Company. In these instruments, the diameter of the cylinder is in all parts the same ; the piston works with great accuracy ; the material is not acted upon by ordinary medicinal agents, and the different sizes and forms of the instrument are TREATMENT. 75 The solution of nitrate of silver, in the abortive treatment of gonorrhoea, may be of considerable strength, when only one injec- tion will be required; or, it may be weak, and in that case should be repeated at short intervals until the effect produced be deemed sufficient. I much prefer the latter course, especially with patients who apply to me for the first time, since it enables me to graduate the effect according to the susceptibility of the urethra, which varies in different persons. The following is the formula for the weak form of injection:— R. Argenti nitratis crystalli gr. j-iss. Aquae destillatae J|vj. M. With this, as with all injections in gonorrhoea, it is essential to success that the surgeon should administer the injections to his patients, or see, by actual observation, that they know how to use them. Verbal directions cannot be relied upon. The patient should be made to pass his water immediately be- fore injecting, or, better still, a quarter of an hour before. We wish to clear the urethra of matter, and to have the bladder empty so that the injection may have some time to act before it is washed away by another passage of the urine, and yet a short interval between the last act of micturition and the injection is advisable, in order that as much of the urine as possible may have drained from the canal and little be left to decompose the nitrate of silver. The prepuce should now be fully retracted, and the glans penis exposed. The latter should be wiped dry, so as to afford a firm hold to the thumb and forefinger of the left hand, applied to its opposite sides, and firmly compressing it around the point of the syringe, intro- duced to its full extent within the meatus. If this pressure be properly made, not a drop of the solution will be lost, as the piston of the syringe is slowly forced down by the forefinger of the right hand holding the instrument, and the whole contents will be dis- adapted to the various purposes for which it is required. The size most generally applicable to the treatment of gonorrhoea is called "No. 1, B." It holds half an ounce, which is not too much for injections in the latter stages of the disease; if used in the abortive treatment of the first stage, it should be only half filled. " No. 1" holds two drachms, and is well adapted for the abortive treatment. "No. 1, A" is of the same size as the last mentioned, but has a very short nozzle, which is intended to obviate irritating the canal with the point of the instrument. The " Urethral Syringe with extra long pipe," is, in fact, a syringe united to a catheter, and is adapted for injections of the deeper portions of the canal or the bladder. The catheter portion may be bent to any curve desired, by first oiling it and heating it over a spirit lamp. 76 URETHRAL GONORRHOEA IN THE MALE. charged into the canal. The syringe should now be withdrawn, and the fluid still retained for a few seconds by continuing the com- pression of the glans. When the injection is allowed to escape, it will be found to be of a milky-white color. This is due to the partial decomposition of the contained salt by the remains of the urine and the muco-pus in the canal. As this decomposition has prevented the application of the injection in its full- strength to the urethral walls, a second syringeful should be thrown in, and retained for two or three minutes. During this time a finger of the disen- gaged hand should be run along the under surface of the penis from behind forwards, so as to distend the portion of the canal occupied by the injection, and insure the thorough application of the fluid to the whole mucous surface. This description of the method of using the syringe is, in the main, applicable to all the injections which may be required in the course of a gonorrhoea; but we are now speaking of the abortive treatment, by means of weak injections of nitrate of silver. We will suppose that this first injection has been administered by the surgeon, who, at the same time, has explained the various steps of the operation to the patient. The directions with regard to diet, etc., that will presently be mentioned in speaking of the second stage, should now be given; the patient should be ordered to repeat the injection every three hours, and, for the present, it is best that he should be seen by the surgeon twice a day. It is also well at this time to prescribe an active purge. This first effect of the caustic injections is manifested in a few hours; the discharge becomes copious and purulent, and consider- able scalding is felt in passing water. In the course of twenty-four to forty-eight hours, however, the discharge grows thin and watery, and, very likely, is tinged with blood. It is now time to stop the injection and omit all medication for a few days, until we see how much good has been accomplished. If the treatment meets with its usual success the discharge will gradually diminish, and finally disappear in from three to five days. Sometimes, however, after growing less, it again increases, showing a tendency to relapse. In that ease, I usually advise weak injections of acetate of zinc, as recommended in the third stage of the disease. Some surgeons prefer to resume the caustic injections in the same manner as at first, if, after a week has elapsed, any traces of the discharge remain. The chief objection to this modification of the abortive treatment is, that it is necessary to leave the administration of most of the injections to the patient, who may be prevented by ignorance, or TREATMENT. 77 • the requirements of his occupation, from using them as thoroughly or as often as is necessary. If we have reason to fear this, we may resort to a stronger solution, and inject it once for all, with our own hands, but I have found the effect decidedly less satisfactory. It was this method of employing the abortive treatment that was recommended by Debeney of France, and Carmichael of England, by whom this treatment was first introduced to the profession. The same method is also still employed and highly recommended by many surgeons, and especially by M. Diday of Lyon. The strong- injection should not contain less than ten grains of the nitrate of silver to the ounce of distilled water, and more than fifteen grains are objectionable, unless with patients who have been under treat- ment before, and in whom the urethra has been found to be quite insensible. R. Argenti nitratis crystalli gr. x-xv. Aquae destillatae ^j. M. The mode of using this injection is identical with that already described. Two small syringefuls should be thrown in; the first to clear the urethra of urine and muco-pus, the second to exercise a curative effect; and the surgeon should feel that the success of the treatment depends, in a great measure, on the thoroughness of its application. As an additional precaution against the fluid extend- ing further back than is necessary, the patient may compress the penis anteriorly to the scrotum, while the surgeon is administering the injection; or the same result may be accomplished by making him sit astride the arm of a chair, and thus compressing the urethra in the perineum. There is still another mode of employing a strong solution of nitrate of silver, by means of an instrument introduced by Dr. F. Campbell Stewart, of this city, and called by his name. This instrument consists of a straight canula inclosing a sponge, which can be made to protrude from its extremity. This sponge is first soaked in a solution of nitrate of silver, and concealed within the canula. The instrument is then introduced for about two inches within the urethra, when the canula is to be partially withdrawn; the sponge is thus exposed to the contact of the urethral walls, in which position it is to be allowed to remain for a minute or two, and then withdrawn by slowly twisting it on its long axis. By the use of Dr. Stewart's instrument, the extent of the application can be limited at will, and it is perhaps owing to this fact that we can employ with safety a much stronger solution than when using a 78 URETHRAL GONORRHOEA IN THE MALE. syringe. I have thus applied a solution of twenty, and even thirty grains to the ounce, without exciting an undue amount of inflam- mation, or other unpleasant symptoms. Care should be taken that the instrument be of sufficient size. Some of those found in the shops are too small, not exceeding a No. 7 bougie in diameter. I have had one manufactured for my own use of the size of No. 10. I cannot leave this subject of the abortive treatment of gonor- rhoea, without again expressly stating that I recommend it only in the first stage of the disease, and not after acute inflammatory symp- toms have set in, or the patient suffers from scalding in passing water. Taking the usual run of cases as met with in practice, probably not more than one out of ten is seen at a sufficiently early period to admit of the abortive treatment. Its employment in the acute stage, as recommended by its inventors, is generally unsuccessful, and dangerous and even fatal results have been known to ensue. Prudent practitioners have limited the use of caustic in- jections to the early stage of gonorrhoea, except in some instances in the decline of the disease; but, in the latter case, the mode of injecting must be modified, so that the fluid may reach the deeper portions of the canal. Treatment of the Acute Stage.—The proper regulation of the diet, exercise, and mode of life of the patient, is of the first importance in every stage of gonorrhoea. In the treatment of the inflammatory stage, as well as in the abortive treatment of the first stage, if the patient can keep his bed for a few days, the battle is half won. The advantages of absolute repose and quiet should be placed promi- nently before him, and every inducement be offered to lead him to avail himself of them. Yet in practice, we find that very few will submit to this constraint. It is very well to say that every patient that puts himself under the care of a physician, should follow his advice implicitly i n all things; but we must take the world as we find it, and the calls of business, or the necessity of secrecy, often render the insistence upon such stringent rules impossible. When life is in danger, men absorbed in business will stay at home, but not merely for an attack of gonorrhoea. This, indeed, should not prevent our doing our best to persuade them, but we shall succeed in but a small minority of cases. Exercise of all kinds should be avoided as much as possible; walking, dancing, riding on horseback, and standing—in the street, at the desk, at a party—are all injurious. Riding is certainly less objectionable than walking, and yet a long ride, even in a rail-car, often aggravates a gonorrhoea or induces a relapse when it is appa- TREATMENT OF THE ACUTE STAGE. 