.^Surgeon General's Cificc '&Kr% »>Q\3 u &-* Section, L:^J^J$%£\ No..^.-.^I^....S.. ANNEX \\. e}tWK i rTif ^ ' ■ r TREATISE ON GONORRHCEA VIRULENTA, LUES VENEREA. X BY BENJAMIN BELL, MEMBER OF THE ROYAL COLLEGE OF SURGEONS OF IRELAND AND EDINBURGH^ ONE OF THE SURGEONS TO THE ROYAL INFIRMARY, AND FELLOW OF THE ROYAL SOCIETY OF EDINBURGH. WITH NOTES, ADAPTED TO THE PRESENT STATE OF PRACTICE IN THOSE DISEASES, TWO VOLUMES JJV ONE. vol. r. v. I £&6 ^ ALBANY ; PUBLISHED BY E. F. BA.CKUS, NO. 65, STATE-STREET. E. & E. Hosford—Printers—Albany, 1814, • * * District of Nero-York, s*. BE IT REMEMBERED, that on the tenth day of October, in the thirty-ninth year of the independence of the United States of Ameri- L. S. ca, E. F. Backus, of the said District, has deposited in this office the title of a Book, the right whereof he claims as Proprietor, in the words following, to wit; « A Treatise on Gonorrhoea Virulenta, and Lues Venerea. By Benjamin Bell, Member of the Royal College of Surgeons of Ireland and Edinburgh, one of the Surgeons to the Royal Infirmary, and Fellow of the Royal Societj of Edin- burgh. With Notes, adapted to the present state of practice in those diseases Two volumes in one. In conformity to the Act of the Congress of the United States, entitled " An Act for the encouragement of Learning, by securing the copies of Maps, Charts and Books to the authors and proprietors of such copies, during the time therein mentioned," And also to an Act, entitled " an Act, supplementary to an Act, entitled an Act for the encoui'agement of Learning, by securing the copies of Maps, Charts, and Books to the authors and proprietors of such copies, during the times therein mentioned, and extending the benefits thereof to the arts of designing, engraving' and etching historical and other prints." THERON RUDD, Clerk of die Southern District of jVe-w-York ERRATA. Volume 1st. Page 89, line 17, for by, read but. Page 207, line 21, for as, read is. Volume 2nd- Page 162, line 42, for azena, read eczema. Page 193, line 19, for breat read breast. Page 222, line 46, in a few copies for intermiscence read intumescence Page 284, line 9, for balanci, read balani, ADVERTISEMENT TO THE PRESENT EDITION. The Editors of the present edition of Bell on the Venereal, have endeavoured to render that work more valuable, by adding to it the improvements in practice as well as the investigations on the nature of the disease, which have been offered since the period at which the Author wrote. This informal ion they have condensed in as small a space as possible, and adhering strictly to the principle of leaving the original text untouched, have presented it in the form of notes to the several sections. In preparing these, a free use has been made of every late writer within their reach, whose opinions or expe- rience have appeared to deserve attention; and should their additions comprise to the satisfaction of the med- ical reader, an analysis or notice of the above produc- tions, their wishes will be fully gratified. Albany, Oct. 8tb, 1814. TO DOCTOR WILLIAM SANDERS, SENIOR PHYSICIAN TO GUX's HOSPITAL, FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON, AND OF THE ROYAL SOCIETY OF EDINBURGH, These Volumes are respectfully dedicated, as a small testimony of regard, and public acknowledg- ment, for the advantages which have been derived from his various exertions to promote the extension and general utility of medical science, by His obedient And very humble Servant, BENJn. BELL Edinburgh, "> tst Nov. 1792. 5 PREFACE. AS many of the symptoms of Gonorrhoea and Lues Venerea become frequent objects of the surgeon's at- tention, I at one time meant to have introduced a trea- tise on these diseases in the System of Surgery pub- lished some years ago, but I was prevented from doing so, by different publications upon the same subject be- ing announced about the same period. As these works have since made their appearance, and, as some of them have been very favourably re- ceived, it may be imagined, that farther writings upon this subject can scarcely at present be required. It must indeed be admitted that many valuable publica- tions have come forth within these few years upon this branch of the profession; particularly one by Mr. John Hunter of London, intitled, A Treatise on the Venereal Disease; and another intitled, Practical Ooservations on Venereal Complaints, by Doctor Swediaur. But although much information may be obtained from both of these works, as well as from some other late publications upon this subject, there is still much left for others to elucidate. Such is the effect of experience and observation, that farther ad- vantages are daily accruing from the labours of indi- viduals in the treatment of this as well as of almost every other disease ; and as Ibis I hope will in some degree appear from the present publication, so I shall still expect to find that the future endeavours of others will prove yet more successful. Among other points which I have more particularly attempted to elucidate, the treatment of Gonorrhoea by injections, and the quantity of mercury to be exr hibifed in Lues Venerea, are, perhaps, the most im- portant ; and I flatter myself that I have given views concerning them, which, in practice will be found to merit attention. The cure of Gonorrhoea by injec- tions is, no doubt very universally practised; but while in a great proportion of cases it proves successful, in viii PREFACE. others it fails entirely : The cause of this, ao far as I know, has never hitherto been explained. Whether I may have conveyed an adequate idea of my opinion upon this point I cannot positively say ; but the obser- vations upon which it is founded are such, that all who pay attention to the subject may be enabled readily to ascertain such cases as will yield to injections, as well as those in which no advantage is to be expected from them. The opinion which I have ventured to support, of the difference between the matter of Gonorrhoea, and that of Lues Venerea, will no doubt be censured by many. They ought, however, to recollect, in matters of opinion, which cannot be proved by demonstration, that some unceriainty must always take place; and be- fore censuring with severity the opinions which others may suggest, they should consider whether their own may not he equally liable to objection. To me it ap- pears that the reasons which I have adduced-in support of my opinion are very conclusive, but I shall make full acknowledgement of my error, if sufficient reasons shall ever be given to show that it is ill-founded. In the mean time, it will be perceived, that the theory which I have adopted does not lead to any deviation from the practice which now generally prevails upon this point, while it serves to explain more clearly than the opinion which has commonly prevailed, several of the phenomena of the two diseases, as well as the cause of different remedies being necessary for each of them. I do not expect that practitioners of experience and observation will derive much information from this publication, but I am hopeful that beginners will de- rive some advantage from it ; for it has been equally my desire to exhibit a correct view of the different s) mptoms of which I treat, and to point out the method of cure in a manner that will be clear and intelligible. Where theory is ever admitted, it is chiefly with a~view to explain, upon rational principles, such"points as the ingenuity of some speculative writers have tended to render intricate. CONTENTS. VOLUMF. I. CHAP. I. Consideration of the Question, Whether Gonorrhoea and Lues Venerea originate from the same Contagion, - Page 17 CHAP. II. Of Gonorrhoea Virulenta. SECT. I. General Observations on the Symptoms, Causes, and Seat of Gonorrhoea Virulenta, - - - - - 37 SECT. II. Of the Prognosis in Gonorrhoea Virulenta, 48 SECT. III. General Observations on the Cure of Gonorrhoea, - .- 50 SECT. IV. Of the First Stage of Gonorrhoea, - - - . - - 57 SECT. V. Of the Second Stage of Gonorrhoea, ... - 70 SEC V. VI. Of the Third Stage of Gonorrhoea, - - - - - 77 SECT. VII. Of the Fourth Stage of Gonorrhoea, 85 SECT. VIII. Of Chordee,......- - - 91 SECT. IX. Of Haemorrhages from the Urethra, ..... 94 SLCT. X. Of Gonorrhoea in Women, -.....y-5 < X CONTENTS. SECT. XI. Recapitulation, .--.--- Page 10 i CHAP. III. Of the Consequences of Gonorrhoea Virulenta* SECT. I. General Remarks on the Consequences of Gonorrhoea, * 104 SECT. II. Of Gleets, , = ------- 105 SECT. III. Of Impotency from Seminal Weakness, - - - - 136. SECT. IV. Of Obstructions in the Urethra from Gonorrhoea Virulenta 134 § 1. Of Tumours in the U-^thra and contiguous parts, - 135 § Z. Of Spasmodic Obstructions in the Urethra, - - 137 § 3. Of Caruncles in the Urethra, - - - - 144 § .;. Of Obstructions in the Urethra from Strictures, proper- ly so called ; of Bougies^ and Fistulae in Perineo, - - 146 SECT. V. Of Deranged Sensations in the Bladder, Urethra, and contigu- ous parts, .--.•-.'. . - . 183 SECT. VI. Of Swellings of the Testicles, - - - - - 194 SECT. VII. Of Swellings of the Spermatic Cord, - 208 SECT. VIII. Of Swellings of the Lymphatic Vessels of the Penis, - 210 SECT. IX. Of Swellings of the Glands of the Groin, - - •. 214 SECT. X. Of Excoriations of the Glans and Prepuce, - - j 211' CONTENTS. XI SECT. XI. Of Excoriations in the Parts of Generation in Women, Page 222 SECT. XII. Of Phymosis and Parapbymosis, - 223 SECT. XIII. Of Warts on the Glans and Prepuce, and Labia Pudendi, - 231 SECT. XIV. Of Gonorrhoea Simplex, - ... 236 VOLUME II. CHAP. IV. On Lues Venerea. SECT. I. General Observations on Lues Venerea, * - r - T7 SECT. II. Of the Symptoms of Lues Venerea, - ■ - - - r* § 1. General Observations,..... ib. § 2 Of Chancres,.......ib. § 3. Of Buboes,........20 § 4. Of the Venereal Sore Throat, .... 3f § 5. Of Venereal Sores in the Nose and Mouth, 42 § 6. Of Venereal Blotches,......50 § 7. Of Venereal Ulcers, ...... 55 § 8. Of Nodes, and other Swellings of the Periosteum, Bones, and Tendons, 62 § 9. Of Venereal Excrescences about the Anus, 70 § 10. Of the Venereal Swelling of the Testes, - - 72 § !1. Of Alopecia,.......75 § 12. Of Blindness, as a Symptom of Lues Venerea, - . 77 § 13. Of Deafness,.......80 § 14. Of Anomalous Symptoms, - - - - - 8! SECT. III. Of the Venereal Virus, * - j *f XII CONTENTS. SECT. IV. Of the Remedies used in Lues Venerea, - - Fage § 1. General Observations, - \' " § 2. Of Mercury, ------- f^ 1. General Observations upon Mercury, - lL)- 2. Of the Effects of Mercury upon the Human Body. - 100 3. Of the Operation of Mercury in the Cure of Lues Venerea, 102 4. Of the Preparations of Mercury, - ^O 5. Of the different Methods of exhibiting Mercury, - 137 6. Of the Duration of a Mercurial Course, and the Quantity of Mercury to be exhibited, - - - -, ' l52 7. Of the Regimen to be observed during a Course of Mer- cury, .........6' 8. Of Profuse Salivation and some other Effects of Mercury, 169 9. Does Mercury ever fail in the Cure of Lues Venerea ? 188 § 3. Ot Guiacum,.......192 § 4. Of Sarsaparilla,.......l96 § 5. OfMezereon,.......198 § 6. Of Opium, - .....201 SECT. V. Of the Cure of Lues Venerea, ----- 208 § 1. Of the Cure oi Chancres,.....ib. § 2. Of the Cure of Buboes,.....223 § 3. Of the Cure of Venereal Ulcers, - 236 § 4. Of the Cure of Venereal Blotches, - - - 243 § 5. Of the Cure of Modes, Swellings of the Periosteum, &c. 244 § 6. Of the Cure of Venereal Excrescences about the Anus, 247 § 7. Of the Cure of the Venereal Swelled Testicle, - 2-i8 § 8. Of the Treatment of Alopecia, Venereal Blindness and Deafness,......- - 250 § 9. Of the Cure of some Anomalous Symptoms of Lues Venerea,........254 SECT. VI. Of Lues Venerea in Infants, - - ... - 257 SECT. VII. Of wrae Peculiarities of Form under which Lues Venerea has appeared in Scotland and Canada, .... 268 *\ SECT. VIIL Of Prophylactics, ----•-..„ 282 SECT. IX. Of Lues Venerea as inducing other Diseases, - - - 284 Appendix, -........ 313,.) A TREATISE ON GONORRHOEA VIRULENTA, AND LUES VENEREA. CHAPTER L Consideration of the Question, whether Gonorrhoea and1 Lues Venerea originate from the same Contagion. AN opinion has been generally received amongst practitioners, that Gonorrhoea Virulenta and Lues Venerea are of the same nature; that they origi- nate from the same contagion ; and are only distin- guished by the circumstance of Gonorrhoea being a lo- cal disease of the urethra, while the other is a general affection of the system. But, as there is cause to ima- gine that these diseases arise from different specific contagions, and as the establishing of one or other of these opinions must influence the conduct of the cure, it becomes a matter of importance to institute an en- quiry into this part of our subject. Both diseases are contracted in a similar way ; both, in the first instance, affect the genital organs ; and they occasionally appear at the same time in the same patient: hence it has been concluded that they have a common origin, and one method of cure has been supposed applicable to either. The refusal of some patients to submit, to the dis- tress and Wiconveniency, the frequent result of a pro- tracted mercurial course, and who nevertheless reco- vered from the usual symptoms of Gonorrhoea, first 3 18 ON GONORRHOEA VIRULENTA, suggested a doubt of the two diseases being produced by the same contagion. It is well known that Lues Venerea can be certainly cured by mercury only; and the opinion respecting the existence of a specific contagion of Gonorrhoea, arising from this obvious and marked difference in the method of cure, appears to be fixed and established by the following facts : The symptoms and consequences of Gonorrhoea are perfect- ly different from those which take place in Lues Ve- nerea. Both diseases have appeared, at different pe- riods in the same countries; and, in some instances, they have remained distinct and uncombined for a great length of time. That the symptoms of the two diseases are differ- * ent, is universally known. A particular detail of such as are peculiar to each, will be given in the ensuing chapters. At present, it is only necessary to observe, that Gonorrhoea consists of a discharge of puriform mat- ter from the urethra ; which, even by those who sup- port the contrary opinion, is now admitted to be in almost every instance, a local affection, and that it ve- ry rarely contaminates the general habit of body : While Lues Venerea is a disease of the constitution, ari- sing from the absorption of venereal virus from any part of the surface of the body, but most frequently from the genitals; by which are produced buboes, ul- cers in various parts, particularly in the nose and throat, pains and swellings in the bones, with a vari- ety of other symptoms which it is not at present ne- cessary to mention. The first appearance of the Lues Venerea is, for the most prat, in the form of a chancre or small ulcer, in some part of the penis. It is universally admitted, that even the slightest affection of this nature is apt to produce the pox, or a general affection of the system; insomuch, that no practitioner of experience will trust the cure of this symptom to local remedies. If the sore be left* to it self, it almost always becomes worse. The matter which it affords is taken up by fhe absorb- ents ; and buboes, with the other symptoms enume- Ch.i. AND LUES VENEREA. 19 rated above, very certainly ensue. These are almost the universal consequences of a sore produced by the venereal virus; but they also occur frequently where the skin remains sound and entire; that is, absorption of the venereal poison often takes place where no ves- tige of ulceration is perceptible. This, indeed, is de- nied by many ; but I have met with various instances of it, and it will be admitted by every practitioner of experience. Now, this being established, in the ap- plication of the venereal virus to every other part of the body, if the matter of Gonorrhoea were of the same nature, why does it not, in almost every instance, enter the system, and produce pox ? So far as we know, the urethra is as plentifully supplied with ab- sorbents as other parts of the body; the same kind of matter, when applied to them here, ought therefore to be productive of similar effects : and hence Lues Ven- erea ought frequently, perhaps in every instance, to be the consequence of Gonorrhoea, were the matter by which the two diseases are produced, the same. As this is a strong argument in favour of the two dis- eases proceeding from different kinds of contagion, much ingenuity has been exerted by those who support the contrary opinion, in endeavouring to account for it. In the first place, it has been said, that Gonorrhoea sometimes terminates in pox, and, therefore, that this of itself is a sufficient proof of the two affections be- ing of the same nature. Were it certain that this ever happened, no farther evidence would be required, as a few well-marked in- stances would be conclusive; but every unprejudiced practitioner will admit, that no sufficient proofs of it have ever occured. In order to support this opinion, data must be re- ceived, which we know to be inadmissible. We must admit, that a person with chancres only, communi- cates to another, not only every symptom of pox, but of Gonorrhoea, and that another with Gonorrhoea on- ly gives to all with whom he may have connection, chancres with their various consequences. This ought, indeed, to be a very common occurrence ; insomuch 20 ON GONORRHOEA VFRULENTA, Ch. I. that every practitioner should be able to decide upon it with certainty, if this opinion was well founded: Instead of which, it will be admitted by all, that the one disease being produced by the other is even, in appearance, a very rare occurrence, I haye paid much attention to the point in question ; and, in almost eve- ry instance, a few cases indeed only excepted, and where the most particular enquiries even were made, it has happened, that a person infected with Gonor- rhoea has received it from another evidently labour- ing under that disease, and that chancres have been communicated by such as were distressed with chan- cres only. This,"I am convinced, will be very commonly found to be clearly the case ; so that a few instances, bearing some appearances of the contrary, are much more rea- dily explained on the idea of the two diseases being produced by different kinds of contagion; and this may also be said of the few solitary cases that may be inet with, of chancre being supposed to terminate in Gonorrhoea, and Gonorrhoea in chancre, and other symptoms of pox. We can more easily conceive that the same person should, in some instances, receive, and therefore be able to communicate, both kinds of con? iagion, than that the incident we are considering should be so seldom met with, were the opinion well founded, of the two diseases being originally of the game nature. However ill founded an established opinion may be, if it has received the sanction of being generally a- dopted, we know how difficult it is to overturn it. There are few who enter so minutely into the consi- deration of such points as to be able to decide upon them ; and of those who do, there are very few who will take the trouble of engaging in such discussions jas are necessary for the conviction of others. This may be considered as the chief cause of the point in question remaining so long in obscurity, as well as of i\\t explanation hitherto usually given, of various cir- cumstances in Gonorrhoea and Lues Venerea having been uniformly made to support it. It will aiso serve to Cll. I. AND LUES VENEREA. 21 account for circumstances being held forth as matter of fact, which, on enquiry, are perceived to be ill founded ; for, when once an opinion is admitted, we are apt to give such an explanation of whatever may seem to relate to it, as can in any way tend to sup- port it. Thus, although few in the present age will assert that Gonorrhoea often terminates in Lues Venerea, yet by many we are told, that it is very apt to do so when it is improperly treated. Whatever puts a sudden stop to a severe or copious discharge from the urethra is by many supposed to do harm. Hence all who con- demn the use of injections in Gonorrhoea affirm, that they often convert a simple clap into a pox, by throw- ing into the blood what otherwise would have been carried off. This, however, is by no means support- ed by experience. A stimulating injection will no doubt excite pain and inflammation in the urethra; and this, in some instances, will be productive of swel- led testes, and perhaps of sympathetic swellings in the glands of the groin ; but I have not known a single in- stance of pox induced in this manner : and as I have long been in the daily use of injections, many cases of it must have occurred, if (he idea I have just stated were well founded. Till of late, indeed, a patient who was so unfortunate as to have a clap suddenly stopped, was so certainly considered as poxed, that he was im- mediately put under a very complete course of mer- cury, by which he was made to undergo a very unne- cessary and distressful confinement. Although this practice, however, is now very com- monly exploded, yet there are some who still adhere to it. I was called, in April 1784, to visit a gentleman who, in a Gonorrhoea attended with a good deal of in- flammation, had been so foolish as to live freely, and to ride much on horseback. This, with the unguarded use of a very stimulating injection, put a sudden stop to the discharge ; and at the same time it excited a very considerable degree of pain and inflammation along all the posterior part of the urethra, towards the 22 ON GONORRHOEA VIRULENTA, Cll. I. prostrate gland and neck of the bladder, attended with a painful and frequent desire to make water. On the idea of these being symptoms of pox, he was immediately put under a course of mercury; and, when I first saw him, he had been using it for the space of six weeks. The surgeon in attendance ac- knowledged that no advantage had been derived from it; and the patient himself said that his distress was daily increasing. They were both, therefore, easily persuaded to lay the mercury aside ; and, by the re- peated application of leeches to the perineum, of fo- mentations, and opiates, to allay the pain, the inflam- mation soon began to subside ; and, in a short time, he was perfectly well. In Pecember 1788, a young man called upon me, with a painful hard swelling in his groin, of an oblong form, nearly an inch in diameter, and reaching from the ring in the external oblique muscle down to the top of the testis. It appeared suddenly, about four months before, and seemed to be the consequence of a clap being too hastily stopped. He was at first attack- ed with a severe pain at the neck of the bladder, which stretched to the groin, and down to the testis of the same side. This, together with a constant and pain- ful inclination to void urine, rendered his life miser- able. Nor was his distress in any degree abated by a course of mercury which he was immediately put un- der. On the contrary, the swelling, which at first was not thicker than a common quill, was now very con- siderable. My idea* of the swelling was, that at first it had been merely an inflammatory affection of the vas deferens, which by degrees had spread to the rest of the spermatic chord ; but, what was unusual, it had never affected either the testis or epididemis. As a considerable quantity of mercury had been taken, and as, instead of proving useful, it had rather appear- ed to do harm, the surgeon whom he employed was easily persuaded to trust the cure to other remedies. Local blood-letting with leeches was frequently re- peated, both in the perineum and groin. The parts were regularly fomented with a sojution of saccharum Ch. I. AND LUES VENEREA. 23 saturni. His bowels were kept easy with gentle lax- atives, and he was put upon a mild diet of milk and vegetables. In a few days the pain abated, and the tumour gradually lessened, till at last, in the course of five or six weeks, it was entirely gone. In the course of last winter, I attended two different patients, with alarming symptoms about the neck of the bladder, evidently induced by the improper man- agement of Gonorrhoea. The parts in both were not merely pained, but considerably swelled ; and, at the same time, almost a total suppression of urine took place. Although in both, the discharge from the ure- thra had been suddenly stopped, I did not advise mer- cury. The patients being both plethoric, were plen- tifully blooded, first at the arm, and afterwards repeat- edly with leeches in the perineum. This, with fomen- tations, and opiates to allay the violence of the pain, assisted by a cooling regimen and gentle relaxatives, very soon completed the cures. These instances are given out of a great number that might be adduced, merely to shew, that the symp- toms which supervene on the sudden stoppage of a clap, are local, and not connected with any affection of the constitution, which they necessarily would be, if they were of the same nature with Lues Venerea. It will perhaps be said, that although this may have happened in a few cases, yet that in others there has been cause to suspect, that Lues Venerea has been the consequence of a clap disappearing in this manner. In answer to this, it is sufficient for me to shew, that this is at least a rare occurrence, as I think I am intitled to do, from my never having met with an instance of it. It has been supposed, that the sudden check given to the discharge in cases of clap, must necessarily throw the matter into the blood, and that pox must accordingly ensue from it. Were the matter of the two diseases the same, this would happen in every in- stance ; so that, when we can show that it seldomhap- pens even in appearance, we are entitled, from this argument alone, to conclude, that they are produced by two different kinds of contagion ; and, where pox 24 ON GONORRHOEA VIRULENTA, Cll. f. has appeared at the sudden termination of Gonorrhoea, that the two kinds of infection had either been com- municated together; or, what may more frequently perhaps be the case, the patient will be found to have received the pocky contagion by communication with a diseased woman'at the very time he laboured under Gonorrhoea. I have already remarked, that Lues Ve- nerea is frequently produced by absorption while the skin remains entire, and where no chancre or excori- ation is perceptible. There is therefore much cause to imagine, that in long continued cases of Gonorrhoea, many may be infected with Lues Venerea by communi- cation with others labouring under it; and as this may happen without any external mark of it taking place, it is not surprising that some fallacy should arise from this circumstance. The abettors of the opinion, that the matter of the two diseases are the same, admit that Gonorrhoea very seldom terminates in pox* And they attempt to ac- count for this, that is, for the two diseases not being produced more frequently by the application of the same matter, by saying, that this depends upon the difference of parts to which the matter is applied. They divide the different surfaces of the body chief- ly into two kinds, what they term secreting surfaces and non-secreting surfaces. By the first they mean all the passages for extraneous matter, including also the ducts of glands, such as the mouth, nose, eyes, arms, * This is even granted by one who keenly supports the opposite doctrine in every other point. In speaking of Gonorrhoea and Chancre not terminating so frequently as might be expected in the production of each other, he says, " Although it does not often happen, yet it sometimes does, at least tliere it " great reason to believe so. I have seen cases where a Gonorrhoea came on, and " in a few days after in some, in others as many weeks, a chancre has appear- " ed ; and have also seen cases where a chancre has come first, ancLan the " course of its cure a running and pain in making water have succeeded?' See a Treatise on the Venereal Disease, by John Hunter, page 16. This is what every practitioner has seen ; but by admitting so clearly that it is a very rare occurrence, Mr. Hunter tends rather to strengthen the contrary opinion : for, were the two diseases produced by the same kind of matter, the one would clearly and necessarily often terminate in the other. In the few cases which Mr. Hunter, in the course of his extensive practice, has met with, there is more cause to imagine, cither that the two diseases were communicated at once, or that the one was given while the patient laboured under the other, than that nature should deviate so much from her ordinary course as to pro- duced them a few instances so very different from what obviously happeni r\ the course of general observation. Cll. I. AND LUES VENEREA. 25 and urethra; and by non-secreting surfaces, the exter- nal skin in general. To which they add a third kind of surface, leading from the one to the other, as the glans penis, prolabium of the mouth, the inside of the lips, and the female pudendum: which surfaces, par- taking of the properties of each of the others, but in a less degree, are capable of being affected in both ways, sometimes by being excited to secretion, and at other times to ulceration*. Upon this, their theory, or opinion of the point in question, is attempted to be established; When the contagion, either of Gonorrhoea or pox, and which they consider to be the same, is applied to any part of the' external skin, particularly to the glans penis where the skin is very thin, chancre or ulceration, they observe, will most readily ensue, as these are non secreting surfaces; while the same kind of matter ap- plied to the urethra must necessarily excite Gonor- rhoea, from this being a secreting surface, and therefore not so easily affected with ulceration as with irritation ; by which an increased discharge, attended with some change in the mucus of the part, must accordingly be produced. This idea, however, is more ingenious than solid. It might answer the purpose of giving a specious ap- pearance to an ill-founded opinion, but it will not stand the test of inquiry. In the first "place, on the supposition of the matter of Gonorrhoea and Lues Venerea being the same, the latter ought to be a much more frequent occurrence than the former, from the greater ease with which the matter of infection must, in every instance, be applied to those parts on which it can produce chan- cres than to the urethra, where, instead of chancre or ulceration, it almost always excites Gonorrhoea. It is difficult to conceive how the matter by which the disease is communicated should find access to the urethra; while, on the contrary, all the external ' Vide John Hunter on the Venereal Disea^ 4 26 ON GONORRHOEA V1IU LENTA, Clh I. parts of the penis, particularly the glans, must be easi- ly and universally exposed to it: and yet Gonorrhoea is a much more frequent disease than pox. Cases of Gonorrhoea are in proportion to those of Chancre and Pox, so far as my observation goes, of about three to one; while it is obvious, that the very reverse should happen, if the two diseases were produced by the same kind of matter*. Again, were this the case, should we not find Go- norrhoea, in almost every instance, terminating in Pox, and Chancre in Gonorrhoea; for every one knows, that in Gonorrhoea the matter is at all times passing from the urethra over the glans and prepuce, and in Chancre, that it is passing from the glans into the en- trance of the urethra. It happens indeed, in a few instances, (Mr. Hunter, we see, has met with some cases of it) that the one disease supervenes upon the other: but we have also seen that these are rare occur- rences; and where they have not been communicat- ed by subsequent connection with an infected person, that the two diseases have probably been given at one and the same time. It is no argument against this sug- gestion, to say, that instances have been met with of a Gonorrhoea appearing during the continuance of chancres of several weeks duration, and vice versa; for every practitioner must have met with instances of these diseases both appearing at the distance of two or three months from any exposure to infection. I have at this moment a gentleman under cure for a deep, foul chancre, altogether within the urethra. It was of several weeks duration before I saw it, and yet no Gonorrhoea took place. He is now getting well by a complete course of mercury, and repeated appli- cation of caustic. I have met with various cases of this, as every prac- titioner must have done ; and, so lately as the month * Mr. Hunter supposes, that the proportion which the cases of Gonorrhoea bear to those of Chancre, is as lour or five to one. Vide Treatise on the Venereal Dis- ease, p. 217. This is surely a weighty argument against the opinion he endea- vours to support, of Gonorrhoea and" Chancre proceeding from the same con- tagion. Cll. I. AND LUES VENEREA. 27 of April last, I was called to a gentleman with a pain- ful chancre on each side of the urethra. The sore extended about the eighth part of an inch up the pas- sage ; and the parts being much inflamed, I hesitated to apply caustic. This rendered the cure tedious, but still no Gonorrhoea took place. At last, after having taken a considerable quantity of mercury, and when the chancres were looking clean, and in a healing state, he was seized with all the symptoms of a severe clap, with heat in making water, chordee, and a plentiful discharge of a thin green matter. This, however, bore all the appearance of a recent infection. I at once said so to my patient; and he candidly acknowl- edged that he had imprudently exposed himself, by having connection with a girl of the town, three or four days previous to the accession of these symptoms. We may also remark, that the discharge from Go- norrhoea frequently becomes so acrid as to excoriate the glans and preputium, and even to excite a very plentiful formation of matter ; but every one knows that th»s is materially different from chancre. It is altogether different in appearance, and so materially different in its effects, that scarcely any practitioner of experience will trust the cure of chancre to any tiling but mercury, while, in the other, mercury, I imagine, is very seldom employed. However exten- sive the excoriations may be, they are easily removed by local remedies; and I have never known an in- stance of pox succeeding to this kind of treatment. Nay, I have met with various instances of such affec- tions, where mercury had been given in considerable quantities with no advantage whatever, and where a cure was effected by the use of an astringent wash. About eighteen months ago, a gentleman came to town from a considerable distance, with an extensive excoriation over all the glans and preputium, attend- ed with a discharge of a large quantity of thin, offensive matter. The quantity of matter indeed was so con- siderable, that at fiist sight it appeared to be the dis- charge from a very inveterate recent case of Gonor- rhoea ; but, on farther examination, it wag found to 28 ON GONORRHOEA VIRULENTA, proceed entirely from the glans and prepuce, the clap by which it was produced being entirely gone. He had taken mercury for the space of six weeks ; and the parts had been regularly bathed in milk and water, but with no advantage. The discharge con- tinued as plentiful as ever, and the preputium was be- ginning to acquire some degree of thickness, and to be difficult to retract. In the space of a week he was completely cured, merely by bathing the parts from time to time with brandy and water, and applying, during the night, a poultice strongly impregnated with saccharum saturni. This, as well as a variety of similar affections, which,. were it necessary, I might enumerate, clearly evince, not only that the matter of Gonorrhoea, when confined to the urethra, does not terminate in pox, but that it proves equally inoffensive to the constitution, where it is even so sharp and acrid as to excoriate the sur- rounding parts. This points out a very marked dif- ference between the matter of the two diseases. In pox, even the slightest sore never fails to throw mat- ter into the system, while the most extensive affections proceeding from Gonorrhoea are so seldom found to in- jure the constitution, that I have never met with an instance of it. By those who wish to support the opposite doctrine, it is said, that the matter of Gonorrhoea would more frequently terminate in pox, were it not for the mucus of the urethra with which it is blended, and by which they suppose it to be rendered not only milder in its nature, but not so apt to be taken up by the absorbents. This, however, is merely ideal; and'no proof can be advanced in support of it. Besides, the force of the argument is entirely done away, when we see, from what has been observed above, that event where the matter of Gonorrhoea is more acrimonious than almost ever occurs in cases of Chancre, so as in some instances to produce very extensive excoriations, that still no affection of the constitution ensues from it. Nay, we see, even in such diseases as are found to proceedlrom what is termed a translation of the matter Ch. i. AND LUES VENEREA. 29 of Gonorrhoea to other parts of the body, and which we suppose to happen through the medium of the cir- culation, that still no affection of the constitution pro- ceeds from them. This is particularly the case in such instances of ophthalmia as sometimes proceed from Go- norrhoea, and in which a considerable discharge takes place, of a puriform matter from the eye-iids, very similar to the matter of a recent clap. I have also met with instances, of patients labouring under Gonorrhoea being seized with a similar discharge from the mem- brane of the nose ; but in none of these have I ever known Lues Venerea ensue. A considerable number of examples might be adduced of each of these ; but the three following will be sufficient. In the year 1786, a young man applied to me, with a very troublesome and painful disease in both eyes. The eye-balls were not much inflamed outwardly ; but as he experienced an intense degree of pain from the ad- mission of light, I concluded that the retina, or other deep-seated parts of the eye, were in a state of inflam- mation ; and the membrane of the eye-lids was not on- ly inflamed, but a constant and copious discharge took place from them, of a greenish yellow matter, bearing much the appearance of the matter of a recent clap. The account I received of hi* disease was this: That he had for eight or ten days laboured under Gonor- rhoea, the symptoms of which, however, were not more severe than usual; when, after being heated with drinking port wine, the discharge from the ure- thra, which had previously been copious, disappeared almost entirely. His eyes, almost immediately there- after, became painful; and, in less than twenty-four hours, the discharge of matter had taken place from the eye-lids. The disease was at first treated with blisters, slight evacuations of blood, and the usual applications of oint- ments and collyria. These not proving successful, a course of mercury was prescribed : but, although dif- ferent attempts were made with it, mischief always ensued from it. It did not lessen the discharge, while it obviously increased the inflammation, and rendered 30 ON GONORRHOEA VIRULENTA, Cll. I. the eyes more irritable. I therefore advised this re- medy to be laid aside. A quantity of blood was taken from the temporal artery of one side ; such vessels as were turged upon the eye-balls were divided ; scarifi- cations were made in the inflamed parts of the eye-lids ; poultices were applied over the eyes, in which opium and sacchas um saturni were dissolved ; and gentle lax- atives were prescribed. By these means the pain soon abated ; the inflammation and discharge of matter less- ened ; and, in the course of a fortnight, no symptom of the disease remained, but a degree of irritability on exposure to much light, with which both eyes con- tinued to be distressed for five or six months thereafter. In the course of the following year, on being attack- ed with Gonorrhoea, but of a more violent nature than the former, he was again seized, after exposure to much cold, and riding on horseback, to a similar af- fection of his eyes. In this instance also, blood-letting, and the other remedies formerly prescribed, proved successful; and he has not, since that period, had any return of the disease. About two years ago, I was desired to visit a patient, who, during confinement from a swelled testis induced by a Gonorrhoea, was suddenly seized with a profuse discharge of matter from one of his nostrils, very simi- lar to the running of the dap. The membrane of the nostril appeared fender, and somewhat inflamed ; but little or no pain occurred from it. The discharge from the urethra had diminished considerably previous to the testis becoming inflamed, and, on this taking place from the nose, it disappeared entirely. This suggested the propriety of attempting to excite a return of the dis- charge by the urethra ; but no advantage being derived from this, I advised the affection of the nose to be treat- ed with injections similar to what we use in cases of clap. An astringent solution was thrown up, some- times with a syringe, and at other times by inserting a bit of sponge immersed in it up the nostril ; and in the course of a few days the running ceased entirely. Since that period, the same patient has been twice af- fected in a similar manner, and the same kind of treat- Ch. i. AND LUES VENEREA 31 ment proved equally successful. No mercury was given, and no symptom of pox has ever appeared. In the course of a few weeks after the recover^ of this patient from the first attack of the disease, I was desired to see a friend of his, who for several years had been distressed with a similar discharge from both his ncstrils.. The running had occurred during the con- tinin'rce of a clap ; and although it had frequently diminished in quantity, yet at all times it was so con- siderable as to be productive of much uneasiness. No ulceration appeared on the membrane of the nostrils, but it. was of a deep red colour, and tender over its whole extent. A variety of remedies had been em- ployed ; and at last, after the disease had gone on for upwards of three years although no other symptom appeared, he war advised to undergo a course of mer- cury. Tils was done in the most attentive manner ; but no advantage ensued from it. In this situation, I expected that the same plan of treatment which proved successful in the preceding case, and which had also done so in others, would likewise answer here. In this, however, I. was disap- pointed ; for, although every variety of injection was used that I ever employed, yet no material advantage ensued from them. The running was sometimes in- deed lessened by them, but it always returned equally severe as before ; and although it has of late, even when no remedies were employed, become considera- bly less, it still continues in such quantities as to prove highly distressful. No other symptom of the disease, however, has ever occurred. As a farther proof of the difference of the contagions of Syphilis and Gonorrhoea, it may be remarked, that no state of pox has ever been known to induce Go- norrhoea, which surely would occasionally happen, if the two diseases were of the same nature. We may also remark, that, in numberless instances, people have been poxed by the matter of Syphilis being by accident applied to a cut or scratch, as often happens with surgeons in the dressing of chancres and buboes; but no one ever heard of a pox being got in this man- 32 ON GONORRHOEA VIRULENTA, CIl. I. ner from the matter of Gonorrhoea. It has indeed been said, that chancres may be produced by insinuating the matter of Gonorrhoea beneath the skin. But ex- periments upon this subject are productive of such anxiety and distress, that they never have been, nor ever probably will be, repeated so frequently as the na- ture of it would require. Nothing, therefore, can be admitted from this argument; for, in order to avoid fallacy, and to give support to the opinion, these ex- periments would not only require to be conducted with accuracy, but to be numerous, and to be repeated on a variety of patients under every possible variety of circumstances ; whereas we have heard of only a single experiment or two being made by any individu- al ; and even these seem to have been made under the management of such as were strongly and obviously biassed in favour of one side of the question. In opposition to these, too, I may mention, that, induced by some late publications upon this subject, two young gentlemen of this place have made some experiments upon themselves, with a view to ascertain the point in dispute ; but the result was materially different from what appears to have happened in the experiments to which I allude. By the introduction of the matter of chancres, as well as of buboes, into the urethra, some pain and irritation were excited, but no Gonorrhoea ensued; and, by fretting the skin of the prepuce and glans with a lancet, and rubbing the parts with the matter of Gonorrhoea, slight sores were produced ; but they never assumed the appearance of chancres, and they healed easily without the use of mercury.—For the reasons mentioned above, however, we cannot place much dependence upon these or any other experiment's that have yet been made upon this subject ; we must trust therefore to experience and ob- servation in the ordinary course of practice for means to ascertain it. The other fact on which the doctrine we attempt to establish rests, is, that Gonorrhoea and Svphilis have appeared at different times in the same countries, and in Ch. I. AND LUES VENEREA. 33 some instances have remained distinct and uncombined for a great length of time. If these two diseases were of the same nature, and proceeded from the same contagion, they ought to have appeared nearly at the same time in every coun- try to which the infection was carried. This does not appear, however, from the history of the disease, to have been the case. From the earlier writers up- on this subject, it is evident, that the Lues Venetea was known in Europe at least forty years before the Gonorrhoea Virulenta. Doctor Astruc, whose accu- racy and minute attention to this subject has not been equalled by any one, asserts, that in his time Go- norrhoea had not been long known in China, although we know that the Lues Venerea had long prevailed in that country: and it would appear, notwithstand- ing any thing that has been said to the contra; y, that the Lues Venerea was imported into the island of Otaheife a considerable time before Gonorrhoea. It seems to have been carried to that and other islands ■in the South Seas by the very first European naviga- tors who touched there, and to have remained distinct, without being connected with Gonorrhoea, for a very considerable time ; for when Captain Cook visited these islands in his second voyage, we have authority for saying, that Gonorrhoea had not then appeared in them. These historical facts all tend to prove, that where only one of these diseases has been imported to any particular district, it has always remained distinct, without producing the other ; and which we cannot suppose would have happened, if both were formed by the same contagion. And, in addition to these, I may add another, not less remarkable, the truth of which may be ascertained by all who incline to in- quire concerning it, as the scene of it lies in our own country. In various parts of the country of Scotland, parti- cularly in some parts of the Highlands ; in Galloway, and in Dumfries-shire; the common people have, for 5 34 ON GONORRHOEA VIRULENTA, Cll. I. a great length of time, been afflicted with the Lues Venerea, under the denomination, as they term it, of Sibbens ; and which, from those distressed with it having no communication with those infected with Gonorrhoea, has still retained its original, unmixed form, without a single instance, so far as I know, of Gonorrhoea, having been ever produced by it*. There is evidence, in some of these districts, of this disease having prevailed among them for upwards of seventy years : Nay, in some of them, it is said, from tradition, to have been left there by the soldiers of Oliver Crom- well, and to have been given, since that period, by one generation to another; and, although I have had op- portunities of seeing many hundred people labouring under it, with ulcers in the throat, nodes of the bones, fungous excrescences about the anus, blotches over the body, with almost every other symptom of Syphi- lis, yet not an instance has occurred to me, as I have observed above, nor have I heard of any, where Gon- orrhoea took place in it. Whether it is from those in- fected with it concealing it longer than usually happens in towns, or what may be the cause of it, I shall not at present pretend to determine; but certain it is that the symptoms produced by it are more inveterate than. we usually find them to be in the ordinary form of this disease. They appear to be more particularly infectious; the slightest communication with those la- bouring under the disease being apt to produce it. The symptoms spread more rapidly, and a greater quantity of mercury is, for the most part, required to remove them; but still Gonorrhoea is never pro- duced in any stage of the disease. A disease very similar to this broke out among the country people of Canada, some years ago, owing, as is imagined, to communication with some of the sol- * This must have happened from the disease in these districts prevailing al- most entirely among poor country people, whose manners do not expose them to the hazard of being infected with Gonorrhoea. None, however, can escape the Sibbens who are much in company with those labouring under it; and so much are they convinced of its being the same disease with Lues Venerea, that even those who get it in the most innocent manner, are so much ashamed tha* they never speak of it as long as it can possibly be kept secret. . ' Ch, I, AND LUES VENEREA. 35 diers quartered among them, who were infected with Lues Venerea. It is attended, as is the case with the Sibbens in Scotland, with all the symptoms of Syphilis in the most virulent form of that disease ; and it is so very infectious as to be communicated by eating or drinking out of the same vessel, or drying with the same cloth that has been used by those labouring under it. It often enters the constitution by absorption from the surface, without any previous ulceration : In which case it afterwards breaks out in buboes, nodes, ulcers, and other symptoms of a confirmed Lues; but not an instance, I am informed, has happened, of Gonorrhoea being produced by it. This, as well as what has occurred in the progress of Sibbens, is precisely what happened with the Lues Venerea when it first appeared in Europe, as well as at a late period in the South Seas ; and there cannot be a doubt of the same circumstances taking place wherever the Syphilis only is communicated. We have seep, in all these instances, that Gonorrhoea has never been produced by it, which surely could not have happened if the two diseases were of the same na- ture, and produced by the same contagion. They could never, in that case, have remained for any length of time so distinct and precisely marked ; for the one must necessarily, in almost every instance, have soon been productive of the other. As a farther support of this opinion, I may add, that if the two diseases were of the same nature, and pro- duced by the same infection, the remedies proving useful in the one, might betexpected to prove likewise so in the other. Instead of this, we find that those upon which we depend with most certainty in Gonorrhoea, have no effect whatever in the cure of Syphilis, while mercury, which is the only remedy, as we have obser- ved above, upon which any dependence can be placed for the cure of Syphilis, does not, in Gonorrhoea, pro- duce any advantage. Nay, that in some cases, it evi- dently does harm. We also know, that Gonorrhoea will often termi- nate whether any remedy be employed or not, merely 36 ON GONORRHOEA VIRULENTA, &C. by moderate living, and keeping the parts regularly clean. The disease by this alone will, in most instan- ces, become gradually milder, till at last it will dis- appear entirely. No such thing, however happens in Lues Venerea. In this as we have already remarked, even the mildest symptom becomes daily worse, un- less mercury be employed ; nor will any practitioner of experience trust the cure even of the slightest chan- cre to any ©ther remedy. Upon this evidence alone, of the method of cure ©f the two diseases being so essentially different, we might J think, conclude that they are different in their na- ture, and that they proceed from different contagions. Were they of the same nature, and proceeding from the same cause, it is not possible to conceive that any medicine would act as a certain cure for one and do harm in the other, and yet every practitioner will ad- mit that mercury, is the only remedy hitherto known, upon which we can depend for the cure of Lues Ve- nerea, while it evidently often does harm, as I have al- ready observed, in Gonorrhoea. lithe subject now under discussion was merely of a speculative nature I should not have entered so mi- nutely into it, for in that case it would have been a matter of indifference both to practitioners and patients whether these diseases were of the same nature or not; but, as the treatment of Gonorrhoea ought to depend much upon this circumstance, I judged it proper be- fore proceeding to treat of it, to make this attempt to have the point in question ascertained. It is perhaps unnecessary to add any further arguments to those of the a'ole and judicious author, as to the specific difference of the dis- eases in question ; we cannot however help observing, that though bota diseases affect the same parts, and are induce'd by the same means, yet that Syphilis appeared at least one hundred years before Gonorrhoea, and that it must be in the knowledge of almost every physician, that the termination of one of the diseases in the other, is so rare an occurrence (if it ever did happen) that we might apply the legal maxim, Exceptio regulam probat. If any other argu- . merit was necessary to prove the position of our author, we would draw it from the almost universal experience of the faculty in eve- ry part of the world, hnhe different mod* of treatment which they SeC. I. GENERAL ORSERVATION?, &C ?if adopt in the two affections, as we believe that with very few excep- tions, Gonorrhoea is treated as a local, andrSyphilis, as a constitution- al affection. The few cases which occasionally occur, and which we have sometimes met with, where both diseases exist at the same time, in the same patient, constitute no rational objection to our doc- trine, as in some of the cases it could be incontestably traced to two different sources of infection, and in others the person from whom it was derived, laboured under both diseases. For a more detailed discussion of this question, we refer to Prac- tical Observations on the Natural History and Cure of the Venereal Disease, by John Howard, Fellow of the Royal College of Surgeons. London, 1806. Ed. CHAP. II. Of the Gonorrhoea Virulenta. SECT. I. General Observations on the Symptoms, Causes, and fical of Gonorrhoea Virulenta. EVERY discharge of matter from the urethra, excited by impure coition, is termed Gonorrhoea Virulenta. As the term implies a discharge of semen, and as this disease is not necessarily attended with any seminal evacuation, it is here obviously misapplied ; but we think it better to retain even a faulty denom- ination when very universally received, than to incur the hazard arising from the confusion which might en- sue from the proposal of amendments. The period at which the discharge fakes place, after exposure to infection, is always uncertain. I have known it happen in a few hours; often in the course of a day or two, and in some instances not till several weeks have elapsed. From the third or fourth day, to the seventh and eighth, is the most frequent pe riod. 38 GENERAL OBSERVATIONS ON Ch. II. This does not appear, however, to have any effect on the nature or violence of the symptoms. Some in- deed have imagined, that the disease must be mild or severe according as it appears early or late after the matter of infection has been applied ; but this does not accord with my observation. I have often known the symptoms mild when they appeared early after ex- posure to infection, and severe when much time had elapsed. In one of the most obstinate cases of Gon- orrhoea I have seen, the running did not appear till nearly the ninth week from the time of infection. A gentleman sailed from Jamaica two days after having connection with a woman of suspicious character. No symptoms appeared till several weeks had elapsed ; he concluded that he had escaped; when, two days before coming into port, being the fifty-eighth of his voyage, a very copious running appeared. In some few cases, the discharge takes place with- out the patient having any warning of its approach ; but, for the most part, it is preceded by symptoms in- dicating some degree of inflammation in the urethra,: A sense of fulness and tightness is felt over all the un- der part of the penis ; the patient has a more frequent desire than usual to void urine, accompanied with a peculiar kind of itching heat along the urethra, at the same time that the extremity of that canal is observed to be of a more deep red colour than ordinary, and more than usually tender to the touch. In some cases, too, the urethra seems to be contracted, or lessened in its diameter; the urine coming off in a stream much smaller than natural, while at other times it is forked, and as if the passage was divided in two. On the appearanceof the running,it is sometimes white, and nearly of the consistence of purulent matter ; but, for the most part, it is thin, and of a yellow green colour. In some cases it is brown, resembling the dis- charge of old scorbutic sores, and in others it con- sists almost entirely of blood, owing to the erosion or rupture of one or more blood-vessels in the urethra. SeC. I. GONORRHOEA VIRULENTA. 39 In a great proportion of cases, the discharge of mat- ter from the urethra, and scalding heat in making water, are the only symptoms which take place; but in others, these are accompanied, with chordee, or painful involuntary erections; with much uneasiness in the testes, which frequently become so tender and irritable that the slightest touch excites pain. Severe degrees of pain often stretch from the penis to the groins and thighs ; and in some cases over all the ab- dominal viscera, particularly over the under part of the belly. In some cases the chordee, and in others these sym- pathetic pains stretching to the groins, and contiguous parts, are the most distressful symptoms of the disease. I have known the latter so severe as to render the patient altogether unable to take any kind of exercise; while the chordee, which is usually worst in bed, is apt to deprive him entirely of sleep. Besides these pains in the parts contiguous to the penis, and which we suppose to be chiefly the effect of nervous irritability, the glands in the groin in some instances swell, and become hard; but unless the run- ning be accompanied with chancres, these swellings very commonly subside, and do not proceed to sup- purate ; an important fact, which may be considered as an additional proof to what was mentioned in the last chapter, of the difference between Gonorrhoea and Lues Venerea. In the course of the disease die glans penis some- times becomes red and inflamed, and a yellow, foetid matter, oozes from its whole surface. In some cases this is accompanied with evident ulceration : in others the skin remains entire, and tlie matter is observed, upon pressure, to proceed from an infinite number of small points. In both they are supposed to proceed from the matter passing out of the urethra, and al- lowed, by the negligence of the patient, to rest too long upon the tender cuticle of the glans. In some cases, however, this inflammatory affection of the glans, and discharge with which it is accompa- nied, takes place of itself, and without any discharge 40 GENERAL OBSERVATIONS ON Ch II. from the urethra. In which case, froiri the resem- blance which the matter bears to that of Gonorrhoea, it has usually been termed Gonorrhoea Spuria. This inflammation, in some cases spreads to the prepuce, in which it very commonly produces some degree of contraction. When the prepuce becomes so much straitened that it cannot be drawn back, a disease is formed, which we term phymosis; and, when it con- tracts behind the glans, a disease termed paraphymo- iis takes place. Although in Gonorrhoea some degree of uneasiness is usually felt along the whole course of the urethra, yet we know, that in most instances, the seat of the disease lies within an inch, or little more, of the point of the penis. In a few cases, however, whether from maltreatment of the disorder; from the nature of the infection being more than usually virulent, or from peculiarity of constitution of the patient, the disease spreads backward till it extends over the whole length of the urethra, even to the bladder itself. The prostrate gland and internal coat of the bladder become affect- ed, and sympathetic pains stretch from these parts along the ureters to the kidneys. When the bladder becomes in this manner diseased, the state of the patient is, for the most, extremely mis- erable : he feels almost a constant desire to make water, accompanied with severe pressure or bearing down upon the affected parts, proceeding from invol- untary spasmodic contractions of the abdominal mus- cles. The whole region of the loins, particularly a- bout the kidneys, becomes so painful and irritable, that much distress is excited by whatever tends to bring the muscles of these parts into action, and the patient often complains of a constant tenesmus, and of a frequent shooting pain about the anus and neck of the bladder. In this stage of the disorder there is seldom any con- siderable discharge from the urethra ; but, for the most part, a large quantity of very viscid, foetid mucus is discovered in the urine, which, in the course of a few Sec. I. GONORRHOEA VIRULENTA. ll hours, subsides, and adheres so firmly to the sides of the vessel as not to be easily separated. ! When a Gonorrhoea has either been improperly treated, or when much inflammation takes place from any other cause, the testes are apt to swell and in- flame, and abscesses often form in Cowper's glands, as well as in other parts of the urethra. When these burst outwardly, or when the urine by any means finds access to them, they are often productive of great dis- tress to the patient and perplexity to the practitioner, as they frequently baffle every attempt that is made for removing them. It will readily be conceived that all the symptoms we have described are seldom or never met with in the same patient, and that these which do take place will be in very different degrees in different cases. This is particularly remarkable with respect to the quantity of discharge, which, in some instances, is so trifling as scarcely to excite any inconvenience, whilst in others it is so profuse as to prove highly distressful. In some cases too, the heat of urine is so inconsidera- ble as not to deserve notice ; and in such instances also, the desire to pass water is seldom very frequent, while, in others, these symptoms are both so insup- portable as to render the patient miserable. In most instances of Gonorrhoea any external inflam- mation which occurs is confined to the extremity of the urethra ; but in some cases, it runs so high as to spread over the whole glans, where it might be ex- pected to terminate, as inflammatory affections in other parts of the body most frequently do, in the for- mation of abscesses. This, however, very rarely hap- pens. We have observed, above, that, in a few in- stances, a purulent-like matter oozes from the w hole surface of the inflamed glans ; but I have scarcely known an instance of any extensive abscess in the substance of the glans. The inflammation, for the most part, terminates by dispersion. In a few cases it ends in mortification. In women the svmptoms of Gonorrhoea are, for the, G 42 GENERAL OBSERVATIONS ON Ch. 11. most part, much milder than in men. It sometimes happens that a flow of matter is all that occurs ; and, as the discharge is very similar to the matter of fluor albus, the two diseases are often mistaken for one another. This absence of pain, however, takes place only where the vagina is the seat of ,the disease. When the urethra becomes affected the symptoms are near- ly the same as in the other sex. A distressful degree of irritation occurs at the extremity of the urethra, accompanied with heat of urine, and a very frequent desire to pass water. In some cases the inflammation spreads to the bladder, and even to the kidneys, ute- rus, and ovaria ; or at least these parts come to be so much affected with pain as to give cause to suspect that they are in a state of inflammation. Pain, even in a severe degree, will no doubt occur from nervous sympathy, and this I believe to be frequently the case here; but 1 have met with different instances of a considerable degree of inflammation being excited by- Gonorrhoea in all the parts which I have mentioned : that is, they have become swelled, hard, and exces- sively painful, insomuch that the slightest touch would create a great degree of uneasiness ; and blood-letting, with other evacuations, were the only remedies from which relief was obtained. In some cases the matter is so sharp and acrid as to excoriate the clitoris, nym- phse, and labia pudendi. This excites a great deal of uneasiness; more than ever takes place in men from a mere affection of the external parts; for, as these parts are in women pressed upon in sitting, the slight- est degree of inflammation is, from this cause alone, productive of much distress. They are often obliged to remain constantly in bed ; being unable either to walk, stand, or sit. It is impossible, in any case of Gonorrhoea, to de- termine at first, in what manner it will terminate, for we often find the most severe, as well as the most ob- stinate discharge, succeed to symptoms of the mild- est nature, while in some cases it ends quickly and SeC. I. GONORRHOEA VIRULENTA. 43 easily, where the symptoms at first were very severe. It is in general believed that the disease will be mild, and of short duration, where the running is white or yellow ; and, on the contrary, that it will necessa- rily prove severe and tedious, where it is at first green, or much tinged with blood. This, however, is by no means universally the case, for instances occur daily, of the running proving tedious, where it was at first of the colour and consistence of purulent mat- ter, while others often happen of its ending quickly, where the matter was at first either deeply tinged with blood, or of as deep a green as this discharge has ever been observed. In the progress of this disease, we always reckon it a favourable circumstance to observe the matter be- come thick and ropy. This cannot indeed be mention- ed as an infallible proof of the discharge heing soon to terminate; but it is, undoubtedly, one of the most favourable occurrences in every case of clap. When the running does not soon become ropy, it is apt to terminate in gleet, the most perplexing symptom in this disorder, and of which we shall speak more par- ticularly in an ensuing chapter. We shall hereafter have occasion to observe that a discharge may be produced from the urethra by dif- ferent causes, very similar to the matter of Gonor- rhaea virulenta. At present it is only necessary to remark, that, in this disease, the discharge is obvi- ously the effect of irritation excited in the membrane of the urethra and contiguous parts, by matter from an infected person being applied to them. Some difference of opinion has arisen on the manner in which the matter of infection is communicated to the urethra. By some it is supposed to happen in consequence of being first absorbed from the surface of the glans, and afterwards deposited on the mem- brane of the urethra; as they do not think that it can pass directly into the urethra, during coition. No good reason, however, can be given fortius opinion: it appears more probable that the matter at first finds 44 GENERAL OBSERVATIONS ON Cll. II. access between the lips of the urethra ; that it after- wards spreads, in a gradual manner, along the pas- sage, by mixing with the mucus, with which it meets, and that the progress which it makes will, in a great measure, depend upon the parts to which it is applied being more or less susceptible of inflammation ; upon the general state of health of the patient; upon his manner of living ; and perhaps upon other causes. I do not conceive, however, 'that the kind of mat- ter by which the discharge is produced has so much influence on the violence or duration of the symptoms as has been imagined. It is indeed the opinion of some that a severe and obstinate case of clap may always be traced to an infection of some peculiar degree of vii ulency ; but this will not be found to happen with any kind of uniformity. So far as my observation goes; it is in Gonorrhoea nearly the same as in small pox. The mildness or violence of symptoms does not depend upon the matter by which the disease is produced so much as upon other circumstances. Hence the same woman will, under the same infection, com- municate the most virulent symptoms to one person, and the mildest to another. That much depends upon the habit of body of the patient, and upon his manner of living, will scarcely be doubted; but the following fact renders it obvious. Three gentlemen, who associated much together, and who were accustomed to live freely, returning one night from a drinking club, resolved to visit a girl of the town, and to take a friend along with them who had that night been a visitor in their society, but who usually lived with much sobriety. They all had con- nection with the same girl. The three associates had all the most severe claps I ever met with ; while the other, who also received the infection, had the dis- ease in the mildest form. This would not, in similar circumstances, always happen, as we sometimes find people who live with much circumspection, liable to very severe attacks of Gonorrhoea ; but, for the most part, the degree of violence of this disease has a con- SeC. I. "' GONORRHOEA VIRULENTA. 45 siderable dependence on the manner of living of the patient. The matter discharged in Gonorrhoea being very similar to what is daily observed, to flow from sores in other parts, and the quantity being often very con- siderable, it was the prevailing opinion, till of late, that it proceeded from sores or ulcers in the urethra. We now know, however, that ulcers very seldom take place here ; and, when they do, that they may be traced to some accidental cause, such as the rupture of a blood-vessel, in no degree necessarily connected with the existence of the disease. On dissection, after death, it is found, almost in every instance, that the membrane of the urethra is entire, and that the matter is produced by inflammation alone. It had long been known, that instances were occa- sionally met with on dissection, where no degree of ulceration in the urethra was discovered. This, how- ever, was considered as a singular occurrence, and that it never happened but where the symptoms were un- commonly mild ; for at that time it was supposed, that ulceration, or a destruction of parts, was requisite for the production of matter. But we now know, that this is by no means the case, and that an inflamed sur- face, even where no abrasion is perceived, will pro- duce all the varieties of matter which sores ever afford, and that different kinds of animal fluids may be con- verted into these, merely by being kept in certain de- grees of heat. By this the difficulty is removed, which otherwise we must have experienced in accounting for the large quantities of matter daily discharged from the urethra in Gonorrhoea ; which, in some cases is so considerable, that nothing less than an affection of the whole extent of that canal could afford it. Now those who ima- gine that the matter proceeds from ulcers, have never gone so far as to say that this ever takes place : nor could it probably occur, but with such consequences as very seldom ensue from Gonorrhoea. What I allude to forms an unanswerable objection to the idea of ul- 46 GENERAL OBSERVATIONS ON Cll. II. cers being frequent in this disease, even although no opportunities had occurred of proving it by dissec- tion. Where the membrane of the urethra is in any point ruptured, either by the bursting of an ab- scess into it, or by any other cause, the most distress- ful consequences almost universally ensue ; for the urine passing into the contiguous parts, forms swel- lings, which usually terminate in fistulous openings, that prove always tedious, and of uncertain event* Every practitioner knows, that even the slightest opening into the urethra is apt to terminate in this manner; so that, if the matter of Gonorrhoea, pro- ceeded from ulceration, the consequences of almost ev- ery case of Gonorrhoea, would necessarily prove much more formidable than we ever, in any instance, find them to be. In cases of long continued Gonorrhoea, the membrane of the urethra is apt to be so relaxed, that fungous ex- crescences form in different parts of it. These not only impede the passage of the urine, but, becoming soft and tender, they at last ulcerate, and throw out very considerable quantities of matter. This however, is never to be considered as the cause of Gonorrhoea, but merely as the effect of it. It often proceeds from mismanagement, either on the part of the patient or practitioner; and sometimes from some constitutional affection to which the patient at the time may be lia- ble. Instead of ulceration, we find, that in a great pro- portion of cases, there is merely a slight degree of in- flammation, extending from the extremity of the glans to an inch or perhaps an inch and a half up the ure- thra. In more obstinate cases of clap, Cowper's glands, with their ducts, which terminate in the urethra, are found affected. In a third stage of the disease, the prostrate gland, and contiguous parts of the urethra are inflamed ; and in the fourth, and what may be reckoned the most distressful stage of clap, the inter- nal coat of the bladder is found inflamed. For the most part, the inflammation is confined to the neck of the bladder; but I have met with instances of its being Sec. I. GONORRHOEA VIRULENTA. 47 perceptible over the whole of it, and of its even ex- tending along the ureters to the kidneys. This inflammation, however, is chiefly obvious at first. On a long continuance of the disease, the parts affected, instead of being either inflamed, or in a state of ulceration, are of a more pale colour than natural ; the membrane of the urethra is found soft and relax- ed ; and coloured mucus or matter may be pressed out from an infinite number of small points over every part of it that has been diseased. This is precisely what happens with every mem- brane that lias remained long under a slight degree of inflammation, particularly with the membrane of the nose and trachea. These parts often afford very con- siderable quantities of matter, or of mucus very much resembling matter, for a great length of time : and yet, upon dissection, they are seldom or never found in a state of ulceration, the membrane being for the most part only slightly inflamed. We may here indeed remark, that the resemblance between the two diseases, Gon- orrhoea and Catarrh, is, in certain stages of each of them, very remarkable. They seem both to origin- ate from inflammation excited upon a membrane. The matter of the one is in many instances very simi- lar to that of the other. They seem both to be local affections only; and the parts on which they are seat- ed are, after death, found to be affected in a similar manner. But although, in the latter stages of Gonorrhoea, in which, chiefly opportunities occur of examining the state of the parts after death, the inflammation is found to be for the most part inconsiderable, yet, in the com- mencement of the disease the parts are often highly inflamed, particularly when those about the neck of the bladder are affected. This is obvious from the symptoms particularly from the violent pain which al- ways takes place, and from the antiphlogistic reme- dies employed for the cure of the disease. 48 GENERAL OBSERVATIONS ON Cll. II SECT. II. Of the Prognosis in Gonorrhoea Virulenta. IN every disease, it is of importance for a practition- er to be able to say at what time and in what manner it will terminate. In none is information of this kind more anxiously wished for than in Gonorrhoea. The hopes and fears of patients lead them equally to wish for it; but, from various causes, and more particularly from want of attention to the exact site of the disease, the duration of Gonorrhoea has always been a matter of much uncertainty. I have observed above, that, on dissection, four dif- ferent set of parts are found at different times to be the seat of Gonorrhoea. When the running proceeds from the extremity, or from within about an inch and a half of the extremity of the penis, as happens in per- haps nine cases out of ten, there will for the most part, be much cause to hope that a cure will soon be obtain- ed. In such instances, when the patient is otherwise in good health, and when he does not interrupt the operation of the necessary remedies by improper con- duct, the disease will not commonly endure a fortnight. Nay, a cure in such circumstances is often obtained in two or three days : but whenever the lower parts of the urethra are affected, particularly when the pros- trate gland and oilier parts about the neck of the blad- der aie diseased, the running, in almost every instance, proves obstinate. Even our most powerful remedies in other cases of clap are here doubtful in their effects. Hence no certain opinion can be formed of the event of the disease. When these deep-seated parts are affected, the dis- ease proves always tedious, whatever the habit of body may be ; but it necessarily proves much more so when the constitution labours under any general affection, particularly when scrophula prevails, than when the patient is sound and healthy. Indeed a scrophuloug taint existing even with the most simple case of clap, SeC. II. GONORRHOEA VIRULENTA. 49 is apt to render it obstinate ; I am so much convinced of this being the case, that in every instance of clap occurring in scrophulous patients I always give a guarded prognosis of the event. Cures are sometimes indeed obtained easily, even in patients of this de- scription ; but, for the most part, Ihe discharge goes on for a great length of time, and resists the effect of eve- ry remedy we employ to remove it. This uncertainty which takes place in the treatment of Gonorrhoea, and the great length of time to which the discharge, in some instances goes on, together with the many untoward and unexpected occurrences which often happen during the cure, tend altogether to render this branch of practice the most distressful of any in the province of medicine. In a great pro- portion of cases, a cure with proper treatment is easi- ly and speedily obtained ; but every candid practition- er will admit that cases often occur in which the dis- charge continues obstinate for a great length of time, even under the use of the most, powerful remedies with which we are acquainted. But, by distinguishing be- tween one stage of the disease and another, and thus giving an opinion to patients of the probable event of it, practitioners would avoid a good deal of embarrass- ment which they often experience, from giving so in- discriminately as they commonly do, a favourable prog- nosis at the commencement of every case of clap. In forming a prognosis, it ought always to be kept in view, that however mild the symptoms may be at first, they may very quickly and unexpectedly become se- vere, by the disease proceeding from one part of the urethra" to another, or even by the inflammation in the part which was at first affected becoming more severe. This arises from various causes, and often from cir- cumstances which it is not in the power of practitioners to prevent. It sometimes occurs, indeed, from the use of improper remedies ; particularly from acrid injec- tions being used with too much freedom ; but it hap- pens much more frequently from other causes, partic- ularly from the tendency which inflammation in one 7 50 GENERAL OBSERVATIONS ON THE Cb. IT. part of a membrane has to spread itself over the whole of it, and to the misconduct of patients, who, instead of living as the'y ought to do, very commonly proceed, during the cure, in the same course of riot and de- bauchery by which they were at first exposed to in- fection. Some patients, even under such circumstan- ces, will no doubt get well ; but there is not a more undoubted fact than this, that the cure of the disease is for the most part both difficult and uncertain where the patient lives in a riotous and intemperate mariner. No situation is more delicate, or more exposed to censure than the one in which the .pnysician is placed when called upon to give an opinion on the probable continuance of a disease. This is particu- larly the case in Gonorrhoea. The impatience, as well as imprudence of the description of persons who are most liable to this complaint, render a prognosis extremely uncertain. Much depends on the habits and mode of life of the patient, his constitutional tempera- ment, and the diseases (if anyHo which he has been subjected, or is prpdisposed. As a general rule, it may be observed, that in persons of a sanguine temperament, and accustomed to live freely, the in- flammation will be more violent in its progress, but with proper cau- tion may be removed in a shorter period, than in individuals of a dif- ferent constitution. It ought to be impressed on every patient that temperance and rest are indispensible in order to effect a speedy cure. The difference of climate and seasons have considerable in- fluence on the degree of inflammation excited. Hot weather tends to render the discharge considerable and acrimonious, and in the spring or beginning of summer the tendency to inflammation is greater, and the symptoms are generally more aggravated than at other seasons of the year. Ed, SECT. III. General Observations on the Cure of Gonorrhoea Virulenta. GONORRHOEA, as I have observed above, has, till of late, been very generally considered as depend- ing upon an affection of the constitution ; or at least the discharge has been supposed to be of such a nature Sect. III. CURE OF GONORRHOEA VIRULENTA. lj[ as at all times to affect the constitution, and therefore that a cure could not be obtained bnt by the use of remedies which operate upon the system at large. For a considerable time mercury was chiefly relied upon. It was employed on the supposition of Gonorr- hoea being a symptom of Lues Venerea; but experience having shewn that no advantage was derived from mer- cury by itself, other remedies were employed along with it. These consisted chiefly of demulcents, evac- uants, and astringents. By a plentiful use of mucilaginous drinks, and oth- er demulcents, it was meant to sheath the bladder and urethra more effectually from the acrimony of the u- rine, and at the same time to render the urine itself less acrid. Purgatives were employed for the purpose of carrying off the morbid matter of the disease, and nitre and other remedies wTere given with a similar intention ; and lastly, as the running was seldom lessened by the use of any of these, but, on the contrary, being fre- quently increased, bark, astringent balsams, and other corroborants, were prescribed for putting a stop to it. In some cases mercury was continued during the whole course ; in others it was left off'at the time of entering upon the use of astringents. Ttie practice of physic when this prevailed being in most points highly improved, we are astonished to find such deficiency as this evinces, in the treatment of a disease which necessarily fell under daily observation. If patients had been left to themselves, without any in- terference on the part of practitioners, the disease would often, in the course of time, have disappeared without any injury being done to the constitution ; for we know that a simple clap will, in most instances, dry up whether any remedies be employed or not; but, by the liberal use of strong purgatives, and especially when this was conjoined a ith a low diet and a course of mer- cury, the constitution was so much debilitated that this alone rendered almost every case that occurred exceedingly obstinate : hence Gonorrhoea was consid- ered as the most distressful as well as one of the most 52 GENERAL OBSERVATIONS ON THE Cll. 11. dangerous diseases to which the human species was lia- ble. Lues Venerea was, for the most part, easily cu- red by mercury ; but no advantage was derived from this remedy in Gonorrhoea: the disease usually proved exceedingly obstinate, and was very apt to terminate either in gleet or in obstructions of the urethra. It soon appeared to practitioners of observation, that ■& the medicines employed in Gonorrhoea, instead of pro- ving useful, rather did harm ; but the period was not yet arrived in which a more effectual remedy was to be proposed. Some, however, went so far as to say that medicines of every kind might be avoided, as they had found, from experience, that the disease went off both m>re easily and more quickly when left to itself then it ever did with the remedies at that time in gen- eral use. A low diet, mercury, and evacuants, of dif- ferent kinds, did much harm, as we have already obser- ved, by inducing such a degree of debility and relax- ation as materially affected the constitution ; and the drastic purgatives, of which large doses were given daily, proved highly prejudicial, by the irritation which they excited. In certain stages of clap a strong purgative never fails to increase the pain ; to excite a more frequent desire to make water, and to increase the discharge: nay, I have known various instances of a return of all the symptoms of Gonorrhoea being in- duced by the operation of a brisk purgative, long after the patient considered his cure as complete. We need not therefore be surprised at the proposal of laying all such remedies as thee!', aside ;and it must be admitted that a cure will often take place, that is, the running would disappear, together with all the symptoms which attend it, without the aid of medi- cine. This would frequently happen where the dis- ease was mild; where the patient was possessed of a healthy constitution ; and where the running was not kept up by any impropriety on the part of the pa- tient. The running would di.sappear here, as happens in coryza and other instances of matter proceeding from inflamed surfaces, whetiier any remedies should SeC. III. CURE OF GONORRHOEA VIRULENTA. O* be employed or not: but this would seldom or never happen where the symptoms were severe, nor where the patient did not live in every respect as he ought to do. In all such cases the cure would prove tedious and uncertain, and the constitution would frequently be ruined, in the attempt. When the mode of cure we have mentioned was proposed, an opinion prevailed that, the discharge was kept up by some general affection of the constitution, and that nothing therefore could be so safe or so pro- per as to allow it to run as long as any part of the mor- bific matter by which it was produced, continued. It was at that time admitted by all, that Gonorrhoea was of the same nature with Lues Venerea. Chancres, as well as all other venereal sores, were kept open till cures were obtained by the internal use of mercurv. An erroneous idea prevailed of some advantage being derived from the discharge which they produced ; and hence even by those who saw clearly that no benefit was obtained from mercury in Gonorrhoea, it was still considered as the best practice to allow the disease as they said, to discharge itself in this manner. Even granting that the matter of Gonorrhoea was the same with that of Lues Venerea, there is no cause to imagine that any advantage would ensue from this practice ; but we now have no reason to doubt of the two diseases being perfectly different. A practice, therefore, which at one period might have been judg- ed proper in one disease, would now be inapplicable in the other ; and hence it has, very generally, been laid aside, although not yet given up by some individ- uals. From the observations we had occasion to make in the last chapter, as well as from other circumstances, fetv will now doubt that the matter in Gonorrhoea pro- ceeding in most instances from an inflamed state of the membrane of the urethra and contiguous parts, gives a local affection only, without being productive of anj general disease of the constitution. From this view ©f the subject, it is obviou^ that no great advantage is J<1 GENERAL OBSERVATIONS ON THE 1>U. H. to be expected from remedies applied to the system at large, and that a cure is to be looked for from the use of local remedies only. In the treatment of a simple sore, of a cut, a burn, or excoriations from any cause whatever, we would not surely expect to succeed by mercury, purgatives, or any remedies directed to the constitution. In all such affections we trust to local remedies, unless the presence of fever, or some other general affection, render other remedies necessary. For the same reason we ought, in Gonorrhoea, to de- pend entirely upon such remedies as act chiefly upon the parts affected ; no others being necessary if it be not occasional blood-letting, and other evacuations, and these only where fever, plethora, or much inflam- mation take place. In local affections of other parts, our remedies are easily and directly applied : in the urethra some nice- ty and attention is necessary, not only in the mode of applying them to the diseased parts, but in judging of the period of the disease, or rather of the state of the parts to which they are to be applied : in other situ- ations these circumstances fall directly under view, and we judge from appearances of the propriety of ap- plying one remedy or another. In the urethra we are directed entirely by the symptoms, and we judge from these of the remedies to be employed, as well as of the parts to which they are to be applied being in a fit state for receiving them or not. If the parts affected in Gonorrhoea were always the, same, no difficulty would occur in the application of our remedies ; but, although the matter in the com- mencement of the disease proceeds in perhaps every instance from inflammation, yet, in some, parts are affected with inflammation, to which it would be im- proper and even hazardous to apply the same reme- dies which in a great proportion of cases are used with much safety and advantage. We shall afterwards have occasion to shew that, in certain circumstances of Gonorrhoea, bougies may be used with much benefit; but, for the most part, we Sect. III. CURE OF GONORRHOEA VIRULENTA. 55 depend entirely upon injections, and chiefly upon such as are of a drying astringent nature. Now it is obvi- ous, that although we may with safety apply an astrin- gent solution to an inflamed surface, as happens dai- ly where the membrane of the urethra only is affected, yet that much risk may ensue from the same solution being applied to the ducts of inflamed glands: in the one case the discharge produced by the inflammation will be lessened and soon removed, and the inflamma- tion itself will subside, while, in the other, by a sud- den stop being put to the discharge of a gland already in a state of increased irritability, more inflammation will be excited, the parts affected will become swelled and painful, and at last the discharge will burst forth with redoubled violence. That this frequently happens in the course of busi- ness, every practitioner of candour will admit: nay, there are few patients who have been liable to differ- ent attacks of this discharge, wdio have not met with it in some degree. For a clay or two the running will often disappear, and they consider the cure as com- plete, when after some degree of tension and uneasi- ness along the greatest part of the penis, particularly in the perineum, the discharge recurs as before, with every appearance of a recent infection. As there are many who condemn the use of injec- tions in Gonorrhoea, it is alledged that this is one of the inconveniences which they produce ; but we shall presently have occasion to shew that this is by no means the case, and that it proceeds entirely from a misapplication of the remedy ; from using it in a state of the disease for which it is improper ; and not from the remedy itself being of a hazardous nature. This leads us to revert to the necessity there is for distinguishing between one state of Gonorrhoea and another. In the description of the symptoms, I re- marked that they are evidently distinguishable mto four sets, indicating four states or stages of the dis- ease ; and as it is a point of the first importance in pi ac- 56 GENERAL OBSERVATIONS, &C. Cll. II. iice to have these different states clearly marked, we shall now proceed to ti eat of them in separate sections. As the author has mentioned the internal use of Mercury in Gon- orrhoea in this section, a few observations on its curative effects may not be misplaced. A notice of other remedies will be found in succeeding sections. The idea that mercury operates in Gonorrhoea in a similar manner to what it does in Lues, namely, by a specifick action, ap- pears at present to be generally abandoned. The point is indeed con- clusively decided by the fact, that the former disease is in numerous instances cured without the exhibition of a single grain. Its utili- ty must of course be derived from other properties, and those are probably its powers in changing a diseased to a healthy secretion. Analogy is in favour of this opinion, as well as the testimony of prac- tical men. Mr. Howard recommends its use in the form of calomel after the inflammatory symptoms have subsided, and the chordee is gone. At this period, the urethra is in a state of debility, and the stimulus of the medicine which in the preceding stage, would have been injurious, is not at present to be dreaded. The quantity administer- ed should not exceed two or three grains of calomel during the twenty-four hours, and this to be continued for a few days only. The exhibition of mercuiy by friction (Ung : Hydrarg : fort : ) either to the perineum, glans penis, or thigh, is seldom, if ever, proper. In the Contributions to Medical Knowledge, published several years since by Dr. Beddoes, there is a paper by Mr. Addington, a sur- geon in the west of England, in which he states his having cured I hundreds of cases of Gonorrhoea, in a very short space of time, by I giving Corrosive Sublimate internally. Three grains of it are to be I alrssolved in one ounce of rectified spirits of wine, and half of this mixture is to be taken undiluted when going to bed. On the second day after, a dose of Sulphate of Soda is to be taken, and in the even- ing, the remainder of the mixture. The salts are repeated in two days after. A violent and profuse salivation for one or two hours, is the consequence of this treatment, but there is no doubt cf its curative effects. It has lately been used with success in this city. As a general rule of practice, we must take the liberty to ob- serve, that with proper care and attention, mercury is but little need- ed as an internal medicine. Inordinary cases, other remedies will suffice. In instances however, where the discharge from the ure- thra is acrimonious and large in quantity, the exhibition of calomel ■ will be found useful. This is also the case in some cf the const-.M cjuences qf < 'or.orr!,rca. Ed. Seel. IV. OF THE FIRST STAGE, &C. 57 SECT. IV. Of the First Stage of Gonorrhoea. IN the first stage of Gonorrhoea, the running is never accompanied with violent symptoms. The extrem- ity of the urethra becomes red, lull, and somewhat prominent. The glans become tender and irritable, and ardor urinse takes place in a greater or lesser de- gree, according to the extent of the inflammation. For the most part the heat of urine is inconsiderable; but in some instances, even in this stage of the dis- ease, it is so severe as to excite a good deal of dis- tress. Chordee sometimes occurs, but seldom in any considerable degree. In the history of the disease we have seen, that in this stage of it, the membrane of the urethra alone is affected, that is, the inflammation by which the dis- charge is produced has not extended to any other ' part. We judge that this is the case when these symptoms only occur which have ju.-t. been enumerated ; when no glandular swellings are discovered along the course of the urethra, and particularly when the running pro- ceeds entirely from within an inch, or an inch and a half of the extremity of that canal. This circumstance of the discharge in Gonorrhoea proceeding from the extremity of the urethra, is at all times a proof of the inflammation not having advanced farther than to constitute what I have denominated the first stage of the disease. No glandular swellings are ever discovered while the running proceeds from these parts ; and on dissection after death, the membrane of the urethra alone is found inflamed : but in some in- stances the discharge proceeds even from the superior parts of the urethra, while none of the contiguous glands are affected. This I consider as constituting the first stage of the disease, equally as when the ex- tremitv of th^ urethra is alone affected. The symp- 8 58 OF THE FIRST STAGE Gil. II. toms are not more violent in the one than in the other, and the method of cure is the same in both. It must, however, be admitted, that %^ do not frequently meet with this; for where the upper part of the urethra is affected, the inflammation is very apt to spread to the contiguous glands, and thus terminates in the second, third, or, perhaps, fourth stage of the disease. We ascertain the place in the urethra, from whence matter is discharged, not merely from the height to which the pain or uneasiness with which it may be ac- companied extends, for this proves often an equivocal mark of distinction, but from compressing the passage at any given spot, and pressing out all the matter be- tween Hand the end of the urethra. If, on removing the pressure, more can be brought down, we are sure that it must come from a greater height, and by pro- ceeding in a gradual manner upwards we may thus, with very little attention, discover almost the exact spot from whence the discharge proceeds. It will af- terwards appear that our being able to do so is of im- portance in conducting the cure. From what has been said it will appear, that in this stage of the disease the running proceeds entirely from inflammation of the membrane of the urethra, with- out any affection of the glands which open into it ; and in the removal of this, the cure entirely consists. Where the inflammation is considerable, as we judge to be the case when the ardor urinae is severe, and especially when it occurs in a very full habit of body, it may be proper to prescribe blood-letting, a dose or two of any gentle laxative, and a low, cooling diet. At the same time violent exercise of every kind should be avoided, particularly riding on horseback. Inflammation, however, in this state is seldom so considerable as to render blood-letting necessary : in ordinary cases we now trust to the use of injections alone, and in all periods of the discharge I use them with equal freedom. Even where blood-letting, and a strict attention to an antiphlogistic regimen is neces- sary, I have never any difficulty in beginning immedi- ately with the use of injections. Sec. IV. OF GONORRHOEA. 59 Those who are not in the daily practice of using in- jections, are afraid of prescribing them so generally as they ought to do ; some, indeed never employ them in any case, from the prejudice being strong which still prevails against them among almost all the older prac- titioners, while others admit that they may be used with safety and advantage, in the latter period of the disease, but never in the beginning, or while the inflam- mation continues in any degree severe. This, however, is a timidity that will soon vanish with all who venture upon a more general use of them. They will find that injections, of a sufficient degree of astringency for removing the discharge, may in this state of Gonorrhoea be employed with perfect safety, even in the commencement of the disease, and whether the inflammation which takes place be mild or severe. An idea is still entertained by many, that the run- ning should not be stopped till some of the virulency by which it was produced is carried off; and hence they object, as we have just observed, to the early use of injections. But, as we have seen that Gonorrhoea is a local affection, and as we know that in other parts of the body local inflammation may at all times be re- moved with safety, nay, that it is the best practice to attempt it, we might from this alone infer, that it would be equally proper here. But independent of this, I can with confidence assert, and all who employ injections generally will do so, that they may in this stage of Gonorrhoea be used at all times, and with more certainty of proving successful the more early they are applied. Of this I am so clearly convinced, that I would advise all who have it in their power, to em- ploy injections instantly on the discharge taking place. They commonly, indeed, prove successful at whatever period they are*used ; but 1 have uniformly found that they act more quickly in the commencement of the disease than in the latter stages of it. While practitioners differ in opinion respecting the most proper period of Gonorrhoea for using injections. 60 OF THE FIRST STAOE Ch. ii. thev likewise differ in their ideas of the kinds of these remedies best calculated for the periods in which they are employed. In the commencement of Gonorrhoea, and at all times when much pain takes place, it is the opinion of many that emollient injections only ought to be used, such as warm oil, emulsions of almonds, in- fusions of althea, and lintseed : but in this there ap- pears to be some mistake ; and I can decidedly say so from having often experienced the inefficacy of the practice. On first entering upon business, I found it the opin- ion of many who used injections with freedom, that those of the emollient kind ought alone to be advised while much heat of urine, or any considerable degree of inflammation continued. These,, it was imagined, would sheath and protect the parts from the acrimony of the urine, and on the inflammation subsiding, they conceived that injections of an astringent nature might be used with more safety. The opinion was plausible, and supported by some of our best practitioners ; I was therefore induced, along with others, to go into it ; but it soon appeared that no advantage was to be derived from it : on the contrary, it was evidently the cause of much distress, by rendering the cure of Gonorrhoea much more tedious than it otherwise might have been ; for injections of the emollient kind never tend to shorten the continuance of the discharge, and often render it more fixed and permanent, by relaxing the parts from whence it proceeds. Neither are injections of thisdescription necessary as a preparative to those of the astringent kind : in this conviction 1 have for many years past laid them alto- gether aside, and during this period have used none but such as are evidently astringent; and although I employ them with all manner of freedom, I have never perceived any bad effects arise from them. In this state of Gonorrhoea, injections of the astrin- gent ki-d may be vised with safety and advantage, from the very commencement of the discharge, as well as at any period of the disease, whatever tiie degree of in- Sec. IV. OF GONORRHOEA. 61 flammation may be. Instead of increasing the in- flammation, they tend, when of a proper strength, to lessen it ; they relieve more immediately than any oth- er remedy, the ardor urinse; and they commonly les- sen or remove the discharge in a very short space of time. In all cases, therefore, of thio kind, where we sup- pose the disease to proceed entirely from the mem- brane of tne urethra, I pay no regard to the continu- ance of the running ; the patient is immediately put upon the use of injections, and no harm ever ensues from it. There is only one symptom which, in this stage of clap, precludes the immediate use of injections, viz. pain and swellings of one or of both testes: a persever- ance in the use of injections during the continuance of this symptom very commonly does harm, and ought not therefore to be advised ; not that they tend to increase the inflammation, even of the testis, but by removing the discharge from the urethra, they de- prive us, as we shall afterwards see, of one of the most effectual remedies for a swelled testicle, proceeding from Gonorrhoea. v A variety of astringent injections are employed by practitioners, but some proving more effectual than others, an investigation of this part of our subject is thereby rendered necessary. Almost any astringent injection will lessen the dis- charge. Port wine, and claret, duly diluted, some- times answer. I have often succeeded with a tea-sp n- ful of brandy added to half an ounce of rose water : nay, rose water itself, or even cold water directly from the spring, will often give a stop to the discharge ; but, for the most part, the effects of these are only temporary. In slight affections, indeed, they some- times complete the cure, but in general we are under the necessity of employing astringents of a more pow- erful kind. Amon*>" the first injections used in Gonorrhoea, mer- cury, in'one form or another, was a constant ingredi- 62 OF THE FIRST STAGE Ch. II. ent. It was not, however, employed as an astringent; for at that period the use of astringents of any kind would have been considered as hazardous. Being ap- plied in this manner directly to the seat of the disease, it was supposed that it might act as a specific in the cure of it. But although I have given full and com- plete trials to injections of the mercurial kind, and in every variety of form, I have not, in any instance, found them to prove more effectual than other astrin- gents. In order to ascertain the point to which I al- lude, with as much certainty as possible, I have re- peatedly made it the subject of experiment. Of dif- ferent patients in Gonorrhoea, all nearly distressed with similar symptoms some have been made to employ a mixture of calomel with mucilage and water ; others have used quicksilver dissolved in mucilage, while some have at the same time been using injections in which mercury did not enter as an ingredient. I admit that in most of these instances mercury prov- ed serviceable, but by no means in such a degree as many of the articles with which it was put, upon this comparative trial. There is no cause, therefore, to imagine that it acts as a specific in the cure of clap. To prevent interruption in this part of the work, formula; will be given in the Appendix to this volume, of all the preparations I wish to recommend. Of mer- curial astringent injections, the prescriptions No. 1, 2, and 3, are perhaps the safest and best that can be used. Calomel used in injections seems to act in a similar manner with lapis calaminaris, armenian bole, and oth- er astringent earths; not by any specific virtues with which they are endowed, but by restoring tone to parts weakened by the disease. It is in this manner, I con- clude, that all of these articles act in the cure of Gon- orrhoea ; and in cases that arc not particularly obsti- nate, they very commonly prove effectual. Lapis calaminaris, or tutia finely levigated, suspended in thin mucilage, makes a very safe and useful injection. No. 4th and 5th are formula? of these ; and No. 6 is a pre SeC. IV. OF GONORRHOEA. 63 scription of a gentleman retired from business, who, at one period, was in very extensive practice in Lon- don, and who in the course of much experience in this particular branch, gave the preference to articles of this kind over all others that he ever employed. These earths possess one important advantage for this purpose : they never do harm, in whatever quanti- ty they are used. If levigated with sufficient care and attention, they may be used in any quantity that the liquid in which they areconveyed can be made to sus- pend. Alum dissolved in water makes a safe and useful injection. It proves equally safe, and still more pow- erful, when conjoined with a decoction of oak bark, or an infusion of galls, for which prescriptions are given No. 7th, 8th, and 9th. Kino, an astringent lately much used in Diarrhoea, proves also an useful ingredient in injections for Go- norrhoea. I have in various cases found it prove suc- cessful where other articles had failed, and I have not observed that it ever does harm. As it is not very soluble in water it becomes necessarry to suspend it when in fine powder, by means of mucilage, as is pre- scribed No. 10th and 11th. Opium proves often an useful ingredient in injections of this kind ; and as it is equally serviceable whether much pain takes place or not, I conclude that it does not act so much as a sedative as it does as an astringent. No. 12th and 13th are formulae of injections with opium. Some of the astringent balsams, properly combined with water, make a good variety of injection for Go- norrhoea, particularly ihe balsamum canadense, and balsamum copaiba, as in No. 13th, and 14th. Lead, in various forms, proves highly serviceable in these injections. Cerusse suspended in mucilage and water is often employed with advantage ;but ace- tum lythargyri, and saccharum saturni dissolved in water are most to be depended on. Formulae of these are given in No. 15th, 16th, and 17th. 64 OF THE FIRST STAGE Ch. II. Of all the astringent injections, however, which ^ I have used, none prove so powerful as white vitriol dissolved in water. In the quantity of a gram and half to an ounce of water, it seldom creates much ir- ritation, and it does not often fail in this variety of the disease, in which alone injections of any kind ever prove materially useful. No. 18th. is the form of in- jection, which, in the common occur.ences of daily practice, I am in the habit of using ; and No. 19th is a combination of vitriol and acetum lythargyri, which, in a few cases, I have found to answer better than either of these articles separately. Many other astringents might be enumerated, from which very useful injections might be prepared, but the formulae which I have given contain the most pow- erful of any with which we yet are acquainted. None of them will at all times pro've successful ; for even in this the most simple variety of the disease, the most active remedies will in some instances fail : but I can from experience in this branch of practice assert, that it will seldom happen where the injection is properly managed and duly persisted in. The vitriolic injection, No. 19, I have mentioned as the most useful formulae of any ; but it will some- times happen that a case will readily yield to others which has long resisted this. When we do not, there- fore soon succeed with one injection, we ought, with- out loss of time, to have recourse to others, by which our purpose will be more easily accomplished than by continuing to employ the same for any length of time together. In all these injections the different ingredients are in such proportions as best suit the general course of business. This was a point of much importance to ascertain, and so far as my observation goes, I have done so ; but cases will no doubt occur from time to time, in which some variety of strength is necessary. All injections of this kind should be of such a strength as to excite some degree of irritation in the urethra, but by no means so strong as to create much pain : 3CC. IV. OF GONORRHOEA. 65 hence, where the preparations I have mentioned do not answer the purpose, they should be made stronger; and when of such a strength as to excite severe pain, they should be more diluted. This, I may remark, is an object requiring much attention, for while it is obvious that injections must do harm when their strength is more than it ought to be, it is equally certain that little or no advantage will be derived from them when they are too weak. I have known a cure accomplished in three days, merely by making an injection of a sufficient strength, where the disease had previously gone on for two or three months, from want of attention to this point. I consider this, indeed, as one of the most important points in the treatment of Gonorrhoea, nor does any thing distinguish the practitioner of experience with such certainty, as his being able to adapt the strength of the injections which he employs to the particular circumstances of every case which falls under his man- agement. In the application of injections there are two cir- cumstances which more particularly require attention, viz. the manner of throwing them up, and the frequen- cy of using them. They may be thrown up either with a small bag of resina elastica, fitted with a pipe, or with a common small syringe; whether the bag or syringe be used, the pipe should be perfectly smooth, of a conical form, not above half an inch in length, and the cone of such a thickness near to the root, as not to allow the pipe to pass above a quarter of an inch into the urethra. The bag or syringe being filled with the injection, and the patient seated with his breech over the side of a chair, so as to prevent the perineum from being pres- sed upon, the pipe, when well oiled, should be insert- ed* into the urethra, as far as it will go, with the right hand, while, with the left, he grasps the penis, and pulls it forward upon the pipe. He must now throw the in- jection up in such a manner that it may reach the far- 9 66 OF THE FIRST STAGE Ch. II. thest part of the urethra that is affected, but not with such force as to excite pain. When the discharge proceeds from near the extrem- ity of the penis, very little force is required for this purpose ; but wl en the upper part of the urethra is affected, if the injection be not thrown up with some degree of firmness, it will not reach the seat of the disease, and hence no advantage will be derived from it. Previous, therefore, to the use of injections, the part of the urethra, whence the discharge proceeds should be ascertained, and it can be easily done in the manner w7e have mentioned above. In using injections it is judged proper by some to desire the patient to prevent them from passing farther in the urethra than the seat of the disease ; lest, by forcing sook' of the matter along with the liquid, the infection should be carried to parts which otherwise might not have been injured. For this purpose the patient must compress the urethra with the middle finger of his left hand, at that point to which it is meant the injection should go ; while the syringe or elastic bag is employed for throwing it up in the other. But although there is necessity for throwing injections farther than the seat of the disease, there is no cause fortius anxiety in preventing them. It does not appear, that in this manner, the infection is ever communicated from one part of the urethra to another; at least I have never met with an instance of it, and I have seldom pointed out this to my patients as a necessary piece of attention. While it does not therefore, answer any good purpose, it certainly renders it more difficult for the patient to throw the injection properly up, as he cannot both make pressure upon the upper part of the urethra, and, at the same time, manage the syringe with that exactness which it requires. The point, however, of most importance in the use of injections is, the frequency with which they should be thrown up ; it is not enough that we discover a composition that will establisti a cure, if we do not use it with that frequency which the nature of the disease Sec. IV. OF GONORRHOEA. 67 requires. In common practice the patient is desired to inject the liquid two or three limes a day : this, if the injection be of a proper strength, will in course of time effect a cure ; but I am perfectly convinced from much attention to the subject, that cures would be much more speedily obtained were injections to be more frequently thrown up. Instead of two or three times a day, I cause them to be used seven, eight, or ten times daily; by which the cure, instead of being protracted for several weeks, is often completed in as many days. This, I must observe, is a point of such importance in the cure of Gonorrhoea, that nothing can compen- sate the neglect of it. The inefficacy of injections is frequently held forth as one' material objection to them, but, for the most part, their failure will be found to depend in a great measure, upon this circumstance. Patients ought, therefore, to be urged to use them, at least as frequently as I have mentioned. When in- deed the discharge lessens, or disappears entirely, there is no necessity for using injections so frequently, but while it continues undiminished, the more frequently the remedy is applied to the parts from whence it pro- ceeds, the more quickly will it be removed. On laying injections aside, even after the running has disappeared entirely, and when there is therefore cause to suppose that a cure is obtained, the discharge often returns with equal severity as at first, either from excess in wine, or over exertion in bodily exercise. In such circumstances the injections must again be em- ployed, and used with as much frequency as before, care being taken not to leave them off till some time after the running has again disappeared. When the discharge returns repeatedly it is apt to weaken and relax the parts so much, that this alone comes at last to constitute a new disease, forming a variety of what in general is termed gleet, This, how- ever, requires remedies of a different kind, and will fall to be considered in a different chapter. 68 OF THE FIRST STAGE Cb. II. It will be remarked that I have only slightly taken - notice of any other remedies in treatment of Gonor- " rhcea : I have purposely done so, from full conviction of the inefficacy of all remedies that are not immediate- ly applied to*the urethra, and from finding that a proper use of injections never fails to prove successful, where a cure by any means can be obtained. Where much pain and inflammation takes place, I have observed above that some advantage may be ob- tained from blood-letting, and a strict attention to an antiphlogistic regimen. I think it right, however, to say, that few cases occur in which this becomes ne- cessary. A patient under Gonorrhoea should live moderately, but by no means upon such low diet as in former times was prescribed in such cases. He ought to live in such a manner as may prevent the inflamma- tory symptoms from becoming severe, but not so low as to run any risk of inducing relaxation or de- bility. The circumstances which most particularly require attention are, abstinence from all manner of connec- 4 tion with women, and from bodily exertion, such as much walking and riding on horseback, which more es- pecially affects the parts concerned in this disease. In the treatment of Gonorrhoea, where no injec- tions are used, where the disease is either left entirely to nature, or treated with demulcents and purgatives, a regular progress towards amendment is, for the most part, observed in the discharge. The matter from be- ing thin, and of a greenish hue, or perhaps of a red cojour from being tinged with blood, becomes of a thicker consistence, tough, ropy, and of a white or yellow colour : but where injections are employed this seldom happens. This natural process is thereby in- terrupted ; and a cure often takes place without any change being perceived in the colour or consistence of the discharge. There are some symptoms which occasionally take place in every stage of Gonorrhoea, and which, it might be expected, ought to have been more particularly no- SeC. IV. OF GONORRHOEA. 69 ticed here, such as chordee, and evacuation of blood from the urethra. But these symptoms being attend- ed with circumstances requiring a peculiarity of treat- ment, quite inapplicable in the ordinary state of Gon- orrhoea, and being all of them highly important in their nature, a separate section will be allotted for the consideration of each of them. We shall now, therefore, proceed to consider the second stage of the disease. On the subject of injections we are sorry to say that we cannot agree with the author, as we are confident that in many instances, from a careless use of the syringe and want of attention in compres- sing the sides of the urethra immediately above the part affected,, the disease has spread along the whole course of the canal, even to the neck of the bladder ; not only protracting the complaint, but also greatly aggravating its symptoms, and inducing frequently one of its most troublesome consequences, stricture. We have heard the same remark made by many physicians and surgeons of extensive practice, more particularly by a British sur- geon of celebrity, who informed us as early as the year 1804, that for the reasons above stated, he had not for several years made use of injections, and had employed as a substitute the Calx Hydrargyi alba, and furnished us with the following prescription: R. Calx : Hydrarg : Alb : Bol : Arnien : aa grs. x. .Mel: Despumat: X\.—tere : simul in mortar : marmor : ut fiat linamentum. This furnishes a linament of the consistence of the honey itself, and is applied by means of a bougie, dircatly to the part affected, by dipping it in the linament about an inch, sometimes more, sometimes less, according to the nature and extent of the case, and introducing it into the urethra about the same distance, rolling the bougie two or three times round in the part, so as to leave as much of the lina- ment behind as possible. This operation is repeated five or six times for the first two or three days, during which time the running is considerably increased in quantity; the repetition of the linament is then gradually diminished, till the running ceases altogether, which it sometimes does in three days, often within the week, and seldom exceeds a fortnight. We have used this prescription exclusively, for eight years, and have not as yet known it fail in a single instance, nor have we ever met with a single case of stricture, in any of our patients, who had confined themselves to this application. It has obviously one advan- tage over injections, that of remaining a much longer time in con- tact with the diseased part, which it must do, from its consistence, and from which circumstance it requires to be less frequently re- peated. 70 OF THE SECOND STAGE Ch. II. We have not used the oxymuriate of mercury internally our- selves, in this complaint, but are assured by some of our friends that they have employed it with great success, and that a mechanic of this city who is noted for his skill in curing this complaint, uses this medicine solely. Vid: Parrs. Mei : Diet: Art: Gonorrhoea, Thatcher's Dispensatory, 2nd edit. Of the muriate of gold as a remedy in this complaint, we shall speak hereafter. Ed, SECT. V. Of the Second Stage of Gonorrhoea. IN this stage of the disease all the symptoms are more violent than in the first. The heat of urine is much more severe; the whole body of the penis be- comes tender, and even painful ; and chordee takes place to a very distressful degree. The matter dis- charged from the urethra is either of an ugly green colour, or deeply tinged with blood, and commonly very foetid. It is found, on examination, to proceed from the more superior parts of the urethra, general- ly from about the middle of the perineum, where the patient complains of a smart pain upon pressure, and where one or more small tumours are often perceptible, produced by the inflammation having extended to Cowper's glands. Although the symptoms of the first stage of Gonor- rhoea are commonly very distinctly marked, yet they frequently proceed to, and terminate in one of the other stages of the disease, particularly in this which we are now considering. This happens from the in- flammation extending along the urethra, either from the matter producing the disease being more than usually acrimonious; from the effect, of improper man- agement on the part of the patient; from the impru- dent use of irritating or very astringent injections ; or from the patient being of a habit of body rendering him particularly liable to be acted upon by causes apt to excite inflammation. Sect. V. OF GONORRHOEA 71 I conclude that it happens most frequently from the first and last of these causes, or, perhaps, from a com- bination of them both; as in a great proportion of cases of this second state of the disease we find it taking place almost from the first day on which the running appeared. It must, no doubt, have fallen under the observation of every practitioner that this, as well as the third and fourth stages of Gonorrhoea, are often induced by the patient living in a state of riot and de- bauchery, and, in some cases, by the immoderate use of irritating injections. But although these are cir- cumstances which in every case of Gonorrhoea ought to be rigidly guarded against, from their tending to excite one of the most distressful complaints to which the human species is liable; yet I am convinced, from what has been mentioned, that the worst states of the disease will frequently occur, notwithstanding all that can be done either on the part of the patient or surgeon to prevent them. As the practice in this state of Gonorrhoea is materi- ally different from what we have recommended in the first stage of it, the utmost attention becomes ne- cessary in distinguishing between them. In the first the matter is, for the most part, discharged from within an inch and a half of the extremity of the penis; and where the disease does not extend farther up the urethra, although the ardor urinae is sometimes con- siderable, yet the pain is never so severe as that which arises from the inflammation in the second stage of the disease. In this last, the whole body of the penis, as we have observed above, is tender and painful; the chordee which takes place is highly distressful, and one or more inequalities, accompanied with pain on pressure, are discovered in the perineum: whereas, in the former, any chordee which occurs is for the most part very moderate. The pain is considerable at all times when the patient is not passing water, and no hardness or inequalities are perceived in the peri- neum. 72 OF THE SECOND STAGE Ch. II. It is proper to remark, that even in the second stage of the disease, these glandular tumefactions in the pe- rineum are not always at first obvious; but upon pressure with the fingers they are easily discovered, even on their first commencement; and in the more advanced stages of the disease they become perceptible, both to the touch and to the eye. Whenever chordee occurs in a severe degree, the whole penis acquires a firmness and tension, particularly where it runs along the perineum. This, however, is very different from the glandular affections to which I allude: the one is a diffused swelling, extending over the whole, or a considerable part of the penis; it does not con- tinue fixed or permanent, and seems to depend upon a morbid irritability in the muscles of the penis, by which they are easily excited to violent and unequal contractions. The others are, at first, small, circum- scribed swellings, painful to the touch, which do not rise and fall speedily, and which remain more or less permanent according as the symptoms with which they are connected are more or less violent* These swellings proceed, as I have already observ- ed, from an inflamed state of Cowper's glands, induced by the inflammation extending along their ducts, which terminate in the urethra, to the glands them- selves. Inflammation here, when it comes to a height, in a manner similar to what ensues from it in other parts, is very apt to terminate in suppuration ; and as the formation of matter in the substance of these glands is apt to excite the most distressful consequences, nothing should be omitted that can tend to prevent it. When matter forms in them, if it be not immediately dis- charged by an external opening, it is very apt to burst into the urethra, and to produce runnings, which, in some cases, do not terminate but with the life of the patient. On the first approach, therefore, of this second stage of Gonorrhoea, all our endeavours should be employ- ed to remove or lessen the inflammation. If the o"v SeC. V. OF GONORRHOEA. 73 tient is plethoric he should lose a considerable quantity of blood with the lancet, and ten or a dozen leeches should be applied to the pained part. Whatever his habit of body may be, the application of leeches should not be omitted, and they ought to be repeated once and again, according to their effects, and to the degree of inflammation axid swelling which take place; saturnine poultices should be applied over the part af- fected, the bowels should be kept open with gentle laxatives, and the patient should be put upon a low, cooling diet. If, either by the violence of the inflammation, or by an imprudent use of astringent injections, a stop has been put to the discharge, much advantage will be de- rived from our soliciting a return of it. This however, must not be done with applications of an irritating na- ture, such as bougies, and stimulating injections, as some have advised, but it may be attempted with safety by throwing up, from time to time, injections of warm oil and other emollients, such as warm decoc- tions of lintseed and althea. But although we find from experience that much harm is done by the application "of stimulants directly to the urethra, we know that they may be applied to the skin both with safety and advantage. Thus, wdien the swelling does not soon lessen, by blood-let- ting and the other remedies mentioned above, I have, in different instances, derived advantage from the ap- plication of blisters to the parts affected, and by cover- ing the bites of the leeches with adhesive plaster; this practice may be adopted even the day after they have been applied. The blister should be made to cover the whole perineum. When the remedies we have advised are limeously and properly applied they will not often fail to re- move the inflammation ; but when this is not accom- plished, and when the swelling or swellings proceed to a state of suppuration, nature should be as much as possible assisted by a frequent and free use of emollient poultices and fomentations ; and as soon as a fluctuation 74 OF THE SECOND STAGE Cll. II. of matter is discovered, it ought to be discharged by an opening made the full length of the tumour. In this manner a sore will be produced that will be difficult to heal; but if the habit of body be sound, a cure will be obtained at last, and there is no other method with which I am acquainted that will so readily prevent the matter from bursting into the Urethra. When this unfortunate circumstance takes place, of matter collected in one or more of these glands, find- ing access to the urethra, scarcely any advantage is to be derived from art in the treatment of it. Injection^, as we remarked in the last section, instead of proving serviceable, rather do harm. They cannot reach the cavity of the gland, where alone they might prove useful, and by preventing for a time that free dis- charge of matter, which, in every abscess is desirable, they cause it to collect, and alternately burst out, in greater quantities than before. When the cause of such an occurrence is not sus- pected, both the patient and practitioner are apt to imagine that it proceeds from the fault of the injection : every variety of the remedy is therefore employed, but nearly the same effect results from all of them, and the patient, after being teased and perplexed for a great length of time, finds himself in no degree bet- ter than he was at first. By some practitioners a course of mercury has been advised in this state of the disease, and particularly frictions with mercurial ointment on the perineum ;' but although I have often seen the practice fairly and completely tried, I never knewr any advantage derived from it. Neither does mercury prove useful in the sores which ensue from opening abscesses in the perin- eum, proceeding from Gonorrhoea. On the idea of these sores being of the same nature with such as suc- ceed to buboes in Lues Venerea, mercury is commonly prescribed ; but although I have known it repeatedly used, not only for the cure of these sores, but for the discussion of the previous tumefaction of the glands, I never knew any evident benefit derived from it. Sec. v. OF GONORRHOEA. 75 All that'in such circumstances can with propriety be done is, to cause the patient to live in such a man- ner as will most effectually brace his constitution ; his diet ought to be of a nourishing kind ; cold bathing, particularly in the sea, proves sometimes useful, and, in some instances, Jesuit's bark, in large quantities, is given with advantage. In no period of this state of Gonorrhoea are injec- tions admissible, and I suspect that the discredit into which they have fallen with many is owing to their being employed promiscuously in every state of the complaint. We have just seen that they cannot be used with any prospect of success, when suppuration has actually taken place, and a very little attention Avill make it appear that they ought not to be advised during the inflammatory state of the complaint. While the parts are inflamed, instead of endeavouring to re- move the discharge, we ought rather to try to promote it. Nothing tends with such certainty to moderate all the symptoms; and I have repeatedly observed that they are all rendered much more severe by what- ever tends, in any degree, to give a check to the run- ning. It is proper, therefore^ that the younger part of the profession be put strictly on their guard against the use of injections in every period of this stage of Gonorrhoea ; a practice which, in the first stage of the disease, is the only remedy, as we have seen, upon which any dependence ought to be placed, but which in this is evidently fraught with danger to the patient, 'and therefore with discredit to those who advise it. Besides the glandular abscesses of these parts, which we have just described, collections of matter are apt to occur in this state of the disease, not only in the cellular substance of the perineum, but in the corpus cavernosum of the penis, as well as in the corpus spoh- geosum urethras. The treatment of these, however, ought to be so exactly what we have pointed out for * the others, that nothing farther need be said upon it. To prevent, as much as possible, the risk of such col- lections bursting into the urethra, the matter should 76 OF THE SECOND STAGE Ch. n. be discharged by a free opening the whole length of the tumor, as soon as it is found to be completely form- ed. When collections of matter in these parts, whether seated in Cowper's glands, or in the contiguous soft parts, terminate, as they sometimes do, in external openings, at the same time that a communication is formed with the urethra, the urine escapes at the sore, and thus another disease is produced, termed a sinus, or fistula in perineo. This falls to be treated like sinuses in every other part: the seat of the abscess must be laid open from one end to the other, and by enlarging the opening in the urethra, if the patient be otherwise in sound health, a cure will, for the most part, be obtained, by endeavouring to heal the sore iiom the bottom in the usual wav.* It may be aljedged, if this proves successful where .„ the matter has already formed an opening, both in- wardly and outwardly, for itself, that a similar prac- tice should be adopted where the abscess has only burst into the urethra. That a free incision should be made into it, and a cure, attempted in the manner we have already advised. Where the opening into the urethra is such as to admit the uiine to pass into the abscess, the practice to which allude ought undoubtedly to be adopted, for no other wiJl prove successful, and the patient must remain in a state of great distress and misery while this continues ; but while the external tegu- ments remain entire, and while the urine does not find ' access to the abscess, no attempt of this kind ought to be made. However inconvenient the discharge of mat- ter from the urethra may be, and however long it may continue, the patient ought rather to submit to it than to the uncertain event of a fistulous opening, which al- ways proves tedious and distressful, with whatever • judgment the disease may be afterwards treated. * V. System of Surgery, chap. xv. I SeC. VI. OF GONORRHOEA. SECT. VI. Of the Third Stage of Gonorrhoea Virulenta. IN this stage of Gonorrhoea, along with ardor urioae, and the other ordinary symptoms of the disease, the patient complains of a severe fixed pain in the upper part of the perineum, accompanied with a sensation of fullness, and tension in all the parts contiguous to the anus. The desire to void urine is more frequent than in either of the two preceding states, and it is com- monly passed with much pain and difficulty ; often drop by drop. Tenesmus, or a painful and frequent desire to go to stool, often takes place, and, in some instances, to such a distressful height, as adds greatly to the misery of the patient. Even in the commencement of the disease the pain in making water is in some cases so severe as to excite heat and other symptoms of fever ; and, in the more advanced stages of it, I have known the fever rise to a very alarming height. This state of Gonorrhoea, in some instances, proceeds from the inflammation spread- ing backward in a slow, gradual manner, from the point of the penis, which we have shewn to be the seat of the first stage of the disease, but more frequent- ly it lakes place suddenly either from the imprudent use of injections, from the patient being in*a riotous course of life, or from his being exposed to violent ex- ercise, either on foot or on horseback. On examining the parts affected, the penis is, for the most part, in a state of tenderness and irritability, nearly indeed, as we have described it to be in the second stage of this disorder ; but, together with this, on compressing the parts about the end of the rectum a sense of pain arises, which is never experienced in either of the states already described, and on intro- ducing the finger into the anus, the prostate gland is found considerably swelled, and in such a state of irri- tability that it can scarcelv bear to be touched. 70 OF THE THIRD STAGE Ch. II. Even the slightest degree of this affection excites much uneasiness, and the desire to pass water seldom ceases for above a few minutes together ; but when the disease has been of long duration, the prostate gland, which nearly surrounds the urethra, or which rather appears, as it were, to form the passage of urine at, this part, becomes often so much swelled as nearly to obstruct the discharge of urine as completely as when the urethra is entirely stopped. Those, indeed, not versanl. in this branch of practice are apt. to mistake this affection for strictures in the urethra ;* of course a delay takes place in using the proper remedies, and at- tempts which are frequently made to overcome the supposed strictures, too often do mischief. Frequent- ly, indeed, neither a bougie, nor catheter, when em- ployed for removing a suppression of urine, proceed- ing from this cause, can be passed ; for the gland is in some cases so much swelled as to obliterate the passage almost entirely, and in others, by swelling on one side only, the passage is thrown altogether over to the other ; circumstances which render the introduction of a bougie either impracticable, or at best difficult and uncertain. As it is in the commencement only of this affection that any material advantage is derived from the inter- ference of art, and as it is a disease which, in the more advanced states of it excites the greatest possible distress, we ought instantly on the first approach of it, to apply such remedies as experience has proved to be the most effectual in removing it. Of all the remedies that I have ever employed, ear- ly blood-letting is almost the only one from which any obvious advantage has been derived. It ought to be advised immediately on the first approach of pain, nor should we be deterred by a weakly or delicate consti- tution. In a person of this description the evacuation ought no doubt, to be more sparingly administered than where plethora takes place; but even in the most delicate habit of body, a quantity of blood should * Vide Strictures. Sec. VI. OF GONORRHOEA. 79 be discharged in proportion to the strength of the pa- tient, in the first place by the lancet, and afterwards by leeches applied to the parts affected. The prac- tice of blood-letting I consider to be equally necessa- ry here as in cases of pleurisy ; in the latter, indeed, the life of the patient is in greater hazard, but in this his future comfort and enjoyment of life are at stake. It ought not, therefore, in any instance, to be omitted. I speak the more decidedly upon this from various instances having fallen within my own observation, of the most distressful consequences taking place from this remedy having been omitted, and from many others having ended easily w here it was employed with freedom. It is in the first stages only of the disorder, however, in which it acts with much ad- vantage ; chiefly, indeed, on the first symptoms of inflammation taking place, for when the prostate gland becomes swelled and inflamed in any considerable de- gree, neither this nor any other remedy can be de- pended upon for removing it. After a long course of time, an enlarged prostate will sometimes be found much diminished, but this happens more frequently without our being able to account for it, than as a necessary consequence of any medicine employed for it. Blisters do not afford that relief here that we some- times derive from them in swellings of Cowper's glands, neither is much advantage ever obtained from saturnine applications. Opium, whether given by the mouth, or in clysters, proves more useful than any other -remedy for removing the pain and lessening the irritation; but probably from coming more directly into contact with the diseased parts, it proves evident- ly most successful when given in clysters, and it seems to answer better in small doses, frequently repeated, than in large quantities given at once. Thirty drops of laudanum, mixed with two ounces of thin starch, and thrown easily into the rectum, very commonly gives immediate relief, and as long as this dose proves ef- fectual it ought not to be increased. 80 OF THE THIRD STAGE Ch. II. While opiates, given in this manner, lessen the irri- tability of the organs of urine, they also give much re- lief by removing that painful and frequent desire to go to stool, with which patients in this disease are often afflicted. /•••<• Hitherto I have said nothing of the use ot injections, which are frequently employed in this, as in other stages of Gonorrhoea, for removing the running. This, however, is a practice that ought by no means to be a- dopted. It has at first been gone into without ^ reflect- ing upon its tendency, and afterwards persisted in mere- ly from having once been adopted. In the second stage of Gonorrhoea I had occasion to remark that the dis- charge, instead of being stopped, ought rather to be encouraged. The same observation applies still more forcibly here, where a stoppage of the running tends always to aggravate every symptom, and where we find considerable relief often obtained by our bringing on a return of it. This, as we observed in the last section, should rather be done by the use of warm emollient injections, than by such as stimulate and give pain. These, I know, are advised for this pur- pose, but as I have known them evidently do much harm, even when managed in the most cautious man- ner, and as we find, indeed, that the disease is often at first induced by this very practice, I do not hesitate to say that it ought very universally to be laid aside. For a similar reason bougies ought never to be employ- ed here. Emollient injections prove useful not merely by so- liciting a more plentiful discharge from the urethra, but by soothing the irritability in the parts affected, and thus lessening the pain : and where opiates are .conjoined with them they act still more powerfully in this manner. An infusion of the heads of poppies and althea root, used warm, answers particularly well for this purpose. Warm poultices, applied external- ly over the fundament and perineum, also prove use- ful. Some advantage too is derived from warm fo- mentations ; and I have known the warm bath afford much relief. Sec. vi. OF GONORRHOEA. 81 All the«* rcme "• s, howpver, act as palliative on- ly ; !o i!iv.ii ube the prtsenl distress may be much mitigated, while nature, in the course of addition to the symptoms mentioned above, may be added the flattened stool, which is indeed a diagnostic of a diseased prostate. Most of the remedies which prove useful in a swelling and enlargement of this organ, have been enumerated, and in most cases a correct opinion is given. Gentle laxatives are perhaps improperly omitted, as they are useful iri diminishing irritation. The warm sea bath is considered by some writers, as of more importance than the author is willing to attach to it. Wnen the inflammation is subsiding, and there is danger of a permanent en- Sec. vn. of gonorrhoea. 85 largement, it has been found by many practitioners, in opposition to the experience of Mr. Bell, that mercury is a valuable medi- cine in reducing the gland. " As to schirrous enlargement" says Mr. Samuel Cooper « no certain mode to diminish it is known to surgeons." He mentions however the Pilule Hydrargyri cum cicuta* as a useful remedy. Mr. Home states a case in which suppositories of opium and hemlock were introduced per ano, and allowed to be dissolved there. They allayed the irritation, as well as diminished the size of the gland. When it becomes jiecessary to puncture the bladder, it is. advisa- ble, if possible, to do so through the coats of the rectum. This is the opinion of the most distinguished surgeons of the present day. Nothing but an enormous enlargement of the gland need prevent it, " and in a case," says Charles Bell, " of the largest gland I ever " saw, I still prefer the attempt to puncture by the rectum, for I " conceive it still to be practicable while we can feel anv part of " the bladder." Operative Surgery, Vol. 1. Chap. 4th. *R. Hydrargyri purificati Z\ Oummi Mimosx nilotipae pulverisatae Xi Succi Cicuta: spissati Xi Herbse cicutae fohorum-, in pulverem Tritorum q : 5 : Triturate the quicksilver, with the gum arabic moistened with a little rain water. Then add the inspissated juice, and lastly the powdered leaves, in sufficient quantity to make a suitable mass for pills. Cooper's Surgical Dictionary. Ed. SECT. VII. Of the Fourth Stage of Gonorrhoea. IT sometimes happens that the inflammatory symp- toms pass easily over the anterior part of the urethra, and shew themselves in more force and violence high- er in the passage. Thus, although the third stage of the disease, in which, as we have seen, the prostate gland is chiefly affected, is sometimes produced by the inflammation spreading from those parts which are only concerned when the second stage of it takes place, yet instances often occur of the inflammation passing 86 OF the fourth stage Ch. ii. from the point of the urethra along the whole course of the passage, without any intermediate part of it being much affected, and fixing in the most violent manner, upon the prostate gland or bladder. In some cases the prostate is affected while the bladder itself remains sound, while in others it passes easily over that gland, and seizes with much violence upon every part of the bladder. In some cases the bladder becomes • affected almost on the first attack of the disease. The inflammation spreads so quickly along the urethra that the bladder is pained in the course of a few hours from the com- mencement of the discharge. It more frequently oc- curs, however, after the running has been of some duration, and, for the most part, can be traced as the consequence of much exposure to cold and dampness; of violent exertion in walking or on horseback, or, as the effect of an injection thrown with too much vio- lence into the upper part of the urethra. The patient, from the first approach of the disease, complains of much uneasiness, which at last termi* nates in severe pain over all the region of the bladder, particularly about the neck of it; accompanied with a frequent and painful desire to make water, and of- ten with tenesmus. In some cases the pain is chiefly seated about the anus, but, in general, all the under parts of the abdomen, particularly about the region of the pubes, are greatly pained, and in some instan- ces, even the kidneys become affected, either from nervous sympathy, or from the inflammation spread- ing from the bladder along the ureters. In general the pain, especially after voiding urine, extends to the glans penis, and as this, with the stop- page which occurs to the flow of urine, are symptoms which always accompany stone, cases of this kind, when the history of the disease has heen concealed, has been mistaken for stone in the bladder. If the running from the urethra has not been stop-' ped by injections, it continues as if no affection of the bladder had occurred; and in general any interrupt Sec. vn. of gonorrhoea. 87 tion that takes place to the discharge proves only tem- porary ; but alongwith the usual running from the urethra, such as takes place in one or other of the dif- ferent stages which we have described, a considerable quantity of matter passes off with the urine. This gives the urine a turbid appearance, as if purulent matter was mixed with it, but on examining the depo- sition, which is usually made in the course of a few Jiours, it is found to consist almost entirely of mucus. On a further continuance of the disease this matter contained in the urine assumes a very different appear- ance. Instead of being broken and divided into flakes, as at first, it now becomes tough and viscid, in a very remarkable degree, resembling isinglass diluted with water to the consistence of jelly. This gelatinous matter is suspended in the urine when first voided, but it soon separates, and falls to the bottom, where it adheres so firmly to the sides of the vessel in which it is received, as to be separated from it with difficulty. In some cases this substance is clear and transparent, but, for the most part, it is tinged of a yellow hue, and somewhat opake. When any considerable quantity of this matter has passed off; the patient is commonly relieved, and con- tinues easy for a longer or shorter period, according to the degree of inflammation that takes place. In some cases the quantity of this viscid matter is very inconsiderable, being no more than what slight- ly covers the bottom of the pot, while in others it seems to form more than half of all that comes from the bladder. When in such considerable quantities, it tends greatly to reduce the strength of the patient, insomuch that few constitutions are able to bear it long. From the nature of the parts in which this disease is seated, we would expect that it should be the most formidable complaint that Gonorrhoea could induce; but this is by no means the case: the disease describ- ed in the last section, viz. swelling of the prostate gland, proves always more so. Few recover from the one, 88 OF THE FOURTH STAGE Ch. II, while cures are obtained bv a great proportion of all who are seized with the other. At least in healthy constitutions this commonly happens, if the disease has not been much neglected at first. In general, in- deed, a considerable time passes over before a perfect cure is obtained ; nay, some degree of uneasiness, and certain deranged sensations, will often continue for a number of years, but after the first violence of the symptoms is over, they generally become, in a gradual manner milder, till at last they vanish entirely. On the fiist approach of the disease, blood-letting is the only remedy upon which most dependence ought to be placed, and, when freely practised, it seldom fails to render the symptoms moderate, and of shorter duration than they otherwise probably would be. A quantity of blood should be taken with the lancet in proportion to the strength of the patient, a num- ber of leeches should be repeatedly applied to the neighbourhood of the anus. With respect to diet, and other circumstances, the patient ought to be treat- ed in the manner we have advised in the last sec- tion. His bowels should be kept moderatelv open with castor oil, or other gentle laxatives, and opiates should be exhibited in sufficient, doses for lessening, or even for removing the pain. WThen treating of swel- ling of the prostate gland we advised opiates to be given in the form of clysters, rather than by the nrmth, and this mode of exhibiting the remedy proves equal- ly useful here. With a view more certainly to allay the irritability of the bladder, it has been proposed to inject opium dissolved in water into it, but this appears to be a dan- gerous- experiment. I have known it done, but the patient was nearly killed by it. Convulsions and oth- er alarming symptoms occurred, but not in such de- gree as to prove fatal. Warm emollient injections, such as warm oil, or the form of injection in the Appendix, No. 23, fre- quently give relief from pain, and give a temporary suspension of that constant desire to pass water which See. vn. Of gonorrhoea. 89 often prevails here; and in some cases the semicupium proves successful when these have failed. A plentiful use of mucilagenous drink, such as in- fusion of lintseed and althea root, and a solution of gum arabic in water, afford relief in all affections of the urinary passages, but in none more than in the one of which we are now treating* AlTthese remedies are meant to alleviate pain and irritation in the commencement of the disease, and when timeously applied, and duly persisted in, they very commonly prove effectual; but in the more ad- vanced stages of the disease, when the pain is not so severe, but when a good deal of uneasiness continues, accompanied with a discharge of that viscid matter which we have described, remedies of this kind do not afford so much relief. Opiates will no doubt tend at all times to allay irritation, by blood-letting, which at first neVer fails to give relief, tends now only to weaken the patient, without being productive Of any advantage. In this situation Jesuit's bark sometimes proves use- ful ; and I have seen instances where a few grains of alum added to each dose, seemed to render it more ef- fectual. Balsam of copaiba, and Canada balsam, prove likewise useful here: but where much benefit is ex- pected from them they should be given in as large do- ses as the stomach of the patient will permit. • Of all the remedies, however, which in such circum- stances I have ever tried, uva Ursi is the most effectual. No advantage is derived from it where the prostate gland is diseased ; but in unmixed affections of this kind^ where the bladder only is affected, it seldom fails to procure relief. It may be given to the extent of a scruple at first, and afterwards half a drachm of the powder three times a day, in which quantity it seldom fails, in the course of a few days, to lessen the pro- portion of viscid matter in the urine; by which, and the ai>atement of pain which at the same time lakes place, we are always certain that the inflammation al~ ho is diminished. 12 90 OF THE FOURTH STAGE, &C Ch. II. On the idea that this affection of the bladder pro- ceeds from a translation of the matter of Lues Vene- rea from the urethra, mercury is commonly used in it; but although I have often given it, I never knew any advantage derived from it; it sometimes even does harm. It increases the irritability of the system in general, as well as of the parts more particularly affected. When affections of this kind have continued long, the bladder is apt to become much thickened and les- sened in diameter: hence, even after all the other symptoms are gone, the frequent inclination to pass urine continues. In some cases this goes on for years: nay, I have known it endure for a great length of time, and only terminate with the life of the patient. It seem3 evidently to be the effect of inflammation, for it succeeds to inflammation of the bladder, by what- ever cause it may be induced. It also occurs from strictures in the urethra, when they happen to be con- siderable and of long duration. For the removal of this thickened state of the coats of the bladder mercury is often prescribed, and in some cases it has ceitainly proved useful; but it seems to prove equally so from whatever cause the dis- ease may at first have arisen*. * This practice of giving mercury in the thickened state of the urinary blad- der which succeeds to inflammation, we find recommended by the late Doctor Ebenezer Gilchrist of Dumfries, to whom we are indebted for much valuable in- formation in different parts of the practice of medicine. The warm bath and opiate clysters, are remedies of great value in an inflammation of the bladder. Mr. John Hunter recommends an opiate plaster, on the pubes or loins, where the nerves of the bladder originate, provided the disease should prove obstinate. Di* luentsare indispensible, in large quantities, and among these, barley water will be found most useful. Ed. Sec. VITT. OF CHORDEE. 9] SECT. VIII. Of Chordee. CHORDEE is a painful, involuntary erection of the penis. Patients in every stage of Gonorrhoea are, in some degree, liable to Chordee ; but it occurs much more frequently and to a much greater height in the second stage of the disease, than in any of the others. It happens at all times of the day, but most frequently when the patient is warm in bed, when it is in some instances so severe as to deprive him en- tirely of rest. During a fit of Chordee the penis be- comes hard and painful to the touch, and for the most part it is curved downwards in a considerable de- gree. Chordee occurs in every period of this stage of Gonorrhoea, and it sometimes remains after the heat of urine and all the other symptoms are gone, but it is usually most severe during the continuance of the inflammation, and becomes more or less so ac- cording as that symptom is in a greater or lesser de- gree. I therefore conclude that Chordee is an effect of in- flammation, and that it proceeds from irritation, com- municated from the nerves of the urethra to those of the contiguous muscles, by which those unequal de- grees of contraction are produced over the whole substance of the penis, which universally take place in this disease. Were it owing to effusions of lymph into the re- ticular parts of the penis, as some have imagined to be frequently the case*, Chordee would be of a more permanent nature than we ever find it to be, and these effusions would be apt to terminate in suppuration. Now, although suppuration is sometimes the conse- quence of inflammatory tumours in these parts, I have never observed that it happens in those tumefac- * V. John Hunter on the Venereal Disease. 92 ©F CHORDEE Ch. II. tions which accompany Chordee. The latter com- monly rise and disappear again in the course of a few hours, and they are more diffused than tumours usu- ally are which*proceed to suppuration. The others rise more slowly, and they terminate, whether by dispersion or suppuration, in a much more gradual manner. Of all the remedies I have ever employed opiates prove most useful in Chordee. The pain and tension are sometimes removed by rubbing the parts affected with laudanum, or with a strong solution of opium in water, and by keeping pledgits immersed in either of these, constantly applied to'them ; but the greatest advantage is obtained from the internal exhibition of opium. Thirty or forty drops of laudanum, given at bed-time, or on the accession of the Chordee, very seldom fails in preventing or removing it. Emollient injections thrown up the urethra, particu- larly when impregnated with opium, have also a pow- erful influence in lessening the violence of Chordee; and as the heat and irritation produced by costivenesfi tend greatly to augment the violence of this symptom, I have known much advantage obtained from the ope- ration of a gentle laxative. A temporary relief is often derived from the ap- plication of a cold solution of saccharum saturni and I have known the external application of camphor prove serviceable ; when dissolved in spirit of wine it proves useful, but it acts with more advantage when dissolved in oil. Frictions with mercurial oint- ment have been much recommended for the removal of Chordee, but as I have commonly found more ad- vantage from rubbing with camphorated oil, I conclude that if is chiefly the emollient properties of the mercu- rial ointment which render it useful, and, therefore, that the inconveniencies which sometimes occur from mercury, may here be avoided. In some cases we derive advantage from tying the penis down with a fillet to the thigh, but it only an- swers in very slight affections, and the practice ought Sect. vnr. of chordee 93 never to be advised in the more severe attacks of the disease. Being an obvious remedy for counteracting an erection, it is not unfrequently employed in the first instance by the patient; but I have frequently known it do harm, either from the fillet being appli- ed too tight, or from the parts being in such a state of tenderness as to render it altogether inadmissible. When none of these remedies succeed, blood-letting sometimes proves useful; particularly by the applica- tion of leeches to the parts affected, nor ought this ev- er to be omitted when the patient is of a plethoric hab- it, or when the pulse is full. When Chordee takes place in a slight degree only, blood-letting is never ne- cessary ; but whenever it is severe, and resists the oth- er remedies we have mentioned, we ought never to hes- itate in advising it. Blood-letting proves more effect- ual than any other remedy in preventing that perma- nent kind of Chordee, which sometimes continues very distressful long after every other symptom of Gonor- rhoea has disappeared. Opium is one of our most effectual remedies in eve- ry stage of this symptom, but particularly where it has been of long continuance. In this state of the disease I have sometimes found, where opium has failed, that henbane, the hyocyamus niger of Lin- naeus, has proved useful. A grain of the extract, prop- erly prepared, may be given three times a day at first, and the dose increased to two, three or more grains, according to its effects. I have given to the ex- tent of seven and eight grains three times a day, with no inconvenience whatever; but this was after the patient had been for some weeks accustomed to the remedy. 