79 rently cured. At home, and at the store or office, the recumbent posture should be maintained as much as possible. It is highly important, also, that the genital organs should be well supported by a suspensory bandage. The kind of bandage is immaterial, provided it fit well and do not chafe the parts; and of these conditions the surgeon should satisfy himself by actual observation. While the more acute symptoms continue, the diet should be exclusively fari- naceous ; and meat, stimulants, asparagus, cheese, coffee, and aoids be forbidden. The perusal of all books calculated to excite the passions, and the company of lewd women, even if no improprieties be committed, should be strictly interdicted. The last-mentioned caution is not generally given without good reason. At the commencement of the treatment of a case of gonorrhoea in the acute stage, it is well to administer an active purge, as five grains of calomel combined with ten of jalap, a full dose of Epsom salts, or three or four compound cathartic pills of the U. S. P. If the inflammatory symptoms be severe, marked benefit will be de- rived from the application to the perineum of half a dozen leeches, which, however, are rarely absolutely necessary. Care should be taken to keep the head of the penis free from any collection of mat- ter, lest balanitis be excited or the disease aggravated by its pre- sence. A pair of triangular-shaped drawers, like ordinary swimming drawers, worn next the skin, affords the best protection to the patient's linen. Water, as hot as can be borne, is the most grateful local application that can be used. I have found that it generally affords great relief to the scalding in micturition and the local pain and uneasiness, and can fully indorse Mr. Milton's statement with regard to it. " The only direct application which I can safely say has never disappointed me, which is at once safe, simple, and use- ful, is that of very hot water to the penis. But to obtain the really good effects it offers, the water must be hot, not lukewarm. In fact, we seldom see so much good ensue as when it is carried to the ex- tent of producing some excoriation and faintness; thus applied, and especially in the early stages of the disease, the weight felt about the testicles soon disappears, the pain on making water and using injections is soothed, and the prepuce and glans rapidly regain a more normal temperature and color."l The best method of employ- ing it is to direct the patient to immerse his penis in a cup of hot water for a few minutes before and after using the injection. After the operation of the cathartic, we may, in most cases, com- 1 Milton on Gonorrhoea, p. 21. 80 URETHRAL GONORRHOEA IN THE MALE. mence at once with copaiba or cubebs, rules for the exhibition of which will presently be given at length. If, however, the penis be still much swollen, and the scalding on passing water severe, we may defer the exhibition of the anti-blennorrhagics for a few days, and administer alkalies or diuretics, either alone or combined with sedatives, for the purpose of rendering the urine less irritating by diminishing its acidity, or diluting its contained salts by increasing its quantity. Again, both these classes of remedies may be given at the same time. From one to two drachms of the chlorate, acetate, or nitrate of potash, or two or three drachms of liquor potassae, may be added to a pint of flaxseed tea; and the patient be directed to take this quantity in the course of twenty-four hours. The follow- ing is also an excellent formula:— R. Potassae bicarbonatis :jij. Tincturae hyoscyami 3J. Mucilaginis 5 v. M. A tablespoonful every three hours. Do not mix tincture of hyoscyamus and liquor potassae in the same prescription, since the effect of the former is destroyed by the presence of a caustic alkali.1 In this stage of the disease, Mr. Milton highly recommends the following:— R. Pulv. potassae chloratis ^ij. Aquae bullientis ^v. Misce et adde— Liquoris potassae ^iij. Potassae acetatis ^iij ad gv. Misce et cola. One ounce three times a day. If the bowels be not freely open, Mr. Milton adds powdered rhu- barb to each dose of this mixture, in sufficient quantity (gr. v ad 9j) to produce two or three loose stools daily. The following is another formula recommended by Mr. Milton:__ R. Potassae acetatis ^j. Spirit aetheris nitrici sjiij. Aquae camphorae £vj. M. One ounce thre» times a day. ' See Paris's Pharmacologia, Ninth Edition, p. 512. This fact has recently been brought forward as new, and confirmed by actual experiment, by Dr. Garhod; Mcdico-Chirurgical Transactions, Second Series, vol. xxiii. London, 1858 TREATMENT OF THE ACUTE STAGE. 81 An elegant and convenient method of administering an alkali is by means of Brockedon's wafers of bicarbonate of potassa, of which two may be given after each meal. The only objection to them is their expensiveness. If the penis be much swollen and florid, the meatus contracted by the distention of its walls, and the urethra in a state of great sensibility, the above general measures should constitute the only treatment, and no local remedies, with the exception of hot water, be resorted to, until the inflammation has somewhat subsided. In the majority of cases, however, especially when the patient has had gonorrhoea before, the local symptoms are not severe, even in the acute stage, and the point of a syringe can be gently introduced within the canal without exciting much pain. When this is the case, an injection containing glycerin and strongly opiated, will be found to afford great relief to the local pain and uneasiness, and hasten the subsidence of the inflammatory symptoms, and the diminution of the discharge. I can speak very decidedly in favor of this application and of its perfect safety; but the opium must not be added in the form of tincture, or the alcohol, which is an irritant, will counteract its effect; and the fluid is to be injected with gentleness, and not with such force as to painfully distend the canal. The following is the formula that I use :— R. Extractii opii Qj. Glycerin ^j. Aquae giij. M. Injection to be used after every passage of urine. In many cases of a subacute form, half a grain or a grain of acetate or sulphate of zinc may be added to each ounce of the mixture, even at the outset, and there are but few cases in which it is not admissible in the course of twenty-four or forty-eight hours, when the inflammation, local pain, and scalding are generally found to be much improved. If the case continue to progress favorably, the quantity of the astringent may be gradually increased, and that of the opiate diminished; and the treatment should be continued according to the rules laid down for the third stage, to be mentioned presently. While pursuing the treatment of the acute stage of gonorrhoea, care should be taken that antiphlogistic measures be not too lon^ persevered with. It should be remembered that the natural ten- dency of the disease is to lower the tone of the system, and a con- dition of debility in turn reacts on the disease and prolongs its 6 82 URETHRAL GONORRHOEA IN THE MALE. duration. We often meet with patients who have treated them- selves with low diet and daily purging for weeks, and yet who are no better of their gonorrhoea. An antiphlogistic course alone may relieve the more acute symptoms, but it will not cure the complaint; and so soon as the pain in passing water has diminished and the local inflammation in a measure subsided, the patient should no longer be confined to his room, and should have a more liberal diet; nor, under any circumstances, should his confinement and abstinence be prolonged, if, after a reasonable time, they are found to produce no change for the better, or the pulse becomes feeble, the skin clammy, and the strength exhausted. Indeed, in some cases, in which the constitution is enfeebled by disease, debauch, or previous attacks of venereal, it is necessary to abstain from all measures calculated to lower the tone of the system, and resort to good living and even quinine, iron, and other tonics, from the very outset of the disease. It is, therefore, to be expressly understood that the antiphlogistic treatment here recommended, is intended to apply, in its full force, chiefly to the disease as it appears in first attacks in men of full habit. Those patients who have had numer- ous previous attacks will rarely require such active treatment in any stage of the disease. The judgment of the surgeon must deter- mine the indications of each individual case. Treatment of the Stage of Decline.—A marked diminution of the scalding in making water, and of the painful sensations in the penis, is, I believe, a better index of the subsidence of the inflammatory action, than the character of the discharge, which, independently of treatment, often continues copious and purulent after the third stage has fairly commenced. In giving directions as to the regimen of a patient in the third stage of gonorrhoea, some, regard should be paid to his usual mode of life. As a general rule, all indulgence in spirituous or malt liquors should be strictly forbidden, and total abstinence be prac- tised until the cure is complete, and for at least a fortnight afterward. You will meet with some patients, however, who have been free drinkers for years, and who will not well bear the total loss of their stimulus, without becoming so debilitated that their gonorrhoea is thereby prolonged and more difficult to cure. In these exceptional cases, it is better to allow a glass of claret, sherry, or even brandy and water, to be taken with the dinner. In any case, malt liquors should be avoided, since they are decidedly more injurious than other liquors which contain a larger amount of alcohol. The patient may now return to a more generous but simple diet, though TREATMENT OF THE STAGE OF DECLINE. 83 salt meats, highly seasoned food, asparagus and cheese should still be avoided. The bowels are not to be allowed to become consti- pated, and this should be prevented so far as possible by regulating the diet. One or two free stools a day are desirable. If the patient have been confined to the house during the acute stage, he may new be allowed to go out, but should be cautioned against walking 01 standing more than is necessary, and the genital organs should be well supported by a suspensory bandage. Patients often inquire whether the use of tobacco is injurious; I believe that it is, and that either smoking or chewing, especially in excess, relaxes the genital organs and tends to keep up a urethral discharge. I have frequently been told by patients subject to spermatorrhoea, that smoking during the evening would invariably be followed by an emission during the night, and I am satisfied that many cases of gonorrhoea are pro- longed by the excessive use of tobacco. I therefore recommend entire abstinence, or, at least, great moderation, both in smoking and chewing, to persons suffering with this disease.1 The chief remedies adapted to the third stage of gonorrhoea are injections, and copaiba and cubebs. By far the more important of these are injections, which constitute our chief reliance in the treat- ment of this affection, when it has arrived at this stage; and, in spite of all that has been written and said against them, I do not hesitate to say, that the surgeon who voluntarily renounces injec- tions, deprives himself of his best weapon in contending with gonor- rhoea, and is comparatively impotent in his attempts to conquer it. The objections that have been raised against this mode of treat- ment need not long detain us. They are chiefly the following: 1. It is asserted that the injected fluid carries before it the muco-pus within the urethra, and thus extends the disease to the deeper por- tions of the canal. Supposing this possible in any case, it cannot take place, if the patient pass his water before injecting, as he should always be directed to do. 2. It is said that injections may excite swelled testicle and other complications of gonorrhoea. This is only possible, when they are used of too great strength or with undue violence. 