94 OF HAEMORRHAGES Ch. U. SECT. IX. Of Haemorrhages from the Urethra. IN the description of the disease, we have seen that the matter of Gonorrhoea is frequently tinged with blood. When the quantify of blood is inconsiderable little or no notice is taken of it, the matter gradually acquires the common appearance, and a cure is ac- complished in the usual way ; but when a blood vessel of any magnitude bursts in the urethra, as sometimes happens when the" inflammation runs high, such quan- tities of blood are discharged as prove highly alarm- ing. I have known different instances of three or four pounds of blood being discharged in the space of a few hours. On the first appearance of this symptom, complete rest should be immediately recommended, for nothing tends more to promote haemorrhages of every kind than bodily exertion. The patient's bowels ought to be opened with a gentle laxative ; his diet should be of a cooling nature ; he ought to be kept in a cool, well- aired apartment, and the penis should be immersed, from time to time in a cold solution of cerussa acetata, in equal parts of vinegar and water. In Haemorrhages of every kind I have derived more advantage from a plentiful use of kino, and partic- ularly in the symptom which we are now considering. It may be given in the quantify of twenty grains four times a day, and it may be used either by itself, or rubbed with equal parts of gum arabic and fine sugar, which renders it both more palatable and more grate- ful to the stomach. In some cases I have derived advantage from astrin- gent injections; particularly from an infusion of red rose leaves, strongly impregnated with alum, as in No. 21, and from No. 14*, of which balsamum co- * Vide Appendix Sec. X. FROM THE URETHRA. 95 paiba forms the basis. The injections should be thrown uji with caution, and retained by compressing the ure- thra as long as the patient can bear them. When all these means fail, and when there is cause to suspect that the patient's life may be endangered by the loss of too much blood, recourse must be had to pressure. I have, in different instances put an im- mediate stop to the discharge by inserting a bougie into the penis. When the bougie is large nothing far- ther is necessary ; but when it does not prove success- ful of itself, if the discharge proceeds from the fore- part of the penis, it may be stopped at once by gentle pressure with a narrow roller ; when it flows from the perineum, by continued pressure with the hand or fin- gers. With a view to obtain a long continued pressure, a catheter of elasticgum may be used instead of a bougie, by which the patient may, with due care and atten- tion, void his urine while the pressure is continued: but if the bladder is emptied immediately before the bougie is introduced, it may, for the most part, be re- tained as long as is necessary. Having in this and the preceding sections consider- ed Gonorrhoea in the different forms under which it occurs in men, we shall now offer a few observations upon the same disease as it appears in females. ——■«-ag*>>® ived greater advantages from a combination of these two sets of remedies, than usually occurs from a separate use of either of them. Cold bathing is a remedy commonly advised in Gleets, and where the constitution is so* much debili- tated as to require attention, it will very generally an- swer a good purpose; otherwise no advantage can pro- bably accrue from it, if it be not from the local appli- cation of cold to the parts chiefly affected. In this SeC. II. OF GLEETS. 117 view, the daily effusion of cold water upon the penis, and the bathing of the perineum, proves sometimes useful. 2. The next most frequent variety of Gleet succeeds to the second stage of Gonorrhoea. After all the symp- toms excited by the. actual presence of inflammation have subsided, this variety of the disease is very apt to terminate in Gleet. In the third section of the last chapter I endeavour- ed to shew, that in this stage of Gonorrhoea, Cowper's glands are chiefly affected, and that they afford a great proportion of all the matter that is discharged. ^Anv inflammation which occurs along with this in the mem- brane of the urethra, is, for the most part, easily re- moved, so that the Gleet, which often succeeds, pro- ceeds either altogether, or nearly so, from the cavities of these glands. Gleet, proceeding from this cause, is, for the most part, easily distinguished from that which we have described as the first or most frequent variety of the disease. In this last, the matter usually proceeds from within an inch, or little more, of the glans, or when parts farther back are affected, the discharge is forced off" from them by very gentle pressure upon the pe- rineum : but, in the other, the matter is, in every instance, found to proceed from the upper part of the urethra; a greater degree of pressure upon the perineum is necessary to force it out ; and some de- gree of fulness, accompanied with irritation, and even pain, is experienced on the perineum being pres- sed upon for this purpose. We are also assisted in the diagnosis by the history of the preceding Gonorrhoea ; for it will be uniformly found that the first variety of Gleet has succeeded to the first stage of Gonorrhoea, and that the second stage of Gonorrhoea has given rise to that which we are now considering. In the treatment of Gleet it is of importance to have this difference ascertained, for the remedies which commonly accomplish a cure in the one, are used in 118 OF GLEETS. CI). III. tlie other either without any advantage whatever, or even with evident proofs of doing harm. 1 bus, al- though in the first variety of Gleet, we depend so much upon stimulating injections, that a cure in most instances cannot be accomplished without them; in the other, where the larger glands- of the urethra are affected, they very commonly render every symptom worse than it was nefore. They at least do so where the injection is of such a strength as to excite pain and inflammation ; and if weaker than this, it may be used for an indefinite length of time, without any effect re- sulting from it. The glands opening into the urethra being here the seat of the disease, astringent injections, applied as we have elsewhere observed, to their excre- tory ducts, may produce a temporary stoppage of the discharge ; but, as they do not reach the cavities of the glands, no permanent advantage can be expected from them. While, again, when an injection is used of such a strength as to excite inflammation upon the ends of these ducts, it is very apt to produce swellings in the glands themselves, which at last commonly terminate in suppuration, to the great distress and disappoint- ment both of the patient and practitioner. Whenever it is therefore discovered with certain- ty, that this variety of Gleet exists, injections should be no longer employed ; or when, for the satisfaction of the patient, a farther trial of this remedy becomes necessary, such preparations only should be used as are moderately astringent. In such circumstances bougies, and blisters to the perineum, are the most effectual remedies I have ever employed. The bougies should be of the mildest kind, such as stimulate the parts gently, without ex- citing inflammation. By this, and by the support which their size and form afford to the weakened parts, they often prove highly serviceable ; and even when they do prove more powerfully stimulating than we may have wished or expected, they do not so readily do harm as injections; for the inflammation with which hoc. II. OF GLEETS. 119 this may be attended is always accompanied with an instantaneous discharge of matter, by which the incon- venience that otherwise might result'from them is very effectually prevented. Bougies ought, for every purpose, to be as large as the capacity of the urethra will admit; but their be- ing of a full size is more particularly necessary in this variety of GlecUhan for any other malady ;* for it is chiefly by their size that they prove useful here. In most instances of this kind it appears, in the course of a .few days, whether bougies are to be of service or not; but no permanent advantage is ever to be expected from them if they are not continued for a considerable time. When the disease has been of long duration, the bougies ought to be applied for the space of ten or twelve weeks, and not even desist- ed from then if the cure be not completed. It is proper, however, to observe, that after bougies have been used for such a length of time as ought to accom- plish a cure, they should from time to time be laid aside, that the effects produced by them may be discov- ered; for while they are daily introduced we can nev- er know with certainty whether any discharge which takes place is the effect of the disease, or of the irri- tation which they excite; as bougies can never be ap- plied for any length of fime together, not even to a sound urethra, without being found covered with mat- ter, or with mucus in the form of matter, on their be- ing withdrawn. When bougies fail, a blister applied over the whole perineum sometimes proves serviceable. Whether it is by the stimulus which they give to the parts affect- ed, or by the discharge which they excite, is uncer- tain : for in some an evident advantage ensues upon the first or second day from their application, and be- fore any quantity of discharge can have occurred, while in others no effect is obsei ved to result from them till the second, third, or perhaps, fourth blister has been applied. In a few instances, some advantage 120 OF GLEETS. Cll. III. has appeared to be derived from a small portion of the blistered part being kept open with epispastic oint- ment, which, in two cases of much obstinacy, led me to advise the introduction of a small seton on one side of the perineum ; but although this seemed like- wise to lessen the discharge, the advantage derived from it was neither so great nor so obvious as to com- pensate the very disagreeable nature*©f the remedy. In very obstinate cases of this variety of Gleet, the patient will frequently be found to be of a scrophulous constitution. If the disease has not already appeared in a more evident manner in other parts of the body, it will at least often happen that the glands of the neck, and other suspicious parts, will appear to be tumefied, and that the complexion of the patient, which is com- monly delicate, gives much cause to conclude that the system is not free of it. In such circumstances, all the remedies usually em- ployed in scrophula will from time to time, be advis- ed. Bark and hemlock have sometimes proved useful^ here ; but no remedy that has yet been employed in scrophula is in any degree equal to sea-bathing. In enumerating the different varieties of Gleet, I have proceeded in the order in which they most fre- quently appear. The next of which I shall take no- tice proceeds from strictures in the urethra. In an ensuing section I shall find it necessary to en- ter more minutely upon the consideration of venereal strictures in the urethra: at present, therefore, it , seems only requisite to say, that they are to be con- sidered as a very frequent cause of Gleet. The spon- gy surface of the substance from which these strictures are produced is very apt to become tender and excori- ated. A slight degree of ulceration thus takes place which continues to give out matter while any degree of the stricture remains, and where the extent of the disease is considerable, this of itself would afford a very copious discharge; but besides this, the re mora which every stricture produces, of urine and mucus Sec. II. OF GLEETS. 121 between the part on which it i? sealed and the bladder, acts as a very powerful cause of irritation, and in this manner renders the discharge more abundant than we almost ever find it to be in Gleet, proceeding from any other cause. "Where strictures are not suspected as the cause of the discharge, as often happens where the obstruction to the flow of urine is not remarkably great, the pa- tient as well as the surgeon is apt to be deceived, and to proceed daily with the plan of effecting a cure by injections, balsam of copaiba, and other astringents. None of these remedies, however, have any influence, and the discharge, after many years' continuance, is found to be nearly in the same slate, either as bad, or perhaps worse, than at first. Of this every practition- er must have met with instances, and they always prove the source of much perplexity and embarrass- ment. In every case, therefore, where Gleet resists the usual remedies, and is thus particularly obstinate, it ought to be our first object to ascertain the real state of the urethra, and to h/urn whether strictures are present hi it or not. In some cases this will at once be known from the slate of the symptoms obtained from the patient, as well as frojn external examination of the urethra from the point of the penis, to the fundament. This, however, will only happen in the more severe degrees of the disease. "Where the ob- struction is slight, it may, as we have already ob- served, pass unnoticed ; so that in all 'such circum- stances, and where there is any cause for doubt, the passage should be examined with a bougie, by which alone any certainty upon this point can be obtained. When the existence of stricture is discovered, all oilier remedies ought at once to be laid aside, and the cure trusted entirely to bougies. Hereafter we shall have occasion to speak more particularly of bougies; at present we need only say, that they are the only remedy upon which we can depend for the removal of Iti 122 OF GLEETS. CI). HI. strictures, and that they very commonly prove effectu- al when duly persisted in. When the discharge proceeds entirely from stric- tures, it will, for the most part, soon subside on these being removed ; but when it continues more than a few days after the bougies are withdrawn, it will be proper to employ astringent injections in order to car- ry it off! Lime-water answers well ; for this particu- lar purpose, indeed, it answers better than any other form of injection 1 have tried, but it requires to be diluted with an equal quantity of common water. 4. The last variety of Gleet of which we have to take notice proceeds from a swelled state of the pros- tate gland, and succeeds, as we have already had oc- casion to see, to the third stage of Gonorrhoea Vjru- lenta. In treating of Gonorrhoea the symptoms were enu- merated by which affections of the prostate gland may be discovered ; but we have no certain means of know- ing to what extent it may be swelled but by examin- ation with the finger in ano. Besides the inconveniency which occurs here from the discharge itself, and which is common to this with every variety of Gleet, there is always a good deal of uneasiness, and even^pain, produced by the swel- ling of this gland, which excites a more frequent de- sire to pass water than any other variety of the dis- ease, together with a sensation of heat and fulness over the whole parts contiguous to the anus. The tenesmus which often takes place is also a very trou- blesome symptom. Gleet, proceeding from this cause, is sometimes combined with other varieties of the disease, particu- larly with that which was last described. In this case the discharge has most frequently the appearance of being a mixture of pus and mucus; but when the run- ning proceeds entirely from an affection of the pros- tate gland, it is thinner than purulent matter, and, al- though sometimes tiuged of a while or yellow colour, it is more frequently of the consistence'and colour of Sec. it. OF GLEETS. *23 mucus. This makes it often be mistaken for a dis- charge of semen. No injections are of any utility in this variety of Gleet; nor is any advantage derived from bougies. On the contrary, thc-v are both apt to do harm, par- ticularly a perseverance in the use of them; a prac- tice which those not accustomed to this branch of bu- siness are very apt to fall into. Swellings of this gland are very commonly attended with some degree ol' ob- struction to the passage of urine, arid when this is mistaken for strictures, as often happens, bougies are immediately advised in order to remove it. Bougies, however, never prove useful here: on the contrary, they very commonly irritate the gland to such a degree, as to excite both an increase of the pain and of the discharge. Opiates are the remedies upon which we place most dependence. ^ By allaying irritation, they not only keep the patient free from pain, but in doing so they tend more than any other remedy to hssen^lhe dis- charge. It must, however, be'acknowledged, that they act chiefly as palliatives; but the mere preven- tion of pain is a point of no small importance in a dis- ease which otherwise is apt to render the patient mis- erable. In speaking of affections of this gland in the third stage of Gonorrhoea, I advised opiates to be used in clysters, instead of being taken by the mouth. They do not, in this form, so readily induce sickness, and they usually prove more effectual in relieving pain. In several instances, where no great advantage was derived from all the quantity of laudanum that durst be given by the mouth, patients have been kept, easy by a grain or two of opium dissolved in a small quantity of mucilage, and thrown from time to time, into the rectum. Where this disease occurs in scrophulous constitu- tions, an occurrence by no means uncommon, hvoscv- amus, cicuta, and sea-bathing, are the remedies usual- ly employed: and although'they do not often accom- 124 OF GLEETs. Cll. III. plish a cure where the gland is much swelled, yet they frequently afford relief; and slighter degrees of the disease have, in some instances been removed by them entirely. Some practitioners, as I have already had occasion to remark, give mercury in every variety of Gleet, but 1 have never known any advantage derived from it, and where the prostate gland is affected it very com- monly does harm. As I have mentioned above, that, in Gleet proceed- ing from strictures in the urethra, some slight degree of ulceration takes place, it may be imagined that mercury ought in such instances to prove useful, from its well known powers of healing venereal ulcers. It is not, however, found to promote the cure of these ulcerations; a circumstance that may be consider- ed as a farther proof of the difference between Gonor- rhoea Virulenta and Lues Venerea ; for if affections of this kind were induced by the matter of Lues Vene- rea, n ercury would seldom fail in curing them, while no other remedy would ever prove successful. But, instead of this, I have repeatedly found, that no ad- vantage is derived from mercury in the treatment of this symptom, while bougies, when properly managed very commonly prove effectual. What we have hitherto said upon the subject of Gleets relates chiefly to the disease as it occurs in men, it being in them both more frequent, and of much more difficult treatment than it usually is in wo- men. We often meet with it, however, in women; but it is proper to remark, that it is equally difficult to distinguish it from fluor aibus, as in a former section we have observed Gonorrhoea to be. Referring to what was the n said upon the means of distinguishing between the two diseases, we shall at present proceed shortly to observe, that in women we depend entirely for the cure of Gleet upon a.proper perseverance in the use of injections. When after a due continuance Sec. n. OF GLEETS. 126 of such as we reckon astringent,* if the discharge still continues, those of a stimulating nature should be em- ployed, particularly Nos. 24 and 25. When the disease is seated in the vagina, as is gen- erally the case, these injections may be thrown up with freedom; but, when the discharge proceeds from the urethra they ought, on account of the contiguity of the bladder, as we had occasion to remark in a for- mer section, to be thrown up with much caution. In women I have sometimes found that a Gleet has proceeded from ulceration within the verge of the va- gina. In such instances injections have little or no in- fluence; and as sores of this kind are commonly con- nected with Lues Venerea, they can only be cured by a course of mercury. It is proper, however, to remark, that women are liable, as men are, to excoriations from the acrimoni- ous nature of the matter of Gonorrhoea. A discharge of matter from this cause will be most readily cured by astringent injections, or bathing the parts with lime- water, or a saturnine solution. I have never known the real venereal stricture oc- cur in women. Excrescences form in the urethra from other causes; but stricture from Gonorrhoea must ne- cessarily, in this sex, be a rare occurrence. If it is ever met with, bougies mtist here, as in men, be de- pended upon for a cure. * Vide Appendix, Nos. 18, 19, and 20. We find the acetite of lead in solution is a favourite prescription of our author, as well as of many others, especially young practi- tioners. We have sometimes used it but not lately, having as we are convinced, observed Gleet to be a frequent consequence:— From our own observations we cannot help thinking that in this complaint, the lead acts as a sedative, and that in some cases an almost incurable degree of local debility is induced. On this subject we are happy to have it in our power to quote a very accurate observer, Dr. Hosack of New-York; He observes, ki In Gonorrhoea lead water is the usual prescription, especially of young practitioners. The writer of this article, many vears since 126 OF IMPOTESCY FROM Ch. III. became acquainted with the pernicious consequences of that injec- tion. Indeed, in every case of Gleet following Gonorrhoea, for which he has been consulted within twenty years past, he has, with- out a single exception, traced it to the debilitating sedative effect of that metal. Most cases too of the inflamed testis, which he has seen attendant upon Gonorrhoea, have been produced by the same cause, viz. the too early and sudden check of the secretions of the urethra by the use of lead injections." . Vid. Med. and Philosoph : Register, vol. iv. page 159. Mr. J. Robertson, surgeon in Edinburgh some years since pub- lished a book on the use of the tincture of cantharides in the cure of Gleet and Leucorrhoea. This remedy unquestionably acts from its stimulant properties, and we know that it has frequently proved successful. It must be employed with caution, commencing sel- dom with more than fifteen drops, as from the great irritability of the parts a distressful degree of inflammation might be the conse: quence : this quantity may however be gradually increased, often to thirty drops, two or three times a day. We have frequently succeeded in performing a perfect cure, with the linament, page 69. Ed. SECT. III. Of Impotency from Scmiyial Weakness. WE here mean by impotency a deprivation of the power of propagating the species. This may proceed from various causes: but it is that variety of it only which is usually supposed to arise from weakness in the seminal vessels that we are now to consider. It is an occurrence which, in young people, either in idea or reality, takes place daily; and as it proves at all times a source of much anxiety and distress, it necessarily becomes a frequent object of attention to practitioners. A degree of debility inducing want of retention in the seminal vessels is, no doubt, occasion- ally met with; but the strong desire which Nature lias wisely implanted in all men to be complete and entire, in whatever relates to the propagation of his species, is often in early youth, the cause of much ill-founded Sec. III. SEMINAL WEAKNESS. 127 suspicion on this point, and of circumstances respect- ing it being considered as real which never took place. Thus there is nothing more common than young people supposing they are weak and debilitated, on perceiving an oozing of mucus from the urethra, or a discharge of semen when at stool. The first, howev- er, is natural to many when in full health, and where IK) suspicion of weakness exists; and the latter, or a discharge of semen, must at all times be the conse- quence of hardened fceces compressing the vesiculae seminales, when these vessels are full of semen. But suspicion on this point being once awake, it is often difficult, and sometimes impossible, to remove it; in- somuch that many have been rendered miserable by this alone, where no vestige of disease existed. It is considered as one of the most certain proofs of weakness in the seminal vessels when a discharge of semen instantly succeeds to an erection, or, perhaps, to an imperfect degree of it. But this may also happen from a state of over-excitement in the other parts of general ion, and I also believe that it often occurs from the seminal fluid being collected in too great quantity in the vesiculae seminales. I have reason indeed to im- agine, as w ill appear in the sequel, that this is the most frequent cau-e of all such affections. It may be said, if the disease exists, and the patient is rendered completely impotent, that the cause of his being so is a point of little importance. It will appear, however, that this is by no means the case; for while real impotency is in a great proportion of cases to be considered as incurable, we have it in our power, per- haps, in most instances of approach to this state to ac- complish a cure. In the last section we have seen that Gleet proceeds at one time from an affection of the glands in other parts of the urethra, but in some cases that it arises from a swelling of the prostate gland. When this ex- ists for any length of time, we find that, not only the duct of the prostate gland becomes weak and relaxed, but that a loss of tone takes place in some of the con- r 128 OF IMPOTENCY FROM Ch. m, tiguous parts, particularly in the excretory ducts of the vesiculse seminales; insomuch that a great propor- tion of all who have long laboured under Gleet from affections of this gland, have likewise been liable, in some degree, to seminal weakness. It is well known that long continued Gleets, are often the cause of Impotency. For the most part, it is supposed, that this happens from the general debility which they induce. In some instances this may be the case ; but I have much reason to think that they act much more i frequently by inducing a local weakness only in the parts destined for the reception of the semen. This I conclude to be the case from this kind of debility tak- ing place where there is no appearance whatever of general weakness, for instances often occur in consti- tutions apparently firm and healthy, of such^ degrees of weakness in the seminal organs, that emissions take place, not merely from partial erections and lascivious ideas, but from the ordinary friction applied to the pe- nis in riding and walking, and, in some instances, from the effect of heat alone, whether excited by wine, ex- ercise, or sitting near a fire. In people who have suffered much from frequent returns of Gonorrhoea, particularly where Gleet has taken place from the cause I have mentioned, I have known several instances of the semen running off by the slightest application of any of the causes just enu- merated. The local weakness thus induced in these parts by Gleet seems very much to resemble the effects of Onanism ; a habit so baneful to many of our youth, that I believe it to be more destructive in its conse- quences than a great proportion of all the diseases to which in early life they are liable. Were it to prove hurtful to those only whose self indulgence gives rise to it, there would be less cause to regret the effects of it; but, besides rendering the parent himself misera- ble, it evidently entails the highest distress upon pos- terity, by generating languor, debility and disease, instead of that strength, of constitution, without which there can be no enjoyment. Sec. III. SEMINAL WEAKNESS. 129 Some, I know, have entertained a different opinion upon this point, and imagine that no bad effects are to be dreaded from the habit of which we are now speak- ing*. But this is so directly contrary to the expe- rience of others, and I have had so many instances in the course of my own practice of constitutions being irretrievably ruined by indulgence in it, that I cannot avoid, in the strongest manner, giving my opinion of it: nor does it appear that any benefit could result to society from a contrary opinion being admitted, even allowing it to be well founded; for although no imme- diate harm might ensue from it to the constitution, it ought to be discouraged as unnatural, and from its tending to divert the attention from an enjoyment of a much superior kind. While, therefmV, there is much cause to consider the practice as mgidy dange- rous to all who follow it, and while such a propensity prevails towards it in that early age when boys cannot form a judgment of its deleterious tendency, I consid- er it as incumbent on those who write upon it to paint it and the baneful effects which result from it in their true and proper colours. In the treatment of ini< variety of Impotency, wheth- er it has been induced by Onanism, or whether it be the consequence of Gleet, it is proper to distinguish it into two stages. The one, so far as f have seen, be- ing of a nature that does not admit of any certain rem- edy, while the other may, in most instances, be com- pletely cured. Many consider it so certainly as incu- rable that the patient is led to despair from the first approach of it, and the opinion is often unfortunately realized merely from the cause I have mentioned, our not distinguishing the two stages of the disease, and allowing that which I suppose may be easily removed, to proceed without any attempt for this purpose, to that state of it, which, in most instances, may be con- sidered as incurable. Practitioners are frequently applied to by7 young * Vide Treatise on tire Venereal nisease, by John Hunter chap. xii. 17 130 OF IMPOTENCY FROM CI). HI. men labouring under what I shall term the first stage of Gleet; who, finding that a seminal discharge takes place from the slightest causes, perhaps merely from their being in company with women ; from lascivi- ous dreams; or from the parts of generation being in any degree overheated, begin to be afraid that they shall never again have the power of retention, and conclude therefore that they cannot with propriety enter into a matrimonial connection. We often find that they admit Onanism to have been the primary cause of their distress, although, for a great length of time, perhaps for a number of years, they assert, and with no reason on our part to doubt them, that they have been entirely out of the practice of it. In this situation, whatever may be the appearance and habit of body of the patient, strengthening astrin- gent remedies are prescribed, such as bark, steel, bal- sam of copaiba, cold bathing, &c.; and whatever are his views, he is advised to avoid matrimony and all venereal intercourses. In a great proportion of cases, however, I am con- vinced that this practice and this advice are errone- ous. Following the bulk of practitioners, I easily adopted them; but no good resulting from them I have long since relinquished them, and I have seldom failed of success by advising measures of an opposite nature. In a great proportion of all that are injured by this destructive habit, a morbid irritability of the or- gans of generation seems to be excited. By this a greater quantity of the seminal fluid is secreted than the vesicular seminales can retain : in consequence of which, it either bursts out during nocturnal dreams, or is easily excited to flow by the application of any of the causes above-mentioned. Even after the habit has been long left off I have known the effects of it continue in a very distressful degree, and 1 conclude that they proceed chiefly from too plentiful a secretion of semen, from the na- ture of the remedy which in most instances has prov- ed successful. SeC. III.' S-EMrXAU WEAKNESS. 131 Instead of advising abstinence from women, I al- ways inculcate as frequent connection as natural de- sires seem to require ; and when matrimony is in view, instead of being afraid of it, as often happens with this class of patients, from a fear of their not performing the functions of it properly, I uniformly hold it forth as the most certain remedy. The idea of inability is so strongly prevalent with many, that they are with difficulty prevailed upon to make the attempt; but the effects of it are so cer- tain, that with patients in such circumstances as we are now considering, it may always be advised with the greatest confidence of success. Nor is the assist- ance of other remedies required in this plan of cure ; at least in various instances, patients, who, for ma- ny years together had been almost constantly taking such remedies as they judged to be of an invigorating nature, without any advantage resulting from them, and who therefore were induced to consider their complaints as incurable, have, on laying all of these aside, become completely and entirely well in the space of a few weeks after marriage. The irritabil- ity of the organs was thus diminished ; the morbid increase of the secretion was removed ; and the se- minal receptacles, not being over distended, were soon found to be endowed with a sufficient degree of retention. This being a very frequent variety of the disease, I can speak of it, and of the remedies employed in it, with some degree of certainty; and I can with con- fidence say, that none of those commonly advised have ever, in the course of my observation, had any obvious influence ; while the plan I have pointed out, very generally surpasses in its effects all that the patient could hope from it. When a swelled state of the prostate gland is con- nected, as I have sometimes found, with this variety of the disease, it necessarily renders the event more doubtful, and the effect, even of, .this and every other remedy, more uncertain.,.. But even, here the 132 OF IMPOTENCY FROM Ch. HI. course I have advised will sometimes prove success- ful. It will not remove any affection of the gland, but where the disease of that organ is not in a great degree, it proves equally effectual in removing the other, as if the gland was entirely sound ; and this obviates one of the greatest sources of misery to the patient. It may be said, that while this or any other varie- ty of Gleet exists, the remedy I have pointed out cannot with any propriety be advised, from the risk of communicating infection. We know, however, that real Gleet does not communicate infection to others ; and the means of distinguishing it from Gonorrhoea are by no means equivocal. Many in- stances have fallen within my own observation, and others must often meet with it, of this being clearly the case. I know', at this time, several instances of men who have been married for many years, who, during the whole period, have laboured under dif- ferent varieties of Gleet, and who have never com- municated the disease either to their wives or chil- dren. Gleet in men seems to be ecjtially incapa- ble with fluor albus in women to communicate infec- tion. la that stage of the disease which we have just been considering, a cure, we observe, may, perhaps, in every instance, be accomplished. But when it has b en of such duration as to form w hat may more pro- periy be termed seminal weakness, and what I shall term the second stage of the disease, a very different prosper i presents itself. The patient may even, in very advanced periods of the disease, derive advan- tage from a well-regulated diet and other circum- stances, by which his situation will be rendered much more comfortable than it. otherwise would be ; but in this situation a complete removal of the disease is scarcely to be expected: at least little dependence is to be placed upon the remedies usually employed for that purpose,. • »,. This very distressful stage of seminal weakness is SeC. III. SEMINAL WEAKNESS. 133 often the consequence of Onanism long persisted in ; and it is, as we have remarked, the frequent conse- quence of Gonorrhoea and Gleet. In all such cases the disease seems to proceed from real weakness, or debility in the excretory ducts of the vesiculse semi- nales ; for it commonly happens where the whole sys- tem is much relaxed and emaciated ; where there is therefore no cause to imagine that it can arise from too plentiful a formation of semen ; and of which, in- deed, we often meet with a very decisive proof, from a constant mucous-kind of oozing being perceived in the urethra, while no ordinary cause of excitement is capable of producing any regular discharge or emis- sion of semen. In this situation a variety of remedies are employ- ed, chiefly with a view to restore and invigorate the tone of the weakened parts; such as bark, steel, bal- samum copaiba, and cold bathing. At other limes, where the disease is supposed to proceed from a defi- ciency of semen, provocatives are prescribed; such as high seasoned foods, all the terebinlhenate balsams, and cantharides. But although I have had many op- portunities of observing a complete trial of these, I never knew any advantage derived from them. The only course, which in such circumstances I ever knew prove useful, was such as merely tended to restore the patient to his usual state of health. If Onanism has induced the disease, nothing will afford even the chance of a recovery till this is left off. Whatever may have been the cause of it, he ought to be put upon a nourishing diet; and he should live in an ele- vated, dry situation. Sea-bathing should be advised; and costiveness, with every thing that might tend to irritate the parts chiefly affected, should be avoided. With a view to lessen that degree of irritability with which this disease is usually connected, opiates have been advised ; but although I have often given them a full trial, I never knew any real advantage obtained from them. On the contrary, they have often appear- ed to do harm; for although they procure rest, yet 134 OF IMPOTENCY FROM Ch. III. the sleep which they give is always disturbed; the pa- tient awakes in a state of more" anxiety and distress than he experienced on going to bed ; and when opi- ates are habitually used, costiveness can scarcely be prevented by means of remedies, which, in this situa- tion, ought not to be given. Hemlock is often used here; but I have never known any obvious advantage derived from it. Hyos- cyamus, by acting as an anodyne, while it does not produce costiveness, has, in different instances, ap- peared to prove serviceable. One grain of the ex- tract may be given at first, and the dose increased in a gradual manner to three, five, six, eight, and even ten grains. Conceiving, from some circumstances connected with the disease, as well as from many of the symp- toms which ensue from it, that it may in some instan- ces be of the same nature with paralysis, I have, in several cases, advised electricity, and in one or two of these it appeared to prove serviceable, but never so decidedly, as to enable me to speak of it with confi- dence. SECT. IV. Of Obstructions in the Urethra from Gonorrhoea Vir- ulenta. WTHEN speaking of Gleet we had occasion to ob- serve that it is often the consecpience of Obstructions in the Urethra. But Gleet, although the cause of some inconvenience and distress, is by no means the symp- tom of most importance with which Obstructions are accompanied. Strictures may take place in a certain extent, without giving much uneasiness, but whenever they arrive at such a height as to impede the flow of urine,they prove always the cause of distressand misery to the patient, and of much embarrassment to the prac' titioner. Sec. IV. SEMINAL WEAKNESS. 13J Obstructions proceeding from Gonorrhoea Virulen- ta may be reduced to four general heads ; tumours in the substance of the urethra and contiguous parts ; spasmodic'affections of the urethra; caruncles, or fleshy excrescences, in the urethra ; and strictures, properly so called. i 1. Of Tumours in the Substance of the Urethra and con- tiguous Parts. AYE have already had occasion to speak of Tu- mours, or swellings of the prostate gland, of swellings of Cowper's glands, and of the other smaller glands of the urethra. All of these produce obstruction to the flow of urine whenever they become of such a size as to diminish, in any degree, the magnitude of that canal. Referring to what has already been said upon this part of our subject, I have at present to observe, that in the commencement of all Tumours in these parts we ought, by every method in our power, to endea- vour to remove them by discussion, for which purpose local and general blood-letting are the remedies chief- ly to be depended on; and as these, when carried a sufficient length, and when assisted by a cooling rrgi- men, and the external use of cold saturnine applica- tions, seldom fail in removing them, they should al- ways be persisted in as long as there is the least chance of their proving serviceable. For although tumours in this situation are often easily removed after suppu- ration has taken place, by the matter being freely dis- charged, and the sore treated in the usual way, yet, before arriving at this size, a good deal of distress al- ways occurs from them, and, in some instances, the sores heal w ith difficulty, while in others the matter bursts into the urethra, where it continues often dur- ing the life of the patient to excite a great deal of dis- tress.- 136 OF TUMOURS IN THE Ch. III. In others again it bursts into the scrotum, and from thence into the surrounding cellular substance, and openings forming in consequence of this, commonly between the scrotum and anus, a very troublesome dis- ease is thus produced, termed fistula in perineo* It is therefore obvious that it is much for the advan- tage of the patient that all tumours of this kind should be removed by discussion ; but when our endeavours for this purpose do not succeed, and when suppuration takes place, we have it often in our power to prevent many of the bad consequences which otherwise are apt to ensue. By opening such tumours immediately on matter being* perceived in them, we prevent the risk of their bursting into the scrotum and urethra, so that in this situation we ought never to wait till they are so fully matured as otherwise might be proper: and when once they have come so far as to render it pro- per to discharge the matter, it ought to be done, as we have formerly7 observed, by making an opening the whole length of the tumour. This prevents the matter from lodging, and from insinuating into the contigu- ous parts, while the sores which ensue heal more kind- ly than theyr usually do when smaller openings have been made. Among other consequences which sometimes occur1 from matter bursting from abscesses in this situation into the contiguous parts, it is proper to mention that the most distressful effects occur from its finding access to the corpus cavernosum of the penis. It usually spreads suddenly over the whole substance of the pe- nis; small openings takes place in different parts of the swelling, at which the matter is discharged ; and these are always very difficult to heal : or, if the matter does not find a vent in this manner, it either bursts into the urethra, or the surrounding parts are apt to mor- tify. When mortification occurs in this situation, it either soon proves fatal, or terminates in the entire loss of the * For the treatment of this, vide system of surgery, chapter Sec. IV. URETHRA. 137 penis ; for a stop is seldom put to the disease till all the parts surrounding the urethra are destroyed, when am- putation of the remainder becomes unavoidable. Indeed the haemorrhagy which is apt to occur from deep seated mortification of the penis is commonly of itself a suffi- cient motive for amputation being advised, for we can seldom put an effectual stop to the discharge till the mortified parts are all removed. For preventing mortification in this situation from spreading, opium has been recommended. I have cer- tainly observed it prove useful in gangrene, both in these parts and in others ; but more dependence is for the most part to be placed upon a plentiful use of bark. Whether or not opiates act in the cure of gangrene as antiseptics, is not, or perhaps, cannot be ascertained. I rather believe that they do not: and I am inclined to think that they prove serviceable only by allaying irri- tation. In this manner they may be employed with advantage wherever gangrene appears to be the con- sequence of a high degree of inflammation. By les- sening or removing pain they may diminish the cause of exertion in the vessels of the part affected, and may thus tend to prevent mortification from extending so far as it otherwise might do : but I have never known them to prove useful where the disease seemed to de- pend upon the loss of tone, either of the part itself, or of the constitution. } 2. Of Spasmodic Obstructions of the Urethra. IRRITATION of the Urethra, from whatever cause it proceeds, has an evident effect in lessening the diameter of the passage. Hence, in cases of stone in the bladder, the irritation, and consequent con- traction of the urethra, is sometimes so great that a staffs even of a moderate size, cannot be introduced. Stones in the kidney have frequently the same pffect. Nav, I have known this contraction of the urethra • 18 138 of sPASMonic obstructions Cb. lit. induced by sand passing along the ureters. In like manner the irritation produced in the urethra by Gonorrhoea, is in some cases so great as to excite con- traction of the passage in a very distressful degree. I have known the urine so completely obstructed by this alone, as to give cause to suspect that strictures were formed of the most alarming nature; in which neither staff; catheter, nor bougie, could be introduc- ed, but with more force than can ever with safety be applied. We judge that obstruction proceeds from this cause, when at one time it occurs in a severe degree, and soon thereafter, perhaps in the space of a few hours, if appears to be entirely or nearly gone. Of this I have met with various instances; in which, from the anxiety of the patient, and from suspicion of a more inveterate kind of stricture, repeated attempts have been made in vain to pass a bougie, and in which the stoppage has gone off entirely upon the exhibition of a dose of laudanum, or rubbing the perineum with anodyne balsam. As the urethra itself does not appear to be muscu- lar, as a small portion of it only can be compressed by the muscles of the penis, and as the obstruction of which we are now speaking occurs in parts of the pas- sage where these muscles do not exist, it has been im- agined that this temporary accession of stricture must be owing to some other cause. It may perhaps hap- pen that the violent irritation excited by chordee may in some instances produce such effusion into the cellu- lar parts of the penis as may7 compress the urethra; and that this may soon be removed by absorption, on the irritation by which it was produced being taken awav. But although this mav be the case in a few in- • r^ mt stances, I am convinced that it is not a frequent occur- rence, and that the urethra itself is endowed with a contractile power, by which, for the most part, this kind of obstruction is produced. Were it to proceed from any kind of effusion com- pressing the urethra, the tumefaction thus produced Sec. iv. or the urethra. 139 would be obvious. Partial circumscribed tumours would either be discovered in the course of the ure- thra, or the whole body of the penis or a considera- ble part of it, would be swelled. We do not find, however, that this is apt to happen ; at least, in most cases of this kind no tumefaction of the pern's is per- ceptible. This kind of spasm or cramp occurs occasionally in every part of the urethra. I have met with it within an inch of the extremity of the glans, but for the most part it happens behind the scrotum, or nearer the pros- tate gland, in the membranous part of the passage. In the treatment of Obstruction in the Urethra it is a matter of the first importance to determine the cause by which it is produced. It is particularly necessary to distinguish between obstruction arising from spasm, and that which proceeds from stricture of the passage. In the latter, bougies, as tye shall afterwards see, are almost the only remedies upon which we can depend, while, in cases of spasm, they very commonly do harm. In the one they remove the disease by acting as wed- ges; in the other they add to the violence of the con- traction by increasing the irritability by which it was at first excited. As the degree of obstruction produced by spasm alone is, in some instances, equal to what usually oc- curs from the most obstinate kind of stricture, it is on- ly from an exact account of the rise and progress of the disease by which we can judge of the difference. When the flow of urine has at first been perceived to be slightly obstructed, and when this has gradually become worse, without ever being in any instance ma- terially better, there will be much cause to imagine that it proceeds from a cause of a fixed nature : while, on the contrary, however complete an obstruction may be, if it came on suddenly, and if it frequently be- comes quickly well without any obvious reason, there will be no cause to doubt of its proceeding from spasm. We find too, in obstruction proceeding from causes 140 OF SPASMODIC OBSTRUCTIONS Ch. III. of a more fixed nature, that some pain is always dis- covered at one or more fixed points. In some cases a degree of hardness is perceived on the urethra being pressed at these points; while in others, although no- thing can be discovered on external pressure, the pa- tienr feels a degree of heat and pain, as if the parts affected were excoriated, or even ulcerated. Besides, in real stricture, a discharge of matter very universal- ly ;;ikes place from the urethra ; forming, as we have already had occasion to see, a very frequent cause of Gleet. But in obstruction proceeding from spasm, any pain which occurs in the urethra does not proceed from one point. It appears to be more diffused; and is seldom in any distressful degree, if it be not by the stoppage which it gives to the flow of urine. No par- ticular spot is discovered to be hard or sore upon pres- sure, and a discharge of matter does not necessarily take place in it. -* Spasm, indeed, may be accompanied with a flow of matter from the urethra. This will always happen where Gonorrhoea or Gleet have previously existed; but it will never, on enquiry, be found to be the cause of the discharge. The remedies to bf employed for the removal of this variety of obstruction are, warm emollients, ano- dynes, blood letting, blisters, and electricity. Bou- gies, in certain circumstances, may be also employed. Rubbing the parts affected, whether the perineum, or more interior parts of the penis, with warm oil, proves sometimes useful. Oil, strongly impregnated with camphor, and Goulard's form of the unguentutn saturninum, when applied warm to the parts affected, also tend to remove this cause of obstruction. I have sometimes known it instantaneously removed by fo- menting the perineum with a decoction of chamomile flowers or althea, or by the application of a bladder filled with warm water. The common anodyne balsam makes an useful ap- plication here. The parts in which the spasm is seated should not only be rubbed with it, but pledgets in> SeC. IV. OF THE URETHRA. 141 mersed in it should be kept constantly applied to them. But one of the most powerful antispasmodics among external applications is, a mixture composed of three parts of laudanum and one of aether. Frequently, however, little or no advantage is de- rived from the external application of anodynes ; while opium, given internally, is productive of the best ef- fects. Forty drops of laudanum, given by the mouth, will often remove a spasm of the urethra that has re- sisted every variety of this remedy applied to the skin; and when thrown up the rectum, in the form of injection, it proves still more effectual in removing pain, irritation, and spasm about the anus, and in the organs of urine and generation, than when received into the stomach. Whether this may proceed from the remedy getting more nearly into contact with the nerves of the diseas- ed parts, or whatever may be the cause of it, is per- haps difficult to determine ; but, from much experi- ence of their effects, I am convinced, that in all such affections, opiates prove most powerful when given in this manner. In plethoric constitutions blood-letting is often the most effectual remedy, not only in carrying off the spasm which presently7 subsists, but in preventing re- turns of it in future. Besides the discharge of blood from the arm in quantities proportioned to the strength of the patient, leeches should be applied along the course of the affected parts, and they seldom fail where the constitution can support the evacuation, of giving very effectual relief. From an idea of spasmodic affections proceeding in most instances from what is termed a weakness of nerves, and from a dread which very universally prevails, of all such affections being rendered worse by blood-letting, this is a remedy we find very rare- ly, employed. But it is proper here, as well as in sim- ilar affections of other parts, to observe, that morbid irritability may be excited by causes of a very oppo- site nature. It sometime? takes place wdiere the con- 142 OF SPASMODIC OBSTRUCTIONS Ch. III. stitution is relaxed and reduced; and, in such cir- cumstances, evacuations of every kind very common- ly do harm. But it more frequently happens from a state of plethora, in which blood-letting proves the most certain remedy, and where opiates, warm bath- ing, and other antispasmodics are often used for a great length of time, without any effect resulting from them. We find from experience, that a stimulus applied to the skin proves often useful in relieving pain and spasm, in parts that are very deeply seated ; and upon trial, the same remedies are sometimes found to remove similar affections of the urethra. Obstructions of this kind have, in different instances, been relieved by the application of volatile liniment, a strong impregnation of oil with volatile alkali, to the parts affected. A ' blister applied over the perineum, has in different in- stances carried off' obstructions of the urethra ; and in some cases where blisters failed, the disease has been completely removed by the application of a warm plaster. In such cases blisters do not seem to act so much by the evacuation which they produce, as by the irrita- tion which they excite ; for it often happens that the pain and spasm are removed as soon as the skin be- comes in any degree uneasy, and long before vesica,- tions can be formed. Hence, a warm plaster, which does not contain such a quantity of cantharides as to render it capable of acting as a blister, by keepingnp a more continued stimulus than blisters, proves, in some instances, more effectual. Electricity has sometimes proved useful in removing | spasm of the urethra ; but it requires to be managed with caution, otherwise it is apt to add to the violence of the disease. In plethoric habits it always does mis- chief and ought never to be advised in these ti.ll blood- letting has been premised. I have had occasion already to remark, that in this variety of obstruction, bougies are very apt to do harm. This proceeds from their being pushed with violence, Sec. IV. OF THE URETHRA. 143 when the parts, from being under some high degree of irritation, are in a state of strong contraction. This ought never, therefore, to be done; for while the parts remain in this situation we seldom succeed ; or if we do get the bougie passed, it is always from the use of more violence than ought to be employed. But bougies prove highly serviceable, even in Spas- modic Obstructions of the Urethra, when the violence of the disease is so far removed that they can be in- troduced with ease, and without exciting irritation : so that, whenever we find this can be accomplished, whether the spasm has been lessened by the use of emollients, anodynes, blood-letting, or any other reme- dy, it ought always to be advised. Besides the pres- ent relief which it affords, by removing any degree of the obstruction which may remain, it tends more ef- fectually than any other remedy to prevent a return of it. This is particularly the case where spasm is conjoined, as sometimes happens, with the more fixed kind of obstruction, which we are presently to proceed to consider. When this takes place all our other reme- dies are to be considered merely as preparative to the use of bougies, which, in such circumstances, are alone to be depended on for a cure. It must always be remembered, however, that bougies are only admis- sible w hen they can be introduced and retained in the passage, without exciting much uneasiness. In all diseases of the genitals the state of the intes- tines require particular attention. So much sympathy subsists between these parts that in people liable to ob- struction in the urethra, I have known a severe fit of the disease induced by a costive stool. Neither is much purging necessary or proper. The bowels should be kept in such a state as to prevent irritation, as far as it can be done, in the rectum and contiguous parts. 144 OF OBSTRUCTIONS Ch. III. $ 3. Of Obstructions in the Urethra from Fleshy Excrescen- ces, or Caruncles. OBSTRUCTION to the passage of urine has long been considered as one of the most distressful, as it i» one of the most frequent consequences of Clap ; and Caruncles, Fleshy Excrescences, or Carnosities, as they are sometimes termed, are mentioned by all the olde^ writers upon this subject, as the most frequent cause ©fit. This idea naturally aroae from their perceiving that warty substances were sometimes formed within the urethra, near to its extremity, similar in appearance to those which often occur upon the prepuce and glans; and not prosecuting the subject by opening the parts after death, they were led to suppose that the more deep-seated obstructions were all of a similar na- ture. So universally did this opinion prevail, and it was so strongly asserted in books, that although it was long ago, by some individuals, particularly by Saviard and Dionis, supposed to be ill-founded, yet even in our times it has been very generally admitted. This is so far the case, that in common conversation upon this subject, Caruncles are usually considered as the most frequent cause of all such obstructions. It is now, however, very certainly known that this cause of obstruction is an uncommon occurrence in the more remote parts of the urethra. Of late years this has become a very frequent object of anatomical investigation; and I have reason to suppose, from all that I have yet heard, as well as from the result of my own inquiries, that it seldom exists farther up the ure- thra than half an inch or so from the point of the glans. Warty excrescences are not unfrequently found to- wards the orifice of the urethra ; but I have seldom seen them, even in this situation, where they did not likewise prevail upon the glans and prepuce. Sec. iv. Itf THE URETHRA. 145 The obstruction to the flow of urine from this cause is seldom considerable ; but it always occasions much anxiety to the patient, from a fear which he is apt to entertain of it<= becoming worse. W ten seated just in the opening of the urethra, as sometimes happens, I have, in different instances been able to remove them with scissors, and with small lig- atures passed round them; but they are seldom so sit- uated as to admit of our taking them off in this man- ner. Neither are we at liberty to destroy them by the application of escharotics, the irritability of the ure- thra rendering this a very hazardous attempt. In all such cases we place our chief dependence up- on bougies; and, when duly persisted in, they seldom fail in effecting a cure. Some difference of opinion has arisen as to the man- ner in which bougies act in removing these excrescen- ces. In strictures of a different kind there is no cause for doubt upon this point, as they evidently act entire- ly as '.vedges, and prove useful in proportion to the ex- tent of mechanical pressure which they afford; but in the cure of Caruncles they have been supposed to act chiefly by inducing suppuration upon the diseased parts, ancl dissolving them in this manner. It is obvious, however, that in the cure of these ex- crescences, there is something farther necessary than the formation of matter. Indeed instances occur dai- ly, of their Iving constantly immersed in matter, some- times proceeding from their own surfaces, and at oth- er times from the contiguous parts, without their being diminished. I rather conceive that bougies, even in this variety of obstruction, operate partly by mechan- ical pressure, and partly by exciting inflammation in the excrescences. We shall hereafter have occasion to see, that some of the remedies employed for the re- moval of warts in other parts, prove chiefly useful by making them inflame; and as bougies are well calcu- lated for this purpose, I think it probable, that while they evidently answer a good purpose by the pressure which thev afford, thev prove likewise serviceable by 19 146 OF OBSTRUCTIONS CI). III. exciting over these excrescences that slight degree of inflammation, which, in the treatment of common ve- nereal warts very commonly makes them drop off. £ 4. Of Obstruction in the Urethra from Strictures, properly so called; of Bougies, and Fislulae in Perineo. IN the more fixed kinds of Obstruction, proceeding from Gonorrhoea, the diameter of the Urethra is les- sened in two different ways. For the most part it is diminished by a thickening faking place at some par- , ticular point in the membrane of the passage itself or mther in the corpus spongiosum urethra?, in a similar manner to what frequently happens in the membrane of the nose in cases of catarrh. At other times the urethra is drawn together, or contracted, as if a cord was tied round it, without any other disease being per- ceptible. In some cases, again, these two affections are con- joined ; and we find, in the same person, the diameter of the passage lessened in one part by a mere contrac- tion, and in another, by a swelling and thickening in the substance of the urethra itself. Every part of the passage is liable to strictures; but they are more frequent behind and immediately above the scrotum, than in any other part. In some cases a single stricture only takes place; but when the disease has subsisted for a length of time, we very commonly find the passage contracted in different parts. Where the urethra is merely drawn together, the disease seldom extends, at any one part, above the eight part of an inch, but where the stoppage proceeds from a swelling of the substance of the urethra itself, it sometimes extends to the length of an inch. From whatever cause the stricture may proceed, we commonly find that the urethra is affected equally all round; but it is very properly remarked by Mr. Hunter, that, in some cases, the disease seems to be SeC. IV. IN THE URETHRA, &C. J47 fixed entirely on one side of the passage, in which case the canal is thrown over to the opposite side. This seems to happen only where the obstruction is produced by swelling of the urethra, and not where it proceeds solely from contraction. Where this unequal diminution of the canal takes place, even in one part only, it is obvious that it must add greatly to the difficulty of introducing bougies ; and where more than one affection of this kind occurs, if they be not exactly opposite to one another, a kind of twisting of the passage takes place, which renders the passing a bougie impracticable. It must, however be admitted, that instances of this are rare. It is somewhat remarkable that the formation of strictures is often so gradual, that a patient is not sen- sible of their taking place till the disease has been of long continuance. Being seldom attended with pain till the flow of urine is much impeded, any partial de- gree of it passes without notice, by wdiich they are apt ito be rendered much more fixed and permanent than otherwise they would be. The patient indeed has sel- dom any suspicion of strictures, till the surgeon, for his own satisfaction, where Gleet continues more ob- stinate than usual, proposes to introduce a bougie. Gonorrhoea having given rise to the Gleet, any diffi- culty that occurs to the passage of the urine is consid- ered to arise from the same cause; and thus a great length of time often elapses before any such examina- tion is made as can with certainty lead to a discovery. This proves often, in its consequences, highly dis- tressful, and ought therefore to be as much as possi- ble guarded against; for strictures, by long continu- ance, become much more firm, as well as more ex- tensive, than they were at first, by which they be- come much more difficult to cure. Cases wdiich at first would have yielded almost to the first attempt with bougies, are, by delay, often rendered so obsti- nate that nothing will remove them but the most exact application of bougies being continued for a great length of time. 148 OF OBSTRUCTIONS Cll. III. In all cases, therefore, in which there is the least cause tosusi^ectthat strictures may exist, an examin- ation should be made wilh bougies. But as patients* themselves are apt to be deceived upon this point practitioners ought, in every instance, to lead their attention towards it. In different parts of this work we shall have occasion to see that Gleet is frequently kept up by strictures: so that whenever a running becomes in any unusual degree obstinate, if there be not some other evident cause for it, a trial with a bougie should be proposed. This however, is sel- dom attended to; by which much unnecessary trou- ble, as well as loss of character, falls upon the practi- tioner, while the patient is made to suffer a great deal of misery which might have been prevented. We have already had occasion to remark that the strictures of which we are now speaking are conse- quences of Gonorrhoea ; but in what.manner they are produced by Gonorrhoea is perhaps difficult to explain. J They have been attributed chiefly7 to ulcers induced by the disease, and to inflammation. At one period I was induced to suppose, chiefly from: the information I had from books, that strictures were in m<»st instances produced by ulcers. But from more frequent opportunities of observing the seat of Go- norrhoea after death, I am now convinced that ulcers very r^eldom take place here, by no means so frequent- ly as strictures, the disease they are supposed to pro- j duce. It sometimes indeed happens, that the mem- brane of the urethra covering strictures, is found in a state of tenderness, or of excoriation, but not com- j pletely ulcerated. This appears too to be the effect of the disease rather than the cause of it. It seems to proceed, in some degree, from the tumefaction of the membrane of the urethra, which often occurs in j strictures and in some measure from the acrimony of I the matter which these very strictures produce. When ulcers are met with in Gonorrhoea, they are in most instances, I believe, produced by the rup- ture, of one or more blood-vessels. If it be not at Sec. IV. FROM STRICTURES, &C. 149 the very point of the urethra, they never proceed from the matter of Lues Venerea. Now we can scarcely imagine that any ulcer which the rupture of a blood- vessel in the urethra could probably produce, would be of such depth or magnitude as to be attended with any important consequence of this kind. Neither are haemorrhages from the urethra frequent; nor have I found that strictures have been particularly apt to hap- pen, even where haemorrhages have taken place in an alarming degree. I consider it, therefore, as decided, that strictures in the urethra seldom or never proceed from ulcers. Inflammation, when violent, may certainly tend to produce them ; and I think several instances have fallen within my own observation where this actually happened. I do not suppose, however, that this is such a frequent cause of strictures as is commonly ima- gined, nor do I agree with those who think that in- jections often produce them. As it was observed, that strictures were, in some instances, induced by inflammation, and injections be- ing supposed, by those who are prejudiced against them, very apt to inflame the urethra, it was long ago asserted, and has since by many been believed, that they tend more frequently than any other cause, to produce strictures. This, indeed, is held forth as the most important objection to the use of injections, and were it in any degree well founded, I admit that it would be a strong reason for laying this remedy en- tirely aside ; for however desirable it may be to have the running in Gonorrhoea quickly carried of, and however efficacious injections may be, no practitioner would advise them were it to be with the risk of indu- cing such a formidable disease as strictures often are. Where strong stimulating injections are unguarded- ly used, such a degree of inflammation may thus be induced as may be productive, of the most obstinate strictures. But this is not the fault of the remedy7,: as I have elsewhere observed, being entirely the effect of an improper application of it. We might with 150 OF OBSTRUCTIONS IN THE URETHRA Ch. III. eaual propriety condemn the use of some of our most effectual and safest medicines, merely from an over- dose having done harm. . Instead of injections being a frequent cause ol stric- tures I have much reason to think that they are more effectual than any other remedy in preventing them. Although I have admitted that strictures are sometimes produced by severe degrees of inflammation, 1 do not consider this as a frequent occurrence. Strictures I conceive to be most Irequeotly the consequence of a state directly the reverse of inflammation. In a great proportion of cases they will be found to take place> where, either from no injection being used, or from some other cause, the discharge has gone on to a very unusual length, where all symptoms of inflammation were gone long before, and where nothing but a Gleet remained. At least this has been very generally the result of my observation, and, I believe, it will be admitted by all who have paid attention tothe point in question. I therefore conclude from this, as well as from the appearances which these parts exhibit on dissection, that this variety of obstruction proceeds most frequently from a state of morbid relaxation or debility, induced in these parts of the membrane of the urethra upon which the inflammation at first fixes with most violence, and from which the subsequent discharge is in a great measure produced. Where stricture succeeds immediately to inflamma- tion, it appears to be that variety of it in which the urethra is compressed, or tied, as it were, with a cord: but where it does not appear till the inflamma- tion subsides, and the discharge has been of long du- ration, the substance of the urethra is found, at those parts where the strictures exist, spongy, soft and prom- inent, bearing every mark of having completely -lost its tone. The existence of this variety of stricture being as- certained, and it will not be confounded with any oth- er disease where the observations contained in the pre- See. IV. I ROM STRICTURES, fcc. 151 ceding parts of this section are kept in view, our next object is to fix upon the method of cure. While the opinion prevailed of strictures being most frequently produced by ulcers in the urethra, as this led to the suspicion of their being connected with Lues Venerea, mercury was advisee) in almost every instance. Mercurial ointment was regularly rubbed upon the seat of the disease, in order to dissolve the cause of the obstruction, and the patient was put un- der a salivation, with a view to the safety of his con- stitution. As this was the prevailing practice of our best sur- geons, both here and in other parts of Europe, when I entered upon business, I was necessarily led to adopt it; but late experience having shewn that mercury is never necessary in the cure of strictures, I have now for many years past laid it altogether aside. Nay, I readily own that I never knew any advantage derived from it, while in many instances, when long persisted in, it evidently did harm. It will not be imagined, that during this late period of time, mercury was ever alone depended upon for the removal of strictures in the urethra. Bougies were then very generally employed ; but mercury, for the reason I have mentioned, was always advised along with them. Bougies had long been known to practi- tioners, but they were so coarsely formed, and theit application so little understood, that scarcely any ad- vantage was derived from them, till Mr. Daran, about fiftv years ago, brought them into more general notice. By*forming them with care, and introducing them with address, Mr. Daran had the credit of giving us the only remedv upon which we can place any depend- ence for the cure of strictures. At least we are cer- tainly in a great measure indebted to him for bringing them into general use. It is true that Mr. Daran attributed virtues to his bougies which they did not possess. Being much in- terested in the sale of them, he wished to throv a mys- tery, over their composition. They acted chiefly, he 152 . OF OBSTRUCTIONS IN THE URETHRA t;Il. III. said, by their suppurative quality : in consequence of which, and by the great discharge of matter which they produced, tumours, and other causes of obstruction in the urethra, were, he alledged, dissolved by them, which could never otherwise have been removed. The con- fidence with which this was asserted, by a man of Mr. Daran's experience, and the considerable discharge of purulent-like matter which usually accompanies the use of bougies, gave weight to an opinion which at last came to be very generally adopted. We now know, however, that it is not by exciting a discharge of matter that bougies act in the cure of stric- tures. Even the mildest bougie we can employ, when kept in the urethra for an hour or two, is covered with a kind of matter on being withdrawn; but this happens as readily where the urethra is sound as when it is ob- structed in various places, and it proceeds entirely from the natural mucus of the passage being increased in quantity, and somewhat altered in appearance, by the irritation excited by the bougie. Even admitting the obstructed parts to be more par- ticularly acted upon, and a greater discharge of mattei excited from them than from the other parts of the urethra, and which Mr. Daran asserted to be the case under his management, of the bougie, still this would not account for the removal of excrescences ; for we know, from daily observation, in other parts of the body, that the whole surface of excrescences of a sim- ilar nature to those which Mr. Daran supposes to take place here, may be kept in a state of complete ulcera- tion, and a great quantity of matter discharged from them for a great length of lime, without any diminu- tion of their size. Bougies, in the cure of these strictures, seem to act solely by pressure, and the support which they afford to the diseased parts. If a bougie, of sufficient firm- ness, exactly or nearly the size of the urethra in its contracted state, be passed at first, and others of a larger size afterwards introduced, we know from ex- perience, that if done with caution, no harm will en- SeC. IV. FROM STRICTURES, &C. 153 sue, and that the stricture for which it was employed, will thus, in a gradual manner, be removed, merely by the pressure of the bougie. In this view, our chief object in the forming of bou- gies should be, to give a firmness sufficient to afford support to the parts which we wish to compress, and a smoothness and flexibility which will admit of their being introduced and retained in the urethra with the greatest possible ease. Numbers 34, 35, 36, and 37, in the Appendix, con- tain prescriptions for bougies of different colours and consistences, with some directions for the method of preparing them ; but the exact formation of bougies being a matter of the first importance, and this being only to be acquired by extensive experience, it is bet- ter for surgeons to procure them from those wdiose sole profession it is to make them, than to attempt to form them themselves. Besides the forms of plasters mentioned in these prescriptions, other articles have been employed for the construction of bougies, particularly cat-gut and resina elastica. Of these the latter is by much the best, and for all the smaMer kinds of bougies, I now find it to be preferable to the best bougies of the common kind. Even when of the smallest size, it can be made of such a degree of firmness as to admit of being push- ed with considerable force, which is not the case with the smaller kinds of common bougies, which are apt to bend, and to become twisted, although introduced with much care and attention. The great ex pence of bougies of this kind has hith- erto prevented them from being so generally known as they ought to be : besides, they were at first made so soft that they nearly dissolved in the urethra on being allowed to remain in it for the space of an hour or two ; but this fault is now so entirely7 removed, that I have known them remain in the passage seven or eight hours at once, and yet as firm on being withdrawn as when tirst introduced. This renders it a valuable article, not only for bougies, but flexible catheters. 20 154 OF OBSTRUCTIONS IN THE URETHRA <^U. III. This resin has one very essential advantage over ev- ery composition that has yet been employed for bou- gies. It does not crack or break while in the urethra, however frequently it may be introduced. Wmen the common bougies are prepared with much attention, and the composition of which they are formed is not too much boiled, they may sometimes be used two or three times with safety ; but, in most instances, they cannot with propriety be introduced more than once. Nav, many of them, on remaining an hour or two in thepassage, are so much cracked as to excite a great deal of irritation and pain even on their first introduc- tion, insomuch that I have met with different instances where patients had been deterred by this cause alone from using bougies, the irritation which they excited being so great as to be perfectly insupportable ; while, on having recourse to those formed of resina elastica, they were found to create no kind of uneasiness. These bougies are formed of fine silk, or linen, dip- ped in tie resin dissolved in aether. They were ori- ginally invented by Mr. Thedn, of Berlin, and now are made by different artists in Paris. There is cause to regiet that the art of forming them is as yet confined to a very few, so that our supplies have hitherto been both scarce and uncertain. In the use of bougies the following are points which particular!) require attention: 1. Trey should be provided in such numbers, and of such variety of sizes, that there may be no doubt of as many being at hand as in any case may be requisite. 2. Gn proceeding to introduce the first bougie, care should be taken to fix upon one of such a size as will probably pass without exciting much pain. It is better ai first to have it rather smaller than might be made to pass, than be afterwards under the necessity of with- drawing it. Of this we may in general judge by the size of stream in which the urine is observed to "flow. It is often indeed found to be forked, and sometimes flattened, owing to the form and nature of the strict- ure, but, with some attention to this circumstance, we Sec. IV FROM STRICTURES, &C. 155 may, for the most part, be determined in the size of bougie that will answer. 3. The patient should be placed in such a posture, as tends, in the most effectual mariner, to relax the ure- thra. He may either be made to stand, with his thighs separated, and* his body bent gently forward, or he may be laid upon his back, with his thighs not only sepa- rate, but raised. He ought, on no account, to be sea- ted. In sitting the urethra is apt to be so much com- pressed that no space is left for the passage of a bou- gie. I have known several unsuccessful attempts to pass a bougie from this cause alone. 