3. It is supposed by some persons that there is danger of the injection penetrating the bladder; but this idea is entirely groundless. It is absolutely impossible to inject the bladder, however great the amount of force employed, by means of a syringe merely introduced within the meatus. A knowledge of the anat- 1 Dr. Shiplet has recently published two cases of gonorrhoea in which the dis- charge repeatedly disappeared on leaving off smoking, and returned on resuming it. [Boston Med. and Surg. Journal, Nov. 22, 1860.) 84 URETHRAL GONORRHCEA IN THE MALE. omy of the canal is sufficient to establish this point and experience confirms it. Moreover, no harm would ensue even if a portion of the fluid should enter this viscus, for it would be immediately neu- tralized by the urine. 4. The chief objection that has been alleged against injections is, that they are a frequent cause of stricture of the urethra. This the opponents of injections have endeavored to prove, by showing that most persons with stricture preceded by gonorrhoea, were treated for the latter disease by injections. This is clearly a mode of reasoning, post hoc ergo propter hoc, and by no means proves the ground assumed. I have heard of some one, who, to show its fallacy, instituted some inquiries among patients with stricture, as to whether they had taken flaxseed tea for their previous gonorrhoea, and who was able to prove, if such reasoning be reliable, that flaxseed tea is a very fruitful source of stricture. As Ricord justly states, it is much more probable that strictures are due to the chronic inflammation, which, in cases of gonorrhoeal origin, has usually preceded them for a long period, than to any influence exer- cised by injections. This well known effect of chronic inflammation of a mucous membrane in producing an effusion of plastic material in the sub-mucous cellular tissue which by its contraction dimin- ishes the calibre of the canal, is a strong argument in favor of this view. The objections to the use of injections are, I believe, founded on their abuse, or on false reasoning, and will not stand the test of examination. When properly used, they constitute the most valua- ble means within our reach for the cure of gonorrhoea, and are employed in the practice of all surgeons, with very few exceptions, who have had the opportunity of testing their value. Injections are particularly adapted to the treatment of the first stage by the abortive method and to the treatment of the third stao-e of gonorrhoea; although, as already stated, in very many cases they may be used with safety and benefit in a weak form, even in the second or acute stage. These remarks in favor of injections do not of course imply that they are infallibly successful, nor that they can be used indiscrimi- nately in all cases. Under certain circumstances, their effect is found to be injurious. If in the course of treatment the patient complain of a frequent desire to pass his urine, and other symptoms indicating irritation or inflammation of the neck of the bladder or prostate, injections should be at once suspended. Continuous pain in the penis, or any considerable amount of tumefaction of its tissues also contra-indicates the use of irritant or astringent injections, although the formula containing glycerin and extract of opium, TREATMENT OF THE STAGE OF DECLINE. 85 which was recommended in the acute stage, may still, in many cases, be employed with advantage. Moreover, it should not be forgotten that injections will sometimes keep up a discharge through the irritation which they excite, however simple may be their composi- tion. After the force of the disease has been subdued, they should therefore be used at gradually increasing intervals, or, from time to time, be altogether omitted, until the necessity of their continu- ance again becomes apparent. The manner of using the syringe in the third stage is essentially the same as in the abortive treatment of the first stage. A larger syringe, however, should be employed, one, for instance, holding three or four drachms; since there is now no necessity of limiting the action of the injection posteriorly, and, on the contrary, it is desirable to extend it as far back as possible, in order that it may reach the whole diseased surface. For this purpose the finger may be run along the under surface of the urethra from before back- wards, as well as in the opposite direction (from behind forwards), as previously recommended, in order to insure complete distention of the canal and exposure of its lucunae. The patient should always pass his water before injecting, and throw in two syringefuls at each application. A great variety of substances have been recommended as the active principles of injections. A choice, to a certain extent, is doubtless desirable, since the same injection does not always suc- ceed equally well in all cases. For instance, one of my patients, whom I have repeatedly treated for gonorrhoea, is always made worse by an injection of sulphate of zinc, and is benefited by a weak solution of nitrate of silver. Peculiarities of this kind are occasionally met with, but I believe that much time is wasted by young practitioners in changing from one to another of the many varieties of injections proposed in books, under the supposition that some specific effect is to be obtained from the contained ingredients, whereas, in most cases, success depends upon the thoroughness of the application, and attention to the general health and any existing complications. My own preferences for an astringent in the active principle of injections in the third stage of gonorrhoea, are very strongly in favor of the sulphate of zinc; which is also the favorite injection of Sig- mund of Vienna, Mr. Milton, and many other eminent surgeons. I have already spoken of the addition of a small quantity of this salt to the sedative injections of the acute stage, after the more inflam- matory symptoms have been subdued. The proportion of the sul- 86 URETHRAL GONORRHOEA IN THE MALE. phate may be increased and that of the opiate diminished, as the case progresses, and the latter finally omitted altogether. The strength of the injection should be such that it may excite a slight uneasy sensation in the urethra for about ten minutes, but it must not be strong enough to cause severe or long-continued pain. As the case approaches a cure, the injection will cease to excite any unpleasant feeling whatever, and its strength need not be further increased. In most cases, we need not at any period exceed the proportion of the sulphate in the following formula:— R. Zinci sulphatis gr. xij. Aquae 3jiv. M. Glycerin may be substituted for half an ounce or an ounce of the water. As to the frequency with which the injection is to be used, I usually direct the patient to inject after each passage of his urine, with the expectation that he will take four or five injections in the course of the twenty-four hours. It is better that the last injection should be applied an hour or two before retiring, since if used di- rectly before going to bed, it favors the occurrence of erections and chordee during the night. If the discharge do not materially diminish under the use of these injections, either alone or combined with the internal administration of copaiba or cubebs, I usually resort to a solution of nitrate of silver, of the strength of from two to five grains to the ounce of water, and inject it myself for the patient, daily, or every two or three days, while at the same time he is directed to continue his injection of sul- phate of zinc. The effect of an irritant like nitrate of silver should be closely watched, and its administration should not, therefore, be left to the patient himself. The acetate of zinc is nearly, if not quite as valuable a remedy as the sulphate, and the remarks above made in favor of the latter are equally applicable to the former. Indeed, if I were asked to name the simplest treatment of gonorrhoea, and the one best adapted to the largest number of cases, I should reply: a weak injection of the sul- phate or acetate of zinc, containing from one to three grains to the ounce of water. Many men about town constantly carry in their pockets a prescription of this kind (generally with the addition of a little morphine or a few grains of powdered opium), with which they almost invariably succeed in arresting their frequent attacks of gonorrhoea, without resorting to the nauseous anti-blennorrhagics, or finding it necessary to consult a surgeon. A great reputation has been acquired for a reddish powder sold by an irregular practitioner TREATMENT OF THE STAGE OF DECLINE. 87 of this city, who tells his patients that the ingredients are entirely unknown to the profession. This powder, subjected to chemical analysis, is found to contain as coloring matter Armenian bole, and as an active ingredient acetate of zinc. The sulphate of zinc was a favorite with Dr. Graves, who was in the habit of combining it with the impure carbonate of zinc, as in the following formula:— R. Zinci sulphatis gr. iij. Calaminae gr. x. Mucilaginis ^ij. Aquae ijvj. M. With regard to the addition of calamine, Dr. Graves says: " How the lapis calaminaris acts, unless on a mechanical principle, it is diffi- cult to explain; but of its utility I am certain, having long used this combination, as recommended in Thomas's Practice of Physic."1 The chloride of zinc is a powerful caustic and irritant which ful- fils, although in a much less perfect manner, the same indications as nitrate of silver, and may, therefore, be used under similar circum- stances. It is a favorite injection with some practitioners, and espe- cially with my venerable friend, Dr. J. P. Batchelder, who employs a very strong solution in all stages of gonorrhoea, and states that but few cases resist more than a week. Dr. B. dissolves gij of the chlo- ride in siij of water, and directs the patient to commence with three drops of the mixture to a tablespoonful of water, and inject three times a day; to add a drop at a time (rarely exceeding eight drops) until a smarting sensation is produced; and then gradually to dimin- ish the strength until the discharge disappears. Of the numerous other formulae for injections sometimes employed in the treatment of gonorrhoea, the following are among the best:— R. Cupri sulphatis gr. xij. Aquae 5iv-vj. M. R. Liq. plumbi subacetatis ^ss-j. Aquae t^iv-vj. M. R. Aluminis gr. xij-xxx. Aquae Jiv. M. Mr. Milton says of alum: " The absence of pain which follows its use, and its feeble curative power, have led me to assign to it only a 1 Clinical Lectures, London Med. Gaz., new series, vol. i., 1838-9, p. 438. 88 URETHRAL GONORRHOEA IN THE MALE. secondary rank. I am, indeed, extremely doubtful, if it possess any superiority over very mild injections of nitrate of silver or sulphate of zinc, and would, therefore, confine its exhibition to those cases accompanied by severe pain, where it may, during a day or two, serve as a pioneer to the others." In the following we have a combination of alum and sulphate of zinc:— R. Liq. aluminis comp. ^j. Aquae Jiij. M. The two following are excellent formulas much employed by Ricord:— R. Zinci sulphatis, Plumbi acetatis, aa gr. xxx. Aquae rosae ^vj. M. R. Zinci sulphatis gr. xv. Plumbi acetatis gr. xxx. Tincturae catechu, Vini opii, aa 3J. Aquae rosae ^vj. M. Vegetable astringents may also be employed either alone or in combination with the salts of the metals. R. Vini rubri !