4. The surgeon being seated on the right side of the patient, should grasp the penis with his left hand, and, at the same time should draw it gently forward, so as to stretch the urethra to such a degree as may prevent it from catching the point of the bougie. With the bougie previously well oiled, in his right hand, he should insert the point of it into the urethra, when it must be passed slowly, though firmly on, till it meets with resistance. Neither should he desist at once on the stricture being met with. It answers better to continue to push on the bougie with a due degree of firmness, than to withdraw it immediately, as is often done. The first application of a bougie to the obstruc- tion, is very apt to excite irritation and spasm, even in the stricture itself; and I have often thought that this was more easily overcome by pushing the bougie on at first than by any subsequent introduction of it. 5, A knowledge of the force that may with safety be employed in passing a bougie, can only be acquired by experience. The less violence that is done to the ure- thra, or to the cause of contraction, the better. It can- not, in some cases, be done without pain, but it should never be made to force a discharge of blood. When blood comes away, the instrument should be instant- ly withdrawn ; for when this takes place, we may always be certain that some parts have been injured which ought not to have suffered, and by contin- uing to force on the bougie, that there is a con- siderable risk of its forming a new passage for itself, 156 OF OBSTRUCTIONS IN TIKI URETHRA 6. The distress which ensues from a new opening being formed by a bougie is apt to be so great, that no- thing should be omitted that can in any way tend to prevent it. When there is cause to suspect, from the quantity of blood discharged, that the membrane of the urethra is injured, the bougie ought not to be again introduced for several days ; not till there is reason to suppose that the wound in the urethra is healed, for, till this takes place, it is obvious that it would be very apt to renew the injury. 7. As bougies might all to be of a conical form, they should not be pushed farther at first than freely through the first obstruction, otherwise the contracted part is apt to be torn open with too much force. It answers better to proceed gradually,- and to increase the size of the bougie, or to push one of the same size farther on, in such a manner, as may avoid every risk of injuring the membrane of the urethra. It is true that cures will be obtained where bougies have been introduced with much violence; where vio- lent pain, accompanied with haemorrhage, has been excitul ; but this is a practice, which, for the reasons I have mentioned, ought never to be adopted. 8 The bougie being introduced, some attention is re- quired to prevent it from slipping altogether into the urethra, as well as for n taming it in the depth at which it is inseited. We oblain tiie first of these objects by bending the end of trie bougie, which, for this pur- pose, should be left a* least half an inch out of the ure- thra ; and the usual method of retaining a bougie in its place, is, by tying a piece of soft cotton thread to the end of it, and fixing it with this either directly to the penis, by passing it once or twice round about the glans, or connecting it to the circular belt of a com- mon suspensory bandage. But the most effectual me- thod, as well as the easiest, which I have tried, is fit- ting the penis with a small bag or pouch of cotton or - linen. The bougie being intiodueed with its end bent down, the bag must be put over the penis, and SeC. IV. FROM STRICTURES, &C. 157 being fixed with two pieces of tape to a circular belt round the body, the bougie is in this manner easily retained. Common bougies being of no great value, may be cut of such a length as to leave half an inch or so, out of the urethra, for the purpose of bending down in the manner I have mentioned ; but those of the elastic gum should be kept of every variety of length, from three or four inches to nine or ten ; and being easily formed with a knob at the large end, they are thus, in the most, certain manner, prevented from slipping in. When this caution has been neglected, and when a bougie is thereby allowed to slip completely into the urethra, it is sometimes, by the aukward attempts of the patient, forced altogether into the* bladder. In this situation, it cannot be removed but by cut- ting into the bladder, as is done in the operation of li- thotomy, and extracting it with forceps. But while the bougie continues in any part of the urethra it may be taken out by an operation of much less importance and hazard. When the end of the bougie can be seen, it may with some care and attention be laid hold of with a small hook, or with narrow-bladed forceps, such as are used for extracting stones that fix near to the end of the ure- thra. But when it has passed so far in, that it cannot be perceived, this method of extraction will not suc- ceed. In this case if can only be got out by making an in- cision upon it directly into the urethra. The skin should be first drawn bac k, when a cut should be made through the teguments and urethra at once, of at least half an inch in length, when, if the end of the bougie can be laid hold of, it may be taken out at this open- ing ; or if this be not practicable, it may be pushed forward till the end of it passes out at the end of the urethra. This may be done either with small forceps or pliers, or by sticking a pin into the bougie at the opening, and pushing it slowly on. The wound for the most part heals easily. 158 OF OBSTRUCTIONS IN THE URETHRA l^ll. III. 10. The circumstances which next require attention in the use of bougies are, the time they should be allow- ed to remain in the urethra, and the frequency with which they should be introduced. § As bougies act, perhaps, entirely in the cure ot stric- tures by the pressure which thev afford, and prove chief- ly useful by the total change of stricture which they in- duce in the parts to which they are applied, they must necessarily require a considerable time for effecting this. The longer, therefore, that they are retained in the urethra, the sooner this will be accomplished. But while we attend to the removal of the stricture, care must be taken to prevent injury by their exciting too much irritation. This, indeed, is the circumstance by which we ought to be chiefly directed. It may be laid down as a general rule that bougies may beretainedin the urethra as long as they excite no pain or irritation; while, in every instance,'they should be withdrawn as soon as much pain is produced by them. At first they can seldom be allowed to remain lon- ger than half an hour at once ; but, on the urethra be- ing for some time accustomed to receive them, they may, for the most part, be left in it for several hours; and this may be repeated once and again during the course of the day. 11. During the time that bougies remain in the ure- thra the patient should be prevented from waiving or moving more than is absolutely necessary. This is not usually attended to with necessary strictness, by which many are prevented from deriving that advantage from bougies which otherwise they would receive. In walking, with a bougie in the urethra, the irrita- tion induced by it is at all times considerable ; but this more especially, when common bougies are employed. The motion in walking is apt to crack and break the plaster of which they are formed, which renders their surfaces rough and unequal, by which it is obvious that much harm must be done. 12. In order to obtain the advantage of perfect rest while bougies are introduced, we are. advised by many SeC. IV. FROM STRICTURES, &C. 159 to employ them only at bed time, and to allow them to remain in the passage during the night. This may an- swer when the patient is not liable to nocturnal erec- tions, but where these arc apt to occur it ought never to be permitted. I have known several instances of much pain and inflammation induced by it. It may, in some circumstances, be more convenient to apply bougies during the day, but it is evident that it may be done with more safety. 13. To admit as long a retention as possible of bou- gies in the passage, some have alledged, that the pa- tient may, with safety, be allowed to void urine while they remain in it. 1 have known this done, and no harm ensue, w here the urine was passed slowly, and with much caution : but I have also known the attempt do much harm, and as ihe trouble of introducing the bougie a second time is not equal to the hazard of al- lowing it to remain, I always advise it to be withdrawn on a desire to void urine taking place. Besides the pain and inflammation which want of at- tention in this matter is apt to induce, and erections oc- curring during the introduction of bougies have like- wise this effect, I have known different instances of its appearing to lay the foundation of spasmodic affections of the urethra, which afterwards proved very obstinate, even after the original strictures were removed. 14. By gradually increasing the size of the bougie, the stricture through which it is passed w ill at last be removed ; but before it is entirely destroyed, it will be proper to push forward the bougie, to discover wheth- er there is any other cause of obstruction or not. It U better, however, not to make the attempt till the open- ing through the first is considerably enlarged, when it will much more readily succeed. Whatever other strictures are discovered, they must be managed in the manner we have advised for the first; the: bougie must, if possible, be made to pass through them all, and the size of it gradually increased till the urethra is opened to its complete, natural size. 15. In passing bougies fortius purpose, it has been a 160 OF OBSTRUCTIONS IN THE URETHRA ClI. III. point in dispute, whether they should be carried the length of the bladder, and allowed to remain in it or not. I am decidedly of opinion that they should be pas- sed completely into the bladder, as soon as this can be done, in order to discover the utmost extent of the strictures; but I also think that they should never be allowed to remain in the bladder. The common bou- gies are so apt to crack, and pieces of the plaster to fall off, that this might very possibly happen from their being immersed in urine ; and we all know, that if a particle should drop, not small enough to pass off with the urine, that it would probably serve as a nucleus for a stone. This would not so readily happen with bougies of elastic gum; but even these, where there is so much hazard, ought not to be trusted, particular- ly as there is no real necessity for it in the management of strictures ; for it is found upon dissection, that they are always seated anterior to the neck of the bladder. They are often in the membranous part of the urethra; but they have, perhaps, never been met with in the prostate gland, I mean in the urethra as it passes through this gland. It must be admitted that the urine is often obstruct- ed by affections of this gland ; by inflammation, as well as by a more indolent kind of swelling, to which, as we have elsewhere had occasion to see, it is some- times liable. But this variety of obstruction, instead of being removed by bougies, is always injured by i them. We are sometimes under the necessity of pas- | sing a catheter, even during an inflamed stale of the '' prostate gland ; but this should only be done for draw- ing off the urine when it has been completely suppres- sed. When the gland has been for some time swelled in such a manner as to create a stoppage to the flow of urine, it is obvious, from its firmness, that bougies cannot remove it, while, by the irritation which they excite, they never fail to do harm. 16. Besides the length of time wdiich bougies should be kept inserted daily, it is an object of importance to determine at what period they may, with safety, be SeC. IV. FROM STRICTURES, &C. 161 laid aside. This, I must acknowledge, is difficult to do, as it depends upon a variety of circumstances with which it is impossible, at all times, to be acquainted. Even where the stricture is so completely removed that boutries pass with ease, and the urine is voided in a full stieam, the disease is apt to recur if the bougies be too soon left off'. They should, in every instance, be worn for a considerable time after all appearances of stricture are gone, and the more obstinate the dis- ease has been, the longer they should be continued. Even after a patient considers himself as m> entirely well that he may conceive no hazard to ensue from the farther use of bougies being entirely dropped, still he ought to have them, at all times, in his possession, so as to be able, on the least return of obstruction, to employ them instantly. This is a precaution not often adverted to, but which ought never to be disregarded by any who has suffered in this manner: and I think it the more necessary to insist upon it, from several in- stances having fallen within my own knowledge of the most distressful consequences ensuing from a neglect of it. It is more particularly proper for all people, in this situation, going upon a journey, to be well pro- vided with bougies; for, when from home, they can- not always readily meet with them, while, at the same time, they are more exposed to the various causes mo^l apt to excite a return of the d^ease. These par- ticularly arc1, exposure to cold and dampness; much fatigue, whether on foot, horseback, or in a carriage; and excess in wine and spirituous liquors. All of these cau-es act with such certainty in indu- cing a return of affections of this kind, that I have seldom known them foil where people have been much exposed to them; and, inmost instances, their effect is perceived soon after their application, I have known a person, who, after being completely cured of stric- tures, for several years, has been seized with a very hazardous and painful return of the disorder, in the course of an hour or two after being much exposed to a cold, east wind. It is particularly apt to occur from 21 162 OF OBSTRUCTIONS IN THE URETHRA Ch. III. violent exertion on horseback, and from being much overheated with wine; more especially from excess in port. wine. A return of stricture is also apt to arise from the urine being, at any time, too long retained after a desire takes place to pass it. This ought always to be guard- ed against; but I also think it right to mention, that patients sometimes err in getting into the habit of void- ing urine too frequently. By yielding immediately to every impulse, such a habit takes place that they are apt, from this cause alone, to continue, during life, to pass it every hour or two. This proves not only very inconvenient, but it is also apt to induce a contracted state of the cavity of the bladder, together with a thickening of its coats, its full distension, which natu- rally ought to occur from time to time, being thereby prevented. Hence it is a matter of no small impor- tance for patients, in this situation, to observe as just a medium as can be done between the two extremes which we have mentioned. On the least return of stricture being perceived, whatever the cause may be, a bougie should be imme- diately introduced. The patient, if he is plethoric, should be blooded in proportion to his strength; his bowels should be opened with a gentle laxative, or with a clyster ; and he should be kept in bed till the violence of the disease be removed. In this manner I have known the most formidable attack soon carried off, while, from treating them with inattention, even the most trifling symptoms have been rendered severe, and in the highest degree obstinate. The sudden and unexpected manner in which pa- tients are often attacked with a return of these affec- tions, has given cause to suspect that they must, in such instances, proceed from spasm. But the obstinacy with which they often continue, as well as every other circumstance attending them, renders it obvious, that, in a great proportion of cases, they proceed from caus- es of a more permanent nature than spasm is almost ever found to be. Sec. iv. FROM STRICTURES, &C 163 17. We have hitherto been supposing that the stric- tures are of such a nature as to permit a bougie to be passed with no great difficulty; in which case, no doubt can be entertained of our being able, by perseverance, either to accomplish a cure or to afford at least very effectual relief, and to prevent any alarming obstruc- tion from taking place to the passage of the urine ; for however bad a stricture may be, if bougies of a small size can be passed at first, we may always be able, as I have already observed, in a gradual manner, to in- troduce those of a larger size. But frequently, either from the passage being contracted to a very small size, or from the stricture being altogether on one side of the urethra, by which the passage is thrown over to the opposite one, after a variety of attempts we find no progress made, or if any thing is gained, it is so in- considerable as to afford no kind of relief. This proves always very dispiriting to the patient, and is apt to dis- pose practitioners not much versant in this branch of business to desist from all further trials: considering the disease to be incurable, they prescribe a course of palliatives, which, for the most part, avail little, while the oaly remedy from which advantage could be ex- pected is deserted. This ought never to be done, at least it ought never to come on the part of the practitioner, nor can any thing warrant the measure but the patient himself be- ing determined against the farther application of bou- gies. This, from impatience and disappointment, is apt to happen; but it ought at all times, to be as much as possible resisted. Even in the most obstinate ob- struction that occurs, if the passage be not altogether obliterated, a surgeon of experience will scarcely fail, if he be not prevented by the impatience or timidity1 of his patient from persevering for a due length of time. 18. When there is cause to suspect that the passage is thrown over to one side of the urethra, by the stric- ture being fixed in the other, a point in which we may sometimes be determined by external examination with 164 OF OBSTRUCTIONS IN THE URETHRA Cll. III. the fingers, and most frequently by the feelings of the patient the extremity of the bougie should be slightly curved or bent before being inserted, and the point of it being turned towards that side where the passage is understood to be, if carried on in this direction, we will sometimes succeed, when various attempts have ,> failed in the usual manner. It will be readily suppo- ,. sed that the curvature given to the bougie must be ve- r> inconsiderable; but even the slightest will some- times give it the direction which we wish it to take,' vhile it does not prevent it from passing, with suffi- cient ease, along the urethra. 19. In the introduction of a bougie it ought to be kept firm between the finger and thumb of the right hand, and pushed gradually forward till it reaches the st.iicture; but, when it has got this length, it common- ly answers better to twirl it between the finger and thumb, taking care to push it gently forward at the same time. At least I often succeed in this manner when the usual method of pushing it directly on, has failed. 20. I have already observed that no more force ■should be used in the introduction of a bougie than is merely necessary for making it pass; but it is proper to remark, that, in tlie hands of a surgeon of experi- ence, much more force may with safety re applied thm oiler-can, with any propriety, venture to em- ploy. By pushing a bougie slowly and gradually for- ward, we often force it through strictures without any dischaige of blood taking place, while much pain and Jaeesath n is sometimes produced even by less violence, when applied in a hurried or quick manner. 21. When we find upon trial that a small bougie," nearly the size of the opening* is made to pass, no force will be afterwards required, if the bougies be gradually increased in size. But when we find upon repeated trials, that the remaining passage cannot be discovered, and when we therefore mean to employ more force, a bougie of greater strength should be used in place of the smaller one. The small-sized SeC. IV. FROM STRICTURES, &C. 165 bougies, particularly those of the common kind, are so easily bent that they should never be employed where much force is required. I have known even surgeons of experience push forward bougies of this kind, and concluding that they had passed the stric- ture, have carried them on till they imagined they had nearly reached the bladder, w hen,'on being withdrawn, they were twisted up in the form of a corkscrew, hav- ing never gone farther than the stricture. With a firm, well-polished bougie of elastic gum, well rounded at the end, and not smaller than a crow's quill, such a force may be applied as will often suc- ceed when no advantage can be derived from those of a smaller, size; and we should not be deterred from proceeding, although the first trials prove unsuccess- ful ; for we often pass the stricture by perseverance when no advantage was gained at first. * 1 have reason, indeed, to imagine, from what has happened in the course of my own practice, that few cases will occur.which may not ultimately be cured by bougies. But when they do, in what manner are we to proceed? When every trial that we dare venture upon with bougies fails, what are we to do ? This, it is evident, must depend entirely upon the state of the parts affected, and upon the degree of obstruction which takes place. If there is still such an opening left as admits of the urine passing off with tolerable ease, I would advise nothing farther to be done. A patient, in such a situ- ation, had better submit to the inconvenience of pas- sing it slowly, and even frequently, than to the ope- ration of removing the stricture, which consists in lay- ing the obstructed part of the urethra open, and in the frequent introduction of a bougie during the process of the reunion of the divided parts. This, however, is an operation of much importance: it is attended with so much pain, and with such uncertain success, that no practitioner of experience would recommend it while the urine is not totally obstructed; and long before this could probably happen the situation of the 166 OF OBSTRUCTIONS IN THE URETHRA Ch. Ill,, parts Iving between the stricture and the bladder is commonly such as to induce the patient to submit more readily to any operation that may be necessary, than he ever would have done in a more early stage of the disorder. Whenever the stricture occasions much difficulty to the flow of urine, that part of the urethra lying between the stricture and bladder, is ne- cessarily distended on every attempt to void urine. This frequent stretching at last weakens the lining membrane of the urethra; the urine is at first in small quantities, and afterwards in larger, forced into the surrounding cellular substance: this, forming one or more small tumours, at last bursts out through a cor- responding number of openings, either in the perine- um, or in the cellular part of the scrotum. At least this is the usual progress of such tumours when-the strictures in the urethra, by which they were produced, cannot be removed. This is the most frequent cause of the disease we have already had occasion to mention, Fistula in Pe- rineo, in which the urine continues to flow out at the newly forced openings, as long as the strictures in the urethra are allowed to remain and which accord- ingly, as we have already observed, makes the pa- tient easily submit to whatever may be necessary for removing them. In such circumstances nothing will prove successful if the diseased parts be not freely laid open. A staff being introduced the length of the stricture, and a small probe passed in at one of the openings, and carried to the opposite side of the strio ture, the intermediate space should be laid open by an incision in the direction of the urethra. In this man- ner the cause of obstruction will be discovered and re- moved, and the other sinuses communicating with the urethra being likewise laid freely open, a cure even of the worst cases that occur, may thus be frequently obtained. To enter more fully into the consideration of this operation, and of the after treatment of the sores, would here be improper, as it would extend this article to too great a length. It could not be done X SeC. IV. FROM STRICTURES, &C. 167 with precision and clearness without entering upon the general doctrine of fistula, and upon different methods of cure that have been proposed for it; and as this has been done in a different work, I must now refer to what I had then occasion to say upon it.* Before concluding the consideration of strictures in the urethra, I think it necessary to notice a method of cure that has been proposed where we fail in the in- troduction of bougies, the repeated introduction of caustic into the urethra, with the view of destroying the cause by which the stricture is produced. This practice prevailed upwards of a hundred years ago, but was soon relinquished. It has lately, how- ever, been revived, or rather a proposal made for re- viving it, by Mr. Hunter of London, under whose di- rection, it is to be hoped that it will soon become as generally useful as we can ever expect it to be. But as I consider this practice as more or less hazardous, and not likely to prove often effectual, I shall briefly slate what leads me to form this opinion, that others may be on their guard against too implicit an adop- tion of it. The introduction of caustic into the urethra must prove hazardous from two circumstances, our not be- ing able, even with all the pains we can take, to ap- ply it to the stricture alone, without injuring the con- tiguous parts of the urethra, and the risk which there must always be of some small portion of the caustic breaking off and being left in the passage. Mr. Hunter has indeed invented a very neat appa- ratus for the introduction of caustic. It consists of a silver tube, open at both ends, nearly the thickness of a common catheter, with a port-crayon, somewhat longer than the tube, into which the caustic is fixed. A stilletfe, with a perfectly round end, is first passed through the tube, and if it be exactly fitted to the end of it, the two together may be carried with perfect ease along the urethra till tney come in contact with * V. System of Surgery, chapters xv. and xx, 168 OF OBSTRUCTIONS IN THE URETHRA XjD. III. the stricture, when the stillette to be withdrawn, and the port-crayon, with the caustic fixed in it, introdu- ced. The caustic being applied to the stricture for about the space of a minute, must be withdrawn along with the instrument, and this must be repeated every two or three days till the cause of obstruction is re- moved. ; . This, from description, appears perfectly simple, and of easy execution : but notwithstanding the ingen- uity of the invention, it is obviously liable to the two objections which I have mentioned. We know even where parts are uncovered, and therefore immediately under view, that it. is exceedingly difficult to destroy diseased parts with caustic, without injuring the con- tiguous sound parts. In the urethra, therefore, where we receive no advantage from the eye, and where the slightest deviation of the instrument may fix the caus- tic upon the urethra itself, instead of the stricture, there must evidently be a good deal of hazard from this circumstance alone, independent of the chance of injuring the contiguous'parts merely by the spreading of the caustic, admitting it to be applied with all man- ner of exactness. Besides, as the size of caustic that can be passed in this manner is necessarily very small, there must always be some hazard of its slipping out or breaking off, an occurrence from which the highest degree of distress would ensue; for it could not be extracted, and dilution could not be employed with such effect as to prevent it from doing a great deal of mischief. Another very important objection occurs to this practice. A great proportion of all strictures, perhaps nearly ninety of a hundred, are seated beyond the curve of the urethra, to which an instrument sostreight as a tube acting as the conductor of another body ought to be, cannot be carried. But Mr. Hunter, fore- seeing the difficulty, has endeavoured to remove it by proposing that the end of the tube should be flexible, and of the same form with the common flexible cathe- ter of silver. But this, while it apparently adds to the See. IV. FROM strictures, kc. 169 ingenuity of the invention, renders it evidently more hazardous. The small point of caustic contained in the port-crayon will be more apt to be broken or loos- ened in passing through a curved tube than through a streight one, while it will not be possible to apply it to any one point with such firmness and steadiness. But even admitting that caustic may with safety be conveyed to strictures in the urethra, yet, in those cases which do not yield to the use of bougies, the obstruc- tion is generally of considerable extent, and the quan- tity of caustic necessary for removing it so great, that the contiguous sound parts of the passage must be much injured, whatever care and attention we bestow in the application of so active a remedy. On these accounts, it would appear, that, for the removal of strictures in the urethra, the application of caustic is either impracticable or unsafe. In all slight obstruc- tions of the urethra, a degree of force may be used with bougies, sufficient for removing them. Whenever this can be done, no person will doubt of the pro- priety of preferring them to the use of caustic ; and when the cause of obstruction is of such extent as to render our attempts with bougies unsuccessful, there will be little or no room to hope that caustic will an- swer the purpose. In other parts of the body we all know how difficult it is to remove even the callous edges of an ulcer with caustic. Nay, in many in- stances, new parts seem to form before the eschar pro- duced by the previous application of the caustic has come off. I have no hesitation, therefore, in saying, that in similar affections of the urethra, proceeding to the extent which we here suppose them to do, caustic would either be altogether inadequate for the purpose, or must be applied in such quantities as would be at- tended with a great deal of hazard. In all such circumstances, I consider it as preferable to let the disease take its usual course. The worst that cim happen i.-, the formation of sinuses behind the strictures, and the discharge of urine from ti;e open- ings which these produce. Few patients incline long 09 170 OF OBSTRUCTIONS IN THE URETHRA to submit to this; but I consider the cure of this state of the disease, by the mode of treatment already poinh-d out, as more certain, while it is obviously much less hazardous t! an the means proposed for pre- venting it by the application of caustic. Since the time our author wrote on the subject of Stricture, a very important improvement in the method of treating tneni has been introduced, viz. their destruction by the use of caustic. We do not mean to say that its use is entirely novel, as we know that a variety of caustics Were used by the older surgeons, as Daran, Pare e, Hiklahus, Astruc, and others, who used Lunar Caustic, Lapis- infernalis, Red Precipitate, &x. ; but that the use of it is now re- duced almost to a system, by which we can frequently relieve this most troublesome complaint in one tenth part of the time, that is required, in the use of the merely mechanical remedy, the bougie. For the revival at least, of this method of treating strictures, we are indebted to the ingenious Mr. J. Hunter, whose repeated fail- ures in the ordinary method, ^by the bougie,) induced him to at- tempt their destruction by the caustic ; and had he been as success- ful in the mode of applying, as lie was judicious inNthe choic; of the application, he would have left little for his successors to do, at least, in those cases of stricture to which this method of treat- ment is applicable. Fortunately, what the z ai of Mr. Hunter did not accomplish, has been atchieved by the science and perseverance of some modern surgeois, at the head of whom we must unques- tionably place Mr. Home, surgeon to St. George's HospiLl, Lon- don. We cannot pretend to give even an outrine, of Mi. Home's " Practical Observations on the treatment of stricture in the ure- thra, See." in the short compass of a note ; yet we cannot refrain from abridging some of the practical maxrms whicn they contain, as a hint to those who unfortunately do not possess tne entire work. Of Strictures properly so called, there are three kinds, viz. the true or permanent stricture, arising from an alteration in the structure of a part of tne urethra, the mixed, or that in which the former is combined with spasm, and lastly, what has (p rhaps im- properly) been termed he true spasmodic stricture. The first of these species mot>t unequivocally demands the use of the caustic, and in such cases Mr. Home makes use of the lunar caustic (nrtiate of silver) which he applies in the following manner. " tie takes a bougie which can be easily passed down the urethra to the stricture, and nseits a piece of lunar caus.ic into the end of it, in such man- ner, that while the caustic is even with its surface, it is surrounded every where literally by the substance of the bougie." This he directs to be done some time before it is to be useu, in order t.at the soft materials of which the. bougie is composed may have time to fix more firmly about the caustic, and prevent its slipping out; Sec. IV. FROM STRICTURES, &C. 171 when prepared in this way, it is oiled and is then ready for use. Tire bougie thus armed, is used ir. the following manner,a common bougie of he same size is passed down to the stricture, in order to clear the canal, and to measure the exact distance of the stricture from the orifice of tire urethra. This distance being marked upon the armed bougie, it is to be passed down to the stricture, as soon as the other is withdrawn. Tne caustic in its passage is scarcely allowed to come into contact with any part of the membrane, be- cause the pnint of the bougie, of which the argentuni nitratum forms the central part,always moves in the middle line of the canal; and indeed the quickness with which it is conveyed to the stricture, prevents any injury of the membrane lining the passage, when the caustic accidental y touches it. In this mode the caustic is passed down with little or no irrita- tion to the lining of the urethra, it is applied in the, most advanta- geous manner to the stricture, and can be retained in that situation, sufficiently long to produce the desired effect. The arguments in favour of this mode of treatment over that by common bougies, are first, tnat a permanent cure is effected, wi ich is seldom the case when the common bou ie is only used ; secondly that the application produces little or no pain, and that inflamma- tion, a c mmon consequence of the application of the common bougie, does not ensue. It is not pretended by Mr H. that every stricture is curable in this manner, but that in all cases, wivch have come under his care, in a very extensive practice, it has proved the most efficacious, and even in cases where it failed of effecting a cure, that it was at- tended with no bad consequences. In the application of the caustic to the second or mixed species of stricture, Mr. Home claims the merit of originality, and observes " having met with a number of facts, from which a general principle appears to be established, that the irritable state of a stricture is kept up, and even increased, by the use of the bougie, but lessen- ed and entirely destroyed by the application of lunar caustx ; I am desrrous to communicate my observations upon these facts, and to recommend the use of the caustic, in many cases of irritable strict- ure, in preference to the bougie. As the use of the caustic upon this principle is I believe, entirely new, and is contrary to every no- tion that had been formed upon the subject, it will require some- thing more, than general assertion, to gain even the attention of many of my readers, still more their belief; I shall therefore detail the circumstances, as they occurred, by which I conceive the pro- priety of this practice, to be established ; and afterwards make some observations, upon the principle on wnich it depends" Mr. Home proceeds, « my connection with Mr. Hunter, afforded me opportunities of attending to cases of stricture, in all their different stages ; many of tnem brougnt on during a long residence in India, attended with great irritability, and exceedingly difficult of oure." 172 OF OBSTRUCTIONS IX THE URETHRA Cll. III. One case of this kind admitted the passing of a small bougie; but, in the course of three years, very little was gained by a steady perseverance in the use of that instrument, either in dilating the canal, or palliating the symptoms of stricture ; this made me look upon die bougie as less efficacious, than I had always been taught to believe it. I was willing, hoAvever, to consider this as an uncommon case, de- pending more on the peculiarity of the patient's constitution, than on the nature of the disease : but I found on a particular enquiry, that several other gentlemen from India, Avere under circumstances nearly similar; the bougie only preventing the increase of the stricture, but being unable to dilate it beyond a certain size ; and when it was left off, the stricture in less than tAvo months returned to its former state of contraction. What plan ought to be tollowed in such cases, I was then unable to determine ; but, that the bougie could not be depended on was evident. During this suspense, the following case came under my care. In August, 1794, a gentleman consulted me, for some symp- toms Avhich had been considered as indicating the presence of Gon- prmcea; but as they did not yield to the common treatment in the usual time, he was induced to take my advice respecting the nature of his complaint. In the necessary enquiry, to obtain a perfect history of the case, among other things it Avas stated, that, nineteen years before, there was a stricture, which became very trouble- some, and that Mr. Hunter, by the desire of the patient, had appli- ed the caustic, by which the stricture Avas removed, and never afterwards returned. He said that he was one of the first per: sons, on whom the caustic had been used. From this account, I was naturally led to believe, that the stricture had gradually re- turned, and was now increased so much as to produce the present symptoms ; a discharge being almost always a symptom of stricture when it is much contracted : but, upon examining tire canal a bougie pf a full size passed on to the bladder without the smallest im- pediment. I therefore took up the case as an inflammation in the urethra; and large doses of the balsam copaibae effected a cure. The circumstance of a stricture having been removed nineteen years before, and not returning, made a strong impression on rny mind; and made me desirous to ascertain, whether this practice could be employed in cases of stricture in general, and the cure produced by it, equally permanent. A short time afterwards I had an opportunity of trying it in the following case. A captain in the East India company's service, in Sept. 1794, ^p(.lieci to me for assistance, iiis complaints were, great irritation in the urethra and bladder, constant desire to make water, and an inability to v-id it, except in very small quantities. These symp- toms had been at first supposed to arise from Gonorrhoea, after- wards rendered more severe by catching cold ; but not yield- ing to the usual remedies for Gonorrhoea, they Avere investi- gated more minutely and a stricture Avas discovered in the urethra. Tne mode of treatment was noAv changed, and the bougie employ- ed j but, its use aggravated all the symptoms, and brought on so SeC. IV. FROM STRICTURES, &C. 173 great a degree of irritability on the bladder and urethra, that there was an alarm fo: the patient's life which was the reason for applying for my assistance. Besides the local symptoms, this patient had those of quick pulse, white tongue, hot and dry skin, loss of appetite and total want of sleep, with frequent attacks of spasm on the bladder and ure- thra. A very small flexible gum catheter was passed, and the water drawn off, in quantity about a pint, which gave him great re- lief ; this was repeated morning and evening, to keep the bladder in a*s easy a state as possible; but, in other respects he continued much the same. As the present symptoms were brought on by the use of the bougie, little good was to be expected from that instrument ; and when the urethra had been so easily irritated, and was disposed to continue in that state, there was no prospect of the bougie after- wards effecting a cure. These circumstances I explained to the patient; and mentioned, in proof of my opinion, the case, in which r,o little had been effected in three years. I then proposed to him a trial of the caustic, with a vieAV to deaden the "edge of the stricture, as the only probable means of effecting a cure. The degree of irritation Avas already great; I was however, led to believe, that the application of the caustic would not increase it, since by destroying the irritable part, it might les- sen, and even remove the spasmodic affection ; but if, contrary to my expectation, the irritation continued, we still should be able to draAv off the water, as the slough formed by the caustic, would pre- Vent the edge of the stricture from acting, and obstructing the in- strument. The application of the caustic was upon these grounds, determined on ; and it was applied in the following manner. I passed a common bougie, nearly the size of the canal, down to the stricture, to ascertain its exact situation, and to make the canal of the urethra as open as possible. The distance Avas then marked upon a bougie armed Avith caustic, of the same size, Avhich Avas conveyed doAvn as quickly as the nature of the operation would admit. It was retained upon the stricture, with a slight degree of pressure ; at first there was no pain from the caustic, but a sore- ness from pressure ; in less than a minute, a change Avas felt in the sensation of the part, it Avas at first a heat, succeeded by the burn- ing pain peculiar to caustic ; as soon as this was distinctly felt, the bougie and caustic were withdrawn, having remained in the urethra about a minute altogether. The soreness he said Avas entirely local, by no means severe, was unaccompanied by irritation along the canal, and he thought the uneasiness in the bladder diminished by it He described the pain as resembling very exactly the first symp- toms of Gonorrhoea. This sensation lasted half an hour after Avith- drawing the bougie. The caustic Avas applied in the forenoon, and he passed the day more free from irritation, than he had been since the beginning of the attack, which had lasted six days. In the evening the Avater was drawn off witn more ease, than the night before. He passed a 174 OF OBSTRUCTIONS IN THE URETHRA Ch. III. tolerable night, and the next day continued free from irritation. On the third day, the caustic was again applied in the forenoon; the painful sensation was less, than on the former application, lasted a shorter time, and in an hour after the armed bougie was withdrawn, he made Avater freely, for the first time since the commencement of his indisposition. He said the irritation in the bladder was re- moved, and he felt very well. His appetite returned, he slept verv well, and continued to void his urine with ease. In this state nothing was done till the fifth day, leaving always a day between the applications of the caustic. On this day a common sized bougie went readily into the bladder ; it was immediately withdrawn, and the cure was considered as corhpiete ; no bougie was afterwards pass. ed, lest it might bring back an irritation upon the passage. I met this gentleman twelve months after, and he assured me, he had continued perfectly Avell, and I have since learned, that, in three years there has been no return. The result of this, and some other cases, induced Mr H. to adopt it, as his general practice in strictures : He does not pretend however, that it will answer in every case, and it is well known that in some irritable cases it is altogether inaclmissable ; in gouty dis- posed persons, it has induced a fit of the gout: in persons who have j been afflicted Avith intermittents, it has excited a return of that complaint, and both of these disorders have been brought on by the use of the caustic, in so distressful a degree, that it was impossible to repeat the remedy. As the arming of the bougie, is a matter of very great im- portance, and as the mode already described, is occasionally liable to the unpleasant accident of leaving the caustic in the urethra, we insert from Mr. Home, the process pursued by a Mr. Pass of London, in the preparation of bougies for this operation. l> In forming the bougie, a piece of wire of the size of the caustic is rolled up along with it, passing into the substance for half an inch; when the bougie is nearly finished, the Avire is withdrawn and the caustic inserted in its place ; after this the bougie is rolled again, so that the sides of the caustic become firmly cemented to the linen, by means of the composition of the bougie, and when cold cannot be separated by any force. In this Avay bougies are now generally armed." The caustic should not be app.ied oftener than once every other day, unless in very obstina'e cases, in which Mr. Home observes, he has applied it daily, without detriment. The preparative bougie, or the one first passed down in order, to ascertain the seat, size and shape of the stricture, is termed by Mr. Home ihe soft bougie, and is made of oil, wax, and resin, in such quantities, as to render it sufficiently firm for introduction, yet yielding enough to receive an impression from the stricture into Avhich it is passed. It should be of a light colour, that these im- pressions may be more aistinctly seen. _ When the soft bougie passes through the stricture, by leaving it m tne canal a few minutes it can be knoAvn whether the stricture is completely destroyed or only relaxed ; in the last case there a Sec. IV. FROM STRICTURES, &C. 175 an impression on the side of the bougie. So necessary is the infor- mation acquired in this way, says Mr. Home, to enable the surgeon to prosecute the cure of stricture by means of the caustic, that without it I should have been unable to pursue this mode of prac- tice. I should have Avanted a sufficient degree of confidence to car- ry me on, which nothing but an accurate knowledge of Avhat had been already clone, could ha\e given, and, in no other way, is that to be acquired. We offer these as a few of the more important practical remarks, and directions, contained in Mr. Home's Treatise on Strictures, Sec. It is however but a very imperfect hint, and we cannot leave his work without recommending it to the most serious and attentive perusal ol every surgeon ; being perfectly satisfied that no abridg- ment of it can do justice either to the work itself or its author. Mr. Whately, another surgeon, to whom we are much indebted for many valuable communications on different subjects, has also furnished us with a treatise on strictures, in which he maintains, that they are not merely a contraction of the fibres of the urethra, but actually diseased portions of the membrane lining that canal, with a continued disposition to increased contraction, and concludes that the camtic is a remeciy calculated to remove the diseased affec- tion, and to dilate the contracted part, effecting a perfect cure, without the troublesome and painlui inconvenience of wearing a bougie. Mr Whately does not, however, use the nitrate of silver as re- commended by Mr Home, but states, that he has discovered in the kaii purum, a most efficacious and valuable substitute, for that painful application ; indeed he considers it more efficacious as well as Kss painful and hazardous. When it is determined that the use of this remedy is admissible, the following are a summary of his directions for its application, viz " Put a small quantity of kali purum upon a piece of strong paper, and break the bit of caus- tic with a hammer into small pieces of about the size of large and small pins' neads. In doing this, care should be taken not to reduce it to powder. Thus broken, it should be kept for use in a phial, closed with a ground stopper. The bougie should have a proper degree of curvature given to it, by drawing it several times between the finger and thumb of the left hand. Mr. Whately next acquaints us, that before the caustic is insert- ed into the bougie it is necessary to ascertain the exact distance of the stricture, (to which the caustic is to be applied) from the ex- tremity if the penis. For this purpose, the bougie, which should be just large enough to enter the stricture Avith some degree of ti htness, ought to be gently introduced into the urethra ; and AMien its point stops at the stricture, which it almost always does, before it will enter it, a notch is to be made with the finger-nail, on the upper or curved portion ol the bougie, on the outside of the urethra, exaclly half an inch from the extremity of the penis. Wueii tne bougie is withdrawn, a small hole, about the sixteenth part of" an inch deep, . .gth, it ought to be managed in every instance with the greatest delicacy and attention. It may be proper to remark, that it proves chiefly useful where the disease is confined to the urethra ; al- though, in some cases, it has succeeded even where the bladder and kidneys have been affected. Where the urine in such cases passes off involunta- rily, blisters, we have said, answer with most certain- ty when applied to the loins. This probably proceeds, from the disease in these instances arising, for the most part, from an affection of the bladder itself; but where it proceeds, as it may sometimes do, from a tendency to paralysis in the urethra and muscles connected with 190 OP DERANGED SENSATIONS Ch. m, it, blisters will prove most useful when applied to the perineum. Where the urine passes offin this manner, balsam of copaiba, and other astringent balsams,are usually given. They are supposed to act chiefly by restoring the tone of such parts, as appear to be relaxed and weakened, and which it is imagined they must do, from their hav- ing a peculiar tendency to pass off by the organs of urine. In like manner the internal use of canlharljcles is prescribed, from an idea of this symptom depend- ing, in every instance, on a loss of lone in the parts af- fected, and from our knowing, that in most cases, can- tharides proves a powerful stimulus both to the kid- neys and bladder. All of these balsams, as wTell as the common turpen- tines, which are not essentially different, may in all such cases be used with safety. In some instance^ they may perhaps prove useful, and I do not imagine they will ever do harm. This, however, cannot be said of the internal use of cantharides. In large quantities they act as a poison : and even where managed wilh caution, the principle of the practice seems, in such cases as we are now speaking of, to be doubtful; for as there is cause to suppose that the disease proceeds more frequently from too much irritability about the neck of the bladder and urethra, than fiom any defi- ciency of tone, there is reason to fear, that by increas- ing the sensibility of the parts affected, they would in many instances be more apt to do harm than good. It is therefore proper, previous to the internal exhibition of cantharides, to determine with accuracy whether the disease proceeds from real weakness or morbid ir- ritability. In the one case they may sometimes prove useful; in the other they will be apt to add to the vio- lence of the disease. Cicuta has been frequently prescribed here ; and when given to such extent as to act as an anodyne, it may sometimes prove useful. Upon the same principle, hyoscyamus may with propriety be prescribed ; hut we have no reason to suppose that either of these arti- cles act in any manner in curing the disease. As no Sec. V. IN THE BLADDER, &d 19! organic affection appears to take place here, they can- not act by dissolving hard or enlarged parts. Any ad- vantage thrived from them will therefore be nearly in proportion to the anod\ ne effects which occur from them ; and in this view, they may prove useful when opiates disagree with the stomach, as in such circum- stances it is of consequence to have it in our power to employ remedies of a similar operation. Electricity has now and then given a temporary re- lief to symptoms of this kind. It should be exhibited in the form of sparks drawn from the parts chiefly affected, particularly from the perineum, and parts most contiguous to the nerk of the bladder. It is proper however, to remark, that the same ob- servations are applicable in advising electricity that were made upon the internal exhibition of cantharides. Both of these remedies, as well as the application of blisters to the loins, have been chiefly prescribed, where in affections of this nature, the urine passes off invol- untarily, and they are advised upon the idea of this symptom proceeding from paralysis of the neck of the bladder. But as there is much cause to imagine that the frequent discharge of urine, which patients in this situation are sometimes distressed with, proceeds more from irritability in the neck of the bladder than from real weakness, there is leason to think that electricity, by increasing the sensibility of the part affected, and w'hich, in many instances, it evidently does, will rath- er tend to aggravate the complaint. Blisters, whether applied to the loins or perineum, may prove useful, not merely by the discharge which they excite, but by the irritation which they produce upon the skin. There is nothing more certain than our being often able to remove pain and irritability from one part by exciting it in others. Of this we have frequent proofs in the application of blisters and other stimulants, in deep-seated pain in the side, where the distress is often removed as soon as the skin becomes warm and uneasy, and long before any vesications are produced. Sinapisms applied to the feet, have, in some instances, removed head-ache when every other 192 OF DERANGED SENSATIONS Cll. 1ft remedy has failed. In like manner blisters seem to op. erate when applied to the perineum, for the removal of those sensations to which patients in this situation are someti es liable. But electricity, as well as the internal use of cantharidt s, by tending to irritate the very parts in which the disease is seated, seem often to increase the violence of the symptom they were meant to rem* ve. By a due perseverance in the use of one or ofherof these remedies we commonly succeed in lessening or even in removing the violence of the distress; butai the symptoms are apt to recur, even after the patient considers himself as well, it becomes an object of much importance to obviate this. For this purpose, nothing proves so effectual as Peruvian bark and cold bathing, A free exhibition of the bark should therefore be pre- scribed, as soon as the pain and other symptoms have begun to diminish, and sea-bathing should be advised whenever it can be obtained. When this cannot he procured, cold water should be applied locally, both to the perineum and loins. Some advantage is derived from the parts being bathed with it, but it proves more effectual when forcibly dashed upon them. An involuntary discharge of urine, which we have already had occasion to speak of, proves always trou- blesome; but the distress which it exeites, is trifling when compared with what arises from the patient not being able to expel it. Even without any inflamma- tion, and where no cause of obstruction can be dis- covered in the urethra, a patient will sometimes find it impossible to pass a single drop. This, no douht, ofr curs frequently from other causes ; but every now and then we meet with it as an evident consequence of ir- ritability in the parts chiefly affected in this disease. All the remedies we have already advised will be equally applicable in the treatment of this symptom, as for the. removal of any of the others. Opiates, however, and warm bathing, prove chiefly useful; hut when relief is not soon obtained, it becomes necessary to draw the water off with a catheter; and, as much harm is apt to ensue from this being long delayed, it Sec. V. IN THE BLADDER, &C. 193 ought to be advised as soon as the bladder appears to be sensibly distended. In some cases the introduction of a bougie will prove effectualI; and as this gives less pain and irritation than the passing of a catheter, it ought in the first instance,. always to be preferred. One of the largest that will easily pass should be made use of; and, after allowing it to remain in the bladder for a few minutes, the pa- tient should be desired to pass his water instantly on the bougie being withdrawn. This ought not to be done with much force and pressure, otherwise the neck of the bladder and urethra are apt to contract instant- ly on the bougie being taken out; while the whole will pass completely off if it can be made to flow easily at first, along with the bougie. When this our intention in employing bougies is frustrated, we are under the necessity of employing the catheter; and, as it is of much importance, in all such cases, to prevent irritation as far as it can possibly be done, catheters of resina elastica should be employ- ed, instead of the common instrument of silver. It not only passes more easily, but when any difficulty occurs in getting it into the bladder, it may, in some instan- ces, be proper to allow it to remain for a day or two together, which can never, with any propriety, be done with catheters of silver. The practice of leaving catheters in the bladder is spoken of by some with much ease, and they advise it whenever any permanent stoppage occurs to the urine; but I have in different instances seen so much mischief produced by it, that it is a measure I never advise but where much pain and difficulty occurs in the introduc- tion of a catheter. In most instances, more pain is ex- perienced from the instrument being allowed to remain in the bladder, than ever occurs from its being fre- quently passed. Besides the irritation, which even the smoothest and softest instrument of this kind excites, they are apt to prove hurtful by incrustations of calcu- lous matter forming upon them, in consequence of de- positions from the urine. There are few people whose Urine is so free of this kind of matter as to prevent a 25 194 OF SWELLINGS OF THE TESTICLES. Ch. III. catheter, inserted into the bladder, from becoming rough with it in a very short space of time. This prac- tice, therefore, ought never to be adopted but wheretlie greatest difficulty is experienced in introducing the ca- theter. t SECT. VI. Of Swellings cf the Testicles. A Swelling of one of the Testis is a very frequent oc- currence in Gonorrhoea. From the resemblance which it bears to a hernia, and from its being supposed to proceed from the running or humour in Gonorrhoea falling down upon the testes, it is usually termed a Hernia Humoralis. In some instances both testicles swell. They sel- dom, however, swell both at once ; but the swelling, on leaving one testicle, is very apt to go to the other; and when both have in this manner been affected, they sometimes swell alternately for a considerable time to- gether. I have known this happen for the space of a year and upwards, where the patient, during the whole period, was never completely free of the disease. In long continued affections of this kind, the pain . becomes inconsiderable , but the first attack of the disease is always accompanied with severe pain. The first warning which the patient receives of it is a very painful sensation in one of the testis, striking along the spermatic cord, near to the middle of his back. On examining the testes he finds it swelled, and so tender that he can scarcely7 bear it to be touched. He feels himself hot, and a general uneasiness prevails over his whole body, particularly over his thighs and abdomen. Neither can he move without increasing the violence of every symptom. At first the swelling is confined to the epididymis; the back part of the testicle feels hard and enlarged ; but m a very short space of time, often in the couise of SeC. VI. OF SWELLINGS OF THE TESTICLES. 195 an hour, the whole body of the testicle becomes swell- ed. In this state of the disease a difference is still per- ceptible between the testis ilself and the epididymis. The latter is hard, and somewhat unequally so ; being, for the most part, hardest and most prominent at the bottom, whereas, a soft uniform swelling prevails over all the anterior part of the testicle. In the progress of the disease, indeed, even the tes- tis itself becomes hard, and if the means employed for preventing it do not prove successful, the swelling of the epididymis and testis together come to form a tu- mour of very considerable magnitude, accompanied with a red inflammatory affection of the scrotum. In this stale of the disease, the pain is often intense, accompanied with a very distressful sensation of the testis moving or rolling about. The skin is dry and parched, the tongue foul, thirst prevails, and the pulse is full, and quick. In short every symptom takes place which usually attends a high degree of local inflamma- tion. There is no period of Gonorrhoea in which this af- fection of the testis does not occasionally supervene. It occurs in all stages of the disease ; even towards the end of it, when both the patient and surgeon are apt to consider the cure as nearly complete : and in some we find it take place where no cause can be assigned for it, where neither the degree of the previous inflamma- tion, nor the mode of life of the patient, were such as could in any satisfactory manner account for it. It is proper, however to remark, that sw7ellings of the testis which take place in this manner, seem, for the most part, to be of a very different nature from those which occur during the virulent state of the disease, and while the inflammation in the urethra is considera- ble.. The latter appear to be altogether inflammatory. The disease proceeds more slowly to its height or acme. It remains more permanently at the size to which it arrives, and it disappears more slowly than the others, which come to* their utmost height, in some instances, in an hour or two from the first approach of the swelling, and again disappear with equal rapidity. These I conceive to be partly inflammatory, and that 196 OF SWrELT 1NGS OP THE TESTICLES. Cll. III. in part they proceed from that kind of sympathy which evidentiv subsists between the penis and testis, and which renders the one very apt to suffer from any dis- ease with which the other may be affected. That swnpathy has much influence in the production of this variety of the disease, is obvious from the swelling be- ing apt to leave one testis, as we have already observed, and to fix, peihaps instantly, upon the other. This does not occur so frequently as the alternate affection of the eyes, from one of them only being at first affected, but every practitioner must have met with in- stances of it. As it is observed that the running in Gonorrhoea is apt to stop on the first appearance of a swelled testicle, tl is gave rise to the idea of the affection of the testis proceeding from the matter falling down upon it, in consequence of being thus obstructed in its passage through the urethra. It is now well knowm, however, that no communication subsists between the urethra and testis, by which matter can pass from the one to the other; nor does the appearance which a swelled testicle affords, give reason to imagine that it proceeds from this cause. Instead of being soft and compressi- ble, which it necessarily would be were it produced by matter, it becomes daily harder, till it arrives at a cer- tain magnitude, when it gradually becomes softer again, but without any fluctuation of matter being perceived in it. There is reason to imagine, that in most instances the testis become affected by the inflammation spread- ing from the urethra along the vasa deferentia. This has been doubted by some, but without any good rea- son being assigned for it, nor has any other mode of accounting for it been suggested. We see that by the vasa deferentia a direct communication takes place be- tween the urethra and the testis, and the first appear- ance of a swelled testicle commences in the epididymis, formed as it were by the termination of this very line of communication. In a great proportion of cases too, the patient is sensible of a pain stretching from the swelled testicle along the groin, which we know to be i\ie direct course of the vas deferens. Sec. VI. OF SWELLINGS OF THE TESTICLES. 197 A variety of other causes might be mentioned, which tend to excite inflammation in the testis in a sim- ilar manner with Gonorrhoea : among these are, the irritation produced by a stone in the neck of the blad- der ; by the irritation on the introduction of a cathe- ter or bougie ; and the inflammation which takes place in these parts after the operation of lithotomy. A swelling of one or both testes is not an unfrequent oc- currence from all of these, particularly from the latter, and from the use of bougies, especially when they are not properly introduced ; and we see no manner in which it can be so readily produced as by the irritation excited about the neck of the bladder, carried along the vasa deferentia. The consequences of sw7elling of the testis, which we have most to dread are, a hardened state of the parts, chiefly of the epididymis, which, even when one, but more certainly when both testis are swelled, is apt to be followed by impotency; and a morbid irritability, which is sometimes so great as to prevent the patient for a considerable time from using any kind of exer- cise, and from following the ordinary occupations of life, without hazarding a return of the swelling of the testis. Suppuration in the body of the testis, from the inflammation induced by Gonorrhoea, is hardly an ob- ject of regard, for it does not take place in one of five hundred cases. But the two circumstances I have mentioned of a permanent hardness in the epididymis, and that distress- ful irritable state of the testis itself, which are apt to succeed to this disease, are objects of the first impor- tance, and require an immediate application of every remedy that can probably tend to prevent them. Scarcely any occurrence can prove more troublesome or inconvenient than swellings of the testis; and an enlarged state of the epididymis, when it takes place in any considerable degree, has, in many instances, as I have already observed, the effect of inducing impoten- cy. To a certain degree, a swelling of the epididymis often continues for a great length of time ; in some in- stances, during the life of the patient, without any bad 198 OF SWELLINGS OF THE TESTICLES. Ch. in, consequence taking place, particularly when one testi- cle only is affected. But I have known so many instan- ces of the contrary, and of* such distressful effects ensu- ing from it, as makes me with confidence say, that no- thmg should be omitted that can or might probably tend to prevent or remove it. As we find that all the symptoms of this disease, as well as the consequences which ensue from it, are usu- ally severe in proportion to the degree of inflammation which takes place, it ought to be our view, in every instance, to prevent this from arriving at any great height. This is most effectually done by blood-let- ting; a proper use of laxatives; opiates; the applica- tion of anodynes and astringents to the parts affected; preserving the body in a proper posture, and suspend- ing the testicle. Of all these remedies blood-letting is the most effect- ual and certain, particularly local blood-letting b\ the application of leeches. In plethoric patients, or where the swelling arrives at any considerable bulk, blood should be taken from the arm in such quantities as the strength wi!S permit, while, at the same time, a nu n- ber of leeches should be applied over the testis. But in weakly people, particularly where none of the symp- toms are violent, the abstraction of blood by means of leeches alone will commonly prove sufficient. The first application of leeches to a swelled testicle excites a good deal of uneasiness. They increase tbe irritability of the parts, and an increase of the tumour seems to be induced by them; but the discharge has seldom continued for the space of an hour or two till the pain abates, the tension, which before was consid- erable, becomes much less distressful, and the swelling even appears to lessen in bulk, and in the course of the following day the patient can allow the parts which he could not previously bear to be touched, to be hand- led with freedom. For the most part one application of leeches, if a proper number has been used, proves sufficient; but when any of the symptoms still continue severe, par- ticularly when the swelling does not diminish, when SeC. VI. OF SWELLINGS OF THE TESTICLES. 199 the pain does not lessen, and when the febrile symp- toms do not abate, it becomes in some cases necessary to repeat the application of leeches once and again. I think it here proper to remark, that we should never hesitate in this situation to take blood with freedom. A constitution must be delicate indeed that will be in^ jured even with repeated applications of leeches; and I am satisfied that very important advantages may be derived in all cases of swelled testes from a timeous and proper use of them. Abstraction of blood by means of leeches is not on- ly useful in shortening the duration of the inflamma- tory symptoms, but, in consequence of this, it proves serviceable in preventing two very distressful conse- quences, which swelling of the testes is very apt to in- duce, viz. that swelled, indurated state of the epididy- mis which I have mentioned, and the most frequent variety of hydrocele, formed by serum collected in the tunica vaginalis. We have already had occasion to remark, that a permanent swelling of the epididymis is a very frequent effect of an inflamed testicle, and I have met with several well-marked instances of hydro- cele proceeding from the same cause. That blood- letting in any way, whetiier general or local, will at all times prevent the accession of these symptoms, I will not pretend to assert; but, from the result of much observation, I am convinced that it answers this purpose with more certainty than any other remedy that has yet been employed. In many situations leeches cannot be procured; when this happens to be the case, nearly the same ad- vantage may be derived from srrmll punctures being made on different parts of the swelling. The punc- tures should he made with the point of a lancet, and if tie scrotum be previously immersed in warm water, nearly the same quantity of blood will be obtained from them as from the same number of leeches. As swelling of the testicle in Gonorrhoea seems in every instance to proceed from the irritation excited in the urethra, it is an object of tie first importance to remove every cause that can in any degree tend toirri- 206 OF SWELLINGS OF THE TESTICLES. Cfl. HI, tafe either the urethra or contiguous parts. Hence, where costiveness prevails, gentle laxatives prove par- ticularly useful. I have known different instances of hardened fceces collected in the rectum inducing swel- lings of the testes; and nothing tends more certainly than this to keep up the disease, by whatever cause it may at first have been induced. But although cos- tiveness is to be guarded against, we are, for a similar reason, to shun the opposite extreme. Strong purga- lives always excite much irritation in the rectum, and are therefore to be caiefully avoided in Gonorrhoea, It must consist with the knowledge of every practi- tioner that they universally do harm. Where the bow- els are moderately easy, no medicines for this purpose can be required, but when they are not in this situa- tion, castor oil, flowers of sulphur, cream of tartar, or any other gentle laxative, should be employed. Even these should be given in small doses, repeated at pro- per intervals, rather than that any risk should be in- curred of exciting irritation in the rectum by their be- ing exhibited in larger quantities. With a view to lessen and remove the irritation and pain in the tumour with as much certainty and expedi- tion as possible, opiates should be prescribed imme- diately on the pain becoming severe. When they can be avoided till one or more easy stools have been pro- cured, they prove most useful; but when much irrita- tion prevails, no regard should be paid to this. A3 the sickness and general uneasiness which sometimes occur from a swelled testis are evidently the effect of irritation, nothing proves so effectual in removing these symptoms as adequate doses of opiates; and at the same time that they remove this distress of the system by lessening the pain, they also tend to carry off the swelling of the testicle. From an idea that opiates tend to increase the heat and other symptoms of fever, many practitioners are afraid of using them wherever fever takes place in any considerable degree : but much experience of their influence enables me to say, that they may be employed with much safety and advan- tage in every stage of swelled testis where the degree of pain is considerable. See. VI. OF SWELLINGS OF THE TESTICLES. 201 This is so remarkably the case, that I have known instances of the hernia humoralis, as it is termed, being cured by opiates alone, which did not yield to the usual remedies. In whatever manner Gonorrhoea may act in exciting swelling of the testis, the tumour, when once produced, excites so much irritation, that, till this be lessened, the swelling for the most part contin- ues obstinate. Next to blood-letting, opiates prove the most effectual remedy for this purpose. While the internal exhibition of opiates thus proves useful, advantage is often derived from applying them to the swelling itself. This may be either by the ap- plication of soft pledgits, soaked in laudanum, or ano- dyne balsam, or by poultices made with a strong de- coction of poppy heads and crumb of bread. All the saturnine applications prove useful here* Wnen Goulard's extract, as it is termed, is employed, or what is nearly the same, the acetum lythargyri, it ought to be in greater quantities than are used in other parts of the body ; for the testes being protected by different coverings, remedies of this kind, when of the ordinary strength, do not readily affect them. When saccharum saturni is employed, as it will not dissolve in sufficient quantity in water, if vinegar be not added, and as vinegar proves an useful application, even by itself, these two remedies ought always to be combined. The steams of warm vinegar act as an useful discu- tient here. In applying them, the testes should be properly suspended over a vessel in which boiling vin- egar is contained; or the swelling may be fomented from time to time with flannel immersed in warm vin- egar, and so strongly wrung, that nothing but steam remains upon it. Vinegar, in every form, acts with much advantage in this disease, and this gives a plea- sant variety in the way of applying it. Whateyer remedy is employed, the body should be kept as much as possible in a horizontal posture, at the same time that the scrotum should be properly sus- pended. We find by experience that no remedy will prove effectual while the patient Continues to walk 26 202 OF SWELLINGS OF THE TESTICLES. I'll. III. about; while, in many instances, a horizontal posture of itself, will have a considerable effect in removing the disease. In suspending the scrotum, care should be taken to do it in such a manner that the testicle he completely supported without being compressed. Pres- sure, even in a slight degree, always does harm, and ought to be avoided. We have already had occasion to observe, that in Gonorrhoea a stoppage of the discharge often takes place on the first approach of a swelled testis. This leads to the ideSt of some advantage being to be deriv- ed from our exciting a return of the running; and there is not a doubt of this proving in some instances useful. The discharge from the urethra not only les- sens the inflammation in the part from whence it pro- ceeds, but it has also an influence on the tumour of the testis. As it is now universally admitted that a re- turn of the running does not act by drawing matter di- rtily from the testis, some have suspected that it never can prove useful. But why may not a discharge exci- ted in the urethra act in a similar manner in removing an inflammation of the testis, that we know from daily experience happens with setons and Other issues in the treatment of inflammatory affections of other parts? The fact indeed, is, that a plentiful return of the dis- charge very commonly relieves all the symptoms of this disease. For the purpose of exciting a-return of the running, bougies prove most effectual; but in affections of the testis they require to be managed with a delicacy not usually observed in this branch of practice: for if more pain or irritation be produced than is necessary for the purpose, instead of acting as a remedy, they necessarily aggravate every symptom. In common practice, I think it better to trust to the frequent ap- plication of warm emollients; such as the immersion of the penis in warm miik, or in decoction of althea, or lintseed ; applying warm poultices over the penis, and injecting warm oil or milk into the urethra. From the instantaneous manner in which swellings of the testes sometimes succeed to a stoppage of the SeC. \I. OF SWELLINGS OF THE TESTICLES. 203 discharge in Gonorrhoea, and from their appearing, we are told in some instances, even to precede this stop- page of the running, some have doubted whether they are to be considered as the cause or effect.* That the testes may first inflame and the running afterward stop, cannot be doubted. But although this may happen in a few instances, the very reverse is what we common- ly meet with, insomuch that patients who have once been affected with swellings of the testes, are very apt to experience a return of the disease in every Gonor- rhoea to which they may in future he liable, solely from the running being carried off in the usual way. I know several, who, for this reason, dare not use even the mildest astringent injection; otherwise they are sure to have a swelling of the testis induced : while, in others, it swells at the termination of the running, whether injections have been used or not. In the course of my observation, therefore, no cause for doubt has occurred upon this subject. By a proper application of the different remedies we have mentioned, swellings of the testes are for the most part soon relieved, and at last carried off entire- ly excepting that permanent hardness to which the epididymis, as we have seen, is particularly liable. But although this is the common event of the disease, yet instances are not wanting, most frequently indeed from the patient's misconduct, of the whole body of the testis remaining swelled, and obstinately resisting all those remedies which usually prove effectual. If, in this situation, some application be not made, by which the size of the tumour is soon diminished, and if it be allowed to remain stationary for any length of time, it is very apt to continue much enlarged, and sometimes of a schiirous hardness during the life of the patient. I may also remark, that it is this state, of the disease which is most apt to terminate in hydro- cele ; or effusion of serum into the tunica vaginalis tes- tis, with which it is sometimes attended. In this situation mercury is commonly employed; * Vide John Hunter, or the Venereal Disease. 204 OF SWELLINGS OF THE TESTICLES. Cll. lit. and, in some instances when given slowly, as an alter- ative, I have seen it prove useful ; but it is doubtful whether a complete course of mercury should ever be advised or not, for when it does not carry off the swel- ling, which seldom happens, it is apt to increase it, and to induce pain and irritation in the tumour when none existed in it before. Whenever mercury, therefore, is advised, it ought to be in such quantities as cannot tend to quicken the circulation or excite fever, A decoc- tion of mezereon has in some instances been given with advantage along with mercury.* It is in this state of a swelled testis, where the tu- mour does not yield, but remains nearly of the same size after the inflammation by which it was induced is gone, that emetics are most likely to prove useful. They have been used, I know, in all periods of the disease; but it is chiefly in the situation we are now speaking of that I have seen them act with advantage. A smart emetic, carried a proper length, will some- times, in the space of an hour or two, lessen the bulk of a tumour which had for several weeks obstinately resisted every other remedy. In some cases one eme- tic proves sufficient, while, in others, it requires to be repeated once and again. Mercurials were formerly used for this purpose. This was done from the dis- ease being considered as a symptom of Lues Venerea, and for which mercury was known to be the only anti- dote. But we now know that tumours of the testes, which take place merely from Gonorrhoea, never par- take of the Venereal Virus; and accordingly emetics, of whatever nature they may be, prove equally use- ful here with mercurials, provided the shock which they give to the system is equally considerable. I have sometimes, in this state of a swelled testicle, applied a blister with advantage. It might not perhaps be altogether safe to apply blisters while the scrotum continues much inflamed ; but when the external inflam- mation and tension subside, they may be advised with safety ; and, in different instances, T have known them • Vide Appendix, No. 15. Sect. vr. of swellings of the testicles. 205 accomplish a reduction of the swelling of the testis, where other remedies had-for some time been employ- ed without any effect. A c\ue perseverance in the use of some or all of these remedies will seldom fail where a swelling of the testi- cle is altogether inflammatory; but where it proceeds in a great measure from irritability, as we judge to be the case where the swelling comes and disappears sud- denly, or where it comes and goes from one testicle to another, other remedies are, in this situation, found to prove more effectual. Even in this variety of the disease, blisters some- times prove useful; and I have known the irritation removed, and the swelling carried off in the course of a short time by opiates; but these afford only a tem- porary relief, and do not prevent the disease from re- turning on the slightest application of any of the exci- ting causes which usually tend to induce it. • The remedies which here prove most effectual are cold bathing, and a plentiful use of bark. Sea bathing, when the season permits, should in the first place, be advised, but when this cannot be obtained, cold water may be used at home, with a proportion of common salt dissolved in it. It answers a good purpose wheth- er the whole body be immersed in it, or merely the scrotum bathed in it, but for the most part, I have thought that it proves most effectual when applied to the scrotum only. As bark and cold bathing act upon the same principle, that is, by7 giving tone and vigour to parts which we suppose to have been deprived of them, they may either be used together, or exhibited separately, as the patient may incline. The testes, we find, are apt to decay. One of them will begin to lessen in bulk, and, in a gradual manner, disappear entirely, or leave only a thin membranous substance in its place. Generally the other remains sound ; but I have known instances of both becoming affected at the same time, and others where the one remained entire as long as any part of that which was first affected was perceptible, but where it also began to decay as soon as the other was entirely destroyed. 206 OF SWELLINGS OF THE TESTICLES. Ch. III. This affection occurs at all periods of life, but most frequently after the 40th year. In many instances, no cause whatever can be assigned for it ; but I have ob- served that it is most frequent in people of delicate con- stitutions, where the muscles are soft and relaxed, and die complexion wan and sallow. I have also found that those in whom it occurs, have, in almost every in- stance, been in early life particularly addicted to Onanism. In a few cases it has appeared as an evident conse- quence of a swelled testicle. On the fulness produced by the disease being removed, the process of absorp- tion by which this was accomplished does not stop, but goes on till the whole testis is carried off. In some in- stances this takes place while the testicle continues to the last of its natural degree of firmness, or even while the hardness still prevails which occurred during the state of inflammation by which the swelling was at first induced: but, in others, before this wasting pro- cess commences, the testicle becomes soft and pulpy, or even dissolves into a fluid. It is seldom attended with pain, the patient being, in many instances, igno- rant of his lo-s till one, or perhaps both, testes are nearly consumed. Hitherto no certain remedy has been discovered for putting a stop to this complaint. Mercury, hemlock, and electricity have been tried, but with no advantage. The cold bath has for a time seemed to prove useful, but the disease returned again, and both testes were dissolved. In one case, where one of the testes was consumed before the patient perceived it, and where the other was evidently affected, I applied a blister over it. This wasting process stopped, and never re- curred again. The patient is about 36 years of age. His inclination and powers of propagation, he says, are still as strong as they were before, and he has late- ly had a child. Among the causes of hernia humoralis, the author's partiality has prevented him from naming injections. The early use of these in the inflamrmatory stage of Gonorrhoea, by checking the discharge from the urethra, has often given rise to this peculiarly distressing Sec. VI. OF SWELLINGS OF THE TESTICLES. 207 complaint. It is generally observed that when the swelling has been removed, the running is less in quantity than it was previously. A disease termed Fungus of the Testis, has been mentioned by some writers and particularly by Mr. Lawrence, the Demonstrator of Anatomy at St. Bartholomew's Hospital, as an occasional conse- quence of the hernia humoralis from Gonorrhoea. Injuries of va- rious kinds are also named among the causes and in some cases it has originated spontaneously. The following symptoms are stated by the writer named above. « It is preceded by a painful swelling of the testis, which is peculiarly hard to the touch. Aftera certain length of time, the scrotum, growing gradually thinner, ulcerates, but the opening which is thus formed, instead of discharging mat- ter, gives issue to a firm and generally insensible fungus. The sur- rounding integuments and cellular substance are thickened and in- durated by the complaint, so that there appears to be a considera- ble mass of disease. The pain abates and the swelling subsides considerably, when the scrotum has given way. In this state the disorder appears very indolent, but if the fungus be destroyed, the integuments come together and a cicatrix ensues, which is insepa- rably connected to the testicle." Mr. Lawrence considers that the glandular substance of the testis as the original seat of the com- plaint and that the confinement of this swollen substance by the dense and unyielding tunica albuginea is the cause of the peculiar hardness of the tumour and the pain attendant on it. The absorp- tion of the coats of the testis and the scrotum remove the tension, and give ease to the patient. It is conjectured by Mr. L. that the disease might be cured spontaneously, but from its being so indo- lent, this would not be eftected until after a long time. The modes which he proposes for removing the fungus, are either, the knife, or if the nature of its attachment permit, the ligature, or it may be freely treated with escnarotic applications. Castration, he con- siders as altogether improper and unnecessary. Nine cases are re- lated by Mr. L., in some of which, red precipitate or lunar caustic (nitras argenti) were used with success and in others the knife. The application of the ligature in one case caused severe pain, but since that time it has, in other instances effected a cure. It must be observed, that Mr. Lawrence considers the removal of the protuberance to a level with the scrotum, by means of the knife as the shortest and most effectual mode of treatment. (Edin-> burgh Med. and Surg. Journal, vol. 4, 257.) Ed. ^ 208 OF SWELLINGS OF Ch. III. SECT. VII. Of Swellings of the Spermatic Cord. THE Spermatic Cord is liable to swellings of dif- ferent kinds, but it is such only as proceed from Gon- orrhoea that we are here to notice. It sometimes happens that inflammation of the tes- ticle spreads to the cord, and excites pain and tume- faction along the whole course of it. At other times the cord inflames without any previous affection of the testis; it becomes tense, hard, and painful. The swel- ling, for the most part, is at first confined to the vas deferens, but at last the other parts of the cord suf- fer also. I I have met with some in which one or two tumified parts were perceived in the course of the cord, while the rest of it remained sound; but, in general, the cord is equally affected, from the testis along its whole course up the groin. On the first approach of this disease, as it is always accompanied with pain and tension, with some inabil- j ity to walk, the patient is induced to treat it with at- tention ; but, where the swelling is not soon carried off, the pain will sometimes abate, or even vanish altogeth- er; and in this state, where the tumour is not consid- erable, the patient is led to suppose that no harm can arise from it; by this neglect the swelling is often ren- dered so firm and hard that no remedies we can em- ploy have any influence in removing it. In some ca- ses I have met with a hard ring, affecting the cord only at a particular spot, where the diseased part was near- ly as firm as bone, while the rest of it was in a soft natural state. \S bile the tumour is confined to one part of the cord I have seldom known it increase to any alarming de- gree, but whether it be circumscribed, or extended I over the whole length of the cord, no time should be t lost in the application of remedies for removing it. In- : Sec. 'VIT. THE SPERMATIC CORD. 209 dependent of other reasons, if the vas deferens be chiefly affected or even only compressed in its couise, the testicle will be rendered as certainly useless as if it were extirpated : even this, in some instances, where one side only was affected, has appeared to render the patient impotent, and it will never fail to do so where the disease affects both sides. The remedies that prove most effectual here are blood-letting, blisters, and such others as are usually employed with advantage in swellings of the testis. These we need not particularly enumerate, as they were fully treated of in the last section; but it may be proper to remark that blood-letting proves chiefly useful on the first approach of the disease, and in this state, when properly applied, that if seldom fails in removing it. It may in some cases, be necessary to take blood from the arm, but tie local discharge of it by leeches applied to the part affected, is at all limes to be more depended on. Where the discharge of blood, however, does not soon lessen the size and hardness of the tumour, we need not afterwards expect any advantage from it. In this case I have repeatedly known blisters prove useful when applied along the course of the cord ; but neither are thev to be depended on if some effect be not soon perceived to result from them. In partial affections of the cord a small blister appli- ed to the diseased part, and the part kept open with ointment of cantharides, has tended to reduce the swelling. Mercury is commonly employed here, and where the disease does not soon yield to blood-letting and blisters it is perhaps the only remedy from which any advantage is to be expected; but I have commonly found, where the swelling has been carried entirely off by mercury, that there has been much cause to ima- gine that the patient at the same time laboured under Lues Venerea. In some cases, the disease has subsist- ed in an evident form of pox in other parts of the body, while, in others, there was only grounds for 27 210 OF SWELLINGS OF Till Cll. III. suspicion. In all of these the mercury seemed to operate with more certainty when a decoction of me- zereon and sarsaparilla was conjoined with it. Mercurial frictions prove more useful here than any other mode of giving the remedy, and the application of mercurial plasters to the swelled parts acts with more advantage in swellings of this kind than in any other in which I have employed them. -as>® quently remedies of this kind are applied, the more ^effectual they prove. They should be used at least five or six times daily, and for the space of a fevy minutes at each application. Emollient ointments are frequently employed in af- fections of this kind, but the very cause which renders astringentsmseful makes every application of this na- ture improper. They constantly increase the dis- charge, while no advantage of any kind accrues from them. Neither do we find that purgatives, or any of the cooling medicines usually prescribed here are of any seal utility. When much inflammation takes place, they may, in some instances, prove useful, but in all ^uch cases blood-letting is more to be depended on; particularly the application of leeches to the parts ifflh Sec. X. GLANDS AND PREPUCE, 221 mediately affected, which, in all local inflammatory complaints, is to be considered as the most effectual remedy. It has been objected to the application of leeches in excoriations of the penis, that the wounds from the bites of these animals are apt to degenerate into venefc real sores. This proceeded upon the idea of all such affections being produced by the matter of Lues Vene- rea ; but now when we know that this is by no means the case, it is obvious that the opinion must be ill found- ed ; and from various and repeated trials of the reme- dy in question I can decidedly say that it is so. But admitting that a case should occur, in which it might be doubtful whether the excoriation and swel- ling was truly venereal or not, still I would not hesi- tate in advising the application of leeches: they would prove more effectual than any other remedy in carry- ing off the inflammatory symptoms, while their bites, if they should put on the appearance of venereal sores, would immediately render the nature of the disease certain, which otherwise might long have remained in doubt. In all sores and inflammatory affections of these parts, the posture of the body and position of the pe- nis are circumstances requiring particular attention. The patient should be kept as much as possible in a horizontal posture; and the penis should be elevated so as to prevent the glans from hanging pendulous. It often happens indeed, where this is omitted that swel lings remain obstinate for many weeks together, which otherwise might have been carried off in a few days, 222 OF EXCORIATIONS IN WOMEN. Cll. Ill, SECT. XL Of Excoriations in the Parts of Generation of Women, THE parts of Generation in Women are liable to excoriations of a similar nature with those enu;nerat OF GONORRHOEA SIMPLEX*. Ol. III. assertion. The running continued for the space of two or three weeks, with all the symptoms of a common clap, and was cured precisely in the same manner, viz. by the use of astringent injections. We have succeeded in removing warty excrescences of every description, including those of a venereal nature, by the application of the undiluted tincture of the oxymuriate of iron. This remedy apparently acts solely by its powerful astringent properties; and we have observed that they are much less liable to recur after re- moval by this remedy, than after the stimulant and corrosive appli- cations of Mr. Bell. Ed. SECT. XIV. Of Gonorrhoea Simplex. I HAVE endeavoured in different parts of this work to shew that the discharge in Gonorrhoea Viru- lenta is the effect of inflammation excited in the ure- thra and contiguous parts by the matter of infection being applied to them. In the end of the preceding section a case is mentioned, in which symptoms occur- red exactly similar to those produced by Gonorrhoea Virulenta from the application of an irritating powder to the urethra ; and there is reason to suppose that they may at any time be induced by whatever excites in- flammation in any part of that membrane. A puri- form discharge from the urethra, induced in this man- ner, and without any connection with an infected per- son having taken place, may be denominated Gonor- rhoea Simplex. We have already bad occasion to see that a discharge frequently occurs in females, usually termed flurr al- bus, which, in particular circumstances, very much resembles Gonorrhoea Virulenta*. * Vide chapter ii section 10, Sec. XIV. OF GONORRHOEA SIMPLEX. 237 In men, we often meet with a disease exactly similar to this; where a copious discharge of matter takes place from the urethra, attended with a scalding heat in voiding urine, and all the other symptoms of Gon- orrhoea, and where there is no suspicion of infection being communicated. There is nothing more necessary than for practition- ers to be aware of this, particularly the younger part of the profession, who are apt to suppose that every discharge of matter from the genitals, especially in men, ought to be considered as venereal. But al- though this is undoubtedly true in a great proportion of cases, yet every practitioner of experience must have met with many instances of the reverse, and in which the reputation of the most virtuous people might have been ruined, were the distinction of which we are now- speaking overlooked. I have met with different in- stances of men newly married being seized with this symptom, in some of which, although there was at first sight much cause for suspicion and anxiety on the part of the husband, yet on being informed by a per- son on whose judgment they placed confidence, that a running of this kind is not unfrequently induced by other causes, and that the discharge which had newly- taken place, would probably shew, by its ending more quickly than Gonorrhoea Virulenta usually does, that it uas of a different nature, they soon became less anxious, and at last were convinced of their fears hav- ing been altogether groundless. In like manner, I have in different instances been consulted by women, who, on finding their husband's linen stained with matter, have fancied that they them- selves had been injured by them; and the imagination being once affected, we all know how difficult it is in such matters to set it right. I was some time ago con- sulted by a lady in circumstances of this kind, who, from the cause I have mentioned, had long been redu- ced to a state of the greatest distress and misery. Her mind was in the first place deeply afflicted with the supposed misconduct of her husband ; and she was 238 OF GONORRHOEA SIMPLEX. Ch. III. fully convinced that she herself laboured under almost every symptom which attends the venereal disease. To this she was in a great measure led, by the opinion of a midwife, who unfortunately informed her, that from much experience in matters of this kind, she was con- vinced that she was poxed, and desired her to apply to me. Instead of this, she put herself under the care of one at a distance from town, where she resided, and who, from not having much experience in matters of this kind, was easily induced to believe that symptoms took place which did not exist but in the imagination of the patient. There was no external mark of dis- ease, but she complained of pains in her bones; se- vere pains in the parts of generation and loins; uneasi- ness in the nose, throat, &c. In short, she had perused a modern treatise on the Lues Venerea, by which she had become acquainted with the symptoms of that dis- ease, almost all of which she now imagined that she laboured under. A complete course of mercury, besides a variety of other medicines, were given in the country, but no ad- vantage being derived from them, the patient came un- der my care. It appeared at once that she was diseas- ed in imaginatioTi only, for I did not find, on the most minute inquiry, that any symptom of the Lues Venerea had existed from the first. She acknowledged, that at different times, both before and after marriage, she had been much distressed with the fluor albus ; but this was the only disease of which she ever complained; and it never was of long continuance. I endeavoured to convince her that she was perfectly sound, that she never had the disease, and that the matter which she had seen on her husband's linen, and which was the only7 foundation of her suspicion, was either produced by his connection with her while she was distressed with fluor albus, or by some other cause of a nature equally innocent. All this, however, would have proved ineffectual, but I luckily had an argu- ment in my power which brought conviction along with it, and which in the course of a few days, made SeC. XIV. OF GONORRHOEA SIMPLEX. 239 all her symptoms vanish, which otherwise might have been of the most permanent nature. At the very time when she suspected her husband to have given her the infection, he had consulted me by letters, which I preserved, in which he expressed his astonishment at the sudden appearance of a discharge of matter from the urethra, accompanied with heat and uneasiness along the whole course of the passage from the glans to the bladder. He never had been infected with Gon- orrhoea, and having had no connection with any other woman than his wife, of whom he could not entertain the least suspicion, he concludes his first letter by enquiring whether or not such symptoms ever originate from other causes than intercourse with an infected person, and,at the same time wished that such medicines might be sent to him as would as quickly as possible put a stop to the discharge. In my answer to this, which I also preserved, I mentioned several causes by which a discharge from the urethra may be excited, and especially the effect of repeated intercourse with wo- men labouring under fluor albus, where the discharge is more acrid than usual. I at the same time sent him an astringent injection, desiring that it might be used if the discharge did not soon disappear. In a subse- quent letter he informed me that he had been perfectly convinced by my account of it that his disease was of an innocent nature; and as a proof of it he mentioned, that it werjt entirely off in the course of eight or ten days, without the injection, or any .other remedy, be- ing employed. A sight of this correspondence, which I was enabled to shew, could alone remove the distress under which my patient had long laboured. I have since that period had occasion to know that her husband has at different times had a return of the discharge from the urethra, in some instances from ex- posure to much cold, fatigue, or wetness, and repeat- edly from connection with his wife when she laboured under fluor albus. This happened with a patient who never before had any discharge from the urethra ; but a running is more 240 OF GONORRHOEA SIMPLEX. Ch. III. particularly apt to occur from causes of this kind, in such as have been frequently liable to Gonorrhoea Vir- ulenta. I know many of this description wdio uniform- ly experience a return of the discharge on being ex- posed to much bodily fatigue, particularly much rid' ing on horseback, orjoltingina carriage on a rough road, on their being overheated with wine, or having more connection than usual even with sound women. The irritation excited in the urethra by a stone in the bladder will, in some instances, induce a very co- pious discharge of matter. Wrhen this takes place from the bladder itself, the matter comes off mixed with the urine, and in no other manner; but when it proceeds from the urethra only, as often happens, it assumes all the appearances of Gonorrhoea Virulenta, and passes off whether any exertions be made to emp- ty the bladder or not. We are led to understand that people who are much employed in working among the warmer kind of spi- ces are very liable to a scalding in making water ac- companied with a discharge of purulent-like matter from the urethra. It is more particularly apt to occur in those who work chiefly among Cayenne pepper: Nay, it has been known to happen from a person car- rying a few pounds of this article about with him for sale. The most frequent cause of strictures in the urethra is Gonorrhoea Virulenta; but they also occur from other causes. They have been met with in all periods of life, even where patients have never had any pre- vious discharge from the urethra. They are particu- larly apt to occur in people advancing in years, be- tween the sixtieth and seventieth year of age and some- times later. A person who in his youth has suffered much with Gonorrhoea Virulenta, is very liable to he attacked about this period with strictures in the ure- thra but, they likewise happen, as I have observed above, where no cause of this kind can be given for them; and in whatever manner they are induced, they r?ec. xiv. of gonorrhoea simplex. 241 are very constantly attended with a plentiful discharge of purulent-like matter. In so'ne, these strictures have been attended with such a concurrence of circumstances, so similar to those which occur in Gonorrhoea, that the best practi- tioners have at first been deceived with them. Where the irritation in the urethra has been considerable, sym- pathetic swellings have occurred in the glands of the groin; and one or both testicles have swelled from the same cause. It is generally known, that a discharge may at any time be excited from the urethra, by the use of stimu- lating bougies. This has in different instances been put in practice, where violent pain and other bad symp- toms have been induced by the sudden stoppage of a Gonorrhoea, but it has also been advised for the same purpose, that is, for exciting a discharge of matter, merely for the removal of pain, where neither Gonor- rhoea nor any venereal symptom had ever taken place; and it has never failed when the stimulus is of a suffi- cient strength of being attended with this effect. We are informed by authors, that gout has in some instances been productive of a discharge of puriform matter from the urethra; and I have not a doubt of its happening in rheumatism. Of this I have met with different well-marked instances, where a flow of mat- ter from the urethra has alternated with pains in the knees, and other large joints; and among labouring people accustomed to work much in water, such as ditchers, a discharge of this nature is by no means un- frequent. A patient of mine, who annually takes a great deal of exercise in following game, is always seized with a discharge of matter from the urethra when he goes in search of ducks, by which his feet and legs are kept immersed in water for several days together. Other causes might be mentioned, by which a dis- charge from the urethra is at times produced, in every respect similar to the matter of Gonorrhoea Virulenta, but these are sufficient to shew that it may fiequently 31 242 of gonorrhoea simplex. Ch. in. occur from causes of the most innocent nature, and in persons entirely blameless. Of this, all who have done much business in this branch of practice will be easily convinced, as instances of it are often occurring ; but the distress which the want of discrimination in mat- ters of this kind is apt to excite, is often so great, not to individuals alone, but to the families with which they are connected; and I have happened to meet with so many disagreeable occurrences of this kind, which might easily have been prevented, that I judged it proper in this manner to take particular notice oi \\. The fact being established that all the usual symp- toms of Gonorrhoea Virulenta may be excited by a variety of causes, may be considered as an additional proof of the matter of Lius Venerea, and of that disease being different; for although the matter produ- ced in this manner in the urethra is so similar to that of Gonorrhoea communicated by impure coition, that the one cannot be distinguished from the other, yet no person ever imagined that the symptoms of Lih-'S Ve- nerea could be produced by any of these, nor by any cause whatever, but the absorption of the matter of that disease itself. It may also be remarked, that this opinion of the difference between these two diseases is farther con- firmed by the method of cure being the same, what- ever may have been the cause of the running. Whe- ther the matter discharged from the urethra be excited by infection communicated by a person labouring un- der Gonorrhoea Virulenta, or by any of the causes I have enumerated of Gonorrhoea Simplex, the method of treatment ought not to be varied. It is true that the latter will, for the most part disappear, whether any remedy be employed for it or not; but this will also happen with Gonorrhoea Virulenta. A cure, how- ever, will be obtained much more speedily by a time- ous and proper use of injections than in any other man- ner ; and if this is admitted in one variety of the dis- ease, it will be found equally applicable in the other. So far, indeed, as my observation goes, ihe discharge Sec. xiv. of gonorrhoea simplex. 243 in Gonorrhoea Simplex is not more readily affected by the internal exhibition of medicines than we have shewn to be the case in Gonorrhoea Virulenta, while a proper application of an astringent injection very seldom fails in removing it. When, however, it seems either to depend upon general debility, or to be much connected with this state of the system, we find from experience that cold+>athing, and whatever tends to restore the loss of tone that has taken place, proves more obviously useful here than in Gonorrhoea Viru- lenta. « Such a complaint," says John Hunter, " as a discharge (from the urethra) without virus is known to exist by its coming on when there has been no late connection with women and likewise by its coming on of its own accord where there had never been any vene- real complaint, nor any chance of infection." Having neglected the opportunity which occurred in the early part of this volume, of offering some remarks on-the subject of Ophthalmia as proceeding from Gonorrhcea Virulenta, we now pro- ceed ro notice it. It will not be much misplaced, since Gonorrhcea Simplex is frequently productive of the same disease, and the ob- scurity which appears to envelope the history of both, leaves us oniy the power of stating a few opinions which of late years have been introduced into notice by writers of some celebrity. That Ophthalmia of a violent kind sometimes occurs from a sup- pressed Gonorrhoea, is not only the opinion of our author,* but oi other medical writers, among whom we may name Van Swieten, Swediaur, Plenck and Scarpa.—The symptoms are peculiarly vio- lent, the tunica conjunctiva and eye-lids become highly inflamed, there is great intolerance to light, a purulent discharge from the eye similar to that which had been suppressed in the urethra, and not unfrequently the disease becomes so deep seated, as to destroy the organ. Cases of this kind are related in Which the suppression of the Gonorrheal discharge proceeded from the use of astringent injections, and it has been observed that the ophthalmia chiefly occurs in the inflammatory state of Gonorrhoea!—Swedbur remarks that the disease has never occurred in women. The method of cure should be of the most speedy and powerful kind. Frequent bleed- * See page 29. f Edmonston on Ophthalmia. Mr. Ware has however observ..- 18 OF THE SYMPTOMS Oil. IV. entrance of the vagina and urethra, but they are sel- dom or never altogether within either of these passa- ges. They are most frequent about the under part of the labia, owing to the matter producing them being most apt to rest here, and from the same cause they often form upon the perinaeum, near the a.nu^. In this situation they prove always highly distressful, and are more apt to terminate in deep and extensive ulceration, than in parts not so liable to be injured; for here they are fretted by every motion of the limbs, nor can the patient be seated without pressing upon them. Whether in men or women, chancres on parts cov- ered with firm skin have a very different appearance from such as occur upon parts more thinly protected. Instead of small circumscribed pimples, such as I have described, the skin appears red and tender for a day or two, and without being previously elevated into small vesicles, ulcerations breakout at once. A foetid viscid matter oozes out, which, on being removed, leaves the bottom of the sores of a deep red colour, and their edges inflamed and ragged, and however entirely this matter may be wiped off, it is soon renewed, and in the space of a few hours forms into a thick firm crust, which either remains till it be torn off, or till it be com- pletely separated from the contiguous parts by the for- mation of new matter beneath. This kind of sore is most frequent in parts covered with hair, particularly about the root of the penis in men, and above the pubes, and on the perinaeum in women. On the subject of Chancre we take the liberty of offering a few remarks, in addition to those of our author ; rather as references to the authorities on this subject, than as even an abstract of their1 observations. Mr. Howard in his Treatise on the Lues Venerea, notices, what he terms," the slightly irritable aphthous Chancre," from its resem- blance to the Aphthae in children. He observes that the two first Stages of it, viz: that of pimple, 'and that of pustule, are generally passed over unnoticed before the disease is suspected, and the first symptom that gives alarm is an uncommon itching on one or more points of the glans or prepuce. Upon inspection a small ulcer is perceivable, not deep, nor perhaps larger than a moderately sized pin's head, the circumference and bottom of which arc thick-enc'.! SeC. II. OF LUES VENEREA. 19 and hard, with a surface yellowish, or resembling a small slough, but with somewhat of the orange coloured tint, like the fat of rusty bacon.—This singular appearance is frequently discoverable by the, naked eye at an early stage : but will be best known by viewing the part with a good lens. At this stage it smarts a- little on being irri- tated, but the most common inconvenience is a slight itching, and very moderate inflammation.—In this species of chancre the poison sometimes appears to remain dormant for a considerable length of time, and Mr. Howard observes that in one case a chancre was so inconsiderable.at the end of six weeks, after the infection had been received, that the patient was only ordered an alterative course oi". mercury, the consequence of which was that it terminated in a ve- nereal eruption. This he states as a case which seldom occurs.— . The older the date of the infection, no matter how slight or trifling the ulcer may seem, the more difficult it will be to assure the pa- tient from secondary symptoms in future ; because the disease is, in this case, quickly verging towards the time of eruption.—The chan- cre or chancres are for the most part devoid of pain, or considerable inflammation, for many clays; and in some instances for weeks; they are small in size, and though attended with considerable itch- ing, yet the glans and prepuce, continue uninflamed, and without phymosis.—This state continues often for weeks, producing only a solutio continui; but local irritation, intemperance of any kind, and even the stimulus of mercury, before the decisive change has been produced on the disease, will change the condition of these ulcers from a quiet to a very uneasy and painful state. A symptom in this *tage sometimes occurs, which has been thought peculiar to Gon- orrhoea, a slight chordee from the extension of the inflammation to the cellular texture of the urethra and corpora cavernosa penis. Mr. H. notices what he terms, (for distinction sake) the livid ir- ritable chancre. It is, from the beginning, painful to the touch; instead of the aphthous it hasa livid or somewhat blackish hue, with a corroded kind of surface and hollow ragged edges ; it creeps on at a great rate, eating away and undermining the surrounding skin, irregularly, like a small spreading phagedenic sore; it is attended from the beginning with much more discharge, than the preceding species, and that discharge seems to be highly acrimonious. The ulceration is extremely irritable, producing great pain, and phymo- sis.—Excoriation and bubo come on mtfch sooner in this, than in the preceding species of chancre, probably on account of the matter being taken up from an abraded surface of larger extent. Between these two kinds of chancre, Mr. Howard observes there are seve- ral intermediate varieties, all however referable from their ap- pearances, to one or other.—He describes a particular form, which he considers more malignant than either of the above. It commences with a brownish kind of scab, somewhat depressed, as if the parts were rotten beneath, with the margin of this scab separa- ting from the sound skin. Intimately connected with the livid irritable chancre destfrioed above, is a Chancrous Excoriation extending over the glans and prepuce, and originating probably from an abrasion of the sebaceous glands. Chancrous Excoriations maybe distinguish' 20 OP THE SYMPTOMS Cll. IV. ed from similar affections of these parts, by their sooner degenera- ting into ulceration. Should the prepuce become inflamed, and a phymosis take place, the complaint may still be known by the vio- lence and pain of the inflammation and the colour of the discharge, which is most frequently of a greenish yellow. The surfaces of these sores appear as if they were covered superficially with half melted lard pv tallow. All excoriations however, on these parts are not chancrous, and the latter should be carefully distinguished from mere if ritation from violent friction,from the excoriation which frequently arises from the sebaceous matter of the glandulae odoriferae becoming acrid from neg- lect, particularly in hot weather ; from scorbutic and scrophulous affections of the glans and prepuce, Sec. For a more detailed ac- count of the nature and variety of chancre, we refer to the work of Mr. Howard, which Ave have so frequently quoted. Also, the Trea- tise on Morbid Poisons, by Dr. Joseph Adams, Chap. Chaticres, and particularly to the very learned work of Mr. John Hunter on this subject. Ed. £ 3. Of Buboes. A venereal bubo is a painful swelling of a lymphatic gland, produced by absorption of the venereal virus. The whole surface of the body having absorbents spread upon it no contagious matter can be applied to any part of it but with the risk of injuring the consti- tution. In various instances of Lues Venerea the sys- tem is infected by7 the matter being carried directly in- to the blood, but in others a swelling previously takes 1 place in one or more of the lymphatic glands lying be- tween the part to which the matter is first applied and the heart. These glands being formed by convolutions of the lymphatic vessels, are apt to be obstructed by any ir- ritating matter which enters them. Hence a venereal bubo is a very7 frequent symptom of the disease ; and, as it is also one of those which give the greatest dis- tress and perplexity both to patients and practitioners, I shall give a more minute description of it than might otherwise have been necessary. The points of most importance in the history of buboes, and which we shall therefore be particularly anxious to ascertain, are, the state of parts" most fa- vourable to their production; their most frequent situ- ation ; the appearances which they assume at different Sec. II, OF LUES VENEREA. 21 periods of their duration, and the means of distinguish- ing them from other swellings which they resemble. I have already observed, that the venereal virus may- be absorbed where the skin is sound and entire: Hence Lues Venerea may take place where no external mark can be discovered upon the part to which the matter of infection was applied. It must be admitted that this is by no means a common occurrence ; but I have met with it in such a number of well marked instances, that I have no more doubt of the fact than of any oth- er that falls daily and clearly within our observation. It has happened too in almost all of these, that a bubo was one of the first symptoms of the disease. I have now upwards of twenty cases recorded of bubo taking place where not a vestige could be traced either of previous Gonorrhcea, chancre, or excoriation. As the first two or three cases of this which occurred to me gave rise to a good deal of difficulty, by the uncertain and undecisive practice with which they were attended, I think it right in this manner to make it known. At the time it was an established opinion, as it still is with many7, that buboes cannot take place without some previous formation of matter in the con- tiguous parts. In the cases to which I allude the cure was therefore protracted to a great length; for till the nature of the disease became more obvious, and which sometimes did not happen till other syTmptoms appear- ed, the use of mercury, from which alone relief could be obtained, was commonly postponed. The swelling was either supposed to proceed from a strain in walk- ing or riding, or to originate from scrophula, by which a good deal of time was lost to no kind of purpose. In a former part of this work we have seen that swel- lings take place in the glands of the groin from inflam- mation produced by Gonorrhoea: These have, with sufficient propriety, been termed sympathetic buboes, and they are by no means uncommon; but the real idiopathic bubo, proceeding from absorption of syphi- litic matter, is, in a great proportion of cases, preced- ed by some obvious local mark of the virus in the con- tiguous parts, most, frequently by chancre. The mat- 22 OF THE SYMPTOMS Ch. IV. ter passes so evidently from the chancre along the lym- phatics to the contiguous glands, that one or more of these vessels are often found hard, and in a state of enlargement, in their course from the sores to the ©lands. This, in some instances, may happen from inflammation excited by the virus; in others, it may he altogether the effect of obstruction to the passage of the lymph. In some cases the lymphatics in this state of enlargement become totally unfit for the pur- poses of absorption; abscesses form in them; and on these bursting, thev are succeeded bv troublesome sores. Chancres, in all their stages, and in every period of their duration, will occasionally produce buboes; but it is worthy of remark, that they seldom occur but with previous marks of inflammation : Hence buboes are most frequent in the incipient state of chancres, while the inflammation by which they were produced still prevails. Indeed more buboes take place during the first eight or ten days from the appearance of chan- cre than in any other period of equal extent in the whole course of the disease. When the original in- flammatory state of chancres is over, and the parts are merely ulcerated without being painful, they will continue in this situation for a great length of lime, without any tendency to buboeSi being perceived, till inflammation is by some cause or other induced upon them: Hence we find buboes very frequently occur soon after Caustic has been applied to chancres, and not uncommonly after the parts have been dressed with precipitate or any irritating ointment. The pain which these occasion tends, in the first place, to create some degree of inflammation, to which buboes very frequently succeed. It is not however the higher degrees of inflammation which prove most favourable to the production of bu- boes. When inflammation suddenly takes place to a great height, and spreads along the lymphatics leading from chancres the system is not apt to be infected. These vessels appear to be deprived by a great degree of inflammation, of the power of absorption, probably SeC. II. OP LUES VENEREA. 23 by their being rendered impervious; but it is equally certain, as I have already observed, that every slight degree of inflammation, as well as whatever tends to stimulate the extremities of absorbents, excites them more or less to action, and thereby tends to increase their power of absorption. Of this we have daily proofs in the practice of inoculating for the small-pox, where we find that infection very rarely takes place, perhaps not once in a thousand instances, if the wound at which the matter of infection was introduced is not excited to inflame: Hence the more irritation that is excited at the time of inoculation the more certainly the disease is communicated. We may here mention another instance of the effect produced by7 the irritation of lymphatics in promoting absorption. In the application of unctuous substances to the surface of the body, particularly in the use of mercurial ointment, the power of friction is universal- ly admitted ; and we cannot suppose that it acts in any other manner than by stimulating the absorbents of the parts. Some indeed have asserted, that in matters of this kind no advantage is derived from friction, and that the absorbents would act with equal influence al- though the ointment was merely applied to them ; but this is so directly contrary to the observation of all who have attended to the effects of friction in such ca- ses, that no farther notice need be taken of it.* It has been remarked that old venereal ulcers do not produce buboes, and this lias given rise to an opinion that the matter produced by these sores is not of a ve- nereal nature, that is, that it would not contaminate the system were it carried into the blood by the ab- sorbents. Mr. Hunter was, I believe, the first who ad- vanced this opinion, and I do not know that it has yet been publicly controverted ; but so far as ray observa- tion goes I can decidedly say that it is not well.found- ed. I admit that buboes, or swellings of the lymphat- ic glands, do not often proceed from venereal sores of long duration, particularly from sucii as arise from in- * It seems to be surprising1 that Mr. Hunter should, hazard an opinion tc this effect. Vidv- Treatise on the Venereul D'a^ase by John Hunter.' 24 OF THE SYMPTOMS Cll. IV, fection of the system; but although they are not fre- quent, yet in various instances we meet with them. I have seen them in the neck, from ulcers in the throat; in the groin, from sores on the toes and feet; and in the axilla, from ulcers on the fingers and hands: and the cause of their not being more frequent may be ea- sily explained. We have just had occasion to remark, that absorption of the matter of Lues Venerea does not often happen if the parts to which it is applied do not inflame. Now we know that it is one of the most characteristic circumstances of old venereal sores, their being seldom accompanied with inflammation, This is particularly the case in ulcers of the throat, where in- flammation seldom takes place to any distressful height. Swellings of the glands in the neck very seldom hap- pen therefore from this cause, but still they are occa- sionally met with; and I believe that they happen as frequently here, in proportion to the frequency of the true venereal inflammation which takes place in these sores, as in any other part of the body7. They occur more frequently in the groin and armpit, from ulcers on the extremities, than they do in the neck from ul- cers in the throat; but this happens obviousjy from ul- cers of these parts being more apt to inflame than ve- nereal ulcers in the throat ; and it serves as a farther proof of the effect of inflammation in increasing the absorbent powers of the lymphatics. In a former work I have shewn the propriety of dis- tinguishing venereal ulcers into two kinds. Chancres I would denominate primary ulcers, being the root or source of all farther infection, while all those may be denominated symptomatic which arise from the syphilit- ic virus havingentered the system. That chancres should be more of an inflammatory nature than symptomatic ul- cers, and therefore that the matter produced by them should be more apt to stimulate the absorbents is notsur- J prising ; for we can readily suppose that the matter of these old ulcers must be rendered mild by being dilu- ted. Even the matter of chancres become less viru- lent when the disease has been of long duration ; and ,}he discharge of an ulcerated bubo, although the bu- l Sec. II. OF LUES VENEREA. 25 bo itself was produced by a chancre, is evidently of a milder nature than the discharge of chancres; for we seldom or never see new buboes arise in the glands ly- ing contiguous to an old bubo in a state of ulceration: But we cannot surely imagine that this proceeds from the matter of these sores not being venereal. I believe it to depend upon the cause which I have mentioned.' The matter of a sore in this situation must be contin- ually diluted by the lymph which is at all times pas- sing into the gland. This may render it so mild that it will not be capable of stimulating the contiguous glands, so as to form obstructions in them. It will rather pass easily along with the lymph into the general mass of blood ; nor will it produce any immediate or obvious effect, even when it has entered the system ; , for when thus diluted by all the blood in the body, some quantity must be required to accumulate beh.re any irritation will ensue ; and till some degree of irri- tation is excited no evident effect will take place. It must either exist in such a state of acrimony, or in such quantity as to be capable of exciting irritation in some part of the solids, otherwise no mark of disease will occur from it : Hence may be accounted for all those instances of Lues Venerea breaking out at ve- ry distant periods after infection was communicated, and of the difference which in this respect we meet with in different patients; the disease in some break- ing out in the course of two or three weeks from the time of infection, while in others it does not appear for eight, ten, or twelve months. Nay, there is rea- son to think that in some it has not appeared till several years have elapsed, and of which I could adduce such proofs as seem to render it certain. That the matter of old venereal sore's is capable of communicating infection few I believe will doubt. Many decisive proofs might indeed be given of it, but I shall only mention the following. When the mat- ter of a chancre excites swelling in the contiguous glands we have few instances of the virus passing into the constitution. The glands will remain enlarged for a considerable time without any mark of the system VOL. II. 4 26 OF THE SYMPTOMS €1). IV. being injured, probably from the matter of infection being stopped in its progress by the diseased state of the glands; but when buboes become ulcerated, if mercury be not employed, the disease, for the most part, soon breaks out in the throat and other parts of the body from the matter of these secondary or symp- tomatic sores having entered the circulation. In some instances, as I have mentioned above, a considerable time elapses before the constitution is affected by the matter of these sores, but it scarcely ever fails of shewing itself at last, and not Unfrequently in the course of a short time from the ulceration of the bubo taking place. When to this we add, that sores of this description are cured in the same manner with every other symp- tom of the venereal disease ; that they daily increase in depth and extent till mercury is employed ; and that they commonly put on a healing appearance in the course of a short time after this medicine has been used, no doubt can remain of their being altogether venereal. Every practitioner knows that in the treat- ment of venereal ulcers, sores sometimes remain after every attempt that we can make for curing them, and long after the virus of the disease is removed by mer- cury. This, as we shall hereafter have occasion to mention, may happen from various causes; but it is not this state of these ulcers which we have now been considering: It is the real venereal ulcer of which we are now speaking, where the nature of it has not been changed, nor the virus of the disease removed by the use of mercury. Venereal buboes are most frequently seated in the groin. This necessarily happens from the manner in which Lues Venerea is usually communicated; for it is the lymphatic glands most contiguous to the parts first infected that most commonly swell. There are few instances indeed of the virus passing through these and fixing upon others : Hence buboes arising from ulcers of the lips and gums are seated under the tongue, and beneath the lower jaw ; from ulcers in the throat, the glands of the neck become affected ; Sec. n. OF LUES VENEREA. 27 from sores on the fingers and hands, \he glands swell about the wrist, elbow, and in the axilla; and the glands about the knee, and on the upper part of the thigh, are most apt to swell from sores of the toes and feet. Tn each groin, and somewhat higher than the root of the penis, there is a cluster or string of lympha- tic glands, chiefly formed by the lymphatic vessels of the penis and contiguous parts. It is the most contiguous of these glands to the penis that are most frequently obstructed by the matter of chancres. It is proper, how7ever, to remark, that buboes some- times occur from the same cause in a string of glands lying upwards of an inch lower than these, owing to the lymiphalie vessels of the penis parsing in some in- stances out of their usual course and stretching down to these glands. From want of attention to this struc- ture of par^,-4)uboes in this set of glands have com- monly been supposed to proceed from the system be- ing infected, unless where they could be obviously traced to an ulcer in the foot or leg ; but we may here observe once for all, that buboes never occur from a general affection of the system alone, They proceed, I believe, in every instance from matter absorbed from a particular spot, and producing, as we have already perceived, obstructions in the lymphatic glands lying in its course to the heart. So evidently do bu- boes originate from local affections, that in chancres of the penis it is commonly the glands in the corres- ponding groin that swell. When a chancre is seated upon the fisenum, or on any other part of the middle of the penis, the glands in both groins are equally apt to be affected; but when the chancre is confined to one side of the penis, or to one side of the scrotum, we meet with few instances of the glands in the oppo- site groin being obstructed. In a great proportion of cases only one of the whole string of glands becomes affected; but occa- sionally it is otherwise. I have known four distinct buboes on one side, and three on the other at the same time, but here there have always been more 28 OF THE SYMPTOMS Gil. IV. chancres than one ; for the most part indeed the pe- nis in such cases is nearly covered with sores. Were the whole lymphatic glands between the heart and the part at which the matter of Lues Venerea enters the system, liable to be affected with it, this disease would be productive of still worse consequen- ces than commonly ensue from it. Glands situated within the cavity of the abdomen would swell and suppurate, from which the greatest danger might be expected ; bu! this does not happen. Scarcely an irstnnee can be adduced of any internal glands beinoj affected by the matter of syphilis ; but this does not depend, as some have imagined, upon the tendency of this disease to affect the more external parts of the body only. The most obvious cause of it is, that the venereal virus is always absorbed from the surface of the body ; we have seen that it is always the first glands it meets with in which obstruction occurs ; and 1 have suggested what appears to be the most proha- ble reason of the glands situated beyond such as are affected at first not being liable to suffer in future, viz. the stop wiiich the swelling of the first of these glands gives to the farther absorption of matter, and the di- luted state of the matter in the progress of the disease, by which it becomes incapable of exciting that de- gree of irritation necessary to produce absorption, or, if absorbed, that it is rendered so mild as .not readily to produce obstruction in any of the glands to which it is carried. If the matter of Lues Venerea was ap- plied to any internal part of the body, so as to excite ulceration, we have no cause to doubt of the effects resulting from it being the same that ensue from the external application of it. The contiguous glands would be first affected, and from thence it would pro- ceed to the rest of the system; but the disease never being communicated in this manner none of the glands sealed internally can ever be affected. Teese circumstances b«ing premised, I shall now enumerate the appearances and symptoms of buboes, Willi the means of distinguishing them from swellings which resemble them. It must be kept in view that it Sec. II. OF LUES VENEREA. 29 is the real venereal bubo of which we are now speak- ing, and not that inflammatory swelling with which the glands in the groin are often attacked in Gonorrhcea. A description of that swelling is given in Chap. III. Sect. IX. The most frequent seat of bubo, as we have seen, is in the groin, and a description of it in this situation will be sufficient. The first symptom of bubo is a slight degree of pain. This excites the attention of the patient, when on handling, a small hard knot is discovered. In some cases this is accompanied both with pain and tension, stretching along an enlarged lymphatic vessel, in the form of a small cord, all the way to the penis; but for the most part the tumour is distinct, and not apparently connected with any other affection. Even where two or more buboes take place at the same time, although near each other, they are always distinct and unconnected at first, insomuch that the patient himself very commonly points them out. If mercury or other discutients be not now employ- ed the tumour becomes gradually7 larger, and from be- ing, as it commonly is when first perceived, of the size of a kidney bean, by the eighth or tenth day, and often sooner, it is usually of the size of a pigeon's egg. From the first appearance of a bubo there is some de- gree of rotundity in the form of it. In the middle it is somewhat raised and prominent, and becomes flat- tened towards the sides, and this continues during the whole progress of the swelling. As the size of the tumour increases it also becomes more painful, and the pain, which at first was confined to ihe bubo itself, spreads over all the contiguous parts. The patient complains upon the slightest degree of pressure, and he cannot walk or move but with much uneasiness. Even when of this size, buboes will sometimes be removed by discussion; but when this does not bap- pen, the swelling, which till this period usually retains a considerable degree of firmness, becomes in a grad- ual manner softer and more prominent; the skin, which for some time retained its natural colour, becomes red and tender: some degree of fever is apt. to take place. 39 OF THE SYMPTOMS Ch. IV. and it is often accompanied with slight shivering fits. A fluctuation of matter is at length discovered, at first upon the surface of the tumour, and afterwards through a considerable part of the whole of it, and on this being discharged, either by the tumour bursting or by an opening being -made into it, the parts are found to have all the appearances of a common ab- scess containing purulent matter. The time which elapses in this progress of bubo, from the first appearance of the swelling till matura- tion is completed, is exceedingly variable, and de- pends upon a number of circumstances; upon the age and habit of body of the patient; upon the degree of pain and fever which take place; and on the gland be- ing superficial or deeply seated; for we find by expe- rience that deep-seated swellings do not so easily or so quickly suppurate as those which are immediately be- neath the skin. Where the constitution is much re- laxed and debilitated, buboes often remain indolent and stationary for a great length of time, while during the full vigour of health and youth, they7 usually come quickly forward : When accompanied with much pain and some degree of fever, from the first their progress in general is rapid,, while they always advance slow- ly when the pain is inconsiderable. This general ob- servation may be made upon the maturation of vene- real buboes, that they suppurate more quickly than glandular swellings of any other kind, and more slow- ly than common abscesses in the cellular membrane. Those who have not had much experience in this branch of business are apt to imagine, from the de- scription which they have perused of the appearances of buboes, and perhaps from their having met with a few instances of the disease in its ordinary form, that no difficulty or doubts can occur concerning them; but this is far from being the case. Where a glandu- lar swelling, such as I have described, appears in the groin, either during the continuance of chancres, or soon after sores of this nature have healed, tf-ere will be no cause to doubt of its being venereal: But bu- boes do not always appear in a simple unmixed state. Sec. 11. OF LUES VENEREA. 31 They are sometimes combined with other affections, where they necessarily assume other appearances; and they occur in some instances, as I have already men- tioned, without being preceded by the least vestige of ulceration. This last circumstance of itself is com- monly productive of doubt, but the difficulty is al- ways increased when the swelling which takes place is not altogether venereal. Swellings with which buboes may be confounded, and from which therefore it is proper with as much ac- curacy as possible to distinguish them, are of different kinds. In some cases these swellings occur in a simple unmixed state, in others they are blended with the real venereal bubo. 1. The most frequent cause of this kind of perplex- ity, is scrophula. When the venereal disease takes place in scrophulous constitutions, buboes as well as almost every other symptom, not only become much more obstinate, but assume appearances perfectly dif- ferent from such as occur in the ordinary form of ei- ther of these diseases. Nor is it necessary that prac- titioners only should be acquainted with this. It ought to be made known in the most unequivocal manner to patients, otherwise they are apt to be perplexed and disappointed, and to blame those who have the charge of them, for what it is not often in the power of art to prevent. Where evident symptoms of scrophula have previ- ously taken place, or where that disease obviously ex- ists at the time, there is no great difficulty of convinc- ing patients of any symptom of Lues Venerea with which they are attacked, being likely to pariake of it; but they should also know, that during the continuance of Lues Venerea, symptoms of scrophula frequently appear where that disease was not previously suspect- ed to exist, and which otherwise might never have ta- ken place. Of this I have met with many instances, where a scrophulous taint, which had till ihen remain- ed concealed, broke out at once with much violence on the system being infected with Lues Venerea. We judge that a swelling of this kind partakes of 7 1 32 OF THE SYMPTOMS Ch. IV. scrophula when,- instead of yielding to a proper appli- cation of mercury, or coming forward to suppuration in the time which venereal buboes commonly require, it either remains stationary or advances in that slow gradual manner peculiar to tumours of a scrophulous nature. Tumours altogether venereal do not advance so rapidly as common abscesses, but they come much more quickly forward than scrophulous swellings. In most instances, a venereal bubo that is allowed to suppu- rate arrives at full maturity in the space of four or five weeks ; often in less time than this, from its fir^t com- mencement; whereas, when conjoined with scrophula, two or three months will pass over before this takes place. The pain, instead of being smart, as happens in buboes, is more of a dull obtuse nature. The swel- ling at first, instead of being firm, as we have describ- ed it to be in buboes, is somewhat soft and compressi- ble, like dough; and even when matter is fully formed in it, the firmness and tension attending it is less. Nei- ther is the redness of the teguments, which takes place as the swelling comes forward, of such a bright hue as in buboes. This kind of connection between Lues Venerea and scrophula, may, in some instances too be discovered by the size of these tumours. The true venereal b i- bo is no doubt very variable in point of bulk, but it never becomes so large as tumours of this mixed na- ture commonly do. Few of the former ever surpass the size of a pullet's e^, but the latter very common- ly become two or three times larger than this. I bave at present two instances of this kind of swelling stretch- ing from the root of the penis, nearly to the spine of the ileum. 2. Venereal buboes are very apt, in the course of their progress, to be attacked with erysipelas. When this does not take place till towards ihe latter stage of the swelling no cause for doubt occurs from it, as the real nature of the primary affection is previously ren- dered obvious. But when it occurs at first, as some- times happens, the practitioner, as well as the patient is thereby apt to be deceived. Tumours of this kind, ^CC. II. OF LUES VENEREA '33 instead of being circumscribed, with their limits dis- tinctly marked, as happens in buboes, are commonly diffused, and terminate in a more imperceptible man- ner in the contiguous parts. Instead of the vivid com- plexion of common inflammation, they are of a more deep copper colour, and the inflammation which takes place occurs suddenly, instead of approaching in a more gradual manner. I may also remark, that the pain in these swellings accompanied with erysipelas, gives more distress froni the sensation which it communicates of a burning de- gree of heat than we ever meet with from these lanci- nating pains which take place in the latter stages of the true venereal bubo. 3. Lumbar abscesses have in some instances been mistaken for buboes. This, however, may at all times be easily avoided, and can never occur but from igno- rance or inattention. Any person of experience will easily distinguish by examination with his fingers, the difference between the one and the other. In the one the swelling is seated in the cellular substance, while it is in the body of a gland in the other. Whoever has once handled these different parts in a tumefied state will be at no loss to distinguish between them ; and to those who have not had this opportunity it is perhaps impossible to mark the difference by any description that can be given of it. I may remark, however, that these two swellings are for the most part sufficiently distinguished by the symptoms which precede and at- tend them. If buboes be not always preceded by chancres, lumbar abscesses are universally attended with pain about the small of the back and in the loins. This symptom indeed very commonly occurs as a fore- runner to the appearance of the tumour in the groin, and almost in every instance, before the tumour ap- pears, the patient is much debilitated by the fever with which he is attacked from the first formation of the disease, and which never in any considerable degree happens in bubo. 4. In some cases, both inguinal and femoral hernias have been mistaken for buboes. Of this 1 have known vol. II. 5 31 OF THE SYMPTOMS Cll. IV, different instances with patients; nor is it surprising that it should be so, for both kinds of swelling appear nearly in the same part; they are neither of them at- tended with any alteration in the colour of the skin, when they first appear, and they are both, for the most part, accompanied with some pain : but still the difference between them is so obviously marked that one can scarcely suppose it possible for any practition- er, however ignorant he might be, to fall into any dif- ficulty upon this point, did we not know that indif- ferent instances it had happened. Hernia? have not only been mistaken for buboes, but buboes have been treated as hernias. Besides the very marked distinction which occurs between buboes and hernia, in the appearances and other circumstances immediately connected with the tumours, and with which every practitioner ought to be acquainted, hernia is for the most part sufficiently distinguished from the other by the sickness, obstruc- tion of the bowels, and other symptoms with which it is accompanied, and which ought also to be so gener- ally known that to enumerate them more particularly would be altogether unnecessary. 5. Ulcers in the feet and legs, from whatever cause they may arise, occasionally produce swellings in the glands of the thighs: These, in some instances, have been mistaken for buboes. The chief means of dis- tinction are these ; our knowledge of the existence of such a sore as we have found by experience to be pro- ductive of tumours of this kind; the seat of the tu- mours, these swellings being commonly on the fore part of the thigh, and somewhat lower than the ordina- ry seat of buboes; and lastly, their being attended with little or no pain, and very seldom proceeding to sup- purate, but rather continuing indolent, and nearly of the same degree of hardness from the first. Even when they do contain matter the skin seldom loses its colour; a circumstance which never happens with bu- boes in a state of suppuration. Women labouring under the venereal disease are equally liable to buboes with men ; and the disease is so exactly similar in both that a description of it in Sec. it. OF LUES VENEREA. 35 the one sex renders it almost unnecessary to speak of it in the other. The only circumstance in which they are different is the situation of the tumours. .From the course of the lymphatics not being exact- ly the same in women the site of buboes in them must necessarily be different. I met with one instance of the swelling exactly upon the middle of the mons ve^ neris ; for the most part, however, they are situated on the course of the round ligaments, near to where they enter the abdomen, or higher in the groin, some- what nearer the pudendum, than in men. These last become equally large with buboes in men ; but the others, it has been remarked, remain small, and still more circumscribed than buboes in their ordinary7 situation. The symptoms we have hitherto been describing, viz. chancre and bubo, are at first always local; that is, they7 are never produced by, although they7 are ve- ry commonly productive of, what may be called the constitutional state of the venereal disease. This has induced some to treat of these symptoms as distinct and unconnected with the constitutional affection; and there would be much propriety in their doing so, were it possible to determine when the matter of chancre or of bubo has entered the system or not, But so far as I know this has never been done; and there is much cause to imagine that no attempt towards it will ever prove successful. Some ingenuity has been shewn in endeavouring to ascertain the time which must elapse between the appearance of chancre and absorption by the lymphatics; and even during this period, the dis- ease, it is said, should be considered as local. To me, however, all such attempts appear to be both futile and dangerous. The point in question can never, in my opinion, be ascertained ; and while the contrary idea pievails, the constitution would in many instances be injured, as it would be very apt to lead, as with some it has already done, to a very hazardous practice, a dependence in the treatment of these symptoms upon local remedies. Chancres and buboes may both re- in ain in a local state for a great length of time. Nay, 3(J OF THE SYMPTOMS Ch. IV, it is possible that their cure might sometimes be ac- complished without any of the matter arising from them entering the constitution; but as this is mere conjecture, as we have no method of knowing when this might be the case, and as we know from daily ob- servation that in almost every instance the constitu- tion is injured even by the slightest degree of these symptoms, I judge it in every respect better to treat of them as constitutional affections. The next symptom we have to describe is univer^ sally allowed to originate from the virus when it has entered the system. On the subject of buboes as a primary symptom, there are a vari- ety of opinions ; many respectable writers, agree with our author that true venereal bubo is sometimes met with when no chancre has preceded, from the direct absorption of the virus. Mr. How- ard observes, " When it arises alone, without any precedent or at- tendant symptom, and without any apparent ulceration on the part% which are usually in the first instance affected, the same general affection of the system, the same venereal pains, eruption and at- tack on the periosteum, and other internal surfaces, may follow from this as from chancre ; even though the latter should never ap- pear." Dr. Adams in his observations on morbid poisons, maintains the opposite opinion and says, " If bubo is the only symptom when our patient is first introduced to us, it becomes an important object, to learn the exact history of its first appearance, of every attendant circumstance, and of every remedy which has been applied. If the tumour is all that has appeared, to say the least, the chances are that it is wo* venereal. Such a disease was well known to Celsus, and even in the milder climate of Italy was often found extremely troublesome. It is contrary to general analogy, that the glands should ever be affected by any contagion without the appearance of primary local action, if the law of the poison is to produce a prima- ry local action where it is first applied : I know of no instance on record, in which the constitution has been affected by a bubo, with- out a previous chancre, or Gonorrhoea. Lastly, as I am aware, that many honest and ingenious men maintain a different opinion, I shall only add, that I have never seen reason to repent, the not having treated such buboes as venereal." If (continues Dr. Adams) a bubo has been the consequence of an ulcer on the penis, which healed spontaneously, we may be certain that it is not venereal. It may be the effect of morbid poison, as probably many of Celsus's were : It may be assisted by, and ma"y SeC. 11. OF LLES VENEREA. 3? even heal under the use of mercury : but this will be no proof of its venereal origin. If the bubo has not appeared till after the chancre has healed,, it will often prove venereal, and must be treated as such. If the first view we have of the bubo is in its open state, the same enquiries, and the same cautions, are necessary as before. The first and most important of all these is, whether mercury has been used for it, to what degree of constitutional irritation and with what effect on the part. The knowledge of all this is absolutely requisite before we commence our treatment, and an attention to it, is equally im- portant, during the whole progress of cure." (Vide Howard and Adams.) Ed. $ 4. Of the Venereal Sore Throat. From whatever part of the body the matter of sy- philis may have entered-the lymphatics, we find that it is more apt to attack the throat than any other part. This does not happen, however, at any certain peri- od. I have known it fix upon the throat in the course of ten days from the first appearance of a chancre, while in some instances it remains perfectly sound till several months after every external mark of the dis- ease has disappeared. In addition to what has already been said upon this point I may observe, that the throat, as well as other parts of the body, are most apt to be soon affected when no buboes take place. When the matter passes directly into the system, along the absorbents, the in- fection shews itself more early than where it is first stopped by buboes, and afterwards taken up by the lymphatics on these swellings becoming ulcerated. In the venereal sore throat the patient is usually distressed with some degree of uneasiness in swallow- ing for some days before his attention is much excited towards H. He feels a sensation of fulness and ten- derness, but not much pain. In some cases this pre- vails over the whole throat, but for the most part on one side only. Unless there has been some recent cause for suspicion the disease is attributed to cold ; but the symptoms continuing, and an inspection being made, an ulcer is in most instances discovered on the part of which he complained in swallowing. 38 OF THE SYMPTOMS Cll. IT. These ulcers in some cases make their first appear- ance upon the uvula, but they are much more frequent, upon one of the amygdalae. On first inspection they are commonly small, but always foul, and accompa- nied with some degree of fulness or swelling, and with an erysipelatous redness of the contiguous parts. In most instances the ulcer remains stationary for a considerable time, not going deeper than the thickness of a shilling, nor spreading to any greater extent than it occupied at first; but in others, unless the most ef- fectual remedies are immediately employed, the ulcer not only becomes deeper, but spreads to a great ex- tent, and in some cases with such rapidity, that I have known the uvula and all the contiguous parts affected in the course of a few dajs. * In some the ulcer, in its course, gives only the appearance of foulness to the contiguous parts, which become covered with a yel- low coloured slough, somewhat resembling the huffy coat of inflammatory blood, while in others it spreads in ihe form of a corroding sore, and destroys all the parts as it goes along. It sometimes destroys a great part of the tonsil before leaving it, but it more fre- quently spreads along the arch reaching from the ton- sil, on which it is seated, to the uvula, and which, to- gether with the contiguous parts of the velum pendu- lum palati, are commonly destroyed before the other tonsil becomes affected. Even in this advanced state of these ulcers the pa tient seldom complains of much pain, if it be not du- ring the action of swallowing. A general uneasiness is felt over the throat, but the pain is never so acute as ihe extent and appearances of the sores would give cause to expect. Wherever much pain tak?s place, we find that it proceeds not from the sores but from that kind of erysipelatous redness with which the contiguous parts are very apt to be affected, and by which such a distressful burning sensation is sometimes induced over the whole throat as renders the patient at all times very uneasy. In some cases of the venereal sore throat this in- flammatory redness takes place without any ulcere- :'ec. n. of lues venerea. 