|vj. Acidi tannici gr. xviij. M. R. Zinci sulphatis, Acidi tannici, aa, gr. xij. Aquse ^iv. M. Tannate of zinc is formed by decomposition of the sulphate. Injections of tincture of aloes are recommended by Gamberini,1 of Bologne, who states that they excite only a momentary smarting sensation, and are very efficacious. R. Tinct. aloes !|ss. Aquae ^iv. M. The subnitrate of bismuth has recently come into favor. It acts as a local sedative, or, when deposited upon the walls of the urethra, may possibly serve to protect the diseased surfaces from contact. Of 52 patients treated exclusively with injections of subnitrate of bis- muth, 36 recovered after an average treatment of twenty-two days.2 i Rev. de The"r. Med.-Chir., Jan. 1, 1860, p. 13. 2 Victoe de Mebic; Report to the Medical Society of London, April 30, I860. COPAIBA AND CUBEBS. 89 I have found only one difficulty attending its use, viz., that it clogged up the urethra, and by its mechanical presence excited an uneasy sensation, which was only relieved by the. passage of the urine. As it is not soluble in water, it should be suspended by means of mucilage, or glycerine, and the bottle be shaken before using. R. Bismuthi subnitratis 3ij. Mucilaginis ^ss. Aquae Jiijss. M. Dr. Irwin (U. S. Army) relies upon an injection of chlorate of potassa (31 ad aquae Sviij), repeated every hour for the first twelve hours, and gradually decreasing the frequency until the second or third day, when he states, " the disease will be generally found to have ceased." Mr. G. Borlase Childs employs an injection of the liquor hydrar- gyri nitratis ("1.ss ad aquas 3i), repeated three times a day. Western eclectics, so-called, often use hydrastin, either alone or combined with leptandrin. R. Hydrastin gr. x. Leptandrin gr. iv. Aquae ^iv. M. Finally, in many cases of gonorrhoea, simple iced-water injected after each passage of the urine, is very serviceable in allaying pain and irritation, and not inefficacious for the cure of the discharge. Copaiba and Cubebs.—Certain drugs which appear to possess a peculiar power in arresting inflammation of the urethral mucous membrane, are called anti-blennorrhagics. The chief of them are copaiba and cubebs. Some interesting investigations made by Ricord to determine the mode of action of these agents, are given in Ricord and Hunter on Venereal. It had already been observed in practice that copaiba and cubebs had but little curative effect upon gonorrhoea of any portion of the male or female genital organs, except the urethra; and it was hence suspected that they acted chiefly by their presence in the urine, and not through the general circulation; but this fact had not been demonstrated. A man with gonorrhoea chanced to enter Ricord's ward at the Hopital du Midi, who had a fistulous opening communicating with the ure- thra a short distance in front of the scrotum, produced by a ligature which had been applied around his penis when a child. He could at will, by separating or approximating the two edges of the fistula,, 90 URETHRAL GONORRHCEA IN THE MALE. either make his urine emerge from the artificial orifice, or cause it to traverse the whole extent of the urethra. Both portions of the canal were affected with gonorrhoea. Ricord administered copaiba to this patient, and directed him to pass his water entirely through the fistula. In the course of a few days, the disease was cured in the posterior portion of the canal, behind the artificial opening through which the urine had passed, while it remained unchanged in the anterior portion. He was now directed to make his water pass through the whole length of the canal, and in a few days more the anterior portion was also cured. By a singular coincidence, two other cases, of a similar character, soon after presented themselves in Ricord's wards, in one of which copaiba, and in the other cubebs, was given in the same manner, and the result in each was the same as in the case just described. From these experiments, Ricord concludes that copaiba and cubebs have but little influence upon gonorrhoea, unless directly applied to the diseased surface, and hence that we cannot expect decided benefit from their administration in any form of gonorrhoea, except that of the urethra in the two sexes. In gonorrhoea of the vagina or vulva, or in balanitis, they are comparatively useless. The presence of these drugs in the urine is still further evinced by the odor which they impart to this fluid, and which is often suffi- cient to pervade the bedchamber occupied by the patient. It must not, however, be inferred that copaiba and cubebs have no effect except by way of the kidneys. They are often used with benefit in other diseases than those of the urinary organs, and cannot therefore be entirely destitute of action through the general circulation. Moreover, they sometimes act as revulsives by pro- ducing copious evacuations from the bowels, and the urethral dis- charge is diminished as after the administration of a purge; their chief action, however, is in the manner described, by their presence in the urine. Such being the case, it might naturally be supposed that an emul- sion of copaiba injected into the urethra would have the same effect, and that thus the internal administration of so nauseous a drug might be avoided. The experiment has been tried in numerous instances, but the result has always been unsatisfactory. As stated by Ricord, both copaiba and cubebs, in passing through the diges- tive organs or kidneys, undergo some modification of an unknown character, upon which their curative power depends, and which cannot be imitated by art. Dr. Hardy, of Paris, is said to have effected a cure in several COPAIBA AND CUBEBS. 91 cases of vaginal gonorrhoea by giving the patients copaiba, and directing them to inject their urine into the vagina after each act of micturition. This course, however, is more interesting as an experiment than worthy of imitation in practice. M. Roquette, of Nantes, states that he has cured two patients who happened to be rooming together, by giving copaiba to one of them and directing the other to inject his friend's urine.1 Testimony on this point, however, is not uniform. In a recent number of the Gaz. Med. de Lyon,2 Diday says: " We seize the present occasion to confess, that injections, and even the retention within the urethra, of urine containing copaiba—a mode of treatment proposed by our- selves in 1843—has not had in our hands the same success as reported by other authors, or as theoretical considerations would lead us to expect." It was formerly supposed that copaiba could be used with safety- only in gleet, and even then in very small doses, and that it was inadmissible in gonorrhoea, especially in its acute stage, having a tendency, as was thought, to excite inflammation of the neck of the bladder and swelled testicle. In the latter part of the last century, however, it was discovered that the natives of South America were in the habit of administering copaiba in large doses in all stages of gonorrhoea, and this, too, with very great success. This led to a bolder method of administering it, and it was soon ascertained that its curative effect is much greater in the acute than in the chronic form of urethritis, and that it is rarely, if ever, productive of those complications which were once attributed to it.3 In short, it would appear that copaiba can be administered with safety and to much greater advantage in the acute stage of gonorrhoea, or at an early period of the stage of decline than afterward, and the same is true of cubebs. Still, when a case of this disease presents itself with marked inflammatory symptoms, it is usual to wait for a day or two until these have been somewhat subdued by the means already mentioned, before commencing with copaiba or cubebs, and I do not think that any time is thus lost; and, in all cases, the effect of the remedy is promoted by the previous exhibition of a cathartic. The diuretics and alkalies, spoken of in connection with the acute stage, may be combined with these drugs, as in some of the formulae to be mentioned presently, or may be given separately. 1 Accidents D6termine*s par le Copahu, L'Union Me"d., Dec. 19, 1854. 2 For June 16, 1863. 3 For an interesting history of the remarkable change in medical opinion with regard to the administration of copaiba, see Trousseau, Traite" de Therapeutique, vol ii. p. 592. 92 URETHRAL GONORRHOEA IN THE MALE. The dose of copaiba is from twenty minims to one or even two drachms, repeated three times a day. It may be given in its pure state upon coffee, wine, or milk, but it is so disagreeable to the palate, and so likely to excite nausea, eructations, and even vomiting, that • few persons can tolerate it in this form. To render it more accept- able to the taste and stomach, it is generally given in combination; and other ingredients are often added for the purpose of assisting its action upon the urethra. The " Lafayette mixture " in common use may be made much more acceptable to the palate by the addition of extract of liquorice, as follows:— R. Copaibae gj. Liquoris potassae ^ij. Ext. glycyrrhizae S;ss. Spiriti aetheris nitrici ^j. Syrupi acaciae ^vj. Olei gaultherise gtt. xvj. Mix the copaiba and the liquor potassae, and the extract of liquorice and sweet spirits of nitre first separately, and then add the other ingredients. Dose.—A tablespoonful after each meal. The following are also useful formulae — R. Olei copaibae, " cubebae, aa 3J. Aluminis gij. Sacchari albi giv. Mucilaginis ^iij. Aquae Jij. M. Dose.—A teaspoonful three times a day. R. Copaibae, Liquoris potassae, aa ^iij. Mucilaginis acaciae ^j. Aquae menthae viridis q. s. ad ^vj. M. (Milton.) Dose.—One ounce three times a day. R. Copaibae gx. Tincturae cantharidis, Tincturae ferri chloridi, aa jij. M. Dose.—From half a teaspoonful to a teaspoonful. But in whatever way combined, many stomachs will not tolerate copaiba in a liquid form; hence I commonly prescribe the solidified mass, formed by the addition of magnesia, and known in the TJ. S. Dispensatory as Pilulae Copaibae. It requires some little tact to pre- pare -this mass; or, rather, difficulty is met with, unless the proper kind of copaiba be used. Two kinds of the balsam are found in commerce, one of which, the best, is solidifiable with magnesia and COPAIBA AND CUBEBS. 93 the other not. The solidified mass should be divided into pills, each of which may contain five grains; and it is desirable to coat them with sugar, both for the purpose of preventing their adhering together, and to render them more acceptable to the palate. This is to be accomplished in the following manner: Put the pills into a vessel with sufficient water to moisten them; then turn them out upon a pan and sprinkle over them finely powdered sugar, at the same time rolling them about by shaking the pan, so that they may be entirely and equally coated. This process may be repeated after they are dry, as many times as is necessary to give them a thick coating of sugar. The dose is from four to eight pills three times a day. Thus prepared, they leave no taste in the mouth, and, being slowly dissolved in the stomach, are much less likely to excite nau- sea than the liquid article. We have another anti-blennorrhagic, but little if at all inferior to copaiba, in the powdered berries of the Piper Cubeba. Cubebs pos- sess the advantage over copaiba of being far less disagreeable to the taste, and less likely to excite nausea, eructations, vomiting, and diarrhoea; and, on this account, are often to be preferred in the treat- ment of gonorrhoea. They cannot be relied upon, however, unless freshly powdered, and preserved in a glass vessel; since the essential oil which they contain is rapidly absorbed by any porous material. Cubebs are conveniently taken, mixed in sweetened water, in the proportion of one to two drachms of the powder to half a glassful of the liquid; and this dose should be repeated three or four times a day. Cubebs are often advantageously combined with iron, especially for persons of weak habit, thus:— R. Pulveris cubeboe ^ij. Ferri carbonatis £ss. M. et ft. pulv. To be taken three times a day. Cubebs and copaiba may be combined together in the same pre- scription. R. Copaibae ^ij. Pulveris cubebae ^j. Aluminis ^iss. Magnesise q. s. ut fiat massa. To be divided into pills containing five grains each, of which from four to eight arc to be taken three times a day. 94 URETHRAL GONORRHOEA IN THE MALE. R. Pulveris cubeboe ^iij. Copaibae ^iss. Aluminis ^ij. Sacchari albi %j. Magnesiae .^iss. Olei cubebae, Olei gaultheriae, aa 3J. M. This mixture forms a paste, of which the patient may be directed to take a piece the size of a walnut, after each meal. The following prescription is particularly adapted to delicate stomachs:— R. Copaibae ^ij. Magnesiae gj. Olei menthae piperitae gtt. xx. Pulveris cubebae, Bismuthi subnitratis, aa ^ij. M. To be divided into pills of five grains each, and coated with sugar. R. Copaibae |j. Magnesias ^ss. Pulveris cubebae ^iss. Ammoniae carbonatis gij. Ferri sulphatis ^j. M. (Me"ot.) To be divided into pills of five grains each: dose, three, three times a day. Copaiba and cubebs may also be obtained enveloped in capsules of gelatin, and this is a popular form of administration. The cap- sules obviate the disagreeable taste of these drugs, but they do not always prevent nausea and eructations, when their contents are sud- denly discharged into the stomach, by the solution of the envelope. In such cases, we may employ the French dragees which have been introduced within the last few years, and of which there are several varieties; some containing copaiba alone, others cubebs, and others still both these drugs combined with iron; I have found them all to be very reliable. The dose is from four to six, three times a day. Injections of an emulsion of copaiba into the rectum, in cases where it is not borne by the stomach, have been recommended, especially by Velpeau. I have never tried this method of adminis- tering copaiba, and should have but little faith in its efficacy. It is acknowledged that a much larger quantity must be used than when it is given by the mouth. A simple injection should first be employed to clear the rectum of fecal matter, when the following mixture may be thrown in:— COPAIBA AND CUBEBS. 95 R. Copaibae gv. Ovi vitelli No. j. Extracti opii gr. j. Aquae ^viss. M. The nausea, eructations, and diarrhoea, which are often excited by copaiba, have already been referred to, and sometimes render it im- possible to administer this remedy in any form to a delicate stomach. The diarrhoea may often be controlled by the combination of alum or an opiate, but more frequently requires the drug to be suspended, and afterward resumed in smaller doses. Copaiba sometimes, also, gives rise to a cutaneous eruption, be- longing to the class of exanthemata, as roseola, erythema, or urti- caria. Such eruptions should be carefully distinguished from those of secondary syphilis, as may readily be done by the absence of coexisting syphilitic symptoms, by the itching that usually, but not always, attends them, and by their disappearance in a few days after the copaiba is suspended. The administration of copaiba should never be continued, if it produce this effect. Another unpleasant symptom not unfrequently occasioned by copaiba, is pain in the region of the kidneys, dependent upon con- gestion of those organs. A few years ago, a patient was under my care for gonorrhoea, who had previously had several attacks of haematuria. Contrary to my advice, he took copaiba, which induced a return of the blood in his urine, and I afterwards learned that the administration of this drug had already produced a similar effect in a former attack of gonorrhoea. I always consider the presence of pain in the kidneys an indication that the copaiba should be omitted; for we have no right, in these days when renal disease is so common, and a healthy kidney so rarely met with at a post-mortem examina- tion, to subject our patients to the risk of permanent injury. Cubebs may occasion, though much more rarely, any of the un- pleasant symptoms just mentioned as likely to occur from copaiba. Both of these drugs, in large doses, will, in rare instances, excite severe headache, giddiness, and even more serious symptoms con- nected with the nervous centres. Ricord mentions a case of tempo- rary hemiplegia, and another of violent convulsions, produced by copaiba; in both instances, these serious symptoms were followed by the outbreak of a cutaneous eruption, also dependent on the drug. The anti-blennorrhagics now mentioned, are of undoubted efficacy in the treatment of many cases of gonorrhoea, but in others they 96 URETHRAL GONORRHOEA IN THE MALE. utterly fail; nor have we any means of distinguishing these two classes of cases beforehand. As I have already stated, I think they hold a second rank to injections in the cure of this disease, and in much the larger proportion of the cases that come under my care, I have ceased to employ them at all. As a general rule, if they are likely to prove successful, their good effect will be apparent in a fortnight or three weeks from their commencement, and if, by this time, the disease continue unabated, they should be omitted, and other means employed to effect a cure. When long continued, they produce disorder of the digestive functions, impair the appetite, and induce general malaise and debility; a condition of the system- highly calculated to prolong the duration of gonorrhoea. Though often of marked benefit, they are by no means indispensable in the treatment of every case of gonorrhoea. Preparations of the Gelseminum Sempervirens are much em- ployed at the South, given internally, in the treatment of gonor- rhoea; but in my hands have not proved of much benefit. This plant acts primarily on the nervous centres, and in full doses pro- duces staggering in the gait, dimness of sight, and double vision. In one of my patients who was taking it, the double vision was due to paralysis of the motor oculi of each eye, which passed off soon after the drug was suspended. The most convenient form for administration is Tilden's fluid extract, the dose of which is about fifteen drops three times a day, gradually increased until dimness of vision or staggering in the gait is perceived. Obstacles to Success.—A mistake, generally committed by patients who treat themselves for gonorrhoea and by some physicians, espe- cially in the early years of their practice, is over-medication and a neglect of the general health. Nothing is more common than to meet with a patient, suffering with gonorrhoea of several months' standing, who has been kept on low diet, and been taking various preparations of copaiba and cubebs, using a variety of injections often exceedingly irritant in their composition or strength, and who is now run down, weak in body and despairing in mind. His digestion is impaired, his appetite gone, and his clap as bad as ever. Let such a man lay aside his capsules, pills, powders, mixtures, and irritant injections; give him substantial food, and a tonic, as quinine or iron; limit the special treatment of his disease to a weak astrin- gent injection, as from one to three grains of acetate of zinc to the ounce of water, and his disease will probably begin to improve at once, and subside entirely in the course of a few days or weeks. Under any circumstances, you will have removed one great obstacle OBSTACLES TO SUCCESS. 97 to a cure, and if the discharge do not entirely disappear, it is pro- bably kept up by some local complication, which can now be attacked with a prospect of success.' The following is a type of this class of cases. Case.—P. A., aged 19, applied to me on May 5th, 1857, for a gon- orrhoea which he contracted about the middle of January. He had been under the care of several physicians, and had treated himself a portion of the time; had taken copaiba in almost every form, and cubebs in large quantities; and had used strong injections of nitrate of silver, sulphate of zinc, alum, and acetate of lead. He was now much debilitated, and complained of general malaise and loss of appetite, and the discharge was still copious. I passed a bougie to ascertain if he had stricture, but could discover none. I then directed him to abstain from all anti-blennorrhagics and to live well, and pre- scribed five grains of citrate of quinine and iron to be taken with each meal, and an injection of sulphate of zinc, three grains to the ounce. In one week from the time I first saw him, the discharge had dis- appeared. There was a slight return of it a few days afterward, which lasted only for a day or two, and did not again appear. In the large class of cases of which this is a type, the disease is kept up by a debilitated condition of the system, and requires for its removal general hygienic measures, and in most cases tonics. I have found the citrate of iron and quinine, and the tincture of the chloride of iron, most serviceable. Independently of debility, the chief causes of the continuance of a gonorrhoeal discharge are the existence of stricture and irritation of the neck of the bladder. It is desirable in every obstinate case to ascertain if the former be present by the passage of a full-sized bougie, and if any obstruction be met with, appropriate treatment should at once be adopted; but even in the absence of stricture, the introduction of an instrument into the bladder two or three times a week has a most beneficial effect upon old cases of clap.1 It sometimes happens that a case of gonorrhoea has been going on well for a week or ten days under the use of the anti-blennorrha- gics and injections—the discharge has almost entirely ceased, and the patient considers himself nearly well, when suddenly a relapse takes place; the discharge is once more thick and purulent; the scalding in making water returns; the injection, which has scarcely been felt for a number of days, excites considerable pain, and at the same time the patient has a frequent desire to pass his urine, and 1 See chapter on Gleet, 7 98 URETHRAL GONORRHOEA IN THE MALE. suffers from an uneasy sensation in the perineal region. The latter symptoms denote that the disease has extended to the deeper portion of the urethra, and that there is irritation or inflammation of the neck of the bladder. Under these circumstances, the case requires to be very carefully watched and judiciously treated. Unless great care be used, the inflammation may extend through the vas deferens to the scrotal organs, and swelled testicle ensue; or the prostate gland may" become involved. If irritant injections now be used, they will prove inefficient and will aggravate the symptoms. It is best to suspend the use of injections altogether, and to resort to the exhibition of alkalies and sedatives, as recommended in the inflam- matory stage, until the subsidence of the symptoms shall enable us to resume direct treatment; the patient should also be particularly careful with regard to exercise. Canada turpentine, the product of the Abies Balsamea, will also be found of essential service in these cases, in place of the anti-blennorrhagics, which should be omitted. It may be made into pills containing five grains each, of which from six to twelve should be taken daily. I have also been much pleased with the effect of tincture of ergot, administered in drachm doses three times a day. Treatment of Special Symptoms.