39 lion. If not prevented by mercury7, ulcers would no doubt form at last ; but I have known the parts re- main swelled, and accompanied with that deep copper- coloured complexion which is very characteristic of these affections, for several weeks together, and with- out any degree of ulceration being perceptible. The disease in this state, although it is commonly fixed on one side of the throat at first, is very apt to leave it suddenly and go to the other; and this we find will happen again and again, till the one side becomes ul- cerated, by which it is kept fixed to a particular spot. Where the throat is affected in this manner, that is, where it is attacked both with the venereal virus and erysipelas, a very distressful symptom commonly takes place, a constant heat and irritation over the whole fauces, by which the patient is kept under a perpetual desire of clearing his tnroat, of an acrid, viscid mucus, with which it becomes so much stuffed from time to time as to render a great deal of exertion for this pur- pose necessary ; and it prevails equally at all times, even during meals, and when the patient should be at rest. That it is chiefly by the irritability which takes place here that this acrid mucus is proouced I conclude to be ihe case, from finding that nothing tends so much to remove it as soothing anodyne applications, conjoin- ed vvith the internal use of opiates. It is commonly too in this inflammatory state of sore throat that patients in Lues Venerea are seized vvith deafness. Deafness may happen from other causes, as we shall afterwards have occasion to mention, but in this case I believe it to proceed from the inflammation spreading to tie tuba eustachiana, so as to render it impervious. Inflammation may act in producing deaf- ntss. either by stuffing this passage with mucus, or by excitim* adhesion between the sides of the duct. In the one case the deafness may only be temporary, but in the other it must necessarily, to a certain degree, remain permanent. In most instances the venereal sore throat does not go deeper than the soft parts; producing sores, such 40 of the symptoms Ch. iv. as I have described, of various degrees of magnitude ; but where the disease has either been too long neglect- ed, or where mercury and other remedies employed do not prove successful, the bones themselves come in some cases to suffer. I have known the body of the upper vertebrae of the neck affected in this manner, and it not unfrequently attacks the bones of the pal- ate and back part of the nose. One of the most distressful circumstances which practitioners meet with in diseases of the throat is, the uncertainly of distinguishing between venereal affec- tions of these parts and others which resemble them, by which a good deal of time is either altogether lost, or employed with much doubt and undecision. From this cause alone ulcers are sometimes allowed to spread, where it might easily have been prevented by a timeous use of mercury ; and in other instances pa- tients are put upon the use of this remedy where it ought by no means to be employed. The complaints most apt to be mistaken for venereal affections of these parts are, those ulcers which occa- sionally succeed to long continued cases of catarrhal inflammation, and such as sometimes take place as the consequence of too much mercury7 having been used, or of the patient being exposed to cold while under a course of mercury. The chief means of distinction between venereal ulcers of the throat and such as succeed to inflamma- tion are these ; ulcers from inflammation very common- ly supervene upon abscesses; they are usually clean, and of a florid red appearance, and accompanied with a good deal of pain. The venereal ulcer again sel- dom or never produces abscess, and in the first place it always forms upon the surface. It is never clean till remedies have been employed for rendering it so ; and although it is always accompanied wTith some un- easiness, the pain attending it is never so severe as in the other. I may also remark, that in the common in- flammatory sore throat the contiguous parts do not usually assume that erysipelatous colour which very universally takes place in venereal ulcers, nor are See. II. OF LUES VENEREA* 41 they apt to induce that plentiful secretion of acrid mu- cus, and the symptoms which ensue from it, which we have shewn to be frequent consequences of the other. We shall hereafter have occasion to speak more par- ticularly of that variety of sore throat arising from the effects of cold when under mercury, as well as from an over-quantity of mercury, having been employed. At present I may remark, that this is distinguished from the venereal sore throat by a very considerable fulness or swelling, not only in both amygdalae of the throat, but over the whole fauces, together with some degree of tumefaction ol" the parotid gland, as well as of all the salivary glands; circumstances by no means connected with venereal affections of these parts. The parts are not so apt to ulcerate as in the venereal disease, and any sloughy appearance which takes place upon them, instead of being of a buffy colour, as happens in the other, is white and milky, somewhat resembling those apthous crusts so fre* quently met with in the mouths of new-born infants. These sloughs too are more extensive than they ever are in venereal sore throats. In the latter they are always confined to such parts as are inflamed, while, in the other, they commonly extend a considerable way over the contiguous parts. The natural unequahties on the surface of the amygdalae have, in some instances, whem in a state of inflammation, been mistaken for venereal ulcers ; this, however, may always be avoided, and never can hap- pen but from ignorance or inattention* Mr. Hunter describes the true venereal ulcer in the throat as a fair loss of substance; part being dug out, as it were, from the body of the tonsil. He further adds, that it has a determinate edge, and is commonly very foul, having thick white matter, like a slough, adhering to it, and not admitting of being washed away. Uicors In such situations are always kept in a moist state, and the matter cannot dry and form scabs, as it does on sores upon the skin. The ulcer is also much more rapid in its progress and generally has Mrrckened edges. (Hunter on the Venereal, Philadelphia Ed. p. 295.) Dr. A.iams observes that although the erlj-es of a venereal ulcer vol,, u. . (j 42 OF THE SYMPTOMS Cll. IV, in the throat are defined, yet its surface is always ragged and une- ven, and of a complexion which can never be mistaken for a clean or healthy sore, that is, for a sore disposed to heal. The pus is of various colours, from the ash colour to the dusky brown. It'is rare- ly attended with pain. In other respects, Dr. Adams' description agrees with Mr. Hunter. (Adams on Morbid Poisons, 2nd Ed. p. 167.) Mr. Howard has remarked that during the progress of the ulcer- ation, the other parts of the gland seem often to be butlittle affect- ed, but they are sometimes enlarged, indurated and even horny. The ulcers at first are not unlike the aphthae of children, but soon increase in depth and width. The appearance of the true venereal ulceration of the throat is compared by Mr. H. to lard or musty bacon half melted. (Howard on the Venereal, Vol. 1. p. 76.) It is of the highest importance, as our author observes, to form a correct opinion whether an affection of the throat be venereal, or not. In addition to the marks put down to distinguish it from a sore throat induced by mercury, may be added, a fcetor of the breath, and an' increased secretion from the salivary glands; symptoms which are never met with in the pure venereal ulceration. The venereal sore throat is distinguished, from the putrid sore throaty by the symptoms of general indisposition, quick febrile pulse, depression of strength, Sec. which accompany the latter and never attend the former—-from common inflammation of the ton- sils by the symptoms me'ntioned by Mr. Bell—from those cases in which coagulable lymph is thrown out on the surface, occasioning appearances, like ulcers, or sloughs, by the greater degree of swel- ling in the last and by removing the lymph, when the surface of the tonsil will be found free from ulceration—from an ulcerous ex- coriation of these parts by the latter being superficial and more ex- tensive. (Hunter.) In all cases of Ulcers ol the Throat, many of which are often scrophulous, a minute attention to the progress of the symptoms is necessary to enable the practitioner to ascertain the cause of disease. In those instances where any doubt exists as to their being venereal, no injury can result from delaying the exhibi- tion of mercury. By steadily watching the progress of the ulcer. noticing whether it increases regularly, but slowly, and not healing during this period in any part, the real truth may soon be determin- ed. If it should proceed in the course we have described, for a few days, its syphilitic character may be considered as well estab- lished. (Adams.) Ei>. § 5. Of Venereal Ulcers in ihe Nose and Mouth. Chancres, or primary venereal ulcers, rise occasion- ally, as we have already had occasion to remark, both in the nose and moulh; but sores of this description, wherever they are seated, having been already de- scribed in $ 2. of this seciion, we are now to treat of rrec.-ir. o* lues venerea. 43 those only7 which originate from the system being in- fected. Next to the throat the matter of this disease fh.es most frequently upon the nose, which, so far as I have had opportunities of observing, is more apt to be at- tacked with it than the mouth. I need scarcely observe, however, that some variety occurs in this. In a few cases the mouth is attacked before either the hose or throat. In others the disease appears first in the ntvse ; but in a great proportion of cases it follows the pro- gress I am now describing; after having for some time fixed upon the throat it goes to the nose, if the dis- ease is not stopped in its course by a proper use of mercury. We may also remark, that although the ulcers in the throat should be cured by mercury, if a sufficient quantity of the medicine be not employed for eradicating the virus, the disease, when it again breaks out, will appear most readily upon the nose, in the same manner as if no mercury had been made use of. This, however, is not universally the case ; for in many instances we find it most apt, to return to the parts where it was last seated, and after again fix- ing upon the throat it proceeds to the nose, as it would have done at first if no interruption had been given to it. It does not however attack every part of the nose indiscriminately. Some have remarked that the mat- ter of this disease has a particular tendency to fix upon the external parts of the body, that this always happens in the first instance, and when it proceeds from these to such as are more deeply seated that it does so vvith some regularity, by attacking such parts first as are most thinly covered. This, however, does not hap- pen with any kind of regularity, and seems only to have been noticed for the purpose of supporting an opinion. Instead of going first to the skin, which it would do were this opinion well founded, the throat, as we have just seen, is most apt to be affected ; and when it afterwards attacks the nose and mouth, it is not even trie most external parts of these that are first ■apt to suffer. 44 OF THE SYMPTOM a fell. IV. In a few instances the disease no doubt appears first upon the outward parts of the nose, but in by much the greatest number the more internal parts are previ- ously affected. The patient at first complains of a troublesome stoppage in one of his nostrils, accom- panied with some degree of tenderness and pain at a particular point. This is often so deeply seated in the nostril that it cannot be seen, being most frequent- ly upon some part of one of the ossa spongiosa ; but vvhen the under part of the passage is affected, togeth- er with a fulness of the membrane of the nose, a small foul ulcer is perceived, which is either covered with a white slough, or a firm brown crust, and on this be- ing removed, although the parts beneath may appear clean and red, they soon become equally foul and sloughy as before. In the commencement of these affections, the dis- charge is commonly inconsiderable ; but on a longer continuance, the matter forms in greater quantities, when it usually becomes thin and very foetid. If the nicer is seated upon any part of the ossa spongiosa, the bone soon becomes diseased, and the matter ac- quires a black dirty color; it becomes larger in quan- tity, and the fcetor still more considerable than at first. In this stage of the disease large portions of these bones are apt to separate and come away7; but before coming to this length, other symptoms have common- ly made their appearance. A weeping eye, as it is termed, or a constant flow of tears over the cherk, frequently occurs in this stage of the disease, owing to the under end of the lachrymal duct, which termi- nates behind the os spongiosum inferius, being apt to be stopped by the disease of this bone. The sense of smelling becomes impaired, and* in some is entirely de- stroyed ; and the figure of the nose is at last affected, in the first place becoming swelled, red, and painful, upon the parts immediately above those that are ul- cerated, and afterwards losing its prominency by the bones of which it is formed coming away. This "does not happen while the disease i« confined to the spongy- bones of the nose, but the septum itself becomes af: Sec. II. OF IJTES VENEREA. 45 ffcted, in wdiich case there is always much hazard of the face being disfigured by this bone giving way, when the nose is apt to fall nearly or entirely flat. This is the usual course of ulcers in the nose; but instead of attacking the internal parts in the first in- stmce, we meet with them occasionally upon the car- tilaginous parts of Ihe nose, in which case they com- monly begin with some degree of inflammation of the skin. After the skin has remained red and tender for some time, small ulcerations appear upon it, and these at 'asl running together, a sore of more or less extent is formed by the whole. Like all other venereal sores., ulcers in this situation are always foul ; the matter they discharge is thin and offensive, and the skin for some way round their edges is of an erysipelatous red co- lour. ■ YVhf n the cartilaginous substance of the nose becomes affected, they often put on a cancerous ap- P' arance; nor has mercury the effect of stopping ti-eir progress so readily here, as in other parts of the body: This has in some instances been the cause of venereal ulcers in this part being treated as cancers, by which, even after being extirpated, the disease has again returned, when a cure might easily have been accomplished by the mercury having been continued for a due length of time at first. Every part of the mouth is occasionally the seat of venereal ulcers ; but although they appear from time to time on the inside of the cheeks and on the gums, they are most frequent, upon the palate and on the tongue. In other parts of the mouth the ulcers ap- pear without any previous warning, being for the most part, fully frV ued as soon as the- part affected is exam- ined by the patient, and which is commonly done soon afier it begins to excite any uneasiness; but in the pa- late no ulceration takes place till the parts have been inflamed for some time. A deep copper-coloured spot is at first perceived somewhere between the uvula and middle of the palate. This at last becomes ulcerated ; and it is worthy of remark, that in no part of the bo- dy do venereal sores advance with such rapidity as they do here. In this respect they are different even 46 OF THE SYMPTOMS Ch. IV. from venereal sores in the throat. These last, as we have already had occasion to remark, seldom proceed to any great depth, nor do they advance with much quickness ; but here their progress is not only rapid but they go at once to the full depth of all the soft parts covering the bones, and in most instances soon do much injury to the bones themselves. I have known the bones of the palate become diseased in the course of a few7 days from the first appearance of ulceration; and it is by no means uncommon to find a great part of the velum pendulum palati destroyed in the space of a few days from the time that it was first perceived to be affected. Venereal ulcers of these parts have at times been mistaken for, and treated as ulcers of a very different kind, but with due attention this may perhaps in every instance be prevented. We are more apt to fall into the error of treating other sores as venereal. Both in the mouth and nose venereal ulcers have been mistaken for cancerous sores; and in the nose they sometimes bear a resemblance to herpetic affec- tions. From both of these we distinguish them not only by the history of each particular case, but by the different appearances which these affections actu- ally assume. Where a patient with herpetic eruptions on other parts of his body is attacked vvith sores of a s ular nature upon his nose or lips, there will be rea- son to conclude that they originate from the same cause; but where this is not the case, and particularly when it is found that the patient either labours under Lues Venerea at the time, or that he was lately affect- ed with it, and not properly cured, this of itself will give ground to imagine that they are venereal. Her- petic sores seldom go to a greater depth than the skin; whereas venereal ulcers, whether on the nose or lips, are apt to penetrate deep into the parts upon which they7 are seated. Cancerous sores are distinguished from these, as well as from every other variety of ulcer, by the schirrous hardness in the parts affected with which in every part of the body they are accompanied ; and they are par- SeC. II. OF LUES VENEREA. 47 ticularly distinguished from venereal ulcers by the smart shooting pains which they always excite; a symptom which does not usually occur in the others. The mouth is equally liable with the throat to soreS from an over quantity of mercury, and from patients being exposed to cold when under the use of it. These are more difficult to distinguish than any others from the real venereal ulcer; for besides the resemblance which in some circumstances they bear to them, as they commonly occur while the patient is under cure of some symptom of syphilis, this of itself is apt to create suspicion concerning them. Independent of this, the very situation of the sores gives some cause to suppose that they may be venereal, so that we are readily induced to consider every ulcer on these parts as being of this nature. Sores arising from this effect of mercury, although somewhat resembling the true venereal ulcer, are read- ily enough distinguished from it by whoever has paid attention to this branch of business. Venereal ulcers are circumscribed, and in the mouth, whether upon the inside of the lips, cheeks, gums, or tongue, they are always of a corroding and somewhat of a cancerous appearance. There is seldom at first more than one sore, which does not, however, continue long station- ary, for in this situation, venereal sores extend quickly7. Now sores arising from mercury are always diffused, and we commonly find them in different parts of the mouth at the same time. Like the first appearance of the venereal ulcer in these parts, they are always su- perficial, but they have not that corroding aspect which the other assumes; and although foul and sloughy, their colour is materially different from those that are venereal. The latter are commonly of a dirty brown colour, in some instances with a slight tinge of yellow; whereas the other has always a whitish appearance, as if the patient had newly been drinking milk. The situation of the sores also affords some means of distinction. Those arising from mercury seem to be induced chiefly by7 the pressure of the teeth and gums upon those parts that are more particularly acted upon 48 OF THE SYMPTOMS Ol. IV, by the medicine; so that we alwayrs find them where the swelling is greatest, and the pressure most consid- erable : Hence they are most frequent on the sides cf the tongue, near to the angles of the jaw; and on the insides of the cheeks; and when they take place in one of these situations, we usually7 find them prevail over the others. Now the true venereal ulcer attacks one part just as readily as another; seldom at first more than one part at once, and we find it just as frequent upon the upper part of the tongue, and on the under part of the mouth between the tongue and the teeth, where pressure has little or no influence, as in any oth- er part. v\ ith due attention to these appearances, and to the history of the case, no practitioner of observation will ever remain long in doubt; but where any uncertainly takes place, the best method of removing it is to desist entirely from the use of mercury. If the sores are venereal they will soon become worse, if not, they will soon disappear when the swelling and tenderness induced by the mercury are gone. I think it proper, however, to remark, that sores of this kind do not al- ways heal as soon as might be expected. In some in- stances, the swelling of the mouth, produced by mer- cury, continues for a great length of time. I have known it in a very obvious manner more than two months after any mercury had been exhibited. In such cases, the sores proceeding from this cause do not readily heal; and where due weight is not allowed to this circumstance, more mercury is in such a situation very often given, by which the constitution is not only apt to be injured but the very sores for which the med- icine was prescribed are rendered worse. In some ca- ses this no doubt proceeds from inattention or want of experience on the part of the practitioner: but it also originates from the fear and anxiety of patients, who, doubting of the real nature of the sores, and dreading their influence upon the constitution, are often so im- patient, that in a concealed manner they persevere in the use of mercury long after they have been desired to lay it aside. UeC. II. OF LUKS VENEREA. 49 I have insisted the more upon this point from a very considerable number of cases having fallen within my own knowledge of the most distressful consequences being produced by measures of an opposite nature be- ing persevered in. Patients in general are so easily alarmed with what- ever gives the least cause to suspect that the virus is not entirely removed, that even the most trifling cir- cumstances, when treated with inattention by practi- tioners, may be followed with very important conse- quences. A spoiled tooth vvith sharp ragged edges, is very apt to produce a sore upon that part of the cheek or tongue to which it is contiguous; and as it takes place in a slow imperceptible manner, without exciting pain, and produces a,foul sore, somewhat resembling a venereal ulcer, if the real cause of it be not discov- ered and removed, very troublesome consequences are apt to ensue from it. From this cause alone I have known a patient put under a tedious course of mercu- ry, which, with very ordinary attention, might have been prevented ; for wherever an ulcer forms, either on the inside of the cheek, or on the tongue, the state of the contiguous teeth should be examined; and w here any spiculae, or inequalities are discovered, they should be completely removed, and due time allowed for the sores afterwards to heal, before any other meth- od of cure is recommended* The venereal ozena or that ulceration and caries of the nose, which constitutes it, is sometimes so malignant in its nature a,d so rapid in its progress, that the bones attacked are actually destroyed in some few instances as soon as the state of the case is clearly known, and in others, before the specific can be used vvith sufficient effect to check the disease. These therefore, of all cases require the most careful attention. Among the forerunners of this symptom, Mr. Howard mentions the following. When the os frontis, in consequence of a previous node, has become carious at its lower and middle part, just above the root of the nose and that caries is of considerable depth, through the outer table of the skull, the disease may insinuate itself thence, inwards, to the os ethmordes and bones of the nose, and precede an ozaena of the most alarming kind. Pains deep seated in the palate VOL. II. 7 50 OF THE SYMPTOMS CI). IV, or bones of the nose, more especially if they are felt towards its root, either with or without a purulent and foetid discharge, be it ever so trifling or small in quantity, when not the effect of catarrh, scrophula, or scurvy, are also circumstances extremely suspicious. As ozsena very seldom occurs without previous well marked venereal symptoms, it is particularly proper to attend to the history of the case. It must be carefully distinguished from the effects of bad teeth, from scurvy, scrophula and from that kind of abscess which sometimes forms in the Antrum Highmorianum.—The disease is often not confined to the nose, but extends to the palate, velum pen- dulum palati, tonsils, and pharynx, and generally the tone of the voice is materially altered. (Howard on the Venereal, Vol. i. p. 113.) It is worthy of remark in this place that Mr. Pearson considers the ozsena to occur frequently as a symptom of Cachexia syphiloidea, or Pseudo svphilis. (SeetheNore on Diseases resembling Syphilis.) The posterior part of the oesophagus, the tongue, the cheeks, and the velum pendulum palati, are sometimes attacked with venereal ulceration, and they sometimes appear singly, without any other symptom of lues, but most frequently in combination. When lues venerea attacks the tongue, Mr. Hunter remark's that it will some- times produce a thickening and hardening of the part, but when there are sores they are generally more painful than those in the throat, and oblige the patient to speak thick. It is often difficult to discriminate a venereal ulceration of the tongue from a cancerous one. In this case Mr. Howard recommends a careful examination of symptoms for years past, and a resort to mercury in all cases, as a cancerous affection is incurable, and if the specific cause only an amendment, the practitioner may in general be assured that the ease is venereal. Ed. § 6. Venereal Blotches, Next to the parts which we have mentioned, the mat-1 ter of Lues Venerea is most apt to fix upon the surface of the body in the form of eruptions, or what are com- monly termed blotches. In a few cases the skin is af- fected before either the throat, nose, or mouth; but this is by no means frequent. Every part of the body is liable to these blotches, but they appear more frequently on some parts than on others. The cause of this is difficult to explain, for when the whole sy stem is affected we cannot a priori say why one part should more readily be attacked than another, but there is no doubt of the fact. In account- ing lor this disease fixing most frequently upon the throat, nose, and mouth, some have ingeniously sug- SeC. II. OF LUES VENEREA. 51 gesled that there is probably some particular attraction between mucus and the matter of this disease, from these parts being plentifully supplied with mucous glands; and mercury being particularly apt to affect these parts, while we know that mercury in every! »r. ^ 11. Cy Alopecia. The disease termed Alopecia by Nosologists, or falling off of the hair, may be produced by different 7G OF THE SYMPTOMS Cll. IV, causes; but it is most frequently met with as a symp- tom of Lues Venerea in the more advanced stages of the disease. The hair of the head first separates in greater quan- tities than usual on being combed. The eye-brows become more thinly covered, and if a stop be not put to the disease of the constitution, all the hair of the head, as well as of the other parts of the body, soon falls off. Before the hair begins to separate, a scurf is usual- ly perceived among the roots of it, which comes away in great quantities on the head being combed, com- monly in the form of fine bran. On this scurf being removed, the skin beneath has a red complexion ; but the patient does not complain either of pain or tender- ness, and the same kind of brany powder forms re- peatedly on the same parts, although carefully remov- ed from day to day. In some instances the hair is renewred in as great quantity as at first; but this is not a frequent occur- rence : It only happens during youth, and where the virus of the disease is quickly and completely eradi- cated. In more advanced periods of life it always re- mains thin, not only upon the head, but on the eye- brows; and when the eye-lashes fall out from this cause they very seldom return. As mercury has commonly been given before the hair begins to separate, and often in considerable quan- tities, this symptom has by some been supposed to be more the effect of the medicine than of the disease. This, however, has not been the result of my observa- tion. I have seen different instances of the hair drop- ping off in Lues Venerea, where no mercury had been employed; and were it, to be produced by mercury, it would necessarily occur more frequently, and it would happen with equal readiness in every disease for which mercury should be prescribed. 1 consider it to be in almost every instance the effect of that scurf which in Lues Venerea sometimes forms among the roots of the hair. The matter by which the scurf is produced getting access to the roots, soon cuts off their connection with the surrounding parts. Sec. n. of lues venerea. 77 j 12. Of Blindness as a Symptom of Lues Venerea. In the first chapter of this work some account is given of blindness produced by the retropulsion of the matter of Gonorrhoea. But blindness which takes place in Lues Venerea is materially different both in its rise and progress, and in the remedies by which it is with most certainty removed. Blindness from Gonorrhoea is always accompanied with much pain. A great degree of irrhability, along with a plentiful discharge of matter from the eyes, and more or less inflammation, are the first symptoms of the disease. But in Lues Venerea, loss of vision to a considerable extent, has commonly taken place long before much pain is experienced ; and if inflammation ever occurs, it is not in any remarkable degree. The matter of Lues Venerea acts in different ways in producing blindness. One of the most frequent seems to be by injuring the optic nerves, whether by acting immediately upon the nerve itself, or by first exciting effusion, or the formation of "tumours in the contiguous parts, by which compression of the nerve is at last produced. It is in this manner I conceive that gutta serena takes place in the latter stages of Lues Venerea. In some cases it comes on in a gradual manner. The sight be- comes less perfect from day to day ; and both the pa- tient and his friends are surprized that this should hap- pen while the external appearance of the eye is not affected. But for the most part the disease takes place almost instantaneously, the patient being entirely de- prived of vision in the course of a minute or two from the time that his eyes became uneasy. Still the exter- nal parts of the eyes remain sound, but the nupils are always greatly dilated, and incapable of any degree of contraction, even when exposed to the strongest light. In some cases only one eye is affected, but for the most part the disease attacks both at the same time. Cataracts sometimes form from this cause. I have met with different instances of this disease in the latter '/8 OF THE SYMTTOMS Ch. IV. stages of Lues Venerea, where no other cause could be assigned for it; and I conclude that it was the ef- fect of the venereal poison, from the peculiar manner of its approach. The lens is at first only partially af-1 fected, .white streaks appear upon different parts of it, which extend by degrees, so as to produce opacity over the whole of it. But the most frequent effect of the venereal virus upon the eye appears upon the vitreous and aqueous humours, and on the lucid part of the cornea. In some cases these humours are deprived of their natu- ral transparency, they become somewhat milky, and at last completely opake. At other times this is evi- dently7 connected with an opake state of the lucid cor- nea, which becomes vvhite and thickened, and in some instances so prominent as to disfigure the whole globe of the eye. When this diseased state of the coats of the eye, and of the humours which they contain occur at the same time, the whole body of the eye affords the appearance of one confused mass. Neither the chrystalline lens, nor any particular part of the eye can be distinguished. Before this opacity takes place in the cornea, a num- ber of obstructed vessels are perceived on it, accom- panied with some degree of tenderness on being expos- ed to light: This gives cause to suppose that inflam- mation is about to occur; but the disease in this form makes no farther progress. The cornea in some spots becomes white and opake, probably by the effusion of part of the contents of these turgid vessels; but all this takes place with little or no pain, and without any of the ordinary concomitants of inflammation^ Nei- ther does this whiteness of the cornea terminate in sup- puration, as opacity of this membrane produced by in- flammation is apt to do. It becomes even more vvhite than the tunica albuginea itself, and evidently more thickened, but I never saw matter form in it. In some cases the venereal virus fixes upon the eye- lids, and chiefly upon their cartilaginous borders. This sometimes happens by itself, but for the most part it is connected with syphilitic eruptions in other parts Sec. II. OF LUKS VENEREA. 79 of the body. The parts become red and somewhat tender, and an effusion takes place among the eye-lash- es, either in the form of a dry scurf, or of a gummy- viscid matter. In this latter state this effusion proves always very troublesome, particularly after sleep, as it glues the eye-lids so firmly together as to render it difficult, and even painful to open them. In this affection of the eye-lids, I have in different instances, observed a symptom which has not, so far as I remember, been remarked by authors. The tears at first form in drops near the internal angle of the eye, and this terminates in a constant trickling over the cheeks. Those who are not accustomed to examine the eyes in this state are apt to consider this flow of tears as the commencement of fistula lachrymalis, whereas it proceeds from a cause which must effectu- ally prevent the formation of this disease. On minute inspection, it appears evidently to arise from the punc- ta lachrymalia being obstructed by the viscid matter forming upon the cartilages of the eye-lids, by which the tears which should pass by these openings into the lachrymal sac, and from thence into the nose, are ne- cessarily forced over the cheeks. In some cases this weeping state of the eyTes proves to be temporary, and disappears with the cause by which it was produced; but in others it continues permanent, owing, I sup- pose, to the puncta being obliterated by the long con- tinuance of the disease. This constant flow of tears over the eye-lids proves always troublesome, and in some cases even painful, by exciting tenderness, and occasionally7 some degree of ulceration of the cheeks. The commencement of Venereal Ophthalmia, may be known ac- cording to Mr. Howard,, by a peculiar fulness, redness and slight turgescence of the vessels of the tunica conjunctiva and cornea, with a want of lustre and clearness in the latter. It is sometimes, he observes, so painful as not to bear the stimulus of light,but most frequently otherwise, and this last, is the most dangerous, as it may cause the patient to be inattentive. Unless the inflammation be ear- ly removed, an incurable blindness will follow.—In Venereal Oph- thalmia, there is constantly present an irksome sense of itching, gO OF THE SYMPTOMS. CI). IV. which is mobt troublesome towards evening, but both it and the pain remit in the morning, and this morning remission is considered by Plenck as a diagnostic mark of the presence of Lues. (Edmonston on Ophthalmia, p. U3.) In the more advanced stages of this disease, besides the effects produced on the humours of the eye, the hairs drop off from the cilia, the iris is changed in colour and the pupil acquires a ragged unequal appearance. Venereal Ophthalmia may be distinguished from the scrophulous, by the want of that inflamed appearance of the ciliary glands, which often attends the latter, by the absence of scrophulous symptoms and by its having been preceded by other syphilitic appearances. (Howard.) Ed. $ 13. Of Deafness from Lues Venerea. When treating of the venereal sore throat in $ 4. of this section, we had occasion to remark that a certain degree of deafness is, in some cases, a consequence of that symptom, the end of the Eustachian tube, when it terminates in the throat, being obstructed. The ef- fect resulting from this being in some instances consid- erable, we are led to suppose that this passage to the ear is of no small importance to the sense of hear- ing: I have known a very distressful degree of deaf- ness produced by it. Besides this, the venereal disease in some instances excites deafness by fixing upon the ear itself. The bones seem to be most liable to be attacked with it. When this takes place the patient is at first seized with a partial loss of hearing. This is succeeded by a dis- charge of foetid ill-coloured matter; and in some cases the bones themselves come away. I need scarcely ob- serve, that a total and permanent loss of hearing en- sues. WThere venereal blotches prevail universally over the body, and have been of long duration, they some- times fix upon the ear, chiefly upon the lap of the ear. In some cases I have known them to affect the meatus externus so as to induce to a temporary deafness. In this event the passage is either stuffed with a dry scur- fy matter, or the lining membrane of the passage be- comes thickened, and occasionally tender and ulcera- ted. If this proceeds no farther into the ear a recove- £ec. II. OF LUES venerea. 81 ty may still take place ; but as the same kind of ten- derness is apt to attack the tympanum, deafness even from this cause often proves permanent. $ 14. Of Anomalous Symptoms. Besides the symptoms of which we have given a de- scription, there are others which from their appearing with less regularity may be termed anomalous. But these, although they occur occasionally in every stage of the disease, prevail with most frequency when lite infection has been of long -duration. 1 he most troublesome of these symptoms are chops, or clefts in the palms of the hands and soles of the feet. A red somewhat purple-coloured eruption appears up- on the skin of these parts. The cuticle separates and comes away. Still the skin remains discoloured; and at last chops form in different parts of it. They gen- erally remain dry, but in some instances they dis- charge a thin acrid matter. They are seldom painful; but they are always obstinate and difficult to cure; and the cuticle is in some cases so completely remov- ed, that by the tenderness which succeeds to this the patient is for a considerable time deprived of the use both of his hands and feet. In some a disposition is formed in the skin and cel- lular substance of different parts of the body to be- come thick, rough, and unequal, producing what by Nosologists is termed elephantiasis, or at least an af- fection which very much resembles that disease. In most instances where this has occurred, different parts of the body7 have been affected with it at once; but in others I have known it confined to one of the extrem- ities. In the slighter degrees of this affection the in- convenience produced by7 it is inconsiderable, and it is seldom accompanied with much pain; but where the limbs swell so much as they sometimes do, the distress which it excites is necessarily severe. A limb which swells from this cause becomes first very unvvieldly; and on the swelling increasing, it at last bursts into vol. ir. 11 82 OF THE SYMPTOMS Ql. IV. sores, wliich discharge a thin acrid matter, are always foul, and very seldom heal. I have met vvith different instances of this thicken- ing of the teguments in the scrotum. The skin retains its natural colour; but it becomes firm, and so much thickened as to form a tumour which in some cases ac- quires a very considerable bulk. All of them that have fallen within my observation came from warmer climates, and two of them were in negroes. They had been mistaken both for hydrocele and hernia, but I found in all of them that the tumour was produced en- tirely by a thickened state of the scrotum. From a hernia in the scrotum they are distinguished by the spermatic cord being entirely free of swelling; by the absence of all the symptoms of hernia; and by the swelling being much more firm than it ever is in hernia. The same degree of firmness serves to distin- guish it from hydrocele, for no impression is made up- on it by pressure; and it is farther distinguished from it by its weight, 'being much heavier than any tumour of equal magnitude containing a fluid. This swelling of the scrotum bears a greater resem- blance to sarcocele, or a scirrhous testicle, than to uny other affection of these parts. It is chiefly distinguish- ed from sarcocele by being totally7 free of pain, and from being of an equal smooth surface. The other is not only accompanied with pain, but the swelling is knotty and unequal. As the sores which occur upon these tumours are ve- ry apt to assume a cancerous appearance, and ulcers of a similar aspect being sometimes observed to suc- ceed to buboes, some have been thereby induced to consider cancer as a symptom of this disease. That the matter of Lues Venerea may occasionally produce sores which terminate in cancer will not be disputed; but we are not from this to conclude, either that the matter of the two diseases is the same, or that cancer should be considered as a symptom of syphilis. Besides the pains resembling rheumatism, which oc- cur in Lues Venerea, and of which we had occasion ip speak when treating of node,s and affections of the Sec. n. "of lues Venerea. 83 periosteum, pains of a different kind are apt to take place in the more advanced stages of the disease. They do not remain fixed or permanent, but produce sharp momentary stings, without leaving swelling or any other mark behind them. They are most frequent in the neck, temples, and jaws. In the latter they are often suspected to proceed from carious teeth, when on examination no affection of this kind can be per- ceived, or if there are any, no relief is obtained from pulling them. A falling out of the teeth has been fre- quently described as a symptom of Lues Venerea, but I have never met with it excepting where the pa- tient had taken a great deal of mercury, and where it appeared evidently to proceed more from the medi-* cine than from the disease. One of the most frequent symptoms of the advanc- ed stages of syphilis is atrophy, or a gradual wasting of the body7. This is no doubt a frequent effect of a mercurial course, particularly when too much of the medicine has been exhibited; but it is also a symptom of the disease. Even where little or no mercury has been given I have known a patient become much ema- ciated in the course of a short time. From a state of obesity, and with a healthy, florid complexion, a person will in some instances 4>ecome suddenly lean, while his face will be wan or sallow, as if the vessels were altogether deprived of red blood. This I con- sider as one of the most fatal symptoms of the disease, from which, in the course of my observation few or none have ever recovered* Irritability and restlessness are two sy7mptoms of this disease. When Lues Venerea has been of long duration the system becomes so irritable that the most trifling occurrences prove distressful. No application can be given to business ; the patient becomes fret- ful and uneasy, and his nights are spent in watch ing. The constant anxiety which takes place here*is of- ten connected with that state of atrophy which we have just described. It seems in some cases indeed 1o be the cause of ib Being always accompanied g4 OF THE SYMPTOMS Gil. IT, with an entire loss of appetite this of itself soon redu- ces the body to the most emaciated state. But the most universal symptom of the anomalous kind which prevails in Lues Venerea is fever. Nor is it confined to one stage of the disease. Occasionally it takes place in all of them. It is necessary, howev- er, to remark, that the fever which occurs in the com- mencement of the disease is very different from that which most frequently prevails afterwards. The first may more properly be considered symptomatic, being always connected with some local affection, such as bubo, sore throat, ulcer, or node, while the other of- ten takes place where no other mark of the disease can be discovered. The one therefore subsides along with the particular cause by which it was produced, while the other continues obstinate as long as the vi- rus of the disease remains in the constitution. It is this last, therefore, which is of most importance, and merits most of our attention. This fever is always of the hectic kind, and accom- panied with some colliquative symptom, particularly with nocturnal sweats. Hence the patient soon be- comes emaciated, but a peculiarity occurs here not met with in other fevers; at the same time that the pa- tient becomes languid and reduced he is commonly able to transact his ordinary business, and often con- tinues to do so for a considerable time after the fever has taken place. He is liable to alternate fits of cold and heat; particularly to much warmth over the whole body in the evening; to restlessness and anxiety during the night, and to a constant quickness of pulse ; hut these symptoms, while they do not come to any great height, do not excite much alarm, and the patient, while no local affection takes place, continues daily in hopes of getting free of them. ^ For a considerable time both the patient and practi- tioner find it difficult to account for these symptoms. They are olfen attributed to cold ; in some cases to an incipient phthisis ; and in others to scrophula. Reme- dies for one, or perhaps for all of these diseases, are accordingly prescribed, and no^axlvantage being deriv Sec. Tl. CF JtJES VENEREA. ... 8j> ed from them, the real cause of the fever either is not discovered, or at last the disease breaks out in some such obvious form as leaves no cause for doubt. Among other reasons of this uncertainty may be mentioned an opinion which much pains has been taken to inculcate, and which of late has unhappily begun to prevail among those who have not had sufficient op- portunities of being enabled to judge for themselves. It has been vvith much confidence asserted, that the matter of Lues Venerea cannot exist in the system, so as to induce any symptom of disease, without shewing itself upon the surface of the body, or in some such manner as to be at once clear and evident. We shall soon have occasion to enter more fully upon the con- sideration of this question, but at present I may ob- serve, that the opinion to which I allude, although supported with some ingenuity7, appears to be alto- gether void of foundation, being directly contrary to tlie observation of all practitioners of experience ; for I hold it as a certainty that this matter of Lues Vene- rea often exists in the constitution for a great length of time, and is productive of fever, as well as a vari- ety of other symptoms, where no local affection ever ensues. It may happen where no mercury has been employed; but we meet with it most frequently where this medicine has been used, but not in sufficient quan- tities for effecting a total removal of the virus; where it therefore remains in the system, and after lurking there for a longer or shorter period, according to cir- cumstances, either breaks out early in an obvious man- ner, or before doing so excites fever or some other anomalous symptom of a still less suspicious nature. In all such cases of doubt and uncertainty7 we must be directed entirely by the history of the rise and pro gress of the complaint, and by our own observation in affections of a similar nature. The chops or clefts in the hands and feet of which Mr. Bell speaks, are commonly called Rhagades. They are seldom station- ary, but come and go, until some other more considerable symptom takes the lead, in which case they sometimes disappear entirelv §6 OF THE VENEREAL VIRUS. Ch. IV. The venereal Rhagades differ from the leprous, in being strongly marked with the copper hue. The latter is a large, thick, white and hardened kind of crust; the former though somewhat scurfv, is not so dry, is yellowish, and is more like a common fissure or chop of the skin. (Howard.) Dr. Willan observes, that Rhagades may be distinguished from Psoriasis Palmaria, in their not affect- ing the toes and fingers. In the latter disease, the colour of the scurf is also darker. (Willan on Cutaneous Diseases, vol. l.p, 165.) Some authors are of opinion that Rhagades are never the effect of Lues. Dr. Adams in particular, states that they are com- mon in warm climates, and that the sole cause producing them,is tire inability to perspire freely. (Adams on Morbid Poisons.) That thickening of the integuments of the scrotum which is men- tioned above, is the venereal form of the Psoriasis Scrotalis, de- screed by Willan. Ed.' SECT. III. Of the Venereal Virus. HAVING in the different parts of the preceding section given a description of the various symptoms of this disease, I shall now offer a few remarks upon the virus by which they are produced. Of the real nature of the venereal virus no correct knowledge is obtained; and as it can never be procur- ed in a simple state we can scarcely expect that much satisfaction would result from any enquiries that could be made concerning it. We meet with it most fre- quently mined with pus or mucus, and sometimes witb blood and serum ; but so intimately is it blended with these fluids, and so little are we acquainted with the peculiar appearances of this matter, that we are not able to distinguish it. By some the matter of Lues Venerea has been supposed to be of an acid nature; others consider it as alkali. One set of practitioner? have said that it 13 of putrescent quality, while others assert the reverse. It is evident, however, that all such opinions must be merely hypothetical, so long a* the matter to be investigated cannot be made obvious to the senses in an uncombined state. Rut although there- may; be some circumstancpsrela- Sec. in. OF THE VENEREAL VTRUS. 87 live to the matter of syphilis which we may never be able to explain, there are others which wo can trace with some precision, and upon which I now mean to make a few observations. The circumstances to which 1 shall advert resolve themselves into the following questions: Upon what parts does tlie matter of syphi- lis chiefly act in producing Lues Venerea ? When re- ceived into the system can the poison remain there without producing the disease? And is it possible for a person with the virus in a latent state, and without any7 mark of disease, to communicate the infection to others? Various opinions have prevailed upon the manner in which the matter of diseases enters the constitution. Some contend that it is taken up solely upon the sur- face of the body ; others that it enters perhaps entire- ly by the lungs ; while some are of opinion that a great proportion of diseases take their origin in the stomach and alimentary canal. But the point upon which pa- thological writers have chiefly differed is, Whether' the matter of disease, when it has once entered the system, acts most particularly upon the solids or fluids ? The humoral pathology, as it is called, prevailed universally for a great length of time. Diseases were supposed to be seated chiefly, if not entirely, in the fluids; and so generally was this opinion received, thai although others were occasionally proposed, they were considered onhy as innovations, and for the most part soon fell to the ground. Of late, however, the opposite doctrine has begun to be more generally received, and it has become fash- ionable to explain the phenomena of every disease, and the operation of almost every medicine employed for curing them, by their influence upon the solids. To me it appears that both opinions have been carried too far; and while one party have supported one opinion, and the other the very7 reverse, that it is probable no disease of the constitution can take place without eve vy part of the system being affected. I think it evi dent, however, that every disease produced by conta gion acts first upon the fluids, and that the solids are ultimately affected in a secondary way only. - 88 OF THE VENEREAL VIRUS. Ch. IV. In Lues Venerea this appears to be still more clear- ly the case than can be demonstrated in almost any other disease; a circumstance, however, that tends to support the general principle of the doctrine, even where this kind of proof cannot be obtained; for if it obviously happens in one disease where the matter of infection can be clearly shown to affect the fluids in the first instance, we have reason from analogy to con- clude that it may likewise be so in others, although it may not from a concurrence of circumstances be in our power to show it. To enter fully upon the consideration of this doc- trine, a greater length of discussion would be requir- ed than the nature of this work will admit. I shall therefore only mention shortly such circumstances as tend most clearly to establish the opinion which I adopt; and even this might have been unnecessary if there was not reason to suppose that much inconsistent .practice would be the consequence of that opinion be- ing admitted, which of late a great deal of pains has been taken to establish. Whatever may be the case in other diseases, that the fluids are chiefly affected in Lues Venerea is ren- dered evident by the following circumstances. I. The contagious matter of this disease is always communicated in a fluid form. But it is alleged, al- though this is the case, that even upon its first applica- tion it shews a tendency to act chiefly upon the solids, hy exciting inflammation wherever it is applied. This appears, however, to be only an accidental, not an essential property of the matter; for instances are fre- quent, as we have already had occasion to remark, in which it enters thesystem without inducingeither infla- mmation or erosion. By the acrimony which the mat- ter seems to possess, inflammation most frequently takes place on the spot to which it is applied, by which the corresponding absorbents are vvith more certainty made to receive it than might otherwise be the case; but no other conclusion can be drawn from this. It happens here, as we have already had occasion to re- Hiark on the practice of inoculating for the small pox, Sec. III. OF THE VEXEREAL VIRUS. 88 that the matter of infection does not readily enter the system where inflammation is not excited ; but surely few will suppose that we would fail in producing either of these diseases, were we possessed of any method of in- troducing the matter into the common course of circu- lation without exciting inflammation. Even this, how- ever, has been alleged by some ; but besides other cir- cumstances which might be mentioned as proofs of the contrary, the clearest evidence of it is obtained, and ol inflammation not being essentially necessary for the production of small pox, from the manner in which the natural form of the disease usually appears, where no inflammation, or any other local affection is per- ceived, till the disease has taken place, when the first ef- fects that occur from it are, fever, and quantities of mat- ter thrown out upon the surface. This takes place in a more obvious manner in small pox, but it also happens in Lues Venerea, in which a great proportion of the symptoms are evidently produced by contagious mat- ter of a similar nature to that which first entered the lymphatics at the time of infection, for the matter produced by venereal ulcers and eruptions will very certainly produce every symptom of the disease, if by any means it is thrown into the system of a sound person. Of this every practi'ione", I presume, is so much convinced, that, even those who have thought proper in theory to support a contrary opinion would not willingly expose themselves to the hazard of being iniected with matter of this kind. 2. It has been a question agitated with some warmth, in what manner does the virus act on being conveyed to the mass of blood? At one period fermentation was considered as a principal agent in producing dis- ease. The matter of infection being received into the circulation, it was supposed by means of fermentation to possess a power of converting the whole fluids of the body into its own nature. This opinion, howev- er, was liable to various objections, and particularly to this, that it is difficult to conceive how fermentation can go on in fluids in circulation. In a state of ex- travasation wo can easily suppose that it may happen; VOL. II- 12 90 OF THE VEiNEREAL MRU*. Cll. IV. but while life subsists the fluids are kept in such per- petual motion that we cannot easily conceive how such a process can take place. But although fermen- tation, in the full acceptation of the word, may not occur from this cause, I think it highly probable that the matter of all contagious diseases, and more especially the matter of Lues Venerea, has a power of assimilating to its own nature a certain portion, and ultimately, perhaps, the whole fluids of the body. 3. This power may be quick or slow in its progress according to a variety of circumstances, but which, from our limited knowledge of the laws of the an- imal ceeonomy7, it may never be in our power to as- certain. 4 While the quantity of matter thus assimilated is inconsiderable no marks of disease will be produced, nor will any effects result from it till it prevails in such quantity as to be capable of exciting some de- gree of morbid irritability in the living principle. 6. From all this I conceive that in Lues Venerea the matter of contagion acts in the first instance upon the fluids, and that the solids are not otherwise affect- ed, than in being excited by this morbid state of the fluids to some degree of unusual exertion for the purpose of throwing them off, by which eruptions on the skin are produced, with ulcers of different parts, as well as all the other symptoms of the disease. 6. From this view of the origin of Lues Venerea we account for the matter of contagion remaining longer inactive in some instances than in others. Be- sides any difference which may take place in the state of the fluids upon which the matter has to act, and by which the assimilation to which we allude may be ac- celerated or retarded, the different degrees of irrita- bility which prevails in different persons, and even in the same person at different times, will also co-operate in producing an early or later formation of the symp- toms; for while some are easily stimulated, andVnay therefore be acted upon almost as soon as the matter of contagion enters the system, others of more slug- SeC. III. OE THE VENEREAL VIRUS. 91 gish temperaments may, for the production of the same effect, require the matter to be accumulated in such quantities as nothing but a great length of time can accomplish. 7. It may be said in opposition to this opinion, that as soon as this accumulated state of morbid matter is accomplished the effects of it should appear equally upon every part of the body ; for the fluids circula- ting over the whole, the effects of any disease to which they are liable should not be confined to particular parts, as we find to be the case in Lues Venerea. To this it may be answered, that many inexplicable cir- c.iinstances occur in every disease, and that in this re- spect liie venereal disease is not different from a varie- ty of others in which particular parts are more apt to be affected than others, and where it is equally diffi- cult to explain why they should be so. Thus it is as impossible to say, why the matter of gout should fix most frequently upon the great toe as it is to explain the cause of the throat and nose being particularly apt to suffer in Lues Venerea. There may be some kind of attraction between particular parts and the matter of certain diseases; or these parts may be more easily irritated than others, and which ever of these may be the case the same consequences will ensue. 8. It is asserted by those who support the contrary opinion, that we cannot in any instance discover the cause of disease to be in the fluids. This indeed they are under the necessity of doing in order to give the appearance of probability to their theory in any case. By discovering therefore, that this assertion is ill- founded, and that in other instances the fluids are ob- viously affected, we might from analogy say, that they are so in Lues Venerea, were the proofs which we have adduced of it less evident than we have shown them to be. Now the action of several other poisons is rendered evident to the senses. This is particularly the case vvith the poison of different kinds of vipers, in which serous effusions take place in different parts of the body, often in the course of a few hours from the time of the bite being inflicted, and in which the 92 OF THE VENEREAL VIRUS. Cll. IV. colour of the whole serum of the blood is even in that short space of time tinged of a morbid yellow colour. 9. They who are of opinion that the cause of disease is not seated in the fluids are under the necessity of de- nying in more instances than one, what in Lues Vene- rea is well known to be matter of fact. They are obli- ged to say that the blood is perfectly sound, and that neither this fluid, nor any of the secretions produced from it are capable of communicating infection. A theory being once formed, every argument that mili- tates against it is apt to be overlooked, while, in order to support it, facts are explained away in a manner which they will not bear. This, in- some instances, may be followed by7 very pernicious consequences, par- ticularly where such modes of reasoning are adopted and promulgated by authors of ingenuity and reputa- tion ; and as Mr. Hunter of London has gone farther than any other author in support of the opinion that the syphilitic virus cannot be conveyed by or affect the fluids, the following observations will relate particular- ly to his work.* " We may observe (says Mr. Hunter) that even the blood of a pocky person has no power of contaminat- ing, and is not capable of giving the disease to anoth- er even by inoculation; for if it were capable of irri- tating a sound sore to a venereal inflammation, no per- son that had this matter circulating, or had the Lues Venerea, could escape having a venereal sore, when- ever he is bled, or receives a scratch with a pin, the part so wounded turning into a chancre," &c. Vide p. 292. Now Mr. Hunter here assumes as matter of fact what is not the case; for although all wounds inflicted upon patients labouring under Lues Venerea do not become venereal ulcers, yet frequently, and in almost every instance of the more advanced state of the dis ease they do so. I have at this time a gentleman un- der my care whose case affords an instance of this, where the bites of leeches applied to the scrotum on account of inflammation of one of the testes, the con * Vide a quarto edition, published in 1786. Sec. III. OF THE VENEREAL VIRUS. 93 sequence of Gonorrhoea, degenerated into venereal sores. This I informed him would not have happen- ed from Gonorrhoea alone. And upon enquiry he ac- knowledged that six months ago he laboured under chancres and bubo, for which he suspected that he had not used enough of mercury, and that for a week past he had felt uneasiness in his throat, where I found, on inspection, that an ulcer had already formed on one of the tonsils. In the course of business I have met with a variety of similar cases, and every practitioner must have done so. It must be remarked, however, that we have sel- dom occasion to take blood, either with the lancet or leeches, in sy7mptoms truly venereal. It is in Gonor- rhcea chiefly that this remedy becomes necessarv; a circumslance, I may observe, that affords a farthei* proof of the difference of the two diseases; for while the symptoms in Gonorrhoea are often so acute, and the inflammation so violent, as to render it necessary to discharge a good deal of blood, this almost never hap- pens in Lues Venerea, a disease in which the parts af- fected become red and of a copper-colour, accompanied with some degree of uneasiness, but in which that kind of inflammation requiring blood-letting scarcely ever takes place. Mr. Hunter w7as resolved, however, not to rest sat- isfied with asserting that the blood of a venereal pa- tient could not communicate infection. In the same page, viz. 292, he even says, that the matter produced by such ulcers as occur in Lues Venerea is not vene- • real, and that it will not produce the disease. That there may be no suspicion of mistake on my part, I shall transcribe his words. " When the matter has got into the constitution it from thence produces many lo- cal effects on different parts of the body, which are in general a kind of inflammation, or at least an increas- ed action, occasioning a suppuration of its own kind ; it is supposed that the matter produced in consequence of these inflammations, similar to the matter from a Gonorrhoea or chancre, is also venereal and poisonous. This I believe till now has never been denied, and up- 94 OF THE VENEREAL VIRUS. Ch. IV. on the first view of the subject, one would be inclined to suppose that it really should be venereal; for first the venereal matter is the cause; and again the same treatment cures both diseases; thus mercury cures both a chancre and Lues Venerea ; however, this is no decisive proof, as mercury cures many diseases besides the venereal. On the other hand, there are many strong reasons for believing that the matter is not ve- nereal. There is one curious fact, which shows it is either not venereal, or if it be, that it is not capable of acting in some respects on the body or same state of constitution, as that matter does which is produced from ajfchaiicre or Gonorrhcea. The pus from these latter, when absorbed, generally produces a bubo, as has been described, but we never find a bubo from the absorption of matter from a pocky sore; for instance, when there is a venereal ulcer in the throat we have no buboes in the glands of the neck; when there are venereal sores on the arms, or even suppurating nodes on the ulna, there are no swellings of the glands of the arm pit, although such will take place if fresh venereal matter is applied to a common sore on the arm, hand, or fingers," &c. Now all this is such loose reasoning as could not have been looked for in a man of Mr. Hunter's expe- rience and observation. His overlooking every argu- ment militating against his favourite theory can alone account for it. If the fact be not general no depend- ence can be placed upon it. If it be general it is not curious: neither is it the case that the matter of chan- cres and Gonorrhcea generally produces buboes. The matter of chancres often does, but it much more fre- quently does not; and few practitioners, I believe, will say that buboes are frequent consequences of Gonor- rhcea. I cannot say what may have been the result of Mr. Hunter's experience, but I have met with many in- stances of buboes, or swelled glands, in the thigh, ax- illa, and neck, as obviously produced by sores in the feet, legs, hands, and throat, as buboes commonly arc In the groin from chancres on t he penis. But admitting SeC. III. OF THE VENEREAL VIRUS. 96 that the occurrence is not frequent, still this is no rea- son for supposing that the matter of these sores is not venereal. If the matter be not absorbed no more harm will ensue from it than if it had never been formed; and in section II. of this chapter I have shown that it is not so frequently absorbed as the matter of chan- cres. The reason of this I have also endeavoured to explain, by shewing, that some degree of irritation is required for the purpose of exciting the absorbents to action; and as the matter of Lues Venerea seems to possess very little power of exciting irritation, except- ing such as is produced by the primary sores of the disease, it is accordingly seldom absorbed, and still less frequently does it produce buboes ; for being of a mild nature it does not so readily stimulate the lym- phatics, so as to produce obstructions in-the glands as it goes along. Mr. Hunter would have found it difficult, or even impossible, to explain consistently with his theory of the disease, a number of circumstances which we dai- ly observe. He therefore denies that they exist-; and he seems to have no difficulty in doing so, even where they are admitted by all unbiased practitioners. In page 291, he says, " It is also supposed that a foetus in the womb of a pocky mother may be infected, and have lh£ disease from her, as it were naturally inter- woven vvith it. This I should doubt very much," &c. And in page 295, he says, " It has been supposed, and asserted from observation, that ulcers in the mouths of children from a constitutional disease, which con- stitutionakdisease was supposed to be derived from the parent, produced the same disease upon the nipples of women who had been sucked by them giving it as it were at the third hand ; that is, the children were con- taminated either by their mother's or father's having the disease in form of a Lues Venerea, of which I have endeavoured to show the impossibility." Mr. Hunter has certainly endeavoured to shew the impossibility of ihis, for Ins system could not other- wise have had the least plausib.e appe'aranco; but none, excepting such as have not had opportunities of being 96 OF THE VENEREAL VIRUS. Ch. IV.A able to form judgments for themselves, will say that he has proved successful. If I can give credit to any fact with which I am acquainted I must believe in this, that children may receive, and frequently do receive the venereal disease from their parents labouring un- der it in a constitutional form; and that ulcers in the mouths of these children will, and frequently do pro- duce the same disease upon the nipples of women whom they suck. Nay, that these will give it again to other children, and these children to other nurses; circumstances which I have so frequently witnessed, so strongly marked, and followed by consequences so distressful' to innocent sufferers, that I cannot help expressing astonishment that a practitioner of any ex- perience should entertain a doubt of their existence. Mr. Hunter, in page 296, proceeds to say, vvith some appearance of exultation, as judging it to he an unanswerable argument, that "were it possible to contaminate once in this way it would be possible to contaminate for ever;" a circumstance which he seems to consider as ridiculous: But surely all this would happen. Nurses and children infected in this manner would undoubtedly continue to communicate the contagion to others as long as they were not cu red of the disease. Nor would there be any thing in all this that does not daily happen ; and in v\hatever way the disease is communicated we have reason to think that it would be the case. - In order I suppose to convince others that he him- self at least is convinced of the opinion which he sup- ports being well founded, Mr. Hunter, in p. 12, goes even farther than anything I have yet mentioned: That the venereal disease is to be propagated only by matter is proved every day, he says, by a thousand in- stances. And in the belief of this being the case he afterwards observes, that he has gone so far as to allow married men who had contracted the disease to cohab- it with their wives, in order to save appearances, and } always with safety ; Nay, that he could carry this still farther, and allow a married man who has a Conor-' rhcea to have connexion with a sound woman, if he SeC. IV. OF THE VENEREAL VIRUS. 97 took care to have all the parts cleared of matter, by syringing the urethra, making water, and washing the glans. I believe with Mr.. Hunter, and every practitioner perhaps will do so, that the risk of communicating in- fection will not be so considerable where no matter is formed as where ulceration actually takes place : but I also know, that a woman would run much risk of being injured by cohabiting with a man whose blood was infected with matter of syphilis, although no lo- cal marks of it should appear, for I have met with various instances of it; and I also know from a varie- ty of facts, that both father and mother, in situations such as this, and where no bad symptoms were ever perceived, have communicated the disease to the foetus. Where this has happened from the mother being in- fected, the matter of contagion must pass from the mother to the child along with the blood; but where it takes place from the father, as is most frequently the case, there is no other mode by which it can be conveyed but by the semen. We shall have occasion, however, to make some farther observations upon this subject when treating of Lues Venerea in new- born infants. From all that I have said, I think it will appear that the matter of contagion in Lues Venerea, in the first place, acts upon the blood alone; that by accumula- tion it comes to irritate the solids or containing parts, and in this manner that effusions and consequent ul- cerations are produced; that the venereal poison may remain long latent in the system ; that this will de- pend upon the irritability of the person, as well as upon the particular state of the fluids at the time, by which they may be more or less liable to the assimila- ting effects of the matter of contagion; and lastly, that there is no cause of doubt that a person vvith the virus in this latent state, and without any external mark of disease* will communicate the infection to others. voi. n. 13 98, OF THE REMEDIES LbEIi Gil. IV. It is sufficient, in remarking on this section to observe, that fur- ther experiments on several points are required in order fully to substantiate Mr. Bell's opinions. We are much inclined to doubt the correctness of his remark, that a person labouring under con- stitutional symptoms can communicate the disease. The observa- tions of Mr. Hunter and his disciples on the mode in which the ve- nereal virus is introduced, and the manner of its acting, are worthy of an attentive examihation. Mr. Pearson observes, that he has seen a number of persons afflicted with lues venerea pass through violent fevers, inflammatory diseases, small pox, &c. without the patient receiving the least benefit as to the former complaint. He adds however, that the change in the female constitution which is connected with pregnancy, has often a wonderful power of sus- pending the progress and of modifying the form of- the disease. SECT. IV. Of the Remedies used in Lues Venerea. i 1. General Observations. AS no disease has engaged more of the attention of practitioners than Lues Venerea, so there are perhaps none in which more remedies have been employed. To- wards the end of the fifteenth century, when the first accurate description was given of this disease, a great variety of remedies was proposed for it ■ and as it daily increased in violence till the use of mercury was introduced, scarcely an article in the materia med- ica was left untried in the short space which elapsed between this period and the fortunate discovery of this powerful antidote. Even long subsequent to this many new remedies were brought forth; for while mercury seldom fails of curing the disease, it was- soon found to be produc- tive of many inconveniences. Every country has accordingly been ransacked, but after all the research- es that have been made, the number of articles em- Set*. IVr. IN LUES VENEREA. 99 ployed in modern practice for the cure of this disease is very few ; and it is these only which 1 now mean to mention. Tlie others, having been found either alto- gether inefficacious, or comparatively of weak pow- ers to those which are retained, have necessarily fal- len into disuse, so that now it would be considered as superfluous to* speak of them. The only antisiphilitic medicines now in general use, are mercury, guiacum, sarsaparilla, mezereon, and opium : Of each of which I shall speak sepa- rately. $ 2. Of Mercury, I. General Observations upon Mercury. Mercury having been long employed for the cure of a great variety of herpetic affections, we are not surprised at finding it early introduced in the treat- ment of Lues Venerea, in which the most obvious of the symptoms chiefly affects the integuments of the body. Besides, as it was universally known to be one of the most active medicines that had ever been made use of we can easily suppose that practitioners would soon be induced to employ it for the removal of a disease which resisted the effects of every other Remedy. Mercury in its crude state is found to be nearly inert, or not capable of producing any active effect, insomuch that it may be taken into the stomach in very considerable quantities. It has been swallowed to the extent of several pounds weight, and repeated daily for two or three weeks together vvith scarcely any effect being perceived from it; so that wherever it has proved active when used in this state as in a few instances has happened, it must probably have been in consequence of its meeting vvith some unusual degree of acidity in the stomach or intestines. This inactivity of mercury7 in a crude state seems to depend entirely upon its insolubility in the fluids which it usually meets with in the human body. Jn 100 OF THE REMEDIES USED CI). IV. this state it either is not absorbed, or if absorbed, by not being soluble it remains inert. I shall afterwards point out the different means em- ployed for rendering mercury active, and for introdu- cing it into the system, but previous to this it will be proper to offer a few observations upon the ordinary effects of mercury, and upon the different opinions which have prevailed respecting its mode of action in curing the venereal disease. On the first appearance of the Venereal Disease, correctives of the blood, evacuant medicines, venesection and similar means were used. As early as the year 1497, mercury was externally exhib- ited in syphilis, but was not administered very freely. About 1517, Guaiac was recommended as a specific, and supplanted the use of mercury, until Paracelsus again introduced the latter and demonstrated its superior efficacy. (Cabinis' Sketch of the Revolutions of Medical Science. See a Note by Dr. Henderson, the Translator, p. 416.)* Mr. Howard observes, that to Berengarius Carpensis or his dis- ciple Vigo, we must attribute the promulgation of the important fact that mercury would cure by making the mouth sore. Ed. II. Of the Effects of Mercury upon the Human Body. One of the most certain effects of mercury is, that it acts as a cure for the venereal disease. It so sel- dom fails indeed, that when it happens not to succeed, as occasionally is the case, we are apt to suppose that this proceeds either from the medicine not having been properly administered; from its not having been giv- en in sufficient quantity ; or from the complaints for -which it is used not being altogether venereal. Besides this, mercury is perhaps one of the most universal stimulants with which we are acquainted. Even in small quantities it often excites heat over the whole body, quickness of pulse, and other symptoms of fever. ^ It is also^ a very powerful evacuant. Other medi- cines act with equal certainty upon particular organs, of which we have examples in the effect of ipecacuan upon the stomach, and of jalap, aloes, and other pur ^CC. IV. IN LUES VENEREA. 101 gatives upon the intestines; but we know of none which so generally affects all the secretions. Almost all preparations of mercury will act as purgatives* They also produce sickness, nausea, and vomiting. They often excite an increased discharge of urine; and few medicines operate with more certainty upon the skin, for they can scarcely be employed without being productive of some degree of diaphoresis. The most remarkable effect, however, which we perceive from mercury is an increased discharge of saliva; and it is perhaps the only medicine which from internal exhibition is known to act with any cer- tainty upon this secretion. It first excites some de- gree of fcetor in the breath, which is often accompani- ed with a gentle nausea, and very commonly with the taste of copper. The gums become red, full, and somewhat tender. The salivary glands become hard and turgid, and at last an increased flow of saliva takes place, accompanied with a good deal of pain in chew- ing, and with a loose vacillating state of the teeth. For the most part this increased quantity of saliva bears some proportion to the quantity of mercury that has been exhibited; but this does not always happen, for occasionally we meet vvith cases in which a very great and long continued discharge of saliva is excited by the smallest dose of mercury that is usually given. In such instances, if the farther exhibition of the medicine be not managed with much caution, besides a great flow of saliva, and swelling of the salivary glands, a very distressful tumefaction takes place over- all the contiguous parts, and particularly of the tongue and fauces. This also happens wherever mercury k given in too great quantities, and especially if the pa- tient is suddenly and unexpectedly exposed to cold or dampness. Where this takes place to any consid- erable degree the whole surface of the mouth over ail the inside of the cheeks, the tongue, uvula, and gums,, are apt to ulcerate, and the matter which ensues from mixing with the saliva gives it both an additional fcetor and an ugly, sanious appearance. Besides the usual symptoms of fever mercury is apt 102 OP THE REMEDIES USED Cll. IV. to excite restlessness, anxiety, general debility, and a very distressful irritable state of the whole system. These are the ordinary effects of mercury, and we shall presently have occasion to see that in the treat- ment of Lues Venerea one of the greatest difficulties we meet with is the management of this medicine; for while the cure of the disease often requires it to be given in considerable quantities, the constitution is apt to be materially injured if it be not exhibited vvith the greatest care and attention. HI. Oj the Operation of Mercury in the Cure of Lues Venerea. Various opinions have been offered of the action of mercury in the cure of this disease. It would be for- eign to our purpose, however, to enter minutely into the consideration of any of them. I mean therefore to make only a few observations upon such as have been most generally received, and chiefly upon that which in my7 opinion ought to be adopted: 1. Some have imagined that mercury acts chiefly in the cure of Lues Venerea by exciting a dissolved or putrid state of the fluids, which they conceive to he a state favourable for the peccant or morbid matter of the disease being thrown off from the system. The chief foundation of this opinion is the fcetor which we commonly perceive in the breath of patients under a course of mercury, and the increase with which it is usually attended of almost all the secretions, When we find, however, that whatever excites a quickened state of the circulation is commonly pro- ductive of an increase to all the secretions, and know- ing that a quickness of pulse is a very common effect of mercury, we conclude, that upon this principle this effect of the medicine is more clearly explained than by any other opinion that has yet been suggested. Besides, we know from actual observation that the blood, during a considerable part of a course of mer- cury7, instead of being thin and dissolved, is of a more firm texture than it usually is in health. Mercury, Sec. IV. IN 'lUES VENEREA. 10? when long continued indeed, never fails to excite much languor and debility, with many of the corresponding symptoms of a putrescent or scorbutic diathesis; but as many of the symptoms of syphilis are daily cured without this taking place, there is reason to suppose that this effect of mercury upon the system is in no way necessary for the cure of the disease. In confirmation of this we may remark, that all the slighter degrees of Lues Venerea are often removed, and insome instances cured, without even the saliva being increased in quantity or affected with fcetor: nay, a peculiarity of constitution sometimes occurs in which we cannot induce either salivation or fcetor of breath by all the mercury that we dare venture to give, and still the cure of the disease goes on, aHhough not so speedily, yet with equal certainly as if these or dinary effects of the remedy had been regularly in duced. 2. The symptoms of Lues Venerea being consider- ed by some as the effect of a peculiar irritation exci- ted by the presence of the poison in the system, they have also ventured to say that mercury cures the ve- nereal irritation, as they term it, by producing an ir- ritation of a different kind.* The reasoning, however, which has been employed in support of this opinion seems to be altogether hy- pothetical, and directly contrary to many facts which fall daily within our observation in the treatment of this disease. Local pains may for a time be suspended, or they may even be removed altogether, by irritation of a different kind being excited either in the contiguous or some more distant parts of the body ; but we know of no constitutional disease that has hitherto been cur- ed by such means. This affords, therefore, much cause to suppose that the opinion is ill-founded when applied to the action of mercury in the cure of Lues Venerea ; for when no such effect is found to take place in other diseases, we cannot, without the strong ' Vide Mr. Hunter's Treatise on the Venereal Disease 104 OF THE REMEDIES USED Cfl. IV. est proofs were given of it, be led to imagine that any thing so very unusual should take place here. Mr. Hunter indeed gives as the chief reason which he sug- gests in support of his opinion, that " the disease can in many cases be cured by raising a violent stimulus of another kind."* I must say, however, that I nev- er met with an instance of this, nor have I been able to hear of any who have done so; neither has Mr. Hunter, in treating of the method of cure, mention- ed any article for the purpose of curing the disease in this manner. The opinion seems to have arisen from mercury be- ing known to act as a very powerful stimulant; but al- though this will be very generally admitted, yet it is also well known that this stimulating effect is not only unnecessary for the cure of Lues Venerea, but that it is one of the most distressful occurrences that we meet with in the treatment of this disease, and that the more we can counteract it, consistently with the quantity of the medicine to be given, the more certainly do we succeed. So evidently is this the case tliat it may be considered as one of the principal desiderata in this branch of practice, a means of throwing mercury in an active state into the system, and in sufficient quan- tity for the speedy cure of the disease without produ- cing these stimulating effects. Were we possessed o( this the cure of Lues Venerea would be accomplished with ease, and probably in one half of the time that is now found necessary7. With the assistance of ano- dynes we in some degree counteract the stimulating property of mercury, but the most powerful we can employ, even opium itself, is not altogether sufficient; so that we succeed only by exhibiting the medicine in small quantities, and interrupting the use of it alto- gether whenever it excites much fever, or proves oth- erwise so powerfully stimulating as to be productive of much uneasiness. Another obvious proof may be mentioned of this stimulating property of mercury being in no degree * Vide p. 365, £ in lues venerea. 113 quantity of any remedy that acts as its antidote; and it is perhaps equally difficult to explain the manner in which such a small portion of matter acts in assimila- ting quickly to its own nature such a large proportion of our fluids, as it is to account for the manner in which the mercury operates which we employ for cur- ing the symptoms produced by it. Upon the whole, therefore, as the action of mercu- ry in the cure of Lues Venerea is not accounted for by any other opinion that has yet been offered ; as we have complete evidence of this disease being at all times the effect of contagious matter entering the blood; as the local effects of this matter are cured by mercu- ry, whether they appear in the form of ulcers or by obstructing the lymphatic glands ; as no other remedy hitherto employed operates vvith any certainty, either in removing the matter from the blood, or in obvia- ting the effects of it; as mercury seldom or never fa-Is in curing syphilis, when it can be made to enter the blood, if it be not in the most advanced stages of the disease, or when Lues Venerea is connected vvith oth- er diseases, or with such peculiarities of constitution as will not bear a sufficient quantity7 of mercury; and as no instance perhaps can be adduced of a cure being accomplished where the presence of mercury in the blood was not rendered obvious either by the usual effects of it upon the mouth or upon gold and silver carried in the pocket, we have no reason to doubt of this remedy operating perhaps entirely as an antidote ; that is, by rendering the matter of contagion inert or incapable either of exciting the disease, or continuing the symptoms even after the disease has been produced. The following observations on the modus operandi of mercury, by Dr. Francis, professor of the Materia Medica in the College of Physicians and Surgeons in the State of New-York, contain a com- pressed view of the several theories on the subject, as well as anew one suggested by Dr. Hosack, and ably illustrated by Dr. F.—« These observations we consider of so much importance, that we would not sin against the author by an abridgment, any more than we would deprive our readers of a feast they will enjoy from perus- ing them in the words of the author. YWfWl a conh lence that the VOL. II. 15 114 OE THE REMEDIES USED Cll IV. intrinsic value of the extract will constitute a sufficient apology for its length. (Vid : Med : & Philosoph. Register, Vol. IV. p. 476.) " Numerous and discordant are the opinions which have been main- tained by professional men on the curative action of mercury in the treatment of disease ; and upon an examination into the history of this medicine, the most superficial observer will perceive that these different opinions have a relation more or less corresponding with the prevailing theories and physiological knowledge of the times. Upon the first introduction of mercury as an article of medicine, when it was administered in its metallic state, it was supposed to overcome all obstructions by its specific gravity. Upon its more general and successful employment by Paracelsus and others, its acticn, it was presumed, was readily explained according to the crude and absurd notions of the chemists. After this period its op- eration, in common with other remedies, was successively elucida- ted agreeably to the opinions of the humoral pathologists, and the corpuscularian doctrines of the mechanical physicians. Its peculiar action, however, in the treatment of lues venerea, has been more especially the subject of consideration among the most distinguish- ed authors who have written on that disease, as well as of those who have treated of the materia medica In not a few instances, it has given birth to the most fanciful and erroneous ideas, relative to the pathology and functions of the human system. Even the great Boerhaave, who acquired and appropriated to his own use the know- ledge of all preceding ages, "who examined systems by experi- ments, and formed experiments into systems,"* believing the vene- real disease to be seated in the cellular and adipose membrane, con- ceived its cure was to be effected by melting down the adipose sub- stance by salivation.! And at the present day, after the more recent and popular thee'.. s of Mr. John Hunter and of Mr. Benjamin Bell, the modus operandi of this medicine remains a question far from being decided. Aware of the many difficulties which occur in accounting for the curative action of mercury in the treatment of disease, the writer does not presume to suppose he can remove the obscurity in which this subject is involved: but as the theory of its operation will be the more readily understood in connexion with its effects upon the body, it seems necessary that they should first be briefly mentioned. Passing over the still more recent and more fanciful opinions en- tertained on this subject, by Doctors Girtanner, Beddoes, Thornton, Blair, and others, a few remarks may first be offered, perhaps with some advantage, upon the respective productions of Mr. Hunter and of Mr. Bell; without the least view, however, to disparage the intellectual labours and numerous scientific discoveries of the for- mer, or the great practical sagacity and eminent professional servi- ces of the latter. Mr. Hunter, entertaining the opinion that no two morbid action; * Johnson's Life of Boerhaave, Woyks, vol. xii. ■j- Pvxiecuones Acad, de Lue Vencrci. Ereiatao ad Lusini Aphrodisiacum, fol. Lug. Bat. 1723 ^c- IV. IN LUES VENEREA. 115 can exist in the system at the same time, maintained that the saluta- ry effects of mercury depended upon its producing an action incom- patible vvith that which already existed ; counteracting the venereal irritation by producing another of a different kind. This opinion of Mr. Hunter may, at first sight, appear to derive considerable sup- port from the method of cure which is generally had recourse to in the treatment of some diseases; as, for instance, the removal of glandular obstruction by the influence of calomel on the salivary glands, and the transfer and diminution of a partial infiammation by the operation of epispastrcs. The general law, however, which lie first devised and employed for the explanation of pathology, that two actions cannot be carried on at the same time in the same part, or in the same constitution, remains yet to be established, notwith- standing the great plausibility with which it has been enforced. It is scarcely necessary to remark, that so far as it regards inani- mate matter, this principle is altogether inadmissible, as is abund- antly proved by the doctrines of projectiles. The history of disea- ses also demonstrates that this law is unfounded, and particularly of those arising from a specific material. That the human body is susceptible of the operation of two distinct contagions at the same time has been satisfactorily shown by the facts recorded by Dr. Pa- trick Russell, of the small pox and measles which prevailed at Al- lcppo, in 1765.* On the authority of Bcrgius and Tandon, men- tion is made of several cases in which the measles and small pox appeared together in the same individual.! Dr. Willan witnessed the occurrence of hooping-cough (a disease of acknowledged spe- cific contagion) during the eruption of the small pox in the same person; the former disorder remained along time after the latter without any material alteration.! Cases of small pox combined vvith measles came under the notice of Dr. Walkcr.§ Desessarts men- tions the complication of small pox with scarlatina.|| Mr. Lecse inoculated an infant while labouring under measles, and both diseas- es went through their ordinary course.^ Two cases which exhibi- ted unequivocal evidence of the possibility of two distinct diseases, small pox and measles, arising at tne same period in the uuman constitution, and each preserving its ordinary course as when sepa- rately existing, attended with all their usual characteristic symptoms, are recorded by Dr. Tracy.** A number of cases of small pox co- existing with measles, and the two diseases going through their reg- ular stages in the same individuals, occurred at the Foundling Hos- pital, at Dublin, as appears from extracts from the memoirs of the * Trans, of the Society for the Improv. of Med. and Chirurg. Knowledge, vol. 2. f King's Observ. on Inoculation; London Med. and Phys. Journal, vol. 14- p. 142. t Reports on the Diseases of London, p. 38. § Inquiry into tlie Small Pox. See also London Philos. Trans No. 429. " Journal de Med. I. 49 : London Med. ltcv. vol. i. p. 313. " Loud. Med. and 1'hvs. Journ. vol. 4. p. 18. " Mitchell and Mill-Vs Med, Repos. v.vl 3. p. l^" 116 OF THE REMEDIES USED Ol. IV. Medical Society of that city, communicated by Dr. Rainey.* All these instances of the continued operation of measles with other dis- orders of specific contagion, it will be proper to bear in recolIectiont are cited from modern authors: the opinions of the more ancient writers on this point being disregarded on account of the errors into which they were led from adopting the principles of the Arabian physicians, and considering and generally treating these different specific disorders, small pox, measles, and scarlatina, as modifica- tions of the same disease.! Mr. Maurice vaccinated two persons who had been previously exposed to measles. The vaccine infection and the measles went through their usual course at the same time.t It appears from the observations of Dr. Woodville, Dr. Willan, and other writers on the cow pox, that if the constitution be submitted simultaneously to the action of the small pox and vaccine diseases, that these dis- orders go through their course at the same time without influencing each other.§ Many cases of this kind might be mentioned. In the report of the New-York City Dispensary, published July, 1809, the physician of the cow pox department, recorded the case of a child who, on the eighth day after it was vaccinated, had the vaccine disease with all its characteristics, and, at the same time, laboured under a " plentiful eruption of small pox," to which dis- order it had been exposed by an imprudent visit some days previous. The two diseases appeared entirely distinct and independent of each other. The physician vaccinated six children from the fluid of the vesicle, who all had the regular cow pox, and were afterwards test- ed by the small pox inoculation without effect. Several children were inoculated with the matter from the small pox eruption who took the disease in its usual form.|| Dr. Adams himself, the un- qualified and indiscriminate panegyrist of the doctrines of Mr. Hunter, asserts, that small pox and cow pox " will proceed togeth- er in the same person without the smallest interruption to each oth- er's course."! Instead, however, of admitting the validity of the fact, in opposition to the universal law of Mr. Hunter, Dr. Adams declares that this circumstance only proves the identity of the tivo morbid poisons. Admirable dexterity of reasoning ! If the constitution, imbued with the peculiar matter of any of the diseases of specific contagion, or under the action of the vene- real virus, were on this account, during the presence of such pe- culiar specific matter, not susceptible of the influence of other * Duncan's Med. Commentaries, vol. 3. p. 444.; Macbride's Practice of Physic, p. 376. f Vide, Sennertus, Med. Pract. vol. 4. cap. xii. Diemerbroeck, Tract, de Variol. et Morbil. cap. xiv. * Lond. Med. and Phy. Jourri. iv. p. 38. § Reports on the Diseases of London, p. 313. Woodville's Reports for a series of Inoculations for Variolx Vaccina:, p. 145, he. II Gillespie's Report on the Cow Pox, in Mitchell and Miller's Med. Repos vol. 13. p. 87. 1 Observations on Morbid Poisons. 4to. p. 398. See also his Popular View of Vaccine Inoculation, p. 41. Sec. iv, i.r lues venerea. 117 diseases of a specific origin, who would not have observed the in- stances of exemption from the operation of contagious and infec- tious diseases, and have ascertained and made known so singular and specific a cause? Who is prepared to say, that the individual labouring under lues venerea is, on that account, exempt from the influence of small pox 5 or that he who is infected with small pox is secured from the attacks of plague or yellow fever ? The hypothesis of Mr. Hunter, however, whether it be correct or not, is irreconcilable with another principle which he himself has elsewhere adopted, that the venereal disease often becomes the im- mediate cause of other disorders, by calling forth latent tendencies into action, as he here admits the concurrence of two distinct ac- tions. " I have seen in many cases," says he, " the tendency so ve- ry strong, that it has taken place before the venereal has been entire* ly subdued."* But enough has been said to prove the co-existence, in the same individual, of diseases essentially different in their pe- culiar character, and arising from the operation of distinct specific causes. Agreeably to the law which Mr. Hunter laid down, the method of treatment in the venereal disease is by counter irritation, and to excite an irritation greater than that of the venereal. Let this prin- ciple be granted as well founded, and it need not here be stated how extensive would be the class of anti-venereal remedies. If the sal-. utary effects of mercury depended upon its producing irritation, then other medicines acting as irritants would occasion similar hap- py effects. Even fever itself, the effect of irritation, might be of the number of anti-syphilitic remedies; yet, in the treatment of lues venerea, it is one of the most common objects of the physician's attention to subdue and guard against fever, as well as other sources of irritation. But the premises on which this ingenious author pro- ceeds cannot be granted. " The removal of venereal action by mer- curial action (to quote the language of an able critic) is gradual and progressive; the mercurial must, therefore, exist along with the venereal, until the latter is entirely overcome ; and if these ac- tions were not at certain periods co-existent, the cure must be ac- complished in a moment, or it could not be accomplished at all."t The theory supported by Mr. Bell, that mercury acts as an anti- dote in the cure of the venereal disease, is no less untenable than that of Mr. Hunter. The experiment, which he has considered as decisive, of the matter of lues venerea on being mixed with tritu- rated mercury (Plenck's solution) becoming inert, and, consequent- ly, incapable of producing disease, can be admitted only as a spe- cies of chemical agency upon inorganized materials, and will by no means apply to the organized animate body. The assumption that such an operation takes place in the human system is altogether gratuitous. If, again, the principle just stated were true, that mer- cury possesses a peculiar " antidotal" or neutralizing power, simi- lar to the operation of an alkali upon an acid, the particular activity ' Hunter on the Venereal, p 26. \ London Med. I^vi' \r. vci 1. p. 20;. 113 OF THE REMEDIES USED Cll. IV. and the advantages which certain preparations of this metal possess, might be regarded as of no practical importance, and corrosive sub- limate and the crude mineral be employed without distinction : the successful treatment of this disease would uniformly depend upon the quantity of mercury administered. But this would lead to the adoption of a practice at variance with the experience of several very eminent writers, and one which Mr. Bell himself thinks pro- per to guard against:* and, indeed, the very small quantity of cor- rosive sublimate which is necessary to effect a cure, renders it al- most certain, as remarked by Dr. Cullen,f that mercury does not cure the disease by being an antidote to the poison. The arguments in support of this theory, derived from the operation of mercury when locally applied,are not to be considered as of any importance; local disease may frequently be changed and effectually cured by the application of local remedies. The venereal disease can be re- moved by such remedies only as produce a general action upon the whole constitution, the medium through which the morbid matter is diffused, and upon which it exerts its destructive influence. Firstly, In what manner does the poison of specific diseases ope- rate upon the human constitution ? and, Secondly, What are the changes effected in the system by the in- fluence of mercury ? Little, indeed, is known concerning the peculiar nature of the vi- r«s of specific diseases : the action which takes place upon the ap- plication of the smallest particle of morbific matter to the human body, and the process by which it generates disease, converting a lo- cal into a general disorder, and thus producing an altered and vi- tiated state of the whole system, it must also be admitted, are nei- ther very obvious to the senses, nor very clear to the reasoning powers of man. The effects themselves, however, have been long and familiarly known; and from duly considering these, a rational theory may, perhaps, be formed of the manner in which they are produced. That the poison of specific diseases, as that of lues venerea, small pox, See. diffuses itself through tlie whole constitution, and assim- ilates unto its own nature the general mass of circulating fluids, seems to be most consonant to all that is understood of their pecu- liar character. Upon the introduction of a particle of variolous matter into the system, an inflammatory action of the part, into which it is inserted, is excited ; by which action new morbific mat- ter of the same nature is generated. This process may be carried on to a greater or less extent, in a longer or shorter time, in differ- ent persons, before the specific material enters the absorbents; and hence tocal infiammation is, in some cases, considerably advanced beiore the system becomes affected ; while, in others, the eruptive Symptoms supervene when it appears to nave made very litt.e pro- gress.J The morbid poison, modified in its action by its degree of * Bell on Gonor. Virul. and Lues Ven. vol. 2. p. 259. | Cullen's Mat. Med. vol. 2. p. 254. -* Woodvilie's Reports oa Cow Pox, p. 15, -«'C. IV. IN LUES VENEREA. 119 acrimony, the condition of the part, and habit of body, is taken up by the absorbents and enters the blood-vessels ; whence it is receiv- ed into the general circulation, and produces its peculiar effects upon the constitution. The fluids, therefore, are thus necessarily first affected, and, as a consequence of their morbid condition, the solids themselves next become vitiated. Hence the multiplication of the matter of variolous contagion in inoculated small pox; and he; ce, on the same principle, the generation of morbific matter, fr"• L\ LUES VENEREA. 121 feet us in utero may also become affected vvith the poison of the dis- ease, -nd exhibit -symptoms similar to those which arise from.the same cause at other periods of life. The general experience of the most eminent practical authors, (with the exception of Mr. Hunter,) has so well established the fact that little further need be said at present concerning it.* The venereal disease may be communi- cated to the foetus in utero, and the healthy child after birth may be- come affected with the same disorder by sucking an infected nurse. Two remarkable cases, in confirmation of the fact last mentioned, occurred in the practice of Dr. Hosack, in the spring of 1807. A healthy infinl, born of respectable parents, was placed under the cine ol a wet nurse, and in about four weeks after, eruptions ap- peared in different parts of its body. The ordinary alteratives were had recourse to without effect: the child became worse ; ulcers on the threat and other symptoms strongly resembling those of lues venerea were observed. Mercury was now administered in the form of the solutio oxymur. hydrargy. by which the disease was com- pletely removed. Suspicions being thus confirmed as to the nature ol the disorder, the infected nurse was dismissed, with an injunc- tion to undergo a mercurial course. Shortly after, and regardless ol advice, she entered into another family in which she again com- municated to a healthy sucking infant the venereal disease, which yielded only to the operation of mercury. These two cases render it no longer problematical, but unequivocally prove that an infected nurse may, merely by her milk, communicate a specific disease to her nursling. Tiiey also, still further, render valid the opinion, that not only the blood but the secretions may, to a certain degree, be assimilated in their nature to the virus of certain morbific pois- on s- l'. is asserted by the advocates cf vascular spasm, that assimila- tici. is founded on an erroneous and vulgar analogy between a mere- ly chemical action and the operation of the animated body ; and it has oeen urged with much force as an objection to the doctrine of a fermentative or assimilating process taking place in the living sys- tem, that such process is always accompanied with ebullition and the extrication of air, phenomena incompatible with the due perform- ance of the functions essential to animai existence. Surely those who have considered this objection of importance have not attended to the ordinary changes which wine undergoes during its secret fer- mentation, as it has lately very properly been denominated ; for in these changes neither ebullition nor motion is necessary to the fer- menting process by which the wine is matured. " Ebullition, or any evident motion," observes Mr. Cruickshank, " is not necessa- ry to constitute fermentation ; after wine has undergone what is cal- led its open fermentation, it continues, after it is bottled, to go through its secret fermentation, where no motion is evident, and every body knows requires time to ripen."f Even granting that the extrication of a portion of air is necessarily, at all times connected * Vide Malion on the Ven. Infect, in Pregnant Women. Lond. Med. Rev vol. 2. p. 44. \ Anatomy of the Absorbing Vessels. VOL. II. 10 122 OF THE REMEDIES USED CI). IV. with the assimilating or fermentative process, it forms no argument against the principle here advanced : air conveyed slowly into the blood vessels is not destructive to animal life, a fact, which the ex- periments of Redi, of Florence, and other eminent naturalists have fully established.* There are two or three other objections urged against the doctrine of assimilation which shall be considered rather on account of the high authority of their author, than of any weight in themselves. In his valuable paper on the origin of contagious and new diseases, Dr. Ferriar asks, " does contagion assimilate all the fluids to its own na- ture ?"f The objections which he considers of great force against this doctrine are, that many phenomena in the symptoms and cure of fevers point out a spasmodic affection, or diseased action of the ex- treme blood vessels as the real cause of fever. In answer to this it may be observed, that the existence of spasm, as essential to the character of fever, rests upon the hypothetical views of those who considered diseases as exclusively affecting the solids, a theory, the absurdity of which has long ago been pointed out. " This affection ha spasmodic affection] is supported," adds Dr. F. " by the action of contagion, and, perhaps, is strengthened as more contagion is pro- duced " According to this principle, spasm must be the prominent symptom the physician has to subdue in the treatment of contagious diseases, and this spasmodic effect will be the more violent in pro- portion to the virulence of the particular poison by which it is pro- duced. But where are the facts which warrant conclusions of this nature ? Does not the history of contagion uniformly prove its ope- ration on the human constitution to be powerfully debilitating and depressing, and establish a pathological principle directly the re- verse of the one maintained by Dr. Ferriar ? Were the fluids infected, observes Dr. F. a patient would not cease to infect others till the whole mass was changed.! It is cer- tainly matter of surprise that this argument should have been offer- ed by a writer who has so long been practically conversant with the operation of febrile infection, and who is so fully awaie how nume- rous are the circumstances which modify the communication of contagious disorders. Why the infected body does not, in all sta- ges of disease, infect the bodies of others, is a problem, the solu- tion of which is no less difficult than why contagious diseases them- selves do not uniformly operate upon the constitution of all who come within the sphere of their influence. Of the various diseases of specific contagion, small pox is justly considered the most viru- lent in its nature and the most universal in its operation: yet the many cases of exemption from the action of variolous contagion, particularly of those recorded by Dr. Lind,§ will assuredly not lead to the absurdity of denying the specific character of the disease, and that it is propagated by contagion. * Redi, vol. 4. p. 223. as quoted by Sir John Pringle ; Diseases of the Army. Appendix, paper vh. f Med. Hist, and Reflect, vol. 1. p. 280. 2d. ed. =F Med. ILst. and Reflect, loc. cit. p. 281. § Papers on Contagion and Infection. "^C. IV. IN LUES VENEREA. 123 Judging from the following passage, which occurs in the essay from which the preceding quotations have been made, it would seem that Dr. Ferriar is by no means convinced of the soundness of his own reasoning. Pie here appears the decided advocate of the very principle which he elsewhere opposes. " It is peculiar to the animal poisons," says he, « that they not only give rise to a disease similar to their original, but that, however small the quantity ap- plied, they convert a large portion of the fluids to their own na- ture.' Analogical proof in support of the doctrine of assimilation might be adduced from considering the changes which.thcdifferentarticles of food undeigo when converted into chyle; but the facts already advanced render, in the opinion of the writer, the existence of such a process no longer controvertible. It appears, therefore, from the changes which take place in the healthy constitution upon the introduction of the peculiar virus of lues venerea, small pox, measles, and other diseases of specific contagion, and from the nature of the alteration which is thereby effected; from the conversion of a local affection into a general dis- order, and the multiplication of the particular morbific matter throughout the system ; from the communication in all cases of the same specific disease, by inoculation, through the medium of the general circulation, and by the secretions, and from other phenom- ena which characterise these disorders, that the fluids of the human body are susceptible of material alteration even in the living state: that this alteration uniformly partakes of the nature of the morbific matter introduced; that the materies morbi thus generated is alone capable of propagating a disease in another constitution, in ail re- spects of the same character, and none other ; in fine, that the circu- lating mass of the system does become assimilated in its nature to the virus of specific or contagious diseases, and, as a consequence,^, that the solids themselves also become affected. For such is the general law of the animal economy, modified by the living principle, that the action of one part is subservient to that of the other ; while they regularly harmonize in health, they all are acted upon by dis- ease. It has justly been observed, " an exclusive theory, either of 5olidism or humorism, is a solecism in pathology." As this alteration in the healthy state of the system, which fol- lows upon the operation of the virus of diseases of specific conta- gion, is characterized by a regular and peculiar train of phenomena, from observing these effects thus constantly produced, many at- tempts have been made to ascertain the particular cause. The ex- planation which has just been offered, seems to convey the most ac- curate idea of .the kind of action which takes place; that the spe- cific matter of these diseases acts as a ferment, and by the process consequent thereon, assimilates the system to their own peculiar nature. Doubtless this process is more or less governed by the liv- ing principle ; and as chemical writers have observed different spe- cies of fermentation in inanimate materials, so aiso pathologists will * Med Hist, and Reflect, he. tit. p. 278, ^ J24 OF THE REMEDIES USED Cll. IV admit a modification of the same action when occurring in living or- ganized matter. " All that is necessary in fermentation," says an able philosopher already referred to, " is, that the elementary par- ticles be separated and recombined, so that the matter be converted into something different from what it was before."* Frr.m the re- futation that has been given of the chief objections to this theory, the reader will have already understood the principles upon which it rests. Secondly. With regard to the changes effected in the system by the influence of mercury. Mercury in the state of an oxide, is one of the most universal stimulants. Its action, though primarily on the nervous syster.:. is communicated to every fibre of the body, and produces a degree of restlessness, anxiety, and debility. When taken into the system, it manifests itself by a quickened circulation, gives the blood the dis- position to take on the buffy coat when drawn, renders the pulse frequent and harder, increases respiration, excites the temperature of the body, occasions a whitish fur on the tongue, and other symp- toms of general inflammatory action. Its effects upon the secre- tions are still more apparent, producing a preternatural flow of sal- iva, an increased action of the mucous vessels of the trachea, lungs, digestive organs, chylopoietic viscera, and whole intestinal canal. It excites a copious discharge of urine, and in the smallest quantity operates with great certainty on the skin. In its thus extensive, in- fluence on the body, it produces a consequently increased action of the absorbent vessels. These may be considered the more ordinary sensible effects of mercury when its action is not particularly mod- ified by the morbid condition of the constitution. From the very general and stimulant operation of mercury in pro- moting the excretions of the whole system depends its curative ac- tion. * This theory of the manner in which mercury produces its salutary effects, was suggested in the lectures on the materia medi- ca formerly delivered by the present professor of the theory and practice of physic in the University of New-York.f It appears to be deduced from the nature of the changes which this powerful remedy uniformly effects, when its action is not interrupted or changed by adventitious circumstances; and believing it calculated to lead to material improvement in practice, in addition to the facts and reasonings with which it was originally enforced, the writer now offers such others as seem still stronger to confirm its correctness. It may be asserted as a fact fu! !y confirmed by modern observation and experience, notwithstanding the general opinion of the older writers to the contrary, that the curative operation of mercury, in lues venerea, depends upon the action which it produces through- out the general system: that its sanative powers are in proportion to its uniform effects upon ail the secretions, and that the advanta- ges which certain preparations of tnis mineral possess Over tnose of others, are ascribable chiefly to their action not being confmed * Cruickshank's Anatomy of the Absorbing Vessels. :; j- Doctor David Hosack, SCO. IV. IN LUES VENEREA. J25 to the increase of the salivary discharge. In proportion also as the action of mercury is general throughout the system, its tendency to run off by any particular secretion is diminished ; and, vice versa, the excitement and consequent increase given to anyone secretion almost uniformly produces a diminution of every other. Admitting these principles to be well founded, it follows that the same salutary effects will not be experienced when the operation of mercury is exclusively directed to the salivary glands, or when it exerts its influence on the intestinal canal alone. Hence, in the ad- ministration of this remedy, in lues venerea, in order most effectu- ally to obtain its full operation, it must be introduced into the sys- tem in a gradual manner: as it is equally the physician's care to guard against an undue augmentation of the salivary discharge, as well as a preternatural increase of the evacuation by the bowels : for, in the former case, by promoting a salivation, the important functions of the skin and other secretions are lessened or suppres- sed ; and, in the latter caseT the remedy is prevented from entering into the general system in proper quantity. That the medical vir- tues of mercury depend principally upon its operation on the exha- lent vessels of the general surface, at the same time that it operates upon the other emunctories of the body, is still farther evinced by the superior benefit which is derived from certain preparations of this me;al which are known to act almost exclusively in producing diaphoresis ; as the combinations of it with the marine acid in the form of the corrosive sublimate. Proofs of a like nature may be drawn from the action of those remedies which are often united with mercury, for the more advantageous treatment of the venereal dis- ease, as antimony, guaicum, sarsaparilla, opium, See. Again; ex- perience has uniformly shown, that if the action of mercury in cau- sing diaphoresis be aided by a proper regard to temperature, food, and regimen, and such means as operate upon the skin, itr, salutary effects are greatly increased : and if its operation be prevented or suppressed by irregularities in diet, or from exposure to cold, they are greatly diminished. This view of the operation of mercury appears still more clear and satisfactory from considering the influence of climate in the re- moval of lues venerea. How mild and tractable even the most ob- stinate and confirmed cases of syphiiis become upon the patient's removal to a temperate latitude is familiarly known. Not that the air of Montpelier, of Italy, or of Portugal, possesses, in itself, any peculiar balsamic influence, but that the effect of a tempera- ture, such as these places boast, is calculated to insure the full operation of mercury upon all the emunctories of the body, and to prevent its partial influence on any particular part. In temperate climates salivation is at ail times studiously guarded against, not less than the pernicious effects which would arise from the inordi- nate action of the medicine upon the intestinal canal; and if, while in the employment of mercurial remedies, the least symptom of such effects appears, the use of those remedies is immediately sus- pended. To restore the tonic powers of the system, if impaired, previous to entering upon the use of mercury, and to support them 126 OF THE REMEDIES USED CI). IV. while under its action, are the principal indications of cure; by these means the constitution is enabled to undergo the necessary al- teration, mercury exerts its natural operation, the venereal poison is eliminated, and a radical cure is effected. Those disposed to en. ter more fully into a consideration of the salutary effects of a tern- perate climate, 8cc. in aiding the general operation of mercury, as an anti-venereal, will find the opinions of Mr. Hunter,* on this sub- ject, completely overthrown by the facts recorded in Harris,! Don Uiloa,| Clark,§ Moseley.,|| Swediaur,*! and Vage.** Availing him- self of a knowledge of the importance of a warm climate in mitiga- ting the severity of venereal affections, the practical physician, as Dr. Swediaur has justly observed, « will be able to put his patient, in any country whatever, in a situation which he finds necessary.for curing this complaint." By keeping him in a mild and uniform temperature, by the occasional use of warm bathing, by enjoining the wearing of flannel, and proper attention to regimen and diet, a substitute not less efficacious than " climate" is obtained, which eminently contributes to the operation of mercury in eradicating the virus of the disease from the system. It is not at all contended for in this place, that mercury induces a peculiar morbid state of the fluids, such as some'bf the other au- thors denominated dissolved, and which a late writer of the same school, Mr, Howard, terms a " putridity sui generis,"ft and that in this manner it throws out offensive matter and effects its salutary ends; but inasmuch as it produces a quickened action of the blood vessels, and a consequent increase of all the secretions, it may justly be considered a most powerful alterative ; and as it possesses in a special degree the property of exciting the excretory vessels of the skin, intestinal canal, and kidneys, it arrests the progress of that peculiar operation which, it has been maintained, takes place, upon the absorption of a specific matter into the system, and which, as has already been observed, has significantly been termed by sev- eral practical writers the assimilating process. In the treatment of the diseases universally acknowledged to arise from specific contagion, mercury has at length become an active constituent in almost all the various articles employed for that pur- pose, and there is every reason to believe that the evils resulting from such practice have greatly counterbalanced the advantages. But the consideration of one only of tiie diseases belonging to this class can here be attempted. Notwithstanding all that has been written, so ill defined are the diagnostic signs of lues venerea, whe- ther it assumes the form of a local affection, or operates more im- mediately on the whole system ; so various and complicated are its * Treatise on the Venereal Disease, 4to. p. 348—9. f Collection of Voyages and Travels, fol. vol. 2. p. 514. * Voyages to South America, vol. 1. p. 280. § Diseases of Long Voyages, vol. 2. p. 440. 1| Treatise on Tropical Diseases, p. 76, 4th ed. t Pract. Observ. on Ven. Complaints, p. 167. ** London Med. and Phys. Journal. ft See his Observ. on Ven. Dis. Lond. 1806. '""^'- IV. IN LUES VENEREA. 127 symptoms in its different stages, and so uncertain its course and termination, that there are few complaints which require a more intimate knowledge of their nature in order to effect a radical cure ; and it may well be questioned, whether the mal-administration of the remedy has not produced as destructive consequences as the dis- ease itself. The practical observer will recollect how numerous are the diseases arising from causes essentially different from that which gives origin to the venereal, yet, nevertheless, in their char- acters bearing an exact resemblance to it; that the venereal not un- frequently exists in combination with other disorders ; and that from errors in the mode of treatment, not only its nature may become altogether changed, but diseases equally formidable be brought on. The existence of diseases of the first kind, « wearing the livery" of lues venerea, did not escape the acute penetration of Mr. Hun- ter ; and the subsequent labours of Mr. Abernethy have more ful- ly disclosed their perplexing nature. But as there are no discrim- inating marks by which they may be distinguished, there is yet no general rule of practice established. The effects of mercury upon them are various. According to Mr. Abernethy, they are some- times cured by it, sometimes they are only checked, and at other times aggravated.* This, however, is certain, that mercury may be misapplied in the treatment of these anomalous cases; and the practical caution of Mr. Hunter is not to be forgotten ; that " it is nearly as dangerous in many constitutions, to give mercury where the disease is not venereal, as to omit it in those which are."f In the diseases of the second kind, it is equally well known, after the removal of the specific infection for which recourse was had to mer- cury, that the other symptoms under which the patient may labour are so deceptive, as frequently to be enumerated among the sedon- dary effects of the venereal, and instead of yielding to the power of the same remedy, become more alarming, and if its use be persist- ed in, terminate fatally. And as far'as relates to the cure of the disease, those most conversant with it have furnished sufficient proofs of the pernicious consequences attendant upon errors in its treat- ment. | i Of these errors the common, and probably the most destructive, is the inducing of profuse salivation, which is generally brought on by throwing into the system large quantities of mercury. To do this in the siiortest possible time is the immediate object, and calo- mel pills, or some other form of mercury, is taken internally, and mercurial unguents or frictions employed. The evident result of such practice cannot fail to be injurious to the constitution. When this discharge is thus excited, it often continues until a total ex- * Surgical Observations, part 2, on diseases resembling Syphilis. ■j- Treatise on the Ven. Dis. p. 381. + See the respective publications of Hunter, Belb Swediaur, and Howard, on the Venereal. Pearson on the effect of various articles in the cure of Lue> Venerea. Alley's Observ. on Hydrargyria. Spens' Cases of Erythema Mcrcu- riale, Ed. Med. and Surg. Journal, vol. 1. p. 1. M'Mullin on the Erythema Mercunale, Ed. Med. and Surg. Journal, vol. 2. p. 25. Willan on the Diseases of die Skin, and Mathias on the Mercurial Disease. 128 OF THE REMEDIES USED Ch. IV. hauslion of the strength of the patient is the result. In many ca- ses, where it has been thought to have removed the disease, it has proved to be only a temporary cessation of its action; and in other instances, it has converted a comparatively mild disorder into one infinitely more dangerous. As the venereal arises from the introduction of a specific morbid matter into the system, so the peculiar action of this matter consti- tutes the disease. The particular manner in which it produces the various changes from a healthy to a diseased state, in which there exists, in a greater or less degree, an altered and vitiated condition of the fluids^ from which source all parts of the body may be affect- ed, is explicable by having recourse to the idea of a ferment, or an assimilating process, as most consonant with the phenomena which accompany the operation of the specific matter of lues venerea. The poison of disease is taken up by the absorbents, the local be- comes a general affection in a longer or shorter time, according to the virulence of the matter and the susceptibility of the constitution. Enough, however, has been said to prove that in the treatment of lues venerea such remedies are to be employed as operate more directly in promoting the action of all the secretory vessels of the body, and especially those of the surface ; because, as before stated, by this action the morbid process which has taken place will be ar- rested, and the assimilated matter carried out of the body. Equal- ly opposed, therefore, to the opinion declared by Mr. Bell, that" no advantage is derived from any increase that may be made to any of the secretions,"* and to that of Mr. Howard, who is the advocate for profuse salivation, even in the mildest form of the disease, and who contends, that the greater the discharge the more certain the cure,f the truth lies between them, and the most certain and effect- ual practice depends upon an increased discharge from the excreto- ry vessels of the whole system. To render plain truths still plainer, and to show, on this subject, more strikingly the incorrectness of Mr. Bell and of Mr. Howard, let it be recollected, that the effect of every preparation of mercu- ry is uniformly evinced by a greater discharge of some of the secre- tions; and this effect is so constant, that it sometimes takes place from the use of the mineral in a crude state.| In short, as Mr. Hunter remarks, there is no proof of its affecting the constitution without this consequence ; and its employment assuredly cannot be followed by any salutary result, unless it operates upon the consti- tution. But it is useless to dwell on this point, and there are prob- ably few men of observation who will accede to the sentiment ex- pressed by Mr. Bell. The opinion stated by Mr. Howard, of the necessity of profuse salivation in every case, had its advocates at a very early period in the history of this medicine, and though per- haps scarcely any opinion has at different times been more warmly embraced, or more indignantly rejected, it nevertheless at the pre- sent day is unfortunately one of the most popular. The older prat> * Treatise on Gonor. Vir. and Lues Ven. vol. 2- p. 272. f Observations on the Venereal Disease, vol. 1. p. 297. r- Mead's Medical Works, vol. 1. p. 106. Sec. iv. IN LUES VENEREA, 123 titioners attempted to justify this absurd and destructive method of Ueatment, by maintaining that salivation melted down and carried away the serum of the blood which contained all the venom of the venereal disease. At the present time, the practice of exciting salivation seems to owe its general reception to the well-known principle espoused by Mr. Hunter, that no two morbid actions can exist at the same time, and that one irritation destroys another. And yet nothing can be more evident, from Mr. Hunter's writings, than tiiat this very method of cure met in him a decided enemy. It is of minor consideration to be informed of the causes which have given origin to tivs mode of treatment; and painful indeed is the recollection of the miseries it has created. No absurdity in medical practice has keen the destruction of more lives; none the source of more pain and calamity. Well might Dr. Hoffman pro- nounce the abuse of this remedy, in the hands of the unskilful, to be more terrible than the sword. Peritiores non sine ratione mer- curialia in heroicorum remediorum numerum retulerunt, eo ouod ejus indolis ac virtutis sint, ut eorum providus usus valde prode'sse, abusus vero validissime nocere possit, ideoque in manu im/ieriti tan- quam gladius in manu furiosi sint* The pages of the older writers, as well as those of the modern, fully confirm the fact. Vet this method of cure is still popular, still pursued both in private practice and in public institutions. From the theory which has already been given of the nature and character of lues venerea, the whole system is the seat of the dis-; case, and the indications of cure will accordingly be more readily fulfilled by the employment of those remedies which attack the dis- order by their operation on the whole system. Of the various rem- edies calculated to obtain this end, mercury possesses superior claims, and those preparations of it which more directly act upon the secretory vessels of the surface, for the reasons before mention- ed, are to be preferred. A preternatural action of any one of the secretions is not to be depended on, as " it is only a proof of the susceptibility of some parts to such a stimulus,"f and the disease will remain uncured, as is shown from the stationary appearance of local affections.^ By topical applications, too, local affections may assume the healthy character, and yet the constitution remain con- taminated. Mercury, therefore, to employ the forcible language of Mr. Hunter, must be in a state of solution in the juices of the body. The importance of this method of treatment in confirmed syphi- litic cases cannot be too strongly kept in mind; as from a disregard to this principle in the employment of mercurial remedies, are to be traced most of the evils-arising from the abuse of mercury; and perhaps, a majority of the instances of failure in effecting the.per- manent removal of syphilis, are to be attributed to the same cause. Were the gums alone the seat of the venereal virus, the icasonin"- * Med. Rational. System, vol. 2. p. 257- \ Hunter on Lues Ven. p. 344. See also Ferriar, Med. Hist, and Reflect Vol. 3. p. 257. t Hunter, p. 341 Saunders on flip Liver, 4th ed. Appendix, p. 73 vol.. ii. 17 130 OF THE REMEDIES USED Gil. IV. of those who contend for the exclusive action of mercury on the sa- livary glands might he admitted as satisfactory. Few, however, if any, have been the abettors of so absurd an hypothesis, though it affords the only possible ground upon which they can attempt to jus- tify their loathsome and pernicious practice. Wiseman, in his Trea- tise on the Lues Venerea, has ably exposed some of the principal errors in the management of syphilis, committed by the practition- ers of his time. ;* and more lately, Dease, in his Observations, has placed in a striking light the pernicious effects of the « hot salivat- ing method of cure." The following paragraph, from the pen of Mr. Dease, happily describes the plan of treatment formerly much pursued. It probably has been the lot of the reader to witness a similar practice, not unfrequently followed atrthe present day, and, singular as it may seem, still recommended with all the weight of professorial authority. " In a confirmed syphilis," says Mr. D." the hot salivating method of treatment was adopted ; the patient was crammed into a narrow room, heated with a stove if it could be pro- cured, the admittance of any fresh air was shut out by blankets put up to the door and windows, and a screen surrounded the patient. There he sat, half suffocated in his own hot, putrid atmosphere, and was rubbed with mercurial ointment until his tongue generally lolled out; the inside of his mouth was covered over with sloughs." " In this hideous pickle," continues Mr. D. " he was to lie for twen- ty-five or thirty days."f That numerous were the victims to this empirical plan of cure will not excite surprise." * Chirurgical Treatises : viii. on Lues Ven. vol. 2. | Observ. on the different methods of treating the Ven. Dis Dublin, 1779 IV. Of the Preparations of Mercury. We have already had occasion to observe that crude mercury is not soluble in any of the fluids which it usually meets with in the human body; and as noef- fects result from it while it remains in this insoluble state it has been considered as a very important object to prepare it in such a manner that it may vvith most ease and safety be introduced into the system in a so- Juble form. It unfortunately happens, however, that all the active preparations of mercury, I mean such as prove effectual in curing Ihe venereal disease, are apt to excite very disagreeable symptoms, particularly salivation to a distressful height, purging, and general debility. Scarcely any point in practice has therefore met with more attentiori than the different methods of exhibiting mercury. Regular practitioners have in all countries been anxious to render mercury at the same Sec. IV. IN LUES VENEREA. 131 time active and safe, while it has been the pride of ev- ery empirick to be'able to boast of some new discove- ry by which this remedy may be given with freedom and safety without being deprived of its essential properties. The preparations of mercury are accordingly very numerous: upwards of five hundred might be enu- merated. The consequence of which is, that much doubt and uncertainty has taken place concerning them; for while one preparation has been in common use with some practitioners, we find it entirely neg- lected by others ; and in some countries preparations of mercury are employed daily which in others are very generally condemned. This would lead to the conclusion of our being able to cure the disease with perhaps equal ease and safety with a great variety of these preparations, and this I believe to be in some measure the case. We are very apt to fall into a routine of practice, from which it is with some difficulty that we emerge, and which there- fore every practitioner ought early in life to guard against. In no instance is the want of attention to this more conspicuous than in our practice in Lurs Vene- rea, where the same practitioner very commonly per- sists in the same method of exhibiting mercury, and is therefore soon induced to suppose thai, no other is equal to it, whereas were he to make trial of others he would find many by which the disease can be cured with equal ease, expedition, and certainty. To enu- merate all the preparations of mercury that have been employed could answer no good purpose; and being unnecessary, the attempt would be improper. I shall shortly mention, however, all such as are in general use, with the views which practitioners have in giving a preference of one to the other. It is found by experience that mercury may be ren- dered soluble, so as to prove active when received into the system, by three different processes; by tritu- ration; by calcination ; and by solution in a variety of acids. ]32 OF THE REMEDIES USED -Cll. IV. Whether any property is communicated by any of these processes to mercury which it did not before pos- sess it may be difficult to determine. It would appear that they render mercury active nearly in proportion to the degree of solubility which they give to it; and this again seems to depend in a great measure upon the degree of separation produced by these processes between the different particles of the mercury : At least this is clearly the effect of trituration. We have seen that in a crude state this metal is altogether in- ert ; and we find by experience that it proves active in proportion to the trituration employed upon it; and as by calcination and solution it is rendered still more active than it can be made by triture alone, we conclude that these processes are better calcu- lated for producing a more complete division of its particles. By agitation alone mercury may be reduced to the state of a powder, as was first attempted by Doctor Boerhaave, and afterwards by the very ingenious Doctor Saunders of London ; but the length of time required for this being very considerable, practition- ers have been accustomed to triturate the mercury with such substances as tend more effectually to keep the particles of the metal separate from each other, by which, while the virtue of the medicine is not les- sened, the process for obtaining it is much shortened. This, accordingly, is the foundation of various active preparations of mercury, of which the following are in most frequent use. I. Where the mercury is triturated with unctuous substances, and used externally only, as is the case in the emplastrum hydrargyri of the London and Edin- burgh dispensatories, and in the unguentum hydrar- gyri vel mercuriale. II. Where it is tritured with gums, mucilages, and saccharine substances, and chiefly employed for in- ternal use, as in the pilulae hydrargyri. Pharm. Lond. and Edin.; in the solutio me-rcurinlis gummosa ot Plenck ; in the injectio mercurialis ; and mel mercu- riale. Sec. TV. IN LUES VENEREA. 133 III. Where it is tritured with dry calcarous pow- ders, such as crabs eyes, and prepared chalk, forming what is usually termed mercurius alkalisatus* Besides these mercury might be tritured with sever- al other substances with perhaps equal advantage. Sulphur alone seems to render it inert or nearly so. The more friction that is employed upon mercury mixed with any other substance the more active it be- comes, while the more that it is rubbed with sulphur the more inert it is rendered. A very active preparation of mercury is obtained by means of heat; it is termed mercurius calcinatus, and is the basis of different pills and powders. In this process the mercury is reduced to a calx by long ex- posure to a very considerable degree of heat. Mercury is found to be more or less soluble in eve- ry acid, and the calx or salt obtained from these solu- tions gives the most active form of the remedy with which we are acquainted. 1st, Mercury combined with the muriatic acid gives, by different processes, the mercurius sublimatus cor- rosivus, or hydrargyrus muriatus corrosivus; and mer- curius duicis, calomel, or hydrargyria muriatis mitis; from the first of which are prepared the solutio mer- curii spirituosa of Van Swieten; the aqua phagadeni- ca and other watery solutions of corrosive sublimate of different authors, and pilulce e mercurio corrosivo. From the latter, viz. mercurius duicis, are prepared a variety of active formulae both for internal and ex- ternal use ; but these differing only in the vehicles by which they are conveyed it is not necessary to enu- merate them here. 2dly, W ith the acid of nitre, from which is prepar- ed mercurius precipiiatus ruber, the basis of various •external applications; ungentum hydrargyri nitrati mitius, vel ungentum citrinum; and the pulvis mer- cunicinereus. * Prescriptions for each of tfiese, as well as for. the preparation of every other article which I shall have occasion to mention, will be given in the Appendix-. J34 OF THE REMEDIES USKD Cll. i V, 3dly, With the vitriolic acid, with which we prepare iurpeihum mine rale. 4thly, With the acid of vinegar, from which is pre- pared Keyser's pills; analogous to which is the terre feuillete mercurielle of Preslavin, prepared vvith mer- cury dissolved in the acid of tartar. Mercury has also been dissolved in the acids of lem- ons, sugar, borax, arsenic, and spar; and in a great- er or lesser degree it is soluble, as I have already ob- served, in perhaps every acid; but as. every useful purpose of the medicine may be obtained from one or other of the foregoing forms, it appears to be un- necessary to enumerate more, particularly, as those who wish for farther information will readily obtain it in the various Dispensatories published in different parts of Europe. It may here be proper to remark, that although all of these preparations are in appearance different from each other, yet all of them seem to have nearly the same effect upon the mercury. They tend all to reduce it to the form of a calx, and in proportion as the cal- cination is completely accomplished the medicine be- comes active or otherwise. Even the trituration of mercury has the effect of reducing it to the state of a calx, and it is obviously in this manner that it is acted upon by acids ; for when dissolved in acids, and the so- lution evaporated, nothing but a pure calx is observed to remain. But although all of these preparations of mercury seem to be more or less active according as the calx which they produce is more or less perfect, there is how* ever some manifest difference in the calces obtained from them. All of them produce the distinguishing characteristics of mercury upo»i the system: they cure the venereal disease, and they excite salivation ; • but this is done much more easily, and with less distress in the operation, by some of these than by others. Of all the preparations of mercury those produced by triture alone seem to be the best for general use. They cure the venerea' disease with th*. same cer- Sec. IV. IN LUES VENEREA. 135 tainly as the others, and they are not go apt to affect the stomach and bowels; although the s.iine prepara- t lions of mercury, when the acid with which they are combined is completely separated from them, may, under proper management, be given vvith perfect safety, and vvith equal certainty of curing the disease. Corro- sive sublimate mercury, as it is termed, is one of the most acrid of all the mercurial calces,* insomuch that scarcely any person can bear it in the dose of a grain, and in the quantity of a very few grains it acts as a poi- son ; but even this very acrid remedy is rendered so mild by being deprived of the acid vvith which the mercury is united, that in the form of calomel it may vvith safety be given to the extent of several grains at once.f ^ We find also that the saline calces of mercury prove in some degree acrid in proportion to the strength of the acid vvith which they are combined : hence all the combinations of mercury vvith the mu- riatic acid, with the acid of nitre, and the vitriolic acid, prove much more acrid than the calces obtained from mercury united vvith the acetous acid, or acid of tartar. It is therefore probable that if these prepara- tions of mercury could be entirely deprived of their saline combinations, that they would not differ in any material point from the preparations obtained of this, metal by triture. As yet however we have not been able by any pro- cess to which they have been subjected, to prevent them from operating very differently upon the humau body, according to the kind of acid vvith which they are prepared, Thus, while simple triturated mercury acts chiefly upon the salivary glands, mercurius subli- inatus corrosivus is more apt to act as a diaphoretic, and it readily excites nausea and vomiting. The same preparation again, when more completely depnved of its acid, does not seem to affect the skin, nor in small doses does it so readily injure the stomach, while it acts with more certainty as a purgative. " Indeed calomel, in proper doses, is perhaps one of our surest * Vide Appendix, No. 8- f Vide No. 9. 136 OF THE REMEDIES USED Ch. IV. purgatives; and in order to act upon the salivary glands it must either be given in small doses, frequent- ly repeated, or combined vvith opium or some othet astringent. The mercurius cinereus is also apt to af- fect the bowels, while the combinuiion of mercury with the vitriolic acid in the form of Turbelh's miner- al, or hydrargyrus vitriolatus flavus, chiefly operates upon the stomach. It is proper that in practice these different actions of the preparations of mercury should be kept, in view; for although all of them, as I have observed already, will, under proper management, cure the venereal disease, some advantage is occasionally obtained from adapting them as much as possible to the nature of the symptoms for which they are intended. Thus, when a meicurial emetic is wished for, we give Turbeth's mineral; calomel is always given as a mercurial pur- gative ; and in particular affections of the skin corro- sive sublimate appears in some instances to succeed where other preparations of mercury have failed. We add to the present section, a list of the various preparations of mercury mentioned above with their synonimes, according to the nomenclature of the Edinburgh and London Pharmacopseias. The old names used by Mr. Bell are placed first in order. Mercurius Alkalisatus. Hydrargyrus cum Creta (Lond.) Quick-; silver with Chalk. Mercurius Calcinatus. Red oxyd of Quicksilver (Lond.) Hydrargyrus Muriatus corrosivus. Oxymurias Hydrargyri, Oxymuriate of Mercury. Corrosive Sublimate. Hydrargyrus muriatus mitis. Murias Hydrargyri. (See Mo- ray's Materia Medica, p. 346.) Muriate of Mercury. Calomel. Mercurius precipitatus ruber. Red oxyd of Quicksilver by Ni- tric acid, (Edin.) Sub Nitrate of Mercury. Red Precipitate. Red Nitrated Quicksilver, (Lond.) Pulvis Mercurii Cinereus. Ash coloured oxyd of Quicksilver, (Edin.) Turpethum Minerale. Yellow Sub-Sulphate of Quicksilver, (Edin.) Hydrargyrus Vitriolatus, (Lond.) Turbeth Mineral. Hy- drargyrus vitriolatus flavus. Hydrargyrus Acetatus. Acetite of Quicksilver, (Edin.) Hydrargyrus cum Sulphure. Black sulphuret of Quicksilver, (Edin.) iEthiops Mineral. Cinnabar. Red Sulphuretted Quicksilver, (Lond.) Ed. SeC. IV. OF LUES VENEREA. 137 V". Of the different Methods of exhibiting Mercury. In the cure of Lues Venerea, mercury, in every form, acts either locally upon particular systems or it enters the system and cures the disease of the consti- tution. We shall afterwards have occasion to speak more particularly of the treatment of local affections ; at present we shall attend chiefly to the different me- thods of throwing mercury into the system. Three different methods have been employed for exhibiting mercury; by conveying it in the form of fumes; by taking one or other of the preparations of mercury into the stomach; and by applying them to the surface of the body. The fumes of mercury are applied to the body by burning different mercurial calces in the patient's chamber. By thus breathing, as it were, a mercurial atmosphere, and having the fumes equally applied to every part of the surface of the body, the usual ef- fects of mercury upon the system are soon produced, more quickly perhaps than by any other method. Cin- nabar is commonly employed for this purpose; but •Turpeth's mineral, with the addition of sulphur, and JEthiop's mineral, answers equally well. Where it is meant to raise a salivation suddenly, or to throw mercury quickly into the system, this is per- haps the surest method of doing it; for with the fumes of mercury a salivation is sometimes excited in the course of a few hours. This brought the practice in- to much reputation when salivation alone was con- sidered as the chief part of the cure ; but now when it is known that Lues Venerea may be cured without much salivation being excited ; that the more gradual- ly mercury is thrown into the system the more effec- tually it operates; and that very violent effects are sometimes produced by fumegating with mercury, the practice has of late been very generally laid a- side. I think, however, that it may occasionally be em- ployed vvith advantage; and in different instances I have found this to be the case. I will not cay that it vol. n. 18 138 OF THE REMEDIES USED f)h. IV. oucrht ever to come into general practice, but I am ciearlv of opinion that it should not in all cases be laid aside. The fumes of mercury being applied to ven- ereal sores will sometimes forward a cure when every other preparation ha3 been tried in vain ; and I have met with a few cases in which the mercury either went off too rapidly by stool when taken into the stomach, or \ here it was not absorbed if applied in the form of unction to the surface of the body, and in which it soon proved effectual when used in this manner. It is par- ticularly useful where venereal sores are seated on p *tsof much importance ; and where, from making a ra^id progress, there is cause to dread that they may prot>* hazardous. In such circumstances we seldom fail in giving a sudden check to the symptoms by fu- megating vvith mercury ; but this is perhaps all that we should expect from it. It is obviously of a more subtile nature than any other mercurial application. It therefore enters the system more readily ; but the effects produced by it are not usually permanent. By a proper application of the fumes of mercury sores may be healed speedily, and the pains induced by venereal nodes very completely removed, and yet the disease will return in full force if* this practice alone should be trusted. When therefore it is judged proper, for the reason I have given, to employ mercury in this manner, and when the symptom for which it was em- ployed is checked, the cure should be completed by some offer preparation, whose effects, although slow a:e more permanent, as very generally happens both from a proper application of mercurial ointment and from the internal exhibition of the common mercurial pill. In this manner much benefit may be derived from a remedy which seems to have been laid aside without any sufficient reason, and from our trusting to it alone when others ought to be given along with it. The fumes of mercury may also be applied with safety. They appear to prove hurtful chiefly when received in loo great quantity into the lungs, but this may easily be prevented by burning a small quantity at once; and we mav even confine the steam to the SeC. IV. IN LUES VENEREA, 139 surface of the body, or to any particular part of it. Such boxes as are employed for confining the steam in vapour baths answer the same purpose here. We have daily proofs of mercury entering the sys- tem by being absorbed from the stomach and intestines; but this mode of exhibiting the remedy is liable to one very important difficulty. Every preparation of mer- cury that has yet been invented is i pt to irritate either the stomach or bowels, by which they not only excite sickness and purging, but by depriving the patient of appetite he soon becomes much emaciated and debili- tated. When pushed far indeed the effects of mercu- ry given in this manner are in some instances very dis- tressful. The stomach becomes so much weakened that any food taken into it is either immediately re- jected, or remains undigested, and the bowels are so entirely deprived of their tone that they seem to lose all power of retension. Even when completely emp- tied a degree of tenesmus often takes place, from which a great deal of misery is often experienced. The preparations of mercury which do least injury to the stomach and bowels are those, as I have already observed, that are obtained by agitation or triture; but even they prove frequently troublesome, and re- quire always a good deal of management. They should never be given in large doses; and as soon as any degree of irritability is induced by them, either in the stomach or intestines, an opiate should be given along vvith them. Of these preparations, the best and most convenient form is the blue pill of the Edinburgh dispensatory, of which four grains of the mass, which contains one grain of mercury, being given three times a-day, will in most instances affect the mouth in a very short time. Some constitutions indeed require more, but this seldom happens where the mercury has been sufficientIv triturated. Wlierever much more than this has been given the mercury either has not been properly triturated or we may conclude that much of it has passed through the intestines without being ab- sorbed, or that the constitution of the patient resists *his effect of mercury. ^ 140 OF THE REMEDIES USED Gil. IV. Mercurius alkalisalus, and Plenck's solution of mer- cury in mucilage of gum arabic, are nearly of the same nature with the blue pill, but they are both more apt to purge, particularly the latter, notwithstanding of all that Plenck the inventor has said to the contrary. When properly prepared no more mercury should be given in either of these formulae than in the mercurial pill; and as a much greater quantity is commonly di- rected, this can only proceed from neither of the pre- parations being made with sufficient exactness, and from much of the mercury which they contain being left altogether inert by not being duly triturated. Many will be surprised at the small doses of these articles which I have mentioned here, as more than double of this is commonly given. It is not uncom- mon to advise six, seven, or eight of the blue pills daily; and twenty grains of mercurius alkalisalus is recommended for a dose.* Now I know from daily experience that the blue pill when properly prepared cannot be given in this quantity. I seldom give more than two pills a day, and very rarely above three; and in each pill, as I have observed, there is exactly one grain of mercury. But the mass from which these are formed is prepared with much attention : they are tri- turated six or seven hours daily for thirty or forty days; and when the mercurius alkalisalus is properly prepared it proves equally powerful; but it is difficult to separate the particles of mercury when rubbed with a dry powder, that this preparation is now very gen- erally laid aside. It requires to be rubbed for a't least one hundred days, in order to bring all the mercury into a state of activity. Some are of opinion that mercurius calcinatus is equal in its effects to any of these preparations/}- The dose is a grain or two evening and morning, either in the form of a pill or powder. It will certainly cure the disease, and it puts a stop to the symptoms perhaps as soon as any other form of mercury; but I have * Vide Mr. Hunter's Treatise on the Venereal Disease. t Vide Appendix, No. 7. Sec. iv. IN LUES VENEREA. 141 sometimes thought that its influence is not so perma- nent; that is the symptoms have been more apt to re- cur after a sufficient quantity of this medicine was sup- posed to be given. But so many facts are requisite to ascertain this that I cannot speak decisively about it. From all that I know of it, however, it does not ap- pear to be equal to the blue mercurial pill. The ease with which it is prepared seems to be the only circum- stance in which it has a preference ; but this is a point of little moment when put in competition with utility. A tendency which it has to act upon the stomach and bowels may for the most part be checked by the ad- dition of a small quantity of opium. Hydrargyrus muriatus corrosivus, commonly term- ed corrosive sublimate, when it does not affect the stomach, proves frequently a very useful medicine. It was never generally employed for internal use till the celebrated Van Swieten brought it into repute. It has since been much used in almost every part of Europe ; and being easily disguised, and not so apt to salivate as other preparations of mercury, it has form- ed the basis of almost all the quack medicines that has of late been employed for the cure of this disease. The form of using this medicine by Van Swieten is, however, the most nauseous of any. He advises it to be dissolved in spirits, and one or two spoonfuls, containing from a quarter to half a grain of mercurv, or even more, is commonly given evening and morn- ing; and this is directed to be continued till a cure is accomplished.* Few can bear it in this manner; for it not only affects the stomach, but in this quantity it is apt to excite diarrhoea. Neither can it be with safe fy given in powder, as it is not easily levigated so fine- ly as to prevent it from acting mechanically upon the stomach. The best form of using it seems to be in a watery solution, and this may either be given in a mu- cilaginous mixture or mixed vvith broths, or the solu- tion may be made into a mass with crumbs of brelad, wheat-flour, or flour of liquorice, and divided into * Vide Appendix, No. 10. 142 OF THE REMEDIES USED Ch. IV, pills.* Iilstead of giving it in larger doses evening and morning, it answers better to give the same quan- litv divided into four or five doses. A grain of mer- cury may in this manner be given daily; that is, a quar- ter of a grain four times a day. Some have advised more, but this is the largest dose that I have ever been able to continue for more than two or three days to- gether. Opiates have not the same influence in preventing corrosive sublimate from acting upon the stomach and bowels which they commonly have with other prepar- ations of mercury. I have found nothing so effectual for this purpose as decoction of guaicum and mesere- on, or plentiful dilution with mucilaginous drinks and broths. These may act in the first place by sheathing the stomach and bowels directly from the effect of the medicine ; and they may also prove useful by promot ing the natural tendency which this form of mercury seems to have to pass off' by the skin. Mercurius duicis, or calomel, is given by some in large doses for the cure of syphilis, even to the extent of ten grains daily.f I have not found, however, that this is necessary, and it very commonly proves inju- rious both to the stomach and bowels, h answers bet- ter in doses of a grain repeated three times a day, by which it more readily enters the blood than when giv- en in larger quantities, and is less apt to be carried off by stool. This form of mercury has long been in general use, and there cannot be a greater proof of its safety aiid utility than its being still preferred by many of our best practitioners. When as completely deprived ag possible of its acid, I believe it to be one of our best saline preparations of mercury. In this state it com- monly operates mildly, and is equally powerful with any other form of the medicine in curing the venereal disease. Mercury in this form is best given in a bolus, in pills, or in powder, for it is scarcely in any degree * Vide Appendix. No. 11. f Vide No. 9 Sec. IV. IN LUES VENEREA. 143 soluble in water, and it is so heavy that watery fluids do not suspend it, so that it cannot easily be given in a mixture. The pulvis mercurius cinereus is another very use- ful preparation of mercury* It also requires* to be given in a solid form. The dose is two, three, or four grains evening and morning. Some have advised more, but I have not found that in common practice more can vvith safety be given. Hydrargyrus vitriolatus flavus, or turpethum mine- rale, is particularly apt, as I have already observed, to act upon the stomach; but even this form of mercu- ry may be so given as to cure the venereal disease and yet prove sufficiently mild in itsoperation.f In doses of five, six, or seven grains it acts as a violent emetic, but it may with safety be given to the extent of a grain, two or three times a day, particularly if each dose be conjoined with half a grain of opium. Hydrargyrus acetatus, or mercury combined vvith the acid of vinegar, is certainly more mild in its ope- ration than any of the other saline calces of mercury; nay, it does not derange the stomach and bowels so much as triturated mercury is frequently found to do; but from all the trials that I have made of it, I do not consider it as equally certain in curing the venereal disease. The symptoms abate while the patient is un der it; but if some other preparation of mercury k not employed either along with it or continued after- wards, they are very apt to appear again soon after it is laid aside. I have judged it proper to take this particular notice of all the preparations of mercury now generally em- ployed for internal use; and from what I have said, it will be obvious that some of them are for ordinary pur- poses preferable to others. In common practice, the preparations of mercury obtained by triture, and par- ticularly the blue mercurial pill, will be found to be the best. But as cases sometimes occur which do not readily yield to any one form of medicine, we are un- * Vide Appendix, No. 15. t Vide No !