—It remains to speak of the treat- ment of certain special symptoms which may attend a case of gon- orrhoea, and one of the most annoying of these is chordee. Various sedatives are employed for the relief of this symptom, among which camphor holds the first rank. This may be given in the form of a pill, combined with extract of lettuce or opium, as in the following formulae:— R. Lactucarii, < Pulveris camphorae, aa^ij. M. ft. pil. xx. Dose.—Two at bedtime. (Ricord.) R. Pulveris camphorae 7)iss. Pulveris opii gr. x. M. ft. pil. No. x. Dose.—One or two. (Ricord.) Mr. Milton prefers camphor in a liquid form in large doses. He directs the patient to take one drachm of the tincture in water on going to bed, and every time he wakes up with chordee,"to repeat the dose. He states that after the continuance of this treatment for two or three nights all tendency to chordee disappears. Lupulin is another remedy of undoubted power in allaying the excitability of the genital organs, and possesses the advantage over TREATMENT OF SPECIAL SYMPTOMS. 99 opium that it does not constipate the bowels. It may be given in doses of fifteen grains, triturated in a mortar with sugar. This quantity is to be taken before going to bed, and may be repeated one or more times in the night if required. Of the above means of relieving chordee, I regard Mr. Milton's method of giving camphor, if it do not disagree with the stomach, and the administration of lupuline, as the best; yet none of the remedies mentioned can be relied upon with certainty of producing the desired effect, for they all fail in many instances. Much may be accomplished by directing the patient to avoid eating or drinking for some hours before going to bed, to be careful to empty his blad- der and rectum, and to sleep on a hard mattress, with but few bed- clothes over him. The position in bed is also of importance, since erections are much less likely to take place when lying upon the side than upon the back. I have sometimes directed a suppository of hyoscyamus and belladonna to be introduced into the rectum with good effect. Another means of relief which I have found highly successful is bathing the genital organs in very hot water directly before going to bed. The reaction after the application of heat has a sedative effect, and in this respect has exactly an opposite influence to that of the cold lotions which are sometimes advised. Hemorrhages from the urethra, occurring during erections, if slight, require no treatment. When copious, they are to be arrested by quiet, the horizontal posture, the application of ice externally, and the injection of ice-water into the canal; and severe cases may require compression effected by the introduction of a bougie within the urethra, and a bandage around the penis, or a compress to the perineum. If abscesses form along the course of the urethra, they should be opened at an early period, for fear that they may break internally, and thus give rise to urinary abscess and fistula. As an attack of gonorrhoea is passing off, it not unfrequently happens that the discharge assumes an intermittent character, entirely disappearing for a few days, and then, without apparent cause, reappearing for a day or two. This may occur several times in succession, and in some cases that I have witnessed, it has assumed great regularity. The surgeon should, of course, assure himself that the return of the symptoms is not due to imprudence, and, if satisfied of this, is generally safe in telling the patient that his disease will soon cease entirely to annoy him. It is important to continue treatment for some days after all traces 100 URETHRAL GONORRHOEA IN THE MALE. of the disease have passed away, since relapses are very readily induced. They are usually brought on by the patient's neglecting the rules with regard to exercise, diet, etc., already laid down, or by his indulging in sexual intercourse. He should be particularly cautioned on these points, and should be directed to continue his medication, both external and internal, in decreasing doses, for at least ten days after the lips of the meatus have ceased to be glued together in the morning. Until every symptom of gonorrhoea has disappeared for this length of time, the patient cannot consider him- self as securely well, and should still be cautious in his habits for a fortnight longer. After the entire cessation of the discharge, patients sometimes complain of abnormal sensations in the genital organs, which they describe under the names of "tickling," "crawling," and sometimes " lancinating," and which may be nearly constant or intermittent at intervals of several hours or several days. These sensations, in most cases, are not dependent upon inflammation or organic changes in the part, but are of a strictly neuralgic character. They are best relieved by the passage of a full-sized sound every few days; and they are much less felt when once the mind is set at rest with regard to any danger of a return of the gonorrhoea. The reader may be interested to know what is the average dura- tion of treatment required in the hands of the best surgeons for the cure of gonorrhoea, laying aside those cases which are seen in the first stage, and which are speedily cured by the abortive method. This may be estimated at three or four weeks. Greater success, on the average, is probably not attainable by any means with which we are at present acquainted. GLEET. 101 CHAPTER II. GLEET. The term "Blennorrhoea," or, in common parlance, "Gleet," is applied to a slight and chronic discharge from the male urethra, unattended with symptoms of acute inflammation. Gleet generally follows without interval an attack of gonorrhoea, as a consequence of the neglect or unsuccessful treatment of the latter; and, as the acute gradually subsides into the chronic disease, it is impossible clearly to define a line of demarcation between them, and to say when the former ceases and the latter begins. In many cases, however, gonorrhoea runs through its successive stages and is apparently cured; when, after an interval of several weeks or even months, the patient returns with the report that he has recently noticed in the morning on rising that the lips of his meatus adhere together, and, on separating them, that the urethra contains a small amount of matter; he suffers no pain or inconvenience, but is still anxious about his discharge and desires to be free from it. In such instances, it is probable that the cure of the preceding urethritis was only apparent, and that a slight degree of inflamma- tion was left in the deeper portions of the canal, not manifesting itself externally, until aggravated by some exciting cause, as coitus, alcoholic stimulants, fatigue, etc. Or, again, it is not improbable that there is a stricture of the urethra, which is the most frequent cause of the continuance of a gleety discharge following an acute attack of gonorrhoea. Other organic changes may exist within the canal and be productive of gleet, as vegetations similar to those met with upon the internal surface of the prepuce, and in rare instances, polypoid growths.1 Idiopathic gleet, or gleet not preceded by acute urethritis, may be dependent upon various affections of the prostate, and especially upon the hypertrophy of this gland so common in old men. It may also arise from disorder of the digestive function, and from disease 1 See Thompson on Stricture, p. 73 et seq. 102 GLEET. of the bladder or kidneys, whereby the urine is rendered abnor- mally irritant. Gleet is often maintained by a state of general debility, or by a strumous, rheumatic, or gouty diathesis. That general debility is a fruitful source of the persistence of gleet, is evident from the fre quency of this disease in persons of broken-down constitutions, and from the beneficial influence of tonics and general hygienic mea- sures in its treatment. Again, gleet is peculiarly frequent and obstinate in persons of a strumous diathesis who are subject to chronic inflammation of other mucous membranes, and under such circumstances is benefited by the administration of anti-strumous remedies. The influence of rheumatism and gout in the production of discharges from the urethra has already been mentioned in con- nection with gonorrhoea. Symptoms.—In many cases of gleet, the discharge is the only symptom. There is an entire absence of pain in the part, of redness and tumefaction of the lips of the meatus, and of scalding in passing water. In some instances, however, the patient experiences a feeling of uneasiness in the penis or perineum, or an itching about the glans or in the deeper portions of the canal, which may either be constant or attendant only upon the passage of the urine. Again, at the first act of micturition in the morning, the obstruction offered to the exit of the stream by the matter which has dried around the meatus and glued its lips together, often gives rise to forcible dis- tention of the canal, and a sharp momentary pain in the urethra, which may be avoided by previously separating the lips of the orifice. The discharge in gleet varies in its character, quantity, and in the time of its appearance. In some cases it is evidently purulent, especially when the gleet has followed a recent attack of gonor- rhoea. In other instances, it is perfectly transparent, and, examined under the microscope, is found to consist of a clear fluid, containing epithelial cells and free nuclei, either with or without a few pus- globules. Again, coagulated masses, like the white of an egg, are sometimes forced from the canal. In some cases, the discharge is constant, and sufficiently copious to stain the linen; but in the majority it is perceptible only in the morning on rising. When dependent upon inflammation of the deeper portions of the canal. or of the prostate, it may only appear during the efforts of the patient at stool, or be mingled with the last drops of urine in mic- turition. The small amount of the discharge in most cases of gleet, SYMPTOMS—PATHOLOGY. 103 and the frequency of this disease among soldiers, has given rise to the name "goutte militaire," employed by the French. The symptoms of gleet now described are liable to be aggravated by any cause which produces urethral or vesical irritation. In other words, a gleet is readily transformed into a clap. A hearty meal, alcoholic stimulants, free sexual indulgence, violent exercise, a long ride, or exposure to sudden changes of temperature, may bring on a copioi/s purulent discharge, attended by tumefaction of the parts, scalding in micturition, and all the symptoms of acute gonorrhoea. Only a 'few hours are required for this change to take place, and, hence, we may explain the sudden reappearance of some attacks of gonorrhoea—often supposed to be due to fresh contagion —when patients, too confident that they are well, are hasty in in- dulging in drink or coitus. Hunter, in his work on Venereal, states that " a gleet is perfectly innocent with respect to infection," and that in the relapses which so frequently occur, "the'virus," in his opinion, "does not return." This statement, although often refuted, still finds place in many elementary works, which are in the hands of medical students. A doctrine more dangerous ty$ the peace of families could scarcely be promulgated. It is, indeed, true, that men are occasionally met with who have for years suffered from gleet, and who have yet had frequent connection with their wives with impunity, but where con- tagion ceases and immunity begins, no one can tell; and even if we were able to pronounce a discharge of a certain degree of purity innocuous, we could not foresee the effect upon it of a few hours' sexual indulgence. It may at the present moment be wholly mucous, and entirely innocent of contagious properties, and yet a short time hence be purulent, and in the highest degree dangerous. The fact is, no one can pronounce sexual congress safe, so long as a urethral discharge exists, and in replying to the frequent questions of patients on this point, the surgeon should not only avoid incurring the responsibility of allowing it, but do all in his power to dissuade from it. Pathology.—Our knowledge of the pathology of gleet is some- what imperfect, since the urethra is beyond the reach of direct observation, and opportunities for making post-mortem examina- tions of persons affected with this disease are very rare. There can be no doubt, however, of the general truth of the law that, while the straight or anterior portion of the urethra is affected in gonor- rhoea, the posterior and curved portion is the most frequent seat of 104 GLEET. gleet, as evinced by the extension of the inflammation in many cases to the testicle, the uncomfortable sensations experienced by the patient in the perineum, and the difficulty of curing the disease by means of injections, unless the fluid be made to enter the deeper portions of the canal; moreover, after the spongy urethra has been freed of its discharge by pressure along the under surface of the penis, an additional quantity may generally be forced out from the bulbous and membranous portions by pressure upon the perineum. In the few post-mortem examinations which have been made of persons affected with urethral discharges, sufficient attention has not been paid to the duration of the disease nor to the symptoms during life. The most minute description of the pathological appearances of gonorrhoea and gleet is the one given by Rokitansky, who says: " We find the anatomical characters to be those belonging to catarrh generally; in the acute stage there is, according to the violence of the process, redness, injection, tumefaction of the urethral mucous membrane, or secretion of puriform mucus; in the chronic stage there is tumefaction of the mucous membrane, enlargement of the follicles, relaxation of the sinuses, and a white or colorless secretion. The inflammation is either uniformly diffused over the urethra, or is limited to one or more spots. The latter is especially the case in genuine gonorrhoea of the male urethra; we here find not only the navicular fossa, but every point as far as the prostatic portion, and especially the vicinity of the bulb of the urethra liable to become the seat of the disease. When the gonorrhoea is very violent and obstinate, a small tubercular swelling, which results from the depo- sition of fibrous matter in the spongy tissue of the urethra, is found at these points."1 Mr. Thompson has found nearly the same appearances: " Observa- tion demonstrates that the two spots which suffer most from gonor- rhoeal inflammation, are the fossa navicularis and the bulb; I have had opportunities of observing this two or three times in the dead- house, on the bodies of patients who had been suffering from gonorrhoea shortly before death. Unusual vascularity is found in the latter situation, particularly if the affection have been chronic, while the intermediate part appears comparatively very little af- fected. There is a preparation in the Museum of St. George's Hospital, which exhibits the urethra of a patient who died while suffering from gonorrhoea, in which an ulcer exists (the only one to be seen) in the commencement of the membranous portion."2 It is i Pathological Anatomy, Sydenham Society's Translation, vol. ii., p. 233. 2 Stricture of the Urethra, p. 84. TREATMENT. 105 impossible to determine whether the ulcer in the case referred to by Mr. Thompson was a chancroid or chancre, or a superficial erosion such as is met with in balanitis; it was probably one of the former, since gonorrhoeal inflammation rarely produces ulcerations involv- ing the whole thickness of the mucous membrane and capable of detection in a preparation that has been preserved for a long time in spirit. The lacuna magna upon the superior wall of the fossa navicularis is probably, in some instances, the source of the discharge in gleet, since it is peculiarly exposed from its situation to participate in the inflammation of gonorrhoea, and its internal surface is not readily accessible to injections. Dr. Phillips states that he has succeeded in curing four obstinate cases of gleet by introducing a director along the upper surface of the urethra until its extremity entered the lacuna magna, and slitting up the wall of the follicle with a narrow bistoury. When the disease is situated in the deeper portions of the canal, we may sometimes determine its seat by the introduction of a bulbous pointed sound or bougie. The patient flinches when the affected part of the canal is reached, and the enlarged extremity of the instrument meets with slight obstruction from the thickened mucous membrane. It appears, therefore, that the pathological changes of gleet are similar to those met with in chronic inflammation of other mucous membranes, as the conjunctiva, tear passages, and the external meatus auditorius, and the extension of the inflammatory process to the membrane lining the follicles and the ducts which open into the deeper portions of the urethra, may account for the well-known persistency of the disease, which is almost proverbial. Treatment.—The treatment of gleet should be addressed to the general condition of the patient as well as to the local disease. It may be laid down as a rule to which there are but few exceptions, that in gleet the tone of the general health is more or less reduced. Not that all patients with gleet are necessarily weak and emaciated; on the contrary, many appear to be robust and hearty; but it is almost always the case that they are not capable of the same amount of exertion as formerly; they are sensible that they have lost a portion of their animal vigor; and the benefit of general hygienic measures and tonics in their treatment is unmistakable. The diet should be plain but substantial, consisting of fresh meat, vegetables, eggs, etc., to the exclusion of salt meats, cheese, and highly-seasoned 106 GLEET. articles; and secretion from the skin should be promoted by means of frequent sponging or bathing. With regard to exercise, although a long walk or ride, especially when carried to fatigue, will be found to aggravate the discharge, yet when commenced with moderation, and gradually and steadily increased in proportion to the strength, it is found to be highly beneficial. Healthy exercise of the mind is no less important than that of the body, and the attention of the patient should be distracted as much as possible from his disease, and all books and associations calculated to excite the passions be avoided. The bowels should be opened daily, if possible by select- ing such articles of food as are laxative, and by regularity in the hour of going to the closet, or, if required, by the administration of medicine. One of the following pills taken at bedtime, will usually insure a free stool in the morning. R. Strychniae gr. ss. Pil. colocynth. comp. ^ss. M. Divide into thirty pills. In the tincture of the chloride of iron, we have a most valuable combination of a tonic and an astringent; which, in most cases of disease of the generative organs in the male and female, is unequalled by any of the more modern and elegant preparations of this imineral. It may be given in doses of from five to twenty drops, largelv diluted with water, three times a day, directly after meals. If the dose be properly graduated, it less frequently excites headache in the male than the female; should this unpleasant symptom occur, iron reduced by hydrogen may be substituted for it, in doses of three grains, three times a day. Where the constitutional debility is marked, the union of quinine with iron may be desirable, as in the following:— R. Ferri et quiniae citratis 3J-ij. Aquae ,?j« Syrupi limonis 3ij. M. A teaspoonful after each meal. R. Tincturae cantharidis 3J. Quiniae sulphatis sjss. Tincturae ferri chloridi gij. Acidi sulphurici dilutigtt. xxx. Aquae destillatae Jviij. M. One ounce three times a day. (Childs.) Other salts of iron, as the tartrate of iron and potassa, or the pyro- phosphate of iron, may be substituted for the citrate, in the first of the above prescriptions. TREATMENT. 107 In the administration of iron I have always found a rule laid down by Trousseau, a good one, viz., not to stop the medicine sud- denly ; after the object for which it is administered has been attained, it may be omitted for a fortnight, when it should again be resumed for a few weeks; in this way its effect is rendered much more per- manent. With patients of a strumous diathesis, cod-liver oil, the syrup of the phosphates, or Blancard's pills of iodide of iron, may often be used with advantage. I have found that the iodide of potassium has a tendency to increase the discharge from the urethra, as it often does the secretion from other mucous membranes, and I do not there- fore administer it. This effect of the iodide may frequently be observed, when we are giving it for tertiary syphilis to patients, who, at the same time, are affected with gleet. From what has already been said of copaiba and cubebs, it is evi- dent that but little good can be expected from their administration in cases of chronic urethral discharge. Moreover, most patients whose disease has arrived at this stage, have already taken them ad nauseam for the preceding gonorrhoea; hence, we are rarely called upon to administer them in pure gleet. In those cases, however, in which the gleet has relapsed into a clap, they may be given with benefit, especially when combined with a tonic, as in the dragees of copaiba, cubebs, and citrate of iron; in Meot's pills, the formula for which has already been given; and as in the following prescrip- tion :— R. Copaibae t^ss. Tincturae cantharidis ,5SS- Tincturae ferri chloridi Jj. M. Dose.—Thirty drops three times a day. The reader will observe that the tincture of cantharides is an ingredient of several of the above prescriptions. Experience has shown that this drug exerts a decidedly curative action in many cases of gleet, and in gonorrhoea also, in the chronic stage. It is a favorite remedy with the homoeopaths, in doses of a drop of the tinc- ture every few hours, in the acute stage of clap, and is considered by them to be indicated by scalding in micturition, chordee, and a green- ish or bloody discharge. I have used it, however, only in the chro- nic stage. The tincture may be given in doses of three or five drops three times a day, or it may be combined with iron, as follows:— R. Tincturae cantharidis 5$. Tincturae ferri chloridi sfvj. M. Ten drops in water, three times a day. 108 BOUGIES. In some cases of gleet there is considerable irritability of the neck of the bladder, as shown by a frequent desire to pass the urine and unpleasant sensations in the perineum. In these cases benefit will be derived from the administration of the salts of potash, combined with hyoscyamus, as in the prescriptions already given when speak- ing of the acute stage of gonorrhoea. Wine of ergot is also an excellent remedy under these circumstances. Bougies.—In all cases of gleet, the urethra should be carefully examined with a full-sized bougie or sound, in order to detect the presence of stricture; and if the slightest contraction be discovered, it should at once receive appropriate treatment, since upon its removal will probably depend the cure of the discharge. Dr. Charles Phillips, whose name is little known to the American public, but who in Paris has acquired an enviable reputation in diseases of the genito-urinary organs, states that gleet is almost invariably depend- ent upon slight stricture, which may be detected by means of bul- bous-pointed and knotted bougies, but which is frequently over- looked from the want of careful exploration with proper instruments.1 Whatever may be the truth of this statement, which, to say the least, requires confirmation, the frequent passage and retention of bougies is one of the best means known for the treatment of gleet, even when no stricture can be discovered by the ordinary mode of examination. The manner in which bougies effect a cure of chronic urethral discharges is somewhat obscure, but is probably to be ex- plained on the ground that they distend the canal, expose lacunae in which matter would otherwise lodge, and separate for a time the dis- eased surfaces; or, again, they may serve to stimulate the vessels of the part, and thus change their action. Bougies tapering towards the extremity and terminating in an olive-shaped point, are well adapted for the purpose. They are introduced easily and with little inconvenience to the patient, and the contraction near their point facilitates the introduction of medi- cated ointments into the deeper portions of the canal. The instru- ment should be large enough fully to distend the canal but not to stretch it, and should be smeared with cerate, lard, olive or castor oil, or glycerin. The bladder should previously be emptied and the patient placed in the recumbent posture. However gently it may be introduced, the first passage of a bougie usually excites a more or less disagreeable sensation, which sometimes gives rise to syncope, and which generally renders it advisable to withdraw the instrument Traite' des Maladies des Voies Urinaires, Paris, 1850, p. 32. BOUGIES. 109 in a few minutes; but after two or three insertions it ceases to give annoyance, and may be retained for hah0 an hour or an hour. It sometimes happens that the bougie aggravates the discharge, and revives the acute inflammation which has for a time disap- peared. In such cases it is best to suspend the treatment and resort to injections, which will often effect a permanent cure. This aggra- vation of the symptoms, however, according to my experience, takes place in a minority of cases only. With this exception, the passage of the bougie may be repeated every second or third day at first, and afterwards every day, or in some instances as often as twice a day. The length of time requi- site for a cure by means of bougies varies in different cases. As examples of their successful employment I may mention one case recently under my care, a gleet of four years standing, which was treated with the tincture of the chloride of iron internally, and the introduction of bougies every second day, and in which a cure was effected in two weeks. In another case, a gleet of nine months, the discharge disappeared in three weeks under the use of the same means. Other cases of a like character might be mentioned, but such satisfactory results cannot by any means be expected in every instance. In many, this treatment must be continued for several months, or other measures, as injections and blisters, be resorted to. Bougies may be medicated in various ways. Calomel rubbed up with sufficient glycerin or oil to cover it, forms a very cleanly and excellent mixture with which to anoint the bougie, and I think materially assists the curative action. Mercurial ointment may also be used, either alone or combined with extract of belladonna, the latter being added in case the urethra is irritable. R. Unguenti hydrargyri ^ss. Extracti belladonnae gss. M. For the purpose of stimulating the mucous membrane, we may employ the diluted ointment of red oxide of mercury, or an oint- ment containing a few grains of nitrate of silver, but such applica- tions should not be continued for any length of time, lest they keep up the discharge. R. Ung. hydrarg. oxidi rubri ^j. Adipis ^iij. M. R Argenti nitratis gr. v-x. Adipis ^j. M. 110 GLEET. Injections.—Injections have been so fully discussed in the preced- ing chapter, that little remains at present to be said of their compo- sition, or the ordinary mode of their administration. In gleet as in gonorrhoea, weak solutions of the sulphate or ace- tate of zinc (containing from two to three grains to the ounce of water) are in most instances to be preferred; and the injection should be made to permeate the urethra as deeply as possible, in order that it may be applied to the whole extent of the affected surface, but care should be taken not to distend the canal with too much force, the sensations of the patient being the best indication when a sufficient amount has been employed. So far as inflamma- tion of the testicle and prostate have any connection with the use of injections, I believe they are more frequently due to violent manipulation than to the irritant character or strength of the solu- tion. Hence, injections should always be used with gentleness, while at the same time the canal should be entirely filled, that none of the folds into which the urethral walls are naturally thrown except during the passage of the urine, may escape coming in contact with the astringent fluid. With this precaution, a weak injection may be employed to advantage every two or three hours; a degree of frequency which will often prove successful when a less degree has failed. In addition to the formulae for injections given in the chapter upon gonorrhoea, the following may be added:— R. Hydrargyri bichloridi gr. j. Aquae ^viij-xij. M. R. Gallae^j. Aluminis 7}ij. Aquae Jviij. M. R. Acidi nitrici gtt. xvj-xl. Aquae ^viij. I have recently employed with very satisfactory results the solu- tion of persulphate of iron prepared by Dr. Squibb, as in the fol- lowing :— R. Liq. ferri persulphatis (Squibb) Jss. Aquae gvj. M. The strength of the above solution may, in some instances, be increased. Ricord advises solutions containing iodine in scrofulous subjects, INJECTIONS. Ill and although the injection of this mineral into the urethra cannot be supposed to affect the 'constitutional diathesis, yet it may exert a beneficial action upon the mucous membrane as when,,applied to the fauces. R. Tinct. iodinii gtt. viij. Aquae ^ viij. M. (Ricord.) R. Ferri iodidi gr. viij. Aquae J viij. M. (Ricord.) I will here repeat a suggestion previously given, that the use of any medicated injection, and especially one containing insoluble ingredients, will prevent even a sound urethra from exhibiting its normal dryness. Without due caution, therefore, a patient may go on injecting long after his disease is cured. Hence, after the dis- charge has for some time been reduced to a very minute quantity, and especially if it appear to consist of little more than the inso- luble deposit of the solution, the injection should be omitted for a few days, in order that the exact condition of the urethra may be determined; or, again, it may be administered only once in the twenty-four hours, selecting for the purpose the early part of the day, and the appearance of the meatus the following morning will indicate what progress has been made towards a cure. Substitutive medication is sometimes employed in gleet as in the abortive treatment of the first stage of gonorrhoea. Thus, highly irritant or caustic injections are used with the intention of exciting acute inflammation, upon the subsidence of which the chronic affection may perhaps disappear. Nature accomplishes the same result in the same manner, when, as sometimes happens, after the cure of a fresh attack of gonorrhoea no traces remain of a preceding gleet. Substitutive treatment, however, is less successful in gleet than in the early stage of gonorrhoea, since the seat of the disease is less accessible and the mucous membrane more deeply affected; moreover, it is less safe, since an irritant injection extended to the deeper portions of the canal is more liable to induce swelled testicle than when limited to the fossa navicularis. Either nitrate of silver or chloride of zinc is most frequently employed in the substitutive treatment of gleet, and, as in the abortive treatment of gonorrhoea, the solution may be a strong one and injected but once, or weak and repeated a number of times. For instance, the surgeon may thoroughly and once for all inject with his own hands a solution of ten or fifteen grains of nitrate of 112 GLEET. silver, or five grains of the chloride of zinc to the ounce of water; or a weaker solution of either (from one to five grains of the nitrate, and from half a grain to two grains of the chloride) may be injected by the patient several times a day until the discharge becomes copious and purulent, when the injections should be suspended until their effect upon the gleet can be determined. Sometimes, as previously stated, the pain excited in a certain portion of the urethra by a bulbous pointed bougie and the slight obstruction presented by the thickened mucous membrane, will indicate the probable source of a gleety discharge; and in such instances, having first measured its distance from the meatus, the affected surface may be cauterized with Lallemand's porte-caustique. Deep Urethral Injections.—In the ordinary method of injecting the male urethra, it is impossible to make the fluid pass through the whole extent of the canal into the bladder. After a certain portion (about half an ounce) of the contents of the syringe has been injected, the remainder escapes above the piston, or, however tightly the glans may be compressed around the point of the instru- ment, flows from the meatus. The obstruction to the entrance of the fluid is due to the contraction of muscular fibres (the compressor urethra? muscle) which surround the membranous portion and serve as a sphincter to the urinary canal j1 and this is the posterior limit of the application of the fluid to the urethral walls by the more common method of injecting. In order to reach the deeper portions of the canal, which are involved in many cases of gleet, it becomes necessary to resort to injections through a catheter, or by means of the " urethral syringe with extra long pipe," manufactured by the American Hard Rubber Company, or with Tiemann's "universal syringe," which is provided with a catheter extremity.2 The length of the urethra should be measured by introducing the catheter and marking the point in contact with the meatus when the urine first commences to flow; upon withdrawing the instru- ment the distance between its eye and the mark upon the stem will be the measurement required. On again introducing the catheter for the purpose of injecting (the patient having first passed his water), it is an easy matter to carry its point within half an inch of the vesical neck without entering the bladder, when the fluid may be thrown in by means of a syringe as the instrument is slowly 1 See the section on the Anatomy of the Urethra in the chapter on Stricture, * This instrument will be found very useful in the treatment of venereal diseases, for instance in deep urethral injections, in injections into the nostrils and pharynx, etc. DEEP URETHRAL INJECTIONS. Fig. 1. 3