« i44 ^1' THE REMEDIES USED Ch. IV, der the necessity of having recourse to others; and from what we have already had occasion to remark, the choice may be readily determined. We shall be- sides have farther opportunities of speaking upon this point when we come to treat of the cure of the differ- ent symptoms of the disease. But although we may in a great proportion of cases be able to cure the disease by one or other of these forms of mercury, and in most instances without any injury to the constitution, yet we find that even the mildest preparation we can employ, and under what- ever caution it may be given, is occasionally apt to af- fect both the stomach and bowels in such a manner that we are under the necessity either of giving it in too small quantities for the purpose of curing the dis- ease, or of laying it aside perhaps entirely, in order to make trial of the medicine in some other form. Our surest method of obviating this effect of mer- cury is to apply it to the surface of the body only, a practice which ought as much as possible to be adopt- ed, and to which the chief objection is, the trouble of applying it. The advantages, however, which attend it are so great that every objection of this kind should as much as possible be made to give way to it. A pa- tient may be so situated that he cannot use the medi- cine in this way ; and instances occur occasionally in which the mercury is not readily taken up by the ab- sorbents on the surface of the body. In both of these cases we are under the necessity of giving it inwardly; but scarcely any other good cause can occur for it. Nor would either of tliese be frequent if the advanta- ges of the practice were sufficiently explained to our patients, and due attention given to the proper appli- cation of the mercury. It sometimes indeed happens that mercury does not easily enter the system in any form, and does not in the usual time affect either the salivary or other excretory organs. In such cases, where the symptoms of the disease are urgent, we should not be confined to any one method of cure, and the medicine should be given in every form in which i! is likely to prove useful; but it is proper to Sec. i\. IN LUES VENEREA. 14J remark, that failures of this kind are much more fre- quent from the infernal exhibition of mercury than from the outward application of it, and which is an- other important advantage that we derive from using it in this manner. Different reasons indeed may be mentioned fortius being the case; the readiness with which mercury given by the mouth is carried off by stool; the great quantity of food with which it is often mixed in the stomach, and by which we may suppose that a considerable part of the small quantity that we dare ever venture to give in this manner is prevented from coming into contact with the'absorbents of the intestines; and lastly, the great extent of surface to which we can apply it externally. By some it is alleged as an objection to this mode of using mercury, that we cannot exactly ascertain the quantity that enters the system. This, however, holds equally strong against every way in which we can give it, nor is it a point of- any importance. It is not so much by the quantity we employ, as by the effects which result from it, that we ought to be directed. The usual effects of mercury upon the mouth, and in the cure of the different symptoms of the disease, will, with some patients, take place from half the quantity of medicine required by others ; but were it an object of much more importance than it appears to be, I do not see how the quantity of active mercury entering the system, in any way we may use it, can be ascer- tained. It is also mentioned as an objection to the external use of mercury, that it is more apt to excite salivation than when given by the mouth. This, however, is not so much an objection to the practice as to the mode of conducting it. Mercury used in this manner enters the system for the most part so readily, that those who have not been accustomed to prescribe it, are no doubt apt to be deceived with it. It proceeds quickly to the salivary glands, and is thus more apt to excite sud- den salivation than when taken into the stomach; but this proceeds altogether from inattention, and may al- ways be prevented by applying the mercury in small vol. n, 19 146 OF THE REMEDIES USED Cll. IV. quantity at first, and increasing it according to its ef- fects. Our being able to affect the system more speed- ilv by the external application of mercury should be considered as another advantage of this mode of ex- hibition ; for the symptoms of syphilis in some instan- ces advance so rapidly that it is an object of import- ance to check them as quickly as possible. Salivation appears to be the effect of a certain quantity of mer- cury in the system, in whatever way it is introduced. Some of the more acrid preparations pass off indeed more readily by other emunctories, but the milder forms of the medicine, and which I have endeavoured to shew, ought in most instances to be preferred, are equally ready to excite salivation. It is true that more time is required to throw the quantity into the system that is necessary for this purpose by one mode than by another, but when this quantity is introduced the ef- fect of the mercury upon the glands of the mouth is uniformly the same in whatever way it is accomplished. Upon the whole, therefore, all the objections that have been made to this method of exhibiting mercury are trifling when compared with the advantages it pos- sesses over every other mode of using it, so that for general practice it ought to be preferred. I own indeed that at one period I was of a very dif- ferent opinion upon this point ; but this proceeded from my not being so well acquainted with the supe- rior advantages of using mercury in the form of unc- tion as I now am, and which I now therefore very generally prefer. Mercury will pass into the system in various forms from the surface of the body. Lues Venerea has been cured by frequent immersions of the feet and legs in a solution of corrosive sublimate. The application of a mercurial plaister to the surface of the body, if of any considerable extent, will also cure the disease ; and we are indebted to Mr. Clare of London for a third meth- od of throwing mercury into the system from the sur- face.* By rubbing calomel into the inside of the * Vide an Essay on the Cure of Abscesses by Caustic, &c. also a New Method of introducing mercury into the Circulation, by P. Clare, Surgeon. Sec. IV. i;v LUES VENEREA. 147 cheeks Mr. Clare found, and his observations have in some degree been confirmed by experience, that we can not only excite salivation by this means, but cure every symptom of syphilis. Nay, the rubbing of a few grains of calomel upon the inside of the preputi- um or labia pudendi soon affects the system and ex- cites the mercurial fcetor in the breath and soreness of the gums. But although I have found this in some in- stances to be true, the practice has also in several of the trials I made of it failed entirely ; that is, it did not cure the symptoms for which it was employed, and which were afterwards removed by other preparations of mercury. I must own, however, that the experi- ence 1 have yet had of this method of using mercury does not entitle me to speak decisively concerning it; but I conclude either that similar failures, or some other objections of importance, have occurred to it in the practice of others, for we do not now hear that it is employed, although Mr. Clare's book has been pub- lished upwards of twelve years. One obvious cause of this, and of the other modes I have mentioned of applying mercury externally fal- ling into disuse is, that all of them seem to be much inferior to the method of introducing it in the form of an ointment, and which was the first, I may observe, thai was employed for the cure of Lues Venerea. It is commonly termed the method of cure by unction, or inunction. An ointment for this purpose may be made vvith dif- ferent proportions of mercury ; but the best I have tried is that in which there are two parts of the unguent to one of crude mercury. In the form commonly used the ointment and mercury are in equal parts ; but the other, while it proves equally powerful, if it be applied over a greater surface, has the advantage of not being so apt to irritate the skin. In order to promote the absorption of the mercury it has been the practice with many to advise the body to be immersed in a warm bath, once and again, be- fore the course is commenced, and to repeat it once or tvvirr- fi week during the whole continuance of it. They U8 OF THE REMEDIES USED Cll. IV. likewise think that the bathing proves useful by giving the mercury a particular determination to the skin, and thus preventing it from producing salivation. I have not found, however, that a frequent use of the warm bath is necessary. It cannot in every situation be obtained but vvith much difficulty, and if not very properly conducted it is apt, during a course of mer- cury, to expose the patient to suffer from the effects of cold. Before the commencement of the course, where the skin is particularly dry, I have sometimes thought it right to advise the use of a warm bath, but as in other instances of a similar nature the remedy has answered equally well where this precaution was not taken, Ido not conceive that it is of much importance, and I now seldom employ it. Where the remedy is chiefly employed for the re- moval of a local affection, such as bubo, we endeavour to make it pass through the lymphatic vessels of the part, and in such cases this determines the place to which the ointment should be applied ; but where no local symptom of this kind takes place it may be ap- plied with equal safety and propriety to any part of the body, and the place of application should be changed from day to day. By this means we obviate the irritation of the skin, which is apt to happen from applying it repeatedly to the same place, at the same time that we promote the absorption of the mercury I may also remark, that although, for the reasons I have^iven above, it does not appear to be necessary to immerse the whole body in a warm bath during a course of mercury, yet that some advantage is occa- sionally derived from causing the parts upon which the ointment has been rubbed to be well bathed with soap and water before repeating it upon the same place. It may therefore be proper to advise this to be general- ly done. In applying the ointment some have imagined that we need only lay it upon the skin, and that it will enter the absorbents with equal certainty whether fric- tion is used or not. This, however, is by no means [ Sec. IV. IN LUES VENEREA. 149 the case. I have repeatedly put it to the test of ex- periment, and it evidently appears that absorption is promoted by gentle friction. This indeed is so con- sonant to general experience, that some may be sur- prised at my taking notice of it, nor would I have judged it necessary if the contrary opinion had not of late been supported by authority of some weight. When the patient is able, the friction should be ap- plied with his own hands : Otherwise it must be done by an assistant, his hands being covered vvith a thin bladder. For want of this precaution, the assistant is apt to be salivated while the patient is deprived of a portion of the mercury. According to the nature of the case, from a drachm and a half to two drachms of the « ointment should be rubbed in daily, and it answers bet- ter to apply it at two different times than all at once. For the purpose of applying properly this quantify of ointment, that is from forty-five grains to a drachm, twenty or twenty-five minutes of gentle friction is neces- sary, the patient while under it being exposed to the heat of a moderate fire. Fumigation with Cinnabar was introduced at an early date, bnt from the injurious consequences which frequently ensued, it grad- ually lost its reputation. In the year 1736, says Mr. Pearson, air empiric, of the name of Chaibonnier, appeared at Paris, profess- ing to use mercurial fumigations, after a new mode, safe and sue- cessful. Several of his patients, Whom he was permitted to select from different hospitals, were undoubtedly cured, yet he often fail- ed and what was more important, a greater proportion of persont died under this mode of treatment, than when mercury was admin- istered in the usual manner. After this time, the practice was nearly abandoned, until the year 1776, when the Chevalier Lalon- ette, a Physician in Paris, published an account of a new method of curing the venereal disease by fumigations. His preparations were free from the inconvenience of sulphureous vapours during their combustion, and he stated that in the space of thirty-five years, he had successfully treated more than 4000 cases, that had resisted all the ordinary methods of cure. The following account of hL method we extract from Mr. Abernethy. " It consisted in inclosing the patient previously undressed, in a kind of box resembling a sedan chair, with an opening at the top to let out the head and an other at the bottom, to which was fitted a small grate, or furnace, having in it a heated iron to convert the mercurial remedy into funic. The preparation he made use of vr3 that is, to guard as much as possible against a return of the disease, a middle course must be observed be- tween the severe degrees of salivation which our fore- fathers judged necessary, and the opposite extreme in- to which the moderns have fallen. In cases of a slight nature, that is, in the incipient state of mild chancres, wh t is commonly termed an alterative course will be found sufficient. If the mouth be rendered gently sore, and kept in this state for eight or ten days after the chancres are cured, no mote will be necessary. But even in the treatment of chancres only, if they have been of long duration or not of the mildest kind, and in every other symp- tom of the disease, the mercury should in a gradual manner be given so as either to induce a very consid- erable degree of soreness in the mouth, and which in most instances will be attended with an increased dis- charge from the salivary glands, or when from pecu- liarity of constitution this cannot be induced, we should persist in the use of mercury till the febrile symptoms which it usually excites are brought to as* great a height as the patient can easily bear. It will generally indeed be perceived that those symptoms of the disease to which 1 allude cannot be cured but with such a quantity of mercury as perhaps in every in- stance excites heat, quickness of pulse, anxiety, and restlessness, and in proportion as the patient is able to bear these in a greater or lesser degree the sooner and m.ne effectually will he get. free of ,the disease. I have already observed that I give a general prefe- rence to the method of cure by unction ; but whatev- er preparation of mercury we make use of, it ought, in ordinary cases, to be pushed in a gradual manner to the extent I have mentioi ed; and when as much of it is employed as is sufficiei.1 for this effect it ought to be continued so as to keep the system in an equal degree under its influence, not only till all the symptoms of the disease are removed, but for some time thereafter. This will in different cases happen at different periods of a course, and with very different quantities of mer- curv. It is therefore obvious that nothing decisive cae 156 OE THE REMEDIES USED CI). 1\ be mentioned, ether of the length of time to which a mer- curial course should extend or of the quantity of the medicine that should be given. Our surest, and per- haps only guide that should be trusted, is the result of experience in similar cases; and as the certainty of guarding against a relapse is a point of the first im- portance nothing should ever be left in doubt that may be required for this purpose. In all primary affec- tions, that is, in chancres and buboes only, and where no other symptom of the disease has appeared, I have found that a course of mercury conducted in the man- ner I have mentioned, and continued for a fortnight after the symptoms have disappeared, has at all times proved sufficient; but wherever the skin, throat, or bones have been affected, I now always advise the remedy to be persisted in for the sp*ce of a month af- ter the cure is apparently completed. I cannot posi- tively say that less than this would not do, but in a matter of such moment, where the health and happiness not only of the patient but of his progeny are at' stake, it is better to exceed by giving occasionally somewhat more than might be necessary than incur the smallest risk of the poison being ever to appear at any future period. I have said that in ordinary practice the mercury should be pushed in a gradual manner to the extent to which we mean to carry it; that is, a small quantity should be employed at first, and gradually increased till the effects expected from it are excited, by which we not only avoid the inconveniences which always occur from a salivation being suddenly induced but are thereby enabled to throw in a much greater quantity, and to keep the system more completely under its in- fluence dining the whole course than we ever can do when much mercury is given at once ; and this, I may observe, is a point of the first importance in thelreat- meni ot syp; lis, for whoever has paid attention to Ihe suljcci must have perceived that our success depends in a great measure upon the effects of the medicine being fully ant! regularly kept up during the whole duration of the course, and winch can seldom be done Sec. iv. IX LUES VENEREA. ■j r-« IO/ where it is not given in a gradual manner at first. W hen the fever, salivation, and other symptoms be- come severe, and which they are very apt to do when the mercury is given in large quantities at first, an interruption must necessarily take place, and it is the effect of every interruption to protract the continu- ance of the course and often to deceive both the prac- titioner and patient. My opinion, in short, upon this point is, that our certainty of obtaining a-speedy and permanent cure of any symptom of Lues Venerea is not merely in proportion to the quantity of mercury we employ, but to the quantity which in an active state can be thrown into the system in a given space of time. But while with a view to this I have advised that in common practice mercury should be given at first in a gradual or slow manner, it is proper to remark that cases are sometimes met with in which it is necessary to adopt a different practice. Wherever the symptoms of the disease are particularly urgent, from their being deeply seated in parts of much importance, and from the progress which they are making being rapid, wc are justified in deviating from this general rule, and in applying the mercury in such a manner as will most speedily get it in a very"ample quantity thrown into the system. In this way a check will soon be given to the farther progress of the disease, when the medicine, during the rest of the course, may be given in the gradual manner which I have just pointed out. The time to be employed in a course of mercury, and the quantity to be given, are circumstances, as I have already observed, that cannot with any exact- ness be ascertained. They depend in a great measure, as we have had occasion to remark, upon the effects with which they are attended, but I may observe in general, that few cases are so bad as to require the medicine, when properly conducted, to be continued longer than nine or ten weeks. In recent cases four or five weeks are for the most part sufficient; while in some obstinate old affections, where the bones have J58 OP THE REMEDIES USED Ol. IV either been diseased, or the ulcers very foul and ex- tensive, I have known it necessary to go on to the twelfth or thirteenth week. During these periods ointment of the strength I have mentioned may be rubbed in from the quantity of three ounces to eight or ten. When the blue mercurial pill is employed and properly prepared the quantity may vary from four or five drachms to two ounces, or even to two and a half or three ounces. Whenever these quantities are exceeded there is much cause to sup- pose that a great proportion of the medicine has not entered the system, either from tlie improper method of applying it or some other cause. The opinion which I have thus ventured to suggest of the effects of mercury depending chiefly upon the quantity which in an active state can be thrown into the system in a given space of time, will, at first, he doubted by many. Being contrary to the practice which nowgenerally prevails, few may be inclined to follow it, but those "who do will have the satisfaction to find that by means of it they render their patients much more secure than can possibly be done in any other manner. By giving as large a quantity of mer- cury as the patient can vvith safety bear, they will find lhatthe most inveterate symptoms of the disease may be cured in much less time, and with much more cer- tainty than they usually are by an alterative course, which, however well it may be adapted for the cure of ihe slighter symptoms of syphilis, is by no means suf- ficient for the removal of the more advanced stages of ihe disease. Many practitioners think that the same quantity of mercury must prove equally useful in whatever time it may be given, provided the mouth be kept mode- rately sore during the whole period. This, however, is not* the case. I have met with various instances of venereal sores, as well as other symptoms, which had either obstinately resisted a very long continued course of this kind, or'whieh had recurred from time to time after a cure had been supposed to be obtained, and which at last were entirely removed by a much less Sec. iv. Ui LUES VENEREA. 159 quantity of the medicine being given in a shorter pe- riod. What I wish to inculcate is, that the more in- veterate symptoms of the disease will seldom yield to an alterative couise of mercury, however long it may be protracted, while the same quantity of the medi- cine will seldom fail, when given so as to keep the sys- tem for a shorter period more completely under its influence. I have now the history of more than fifty cases in which this actually happened; where venere- al sores, from resisting mercury under an alterative course, were judged to be incurable, and where com- plete cures were afterwards obtained merely by carry- ing the use of mercury to a greater length than had previously been done." We cannot do better than add the observations of Dr. Francis on this subject, as they contain a summary of our own practice, and the Feasons on which it is founded. " If the view which has been taken of the nature and seat of the venereal disease be well founded, and the circumstances which mod- ify its character and method of treatment be correctly stated, much- also depends upon a judicious choice of the different mercurial pre- parations. Those combinations of mercury must possess a decided advantage which are least calculated to excite the salivary discharge^ and whose operation is general throughout the system. Of the va- rious preparations of this mineral, now in most general use, the oxygenated muriate of mercury, or, as it is commonly called, the corrosive sublimate, (the oxymurias hydrargyri, l. p. murias hy- drargyri, e. p. murias hydrargyri corrosivum, -q. p.) is particularly recommended for this purpose. This form of mercury, like every other, has had many opponents and adherents. It is thought by some to have been first employed as an anti-venereal by Basil Valen- tine ;* but, upon the authority of the celebiated Van Swieten, it came into general use only in 1754, and the favourable reports of its efficacy " would fill," says Mr. Pearson, « a volume of consid- erable magnitude." In the number of ils most decided advocates may be found the distinguished names of Locher, De Haen, Pringle, Cleghorn, Gorden, Russell, Stoll, Lewis, Dease, and Selle. Among the principal advantages which the corrosive sublimate possesses over tnat of every other preparation of mercury are, that, judiciously administered, it is particularly mild and safe in its ope ration, will admit of a more extensive use in all the various forms of lues venerea, and subject the patient to fewer inconvenience^: that it readily enters into the general circulation, becomes misciblc v.ith the several fluids of the body, the soonest arrests the pi ogress * Pearson on the Effects of Various Art^-lo. Sec. p. 100. 160 OF THE REMEDIES USED Ol. IV. of the complaint, and eliminates the morbid matter through those emunctories best calculated for that purpose : that it supersedes the necessity of salivation, by its action on all the secretions, and by promoting especially the cuticular discharges, and the evacuations from the kidneys : that it is the only preparation to be depended oi, in those peculiar habits of body so susceptible to become salivated by every other form of mercury now in use : that in its ultimate ef- fects upon the constitution, it is attended with comparatively no in- jury. These facts are indeed truly important, and many of them are granted by those who altogether reject the use of this prepara- tion. It is not a little unfortunate for the advocates of other combina- tions of mercury, that the objections which have been brought against the corrosive sublimate are so dissimilar. It has been as- signed as a reason against the preparation itself, that it has failed of its salutary effects by being given in too small doses. By some its anti-venereal properties are said to be lost on account of its too readily exciting the cuticular discharge ; by others it is owing to its defective action on the secretions of the skin and mouth. By some it is admitted to be beneficial in the primary stage of the disease, and by others it is contended that it is calculated to remove only se- condary symptoms. It is also declared that it is violent and uncer- tain in its operation,and that it does not render the cure permanent.* Some of these objections are, indeed, weighty, and, were they well founded, would fully justify the abandonment of this peculiar com- bination of mercury; but if the least reliance is to be placed upon the experience and observation of those who have employed the corrosive sublimate with the most disinterested and honourable views, and solely to determine upon its anti-venereal powers, evi- dence sufficient to prove the fallacy of these objections, and derived iVom indubitable sources, might be adduced. The testimony of Dr. Locher, of the Vienna hospital, is so full and explicit, that it were an omission not to insert it. Having witnessed the « horrid calamities" arising from salivation and other abuses which existed in that institution in the management of venereal patients, upon the recommendation of Van Swieten, he made trial of the corrosive sublimate. From the year 1754 to 1762,. he cured by it no less than four thousand eight hundred and eighty persons, without inducing salivation ; and testifies, that " no persons died, or experienced the least painful and dangerous symptoms, in conse'quence of this rem- edy."! In the cases in which the same preparation was recommend- ed by Pi-ingle,! tne cures that were eftected were permanent, and from the repeated experience of many other distinguished practi- tioners, the same result ensued. Multa nobis cxempla visa sint luis venerese, murcurio sublimato corrosivo perfecte sanal££.§ ■•* Hunter, Howard, Pearson, Mathias, and others. | Locher's Observut. Pract. as quoted by Van Swieten, Commentaries, voL IF. p. 294. i Goiden, Lond. Med. Obs. and Inq. vol. 1. p. 365. vol. 2. p. 73. § Ratio Medendi, pars secunda, p. 229. Sec also Mcdica. Clinica, by Chris- tian Gottlieb s.jlle. Berlin. 1802. *ec. IV. IN LUES VENEREA. IG1 To enter into a consideration of the treatment of the various symptoms which characterize lues venerea in its simple and in its more confirmed state, is not deemed necessary, nor will it here be attempted. Fully convinced, as the writer is, of the decided advan- tages which the corrosive sublimate, as an anti-venereal remedy, possesses, in most cases, over other mercurial preparations, he cannot forbear adding a few further observations for the purpose of recommending to more general use this combination of mercury. Avery forcible reason why a preferer.ee ought to be given to the corrosive sublimate as an anti-venereal remedy, is the mildness of its operation when compared with most other mercurial prepara- tions. In the mind of the judicious practitioner, there need exist no apprehensions of the severity of its action ; few articles of the materia medica can be more readily accommodated to the peculiar condition of the patient and the nature and stage of the disease. The evidence of its mildness may be adduced from the salutary ef- fects which it produces in the constitution of delicate children, and even of infants. In not a single instance, within the recollection of Dr. Hosack, has it ever been followed by pernicious consequences, though long employed by him in many cases in which the patient laboured under some hereditary taint, obstinate cutaneous eruption, or other symptoms indicating an alterative course of remedies. The destructive effects which have been mentioned as attending its ad- ministration, such as excessive pain and irritation of the stomach and bowels, headach, fever, Sec. may, in certain cases, arise from some peculiarity of constitution obnoxious to mercurial remedies, but are doubtless, in general, to be attributed either to the impro- per preparation of the corrosive sublimate, or to its having been given in undue quantity. It has been asserted that this mercurial salt is particularly injurious to those labouring under pulmonary af- fections. That this objection is ideal, or rather that, of all mercu- rial preparations, it applies with least force against the corrosive sublimate, must be evident upon considering the general operation of this form of mercury. Every combination of this mineral may prove more or less injurious in the forming stage of consumption, on account of the active inflammation which is then present, and the additional irritation attendant upon mercurial action. For it mav be laid down as a general principle, that mercury is in itself in- jurious when administered to any considerable extent during the existence of inflammation and febriie excitement, and before the employment of blood letting or other evacuants. From the mild operation of the corrosive sublimate, properly prepared, may be inferred the utility of its employment in persons of delicate habit, and in those cases especially where the constitu- tion is materially impaired. In cases of this kind its exhibition is followed with the best effects. That the tonic powers of the system may, however, in certain instances, be so far weakened as to render the employment of every form of mercury not only inefficacious in the re noval of syphilitic complaints, but productive of the most distressing symptoms, and, consequently, that the use of the oxy- genated muriate will at times be the cause of much inconvenience VOL. IT. 21 .(62 OF THE REMEDIES USED Cll. IV. and real suffering, there is left no room to doubt. In irregular ca- ses of this nature, the remedy necessarily fails of producing its or- dinary beneficial effects; and as it becomes an additional source oi irritation, it greatly increases the debility which already prevails. These effects, as has just been remarked, do not result from the exclusive employment of any particular form of mercury; they seem to arise less frequently from the corrosive sublimate, but are common to all mercurial ^preparations. For if the constitution has not the power to support the action of mercury, vain is the attempt to eliminate from the system the virus of lues venerea. Hence, in the treatment of certain diseases of hot climates, especially in un- healthy situations, it is not an vrncommon practice to administer the bark daily during the whole course, for thp purpose of enabling the constitution to bear a sufficient quantity of mercury to subdue the complaint.* Upon the same principle that learned physician and distinguished writer, Dr. Chisholm, maintains, that in the manage- ment of disease a reduction of plethora at the commencement, and the augmentation of the vis vitae in the advancement, are to be par- ticularly attended to, in order to ensure the successful administra- tion of. mercury.f Dr. Ferriar has observed instances in which the venereal disease itself assumed a peculiar character owing to debili- ty ; where the debility so far prevailed that the constitution had not power to form a genuine syphilis. When this happens, mercury •will not effect a cure. " Under these circumstances," adds Dr. Ferriar, " I have advised with success a course of tonics without mercury, to raise up the constitution to a higher level. Mercury inay then be expected to cure."! It was deemed proper to make these few remarks on the condi- tion of the system necessary to ensure the successful operation of mercury, not only from the circumstance of its being too generally overlooked, but because it strengthens the belief that the pernicious effects which have been so hastily attributed to the corrosive subli- mate, might have been more satisfactorily accounted for by advert- ing rather to the debilitated state of the constitution than to the acrid nature of the preparation itself. Difficult as it is to establish any diagnostic signs by which the de- predations of Venus and of Mercury on the human constitution may / be accurately distinguished, enough is known concerning the nature of mercurial affections to lead to the abandonment of that indiscrim- , inate recourse to the external application of this mineral, which lias novv become so general. Mr. John Pearson states that the mercurial cezena, or erythema, as it is also called, may arise after the employment by friction of a single drachm of mercurial oint- ment, and after the internal use of a dose of calomel: and were it necessary to say any thing in corroboration of this fact, the writer might detail the particulars of a case of vesicular eruption that lately came under his notice, which occurred in an adult patient to whom had been administered eight grains of calomel. The vesicles * Vide Clark on the Diseases of Long Voyages. \- Essay on the -Malignant Pestilenti.,1 Fever, vol. 1. ± Med U:st and lienect. vol, 3. p. 253. Sec. IV. IN LtnES VENEREA. ]6J first appeared, and were confined, chiefly about the anterior and su- perior part of the chest and on the chin ; they were of the size ol an ordinary split pea, of a pale or rather light gray colour, unaccom- panied with inflammation or fever, and strongly resembled the erup- tion described by Dr. Willan, in his fourth order of Cutaneous Dis^ eases * The serous fluid they contained was discharged on the se- cond or third day, and the excoriated surface readily healed. But notwithstanding that the internal as well as external use of mercu- ry, even in small quantity, will, in certain habits, give origin to the mercurial erythema, yet a careful examination of what has been written on the subject seems to warrant the conclusion that this form of disease arises, in a great majority of instances, from mercury externally applied. If this opinion be well founded, it presents strong additional arguments in favour of the internal use of the cor- rosive sublimate as an anti-venereal remedy. That the corrosive sublimate, of all mercurial preparations, soon- est affects the system and arrests the action of the venereal virus. is a truth grounded upon the concurring experience of the most distinguished practitioners. It is but proper to state, that the preparation of mercury now re- commended, nas been employed for the last twenty years in the pri- vate practice of Doctor Hosack, and during his attendance at the New-York State Prison, New-York Hospital, and the Alms-house of this city, as physician of those institutions. It has invariably been found to be the remedy best calculated for the removal of lues venerea, both in its primary and secondary stages; and not a single case is recollected in which the cure has not been permanent. Those injurious effects upon the stomach and bowels, which are so much apprehended, were avoided by a cautious employment of the medi- cine, and by a due consideration of the peculiarities in the constitu- tion and state of the patient, From this form of mercury, saliva- tion scarcely ever was induced ; and while under its influence, the employment of the decoct, guaiac. et sarsaparil. was found to be an excellent auxiliary in recent cases ; and in the secondary stage of the disease, where the patient had been neglected, or when impro- prieties in the cure had been committed, k was almost indispensable. Though satisfied that the oxymuriate of mercury possessed full claims to the title of a powerful anti-vciK-reai remedy, from a peru- sal of the testimony published in its favour, and from a personal knowledge of the result ol" several cases in which it lad been cm- ployed; with the view of more fully determining so important a .'natter, and to ascertain, as far as practicable, whether the objec- tions which have been stated against it, particularly those of the distinguished Mr. John Pearson, were founded in reality, at the sug- gestion of the writer, the use of the corrosive muriate of mercury was adopted in the spring of the year 1811, in the New-York Hos- pital, by Dr. John C. Chcesman, the then house surgeon. From the extensive charity which this excellent institution aftyrded, there * Vide Cutan. Diseases : order P.ulls, III. Genus, sp. i 164 OF THE REMEDIES USED Cll. IV. was abundant opportunity of seeing almost every form of this dis- ease, from the more mild to the most aggravated ; cases of recent infection and those of long standing. After a careful examination of the histories of a great variety of cases, a selection was made of several of those patients who were affected with the primary, and of others labouring under the secondary stages of this disease. The corrosive sublimate was given in some instances in the form of the spirituous solution, and in other instances made into pills; the de- coction of guaiacum and sarsapariila was employed as an auxiliary, and occasional recourse was had to the application of the lunar caus- tic ; but the external use of every preparation of mercury was omit- ted In no one instance were unpleasant effects produced by the action of this mercurial salt; and, contrary to the opinion enter- tained by Mr. Pearson, of the efficacy of this remedy, the result of these several cases was attended with complete success. To multiply further arguments, or offer additional proofs in fa- vour of the oxygenated muriate of mercury does not seem neces- sary. It may be confidently pronounced a safe, convenient, and ef- ficacious remedy in lues venerea. How far a too ready acquies- cence in the force of authority may be assigned as the cause of that want of confidence in the virtues of the corrosive sublimate, and of that apprehension of its pernicious qualities which at present pre- vail among many practitioners, it is impossible to ascertain. It is evident that the opinions of Mr. Pearson are those chiefly which have been adopted and reiterated by every subsequent writer who has opposed the use of this mercurial combination. But the suc- cess attendant upon the administration of the oxymuriate of mercu- ry furnishes the most satisfactory answer that can be given to those who have denied its efficacy. Upon the successful result of the ca- ses of lues venerea which existed in the New-York Hospital in 1811, the corrosive sublimate again became the principal anti-venereal remedy in that extensive establishment. This form of mercury, since that period, has also been in general use in the New-York Alms-house, in the treatment of syphilis in its different stages; and in most instances it is now employed for the same purpose by the physicians of the City Dispensary. The observation and experi- ence of the writer during the last three years, in a number of un- equivocal cases of lues venerea, have tended to corroborate the fa- vourable opinion he formerly expressed,* and induce him to recom- mend with increased confidence a more extended application of this preparation of mercury. Various are the forms in which the corrosive sublimate has been used in the different stages of lues venerea, and in other disorders indicating an alterative course of remedies. Its external applica- tion in the form of ointment, has been recommended by some ; but Vide An Inaugural Dissertation on Mercury: embracing its Medical Ills toiy, Curative Action, and Abuse*in Certain Diseases. .Ye-jj-1'ork, 1811. The present communication, and a former one on the same subject, which appear- ed in the Register for April, 1813, may be considered an constituting the col- legia^ exerc.se just mentioned, though, now in some parts enlarged" and per iiaps somewhat unproved ktr. IV. IN LEES VENEREA. 165 against this practice many forcible objections might be brought. The internal use of the spirituous solution of Turner, in which the proportion of ardent spirits to the mercurial salt was remarkably small, has justly been accused as the source of much mischief. The formula of Van Swieten deserves a decided preference ; for the muriated quicksilver dissolved in spirits and exhibited in doses lim- ited to the quantity of one eighth of a grain, two, or, at most, three times in twenty-four hours, seldom produces the least nausea, or any derangement of the stomach or bowels. The corrosive sublimate, dissolved in common brandy, in the proportion of two grains of the salt to one ounce of the liquid, is a valuable and convenient preparation for delicate children. It may be given vvith the greatest safety, in a little sweetened water, to the amount of three or four drops to a child of one year, and repeated three times a day ; and to a child of two or three years old six or eight drops three times a day. After its employment two or three days the dose may be increased to ten or twelve drops. A solution of the oxymuriate of mercury in common distilled water, with the addition of a little muriated ammonia, (sal ammo- niac) is also a judicious and safe pharmaceutical combination. But the best form of administering the corrosive sublimate is that in which this mercurial salt, united by solution witir the muriate of ammonia, is made into a mass with the crumb of wheat bread, and then divided into pills. R. Oxymuriat. Hydrarg. j'- *- Muriat. Amnion, aa gr. xv. 1^ Aq. distillat. vel. font. Jiss. Solutioni addatur Panis medul. sic. q. s. Ut fiat massa, in pil. cxx. dividenda. Every pill in this prescription contains, if the materials be uni formly combined, the eighth of a grain of the corrosive sub.imate. The dose can therefore easily be regulated with the greatest accu- racy. Of these pilis one is to be taken every night and morning, though, in some aggravated cases, another pill may be taken at tne middle of the day with additional advantage. In this manner a quar- ter of a grain of this preparation of mercury will, in ordinaly cases, be taken in twenty-four hours; and in the more severe form of lues venerea the additional eighth of a grain. Instances may occur in which it may be advisable to administer half a grain daily. Mr. Bell has given a grain of the corrosive sublimate divided in four or five doses, but has not been able to continue this quantity lor more than two or three days together. The corrosive sublimate to the amount of one quarter of a grain a day, and, in some cases, an additional eighth of a grain, in phis, muy be continued for a long time without producing the least incon- venience in the stomach and bowels, and with greater certainty and more beneficial effect than the same quantity of this salt in the form of the spirituous solution. The use of the corrosive sublimate ought to be continued two or three weeks-after the disappearance of the disease, in order more effectually to accomplish a radical cure. 166 OF THE REMEDIES USED Cll. IV. It has already been observed, that the oxygenated muriate of mer- cury operates more readily on the constitution than any other form of this mineral, and that even in very small quantity it soonest ar- rests the progress of venereal symptoms, and, by its general ac- tion, eliminates the poison of the disease. It deserves to be stated that during the use of this preparation, all those precautionary measures with regard to diet and regimen, which are generally re- commended by writers, need not be regarded with the same scru- pulous attention, while in the use of the corrosive sublimate, as during the employment of other mercurial medicines. For as the corrosive sublimate rarely affects, to any considerable degree, the salivary glands, those subjected to its use are not rendered so sus- ceptible to the influence of cold, and the physician is seldom under the necessity of devising means for the purpose of obviating the pernicious consequences of salivation. Instances of peculiarity of constitution may occur which require much management and dis- cretion in the use of this remedy. Mr. Bell has observed, that opi- ates have not the sarhe influence in preventing an undue action of 'he oxymuriate of mercury upon the stomach and intestinal canal which they commonly have with other mercurial preparations.* The limited experience of the writer has not in any case corrobora- ted this opinion: on the contrary, he has found an occasional re- course to small quantities of opium highly serviceable. As some one or more articles of the vegetable kingdom are in general employed in those cases in which the corrosive sublimate is administered, it perhaps would not be irrelevant to examine how far they are entitled to particular confidence. It may be proper to re- mark, that of the many substances which have been employed as auxiliary remedies, or. are now in use, the lignum guaiaci and the radix sarsaparille unquestionably claim the first notice. They arc acknowledged to be useful during the administration of the oxymu- riate of mercury, in cases of recent affection ; and in the secondary symptoms ot the disease, for the removal of the evils which have taken place from the injudicious employment of mercury, !kc their salutary operation has been uniformly evinced, The compound decoction of guaiacum and sar^npprilln mav reo'l- dy be prepared in the following manner • R. Rasnr. ligni guaiac. Rad. sarsapar. fiss?e 55. $1. Coq. in aq. font, lbiij. ail. lbij Of this decoction the above quantity, taken warm, ought to be drunk within the twenty-four hours. Of its effects as a powerful alterative for the removal of some of the most painful symptoms of lues venerea and obstinate cutaneous affections, indubitable evidence. exists in the pages of the old and in those of the-most eminent mod era authors.! During a period of more than foitv -five years its vir- tues for these purposes have been tested in the practice of that * Treatise on Conor, and Lues Ven. vol. 2. p. 248 f Vid<- Aphrodisiacs. YA Bocrhwii. \u0. Hunter, B»H. fro. SeC. IV. IN LUES VENEREA. 167 learned and distinguished physician, Dr. Samuel B*rd, and for more than twenty years in the practice of Dr. David Hosack. Its saluta- ry properties appear to be owing chiefly to the general excitement which it produces and to its action as a diaphoretic. When had re- course to, while in the use of mercury, particularly in the treat- ment of those cases where the disease is of long continuance, it proves eminently useful by promoting the natural tendency which the corrosive sublimate possesses to increase the cuticular dis- charge. The compound decoction of the guaiacum may be taken with success for the removal of many of the morbid effects produced by the improper employment of the different preparations of mercury, and for restoring the constitution to its wonted vigour. The advan- tages arising from the use of the Rob Anti-syphilitique,* for which so enormous a consideration is demanded, may with confidence be attributed principally to the sarsaparilla which enters into its compo- sition. As the local effects which arise from the venereal virus depend upon constitutional irritation, or the action of lues venerea upon the constitution, these effects in most cases are to be permanently re- moved by those remedies only which operate through the medium of the whole system. But the consideration of the local applica- tions, best calculated as efficient auxiliaries for the removal of these consequences is at present purposely omitted." * Vide. M'Neven's Account of the Rob of LafFacteur, in New-York Ivied, anc. Phil. Journal, vol. 3. p. 23. VII. Of the Regimen to be observed during a Course of Mercury. It was formerly the practice and still is in some pan- of Europe, to put every patient while taking mercury upon a low diet, and previous to the commencement of the course blood-letting and purgatives were pre scribed. When it is necessary in a full habit of body to throw in any considerable quantity of mercury very quick- ly, and especially when it is known that the patient has been liable to inflammatory complaints, some pre vious evacuation is proper, and the patient during the first part of the course, should be kept upon a low al- lowance. But in general there is no cause for this, and the cure proceeds with least difficulty when the patient is kept upon his usual diet. It is the effect indeed of mercury to produce weakness in such a degree, that if 168 OF THE REMEDIES USED Ol. IV, not counteracted by nourishing diet, it is apt to injure the constitution materially. Of this I have met with so many instances, that unless where some strong ob- jection "occurs to it, I always desire patients under mercury to live as well as a person in health ought to do. A full allowance of animal food would in most instances be improper, but I have never observed any barm occur from a plentiful use of any other article that did not disagree with the stomach and bowels. When mercury is taken by the mouth acid vegetables are apt to do harm ; but there is no cause for avoiding them when the cure is conducted by unction. Patients under mercury are commonly desired to avoid wine and even malt liquor. A great quantity of either ought never to be given; but in moderate quantities they may be used with safety. Different opinions have also been entertained respecting the propriety of patients going abroad while under mer- cury. Ho far as my observation enables me to decide, I think there should be but one opinion upon the sub- ject. We are often obliged to allow venereal patients when using mercury to go abroad, and to manage their ordinary business, but I have never done so hut with regret. Exposure to the irregularities of tie ex- ternal atmosphere always does harm in a course of mercury. It is apt to produce distress at stomach, pains in the bowels, and purging. This necessarily impedes the operation of the medicine by which the cure is not only protracted but rendered more uncertain. 1 an clea.ly of opinion therefore, that tnis kind of expo- sure should at ail times be avoided. At tho ^metinie I do not think it necessary that patients under .oeicuiy should be kept in a great degree of heai. J.)n the con- trary, much advantage is derived from their Irving \u large well aired apartment, and in a degree of heM that is most agreeable to their own feelings. Nay, ex- cept in the cold weather of winter and spring, there is no necessity for confinement to one apartment; and any unusual quanlih of cloathing, whetiier in !x-d ur during the day, is altogether unnecessary. In short, ^ec. iv. IX LUES VEXEKEA. K6.9 much exposure appears obviously to prove hurtful, while no advantage is derived from the patient being kept in an unusual degree of heat. I think it proper, however, to observe with respect to cloathing, that linen should never be worn next the skin during the use of mercury; whether the patient sweats much or not it keeps the surface of his body colder than it onght to be ; and if he is liable to plen- tiful perspiration he is even apt to be .hurt by it. Flan- nel should be wore during the cold of winter and spring, and cotton when the weather is more temperate. We hare not found it necessary, except in very peculiar cases, or from the great inclemency of the weather, under our mode of treatment, to confine the patient to his apartment; nor have we at any time seen any ill effects from this license. Ed. VIII. Of Profuse Salivation and some other Effects of Mercury. We have already had occasion to see that in the cure of Lues Venerea there is no advantage to be derived from any increase that may be made to any of the secretions. But we have also seen that the advanced stages of the disease cannot be with certainty cured without such a quantity of mercury being thrown into the system as very commonly excites an increased dis- charge of all the secretions, and particularly of the saliva. When this continues moderate no harm ensues from it, but occasionally they come to such a height as to produce much inconveniency and distress. In- deed the readiness with which mercury in some cases runs to the mouth is such that it is with difficulty a suf- ficient quantity for curing the disease can be given ; and it produces, I may observe, one of the most dis- tressful circumstances that we meet with in practice. The most certain method of preventing severe sal- ivation is the gradual exhibition of mercury in the manner we have already pointed out. Occasionally we succeed in preventing it by guarding against exter- nal cold, by confinement to the hou«e and the use of vol. in '22 * 170 OF THE REMEDIES CSF.iJ Cll. I\. warm cloathing of flannel or cotton. But while in this manner we support a gentle and equal flow of the matter of perspiration, severe sweating is to be avoid- ed, which always proves hurtful, and even sometimes, as I have thought, more so than profuse salivation. But in some cases, even with all the attention that can be given, the mouth becomes quickly sore, and a grad- ual discharge of saliva takes place much sooner than is expected. Purgatives are the remedies most frequently em- ployed for removing salivation: I have not found, however, that they prove useful, and when persisted in they never fail to do harm, for they weaken the pa- tient, while they seldom have any effect in lessening the salivary discharge. Blisters"have also been advised. The sense of suf- focation, which the swelling of the salivary glands sometimes gives, would appear to indicate the use of blisters. We do not perceive, however, that they have much influence upon the discharge, while by tbe irritation which they excite they very commonly do barm. As sulphur when combined with mercury renders it so inert that it scarcely acts upon the human body, many have imagined that it ought to have some influ- ence in lessening or removing the ordinary effects of mercury upon the system. We do not find in prac- tice, however, that these views which theory suggest- ed are in any degree realized. It has often been em- ployed for lessening the violence of salivation, but few instances have occurred of any advantage being derived from it. To me it appears that this effect of mercury is en- tirely local, and to be cured therefore with most cer- tainty by local remedies. It is obviously the conse- quence of irritation produced by mercury upon the salivary glands: The dread, therefore, which some have entertained of applying local remedies seems to have no good foundation; and accordingly I have found that they may be employed with freedom. As a- wash for this purpose lime-water proves useful, but Sec. iv. IN LUES VENEREA. 171 it requires to be diluted. A strong infusion of red- rose leaves, of galls, oak-bark, and other astringents, prove also serviceable; but the most effectual appli- cation 1 have ever employed is a strong solution of bo rax.* A little of it being kept in the mouth from time to tine proves exceedingly pleasant and sooth- ing, and at last has often an obvious effect upon the quantity of the discharge. It may prove in some de- gree useful as an astringent, but it seems to act chiefly as a sedative by lessening the irritable state of the sa- livary glands. It is evidently in this manner that opium proves use- ful in removing salivation; for although some advan- tage is derived from applying it directly to the parts affected in the form of a gargle it proves always much more useful when given internally. A dose of lauda- anum, sufficient to allay the irritation and pain which always accompany a profuse salivation, and to pro- cure sleep during the night, not only gives temporary relief but is the most powerful remedy we can employ for removing the discharge. When the uneasiness is severe the opiate should also be repeated in* the morning. Wrhere salivation comes suddenly to a greater height than the quantity of mercury we have employed should give us cause to expect we are apt to be at a loss, and afraid of giving more lest distressful consequences ensue from it. In such circumstances, however, I have often found that although the usual quantity of mer- cury was continued daily, the salivation was not in- creased, and that in this manner it might be persisted in till the cure was completed. This will not indeed be always the case; but it succeeds so frequently, that in every instance a trial should he made of it, for a cure may thus be effected in a few weeks which otherwise might be protracted for several months. It has also been remarked, if salivation excited in this manner be allowed to subside entirely, that the same, or even a greater quantity of mercury, may * Vide Appendix No. 2n 172 OF THE liEMEDIES kJiEii Ol. IV. afterwards be exhibited without any risk of the dis- charge coming again to a similar height. Of this I have met with several instances, so that the practice may always be adopted when it is found that a prop- er quantity of the medicine cannot be continued with safety from the first. One of the most distressful occurrences which we meet with in this disease proceeds from a peculiarity inherent in some constitutions, by which even the smallest quantity of mercury that we employ is apt to rush with violence to the mouth. This is particularly apt to happen where the patient at the same time la- bours under the sea scurvy. In this case our only remedy is the removal of the scorbutic diathesis by a plentiful use of acid vegetables and other antiscorbu- tics, but wi-ere it does not proceed from this cause all that we can do is to give those preparations of mercu- ry that are least apt to affect the mouth, and to pre- scribe them in the smallest doses. In this view corro- sive sublimate in small quantities is particularly indi- cated ; and in such constitutions I have sometimes found that Plummer's pill, a combination of calomel and sulphur, and which in common practice no great dependence can be placed upon, has proved complete- ly successful.* It luckily happens, however, where salivation is thus easily excited that the symptoms of syphilis in general yield to a small quantity of mercury. Some of the worst symptoms of the disease will give way to a sali- vation induced by a very few grains of mercury. Even the uneasiness produced by nodes subsides at once on the salivation being fully excited. But it is proper to remark that this first effect of the mercury will not prove permanent if it be not followed out with farther quantities, given at such intervals as the state of the salivation will admit. I have repeatedly found, however, that this may be done with safety, even where a severe degree of salivation has previous- ly taken place. In one case of this kind, where there ' Vide Appendix, No. 21. SeC. IV. IN LUES VENEREA, 173 were deep venereal ulcers on the shoulder and on the head, as well as a node upon one of the bones of the forearm, a violent salivation was excited by the ex- hibition of five mercurial pills, each of which con- tained only one grain of mercury. This gave an en- tire check to the pain which accompanied the node, and to the progress of the ulcers, and although other five pills only were given the salivation was kept up for eight weeks, when the sores healed and the cure was complete, no venereal symptoms having yet ap- peared, although several years have elapsed. In the progress of a long continued salivation tooth- ach and pains in the jaws and gums are apt to occur, and they add much to the distress of tlie patient, There is one advantage that we derive from giving mercury in a gradual manner; by beginning with small quantities and increasing them slowly the glands of these parts do not swell so suddenly, nor is the pain which ensues so severe as when too large doses are made use of at once. YVe also derive some advan- tage from keeping the parts moderately covered with thin flannel. There is no necessity for the head being so warmly covered as is commonly done, nor is it at all necessary where these pains do not take place; but when once they have occurred nothing proves more useful than moderate warmth. Indeed flannel seems here to be equally useful as it is in the ordinary form of rheumatism; from which, and from the resemblance which these pains to which patients taking mercurv are liable in their jaws and head'bear to rheumatic af- fections, I conclude that they are of the same nature. Before a patient enters upon a course of mercurv. if tnere is cause to imagine that he will be long kept • under it, and that a large quantity of the medicine will be necessary, we may save him a good deal cf distress by inspecting his mouth and removing any teeth that are either very loose or much spoiled; for teeth in this slate never fail to give much pain when the full effect of the mercury upon the mouth has taken place. The points of teeth that are ragged ought also to be re- moved, as they are apt to produce painful and trouble- 174 OF THE REMEDIES USEl* Ch. IV, gome ulcers on the contiguous parts as soon as they become much swelled. Ulceration of the inside of the cheeks and other parts of the mouth occurs also, and often in a very distress ful manner from the mercury alone, where no teeth in this state can be discovered. The most effectual me- thod of preventing this is, to cause the patient, from the very first effect of mercury upon these parts, oi even before this takes place, to wash his mouth several times a day, perhaps every two hours, with port wine and water, an infusion of red-rose leaves, or any other astringent. In this manner we strengthen the parl^ against the usual action of the medicine, and it also proves useful by preventing that foulness of the mouth which in every course of mercury is apt to take place, Fig tea and other emollients are commonly employed for this purpose, but I have not found that they an- swer so well as astringents. In speaking of the different preparations of mercu- ry we had occasion to remark, that almost all of them, when given internally, are apt to injure the-stomach and bowels. It is chiefly the bowels, however, which suffer from mercury, and thev do so in some instances in a very alarming degree. The purging which takes place proves not only painful and debilitating, but of- ten exceedingly obstinate. At first the discharge consists chiefly of fceces, but afterwards these are mix- ed with slime, and often with considerable quanti- ties of blood. The patient is also apt to suffer from a very frequent tenesmus. From the similarity of symptoms we should be apt to imagine that purgatives might be equally servicea- ble here as in common cases of dysentery and diar- rhoea ; but We do not find this to be the case. We de- rive some advantage, however, from sheathing the intestines with a plentiful use of the farinaceous vei getables, and animal jellies prepared with waives feet, and shavings of heartshorn. Milk boiled to the consis- tence of a jelly with' wheaten flour, or flour of rice, proves likewise an useful remedy. ! I Sec. IV. IN LUES VENEREA. 175 # In preventing this effect of mercurv upon tlie intes- tines we derive most advantage from the patient being kept in a moderate and equable heat, and from his skin being preserved in a perspirable state, and so re- markable is the influence of this, that the slightest check to the discharge by the skin seldom fails of in- ducing purging. The fact indeed is so generally ad- mitted that I would not have taken this particular no- tice of it, if a contrary opinion had not lately been advanced, and from which much mischief might en- sue, were the practice to be adopted which it tends to inculcate.* Camphor proves sometimes useful in correcting this symptom. It may be given for tl£> purpose to the ex- tent of eight or ten grains, thre% times a-day. Some of the absorbent earths, and kino, are occasionally used with advantage ; but opiates, particularly when thrown up by the rectum, are the remedies upon which we chiefly depend for removing the pain, and this is very commonly attended with a diminution of the dis- charge. Wrhen a clyster of thin starch and fifty or sixty drops of laudanum can be retained it seldom fails to give immediate relief, but where the tenesmus is severe whatever is injected by the anus is very apt to be instantly returned. In this case opium conjoin- ed with kino, in the form of pills, seems to be the best form of the remedy, It is here proper to remark, that although purging and gripes are frequent consequences of the internal use of mercury they are seldom observed during the longest mercurial course where unction only is em- ployed. When the course is conducted in this man- ner loose stools may occasionally occur, but they may be generally traced to the effects of cold and damp- * Mr. John Hunter, whose ingenuity and abilities are only to be eqalled by his singular opinions, does not imagine that the operation of mercury can be affected bv cold, not even by the patient being allowed to walk " in frost and snow.*' Mr. Hunter does not say that he h^s practised this method, and I cannot avoid observing that nothing should have warranted the pubhcat.on of such an opinion bitf. very ample exper.cnce of its being well founded. Vide Mr. Hunter's Treatise oil the Venereal Disease, p. 349. 176 OF THE REMEDIES USED Cll. IV, ness. I have seldom observed an instance of severe or obstinate diarrhoea from the external application of mercury, where the commencement of the purging could not be traced to some other cause. When none of the means employed for removing purging induced by this cause prove effectual, we are under the necessity of advising a temporary suspen- sion of the mercury, without which, indeed, all our remedies will frequently fail. Profuse sweating, I have already noticed as an ef- fect that sometimes ensues from mercury, and it ought to be guarded against with much attention. Nothing tends more to induce debility and injure the constitu- tion than a long cotllfcuance of this symptom. The most effectual TOethod of preventing sweating is to avoid much warmth, so that patients are seldom hurt with it who pay due attention to the heat of their apartments. It was formerly the practice to con- fine patients under mercurv to small apartments ; to prevent as much as possible all kind of access to the external air ; and to have the bed placed by the side of a large fire. These measures prove detrimental in different ways, and they seldom fail to excite a con- stant and profuse perspiration. The most effectual method of preventing this is, to keep the patient in an equal moderate temperature, in a large apartment, and even to admit of his going from one apartment to another, which, in most instances, may be done with safety. A nourishing diet, a moderate allowance of wine, the free use of Peruvian bark, and of the vi- triolic acid, are the most effectual remedies against this effect of mercury. But nothing proves successful where the apartment is kept too much heated. In some cases the kidneys are particularly acted up- on by mercury; but the discharge of urine which it excites is seldom so great as to injure the patient. Were it ever to do so, the remedies commonly em- ployed in diabetes would be advised, and of these the most effectual perhaps that we could give, would be such as operate by promoting a diaphoresis. *P-r. I'- TA LELS VENEREA.. 177 It is not an uncommon effect of mercurv to excite an eruption upon the surface of the body, In some this appeals as a miliary rash, somewhat resembling- measles ; while in others it is considerably elevated, and seems to be produced by a serous eiTu-ion between the cutis and scarf skin. In some the eruption is partial, being confined to particular spots, while in others it prevails generally over the whole body. This eruption or efflorescence is not attended with pain, but the heat and itchiness which accompany it are in some instances so distressful that it keeps the pa- tient at all times very uneasy, and deprives him en- tirely of rest. The remedies which I have found to answer best are the internal use of opiates, conjoined with the ap- plication of flour, or starch-powder to the parts affect- ed. The skin is kept sufficiently cool and easy by one or other of these powders being from time to time freely applied to the eruption; and by a proper exhi- bition of opiates we secure rest during night. In some instances, however, we are obliged to avoid the use of opiates; for although they may answer the pur- pose of procuring sleep they tend evidently to in- crease the heat and itchiness of the eruption. We find, indeed, that in some constitutions opium excites an uneasy itchy sensation over the whole body, even where no irruption has previously taken place; and it is perhaps with such patients only that it cannot be employed in the treatment of this eruption. The eruption to which I allude appears to arise en tirely from the effect of the mercury upon the system; but it does not seem to depend on any particular pre- paration of the remedy. It takes place indiscrimi- nately from all of them, and not more readily from unction than from these preparations that are used internally. But there is a kind of eruption of a local nature, produced entirely by the friction employed in the application of unction. This appears in the form of distinct pustules, which in some are accompa- nied with a good deal of uneasiness, while in others vol. n. 2:3 178 OE THE REMEDIES E*£D Cll. IV, they produce no kind of distress. No remedy proves of anv avail while the application of the ointment is continued, but the eruption may always be pre- vented by the precaution we have formerly given, of not applying the friction in daily succession to the same part. Mr. Pearson does not place much confidence in the efficacy of the articles mentioned by our author, (Lime Water, &c.) for the remo- val of salivation, but recommends a discontinuance of the mercury for a time, a free exposure to cool dry air, the occasional use of cathartics; the Peruvian bark and mineral acids, with the assiduous application of astringent gargles. The only danger to be appre- hended from this course is a sudden suppression of Ptyalism, which is often productive of serious consequences. In a case related by Dr. Silvester, the patient was unable to retain hardly any food in her stomach for the space of three months, and Mr. Pearson has ob- served not only violent pains, but general convulsions produced from this cause. This however cannot be attributed to a cool and dry air, since it has occurred in patients confined to a warm temperature, but rather originates from exposure to cold and moisture. The remedy for this suppression is a quick introduction of mercury into the body, so as to produce a soreness of the gums, with the occasional use of the hot bath. When the ptyalism is accompanied with ulceration of the tongue, of the cheeks, or of the tonsils, Mr. Pearson has found,that by sus- pending the use of mercury, and exhibiting the sulphuric acid dilu- ted three or four times a day, a very speedy amendment was produ- ced. Mortification is sometimes a consequence of this complaint, and in this case we would recommend the application of blisters, as pointed out by Dr. Physick : That sudden and violent rushing to the mouth of which Mr. Bell speaks, when even the smallest quan- tity of mercury is exhibited, is often relieved by the application of pounded ice to the jaw, and the use of cold acidulated gargles, ca- thartics and blisters, are also sometimes advantageous. In cases of diarrhoea or dysentery originating from the use of mer- cury, the exhibition of opium, not only in the form of clysters, but by the mouth, is the most efficacious remedy. Mr. Pearson states that in the course of two or three years after his appointment at the Lock Hospital, he observed almost every year, one or two cases of sudden death among the patients, without any assigned cause, and the subjects were commonly persons who had nearly and sometimes entirely finished their mercurial course. On enquiring of his colleagues Messrs. Bromfield and Williams, they acknowledged themselves ignorant of the cause, mode of pre- vention, or treatment of the disease, and remarked that they had never discovered any .morbid appearances in the bodies of those who had died thus unexpectedly. Mr. Pearsoi> after diligent attention SeC. IV. 1$ LUES VENEREA. 179 ascertained that these effects were owing to mercury acting as a pois- on on the. system, quite unconnected with its agency as a remedy, and its deleterious qualities, were neither in proportion to the in- flammation of the mouth, nor to the actual quantity of that mineral absorbed into the body. This morbid condition of the system he has denominated Mercurial Erethismus, and observes that it is charac- terized by great depression of strength, a sense of anxiety about the praecordia, frequent sighing, trembling partial or universal, a small quick pulse, sometimes vomiting, a pale contracted countenance, a sense of coldness, but the tongue is seldom furred, nor are the vi- tal or natural functions much disordered. A sudden or violent exer- tion of the animal power has, when these symptoms are present, generally preceded the sudden death of the patient. To prevent its dangerous consequences it is necessary immediately to discontinue the use of mercury, whatever may be the state of the venereal symptoms. The patient must be exposed to a dry cool air, in such a manner as shall be attended with the least fatigue. He ought to be taken into a garden or field and live as much as possible in the open air. This mode of treatment will often relieve him in the space of from ten to fourteen days, and Mr. Pearson observes that he has scarcely lost a patient since he first adopted it What may appear remarkable, he adds, is that the persons afflicted with it can very often employ mercury efficiently afterwards, without suffering any inconvenience. (Pearson on the effects of various articles in the cure of Lues Venerea, 1st Edit. 1800. P. 130-T-3.) In the garly stages of the Erethismus, its further progress ac- cording to Mr. Pearson, may be frequently prevented by exhibiting the Camphor mixture with large doses of the volatile alkali, sus- pending at the same time the use of mercury. Also when the stomach is not oppressed by sarsaparilla, this medicine is produc- tive of infinite benefit. (Rees' Cyclopedia, Art. Erethismus, in which the writer quotes the second edition of Mr. Pearson's work.) In the concluding paragraphs of this section, Mr. Bell has given the first printed account of a disease which of late years has excited great attention among medical men. This honour is universally al- lowed him, although Mr. Pearson asserts that he has been in the habit of describing it, since the year 1783, in his Lectures on Sur- gery, and that he became xquainted with it in 1781. Cases have „ also been observed as early as the year 1798, in the Royal Infirmary of Edinburgh. It was however far from being familiar to practition- ers until the year 1804, when it was described by Dr. Thomas Spens of Edinburgh, under the name of Erythema Mercuriale in the Edinburgh Men. and Surg. Journal, vol 1. p. 7. by Dr. Moriar- ty, of Dublin, under the name of the Mercurial Lepra, and by Dr. Alley, his countryman, in " an Essay on a peculiar eruptive disease, arising from the exhibition of mercury." The latter gentleman, in 1804, assigned to this complaint the appellation of the Mercurial Disease, but in 1810, gave it in a new edition the name of Hydrar- gyria. The term used by Dr. Spens was adopted by Dr. MeMullin, in his Essay on this disease in the Edinburgh Med.and Surg. Journ- al for January, 1806, and in 1807, Mr. Pearson published an ac* 180 OE THE REMEDIES USED Oil. IV. count of it under the appellation of Eczema Mercuriale, in the se« cond Edition of his work on the effects of various articles in the cure of Lues Venerea.—The above, is we believe, a complete list of writers on this subject, particularly as Mr. Mathias* work on the Mercurial Disease more properly relates to that class of com- plaints which of late years has been described under the name of Diseases resembling Syphilis. Dr. MeMullin commences his Essay by observing that eruptions of various kinds are very common symptoms of syphilis, but a very unusual efivct of mercury. In consequence, until the real nature of the erythema was discovered, it was considered an anom- alous form of lues venerea, and mercury was given to a greater ex- tent tnan before, thus applying the cause of the disease for its re- moval, and aggravating all its symptoms. The observation of this fact, together with another of less frequent occurrence, namely, a similar eruption appearing inpatients using mercury for other com- plaints, and in whom no suspicion of syphilis could be entertained, at last led to the important discovery, thai the eruption was entire- ly caused by the mercury, and not at all connected with the origin- al disease. The following account of the symptoms of Erythema Mercuriale, ■we extract from Dr. McMullin's valuable Essay. " The different appearances," he observes, " which this disease assumes, accord- ing to its severity and duration, will be best understood by describ- ing it as consisting of three distinct stages. The first stage commences with languor, lassitude, arjfl cold shiv- erings; these symptoms are succeeded by increased temperature of the body, quick pulse, nausea, head-ach, and thirst. The patient is troubled with a dry cough, and complains of difficult respiration, anxiety, and sense of stricture about the praecordia. The tongue is usually moist, and covered with a white glutinous slime ; it some- tinges appears clean and bright red in the centre, whilst the margins remain foul. Tne skin feels unusually hot and itchy, with a sense oi prickiing, not unlike the sensation experienced from the appli- cation of nettles. The belly is generally costive, but a diarrhoea is often produced by very slight causes. On tne first or second day an eruption most commonly shows it- self, the colour of whicn is either dark or bright red : the papulae are at first uis.inct and elevated, resembling very much those in ru- beola. Sometimes, but rarely, tne eruption appears like urticaria, ana in such instances the disease is observed to be very mild. The papu.ae very speedily run togetner in such a manner as to form a Rutiusta redness, which disappears on pressure. In most cases it begins first on the scrotum, inside of the thighs, fore arm, or where mercurial friction had been applied, and the integuments of the parts artccteu become much swoln. There have also been observ- ' ed instances where an eruption of a purplish colour, and unaccom- pamv.u by papulae, has diffused itself suddenly over the entire body, 1 ins, however, may be considered as uncommon. In every instance which came under my observation, it was confined at first to a few places, and from thence gradually extended, until the different por Sec. iv. IX LUES VEISE^EA, 181 lions of the eruption had united, and the papulse were also rough to the feel. But in those cases which resemble urticaria, a number of minute vesicles, which contain a serous fluid, appear, from the commencement, interspersed among the papula. Contrary to what happens in most diseases accompanied with cutaneous affections, the febrile symptoms are much aggravated, and continue to increase after the eruption has been completed. The pulse in general beats from 120 to 130 in a minute, the thirst continues urgent, and the pa- tient, extremely restless, seldom enjoys quiet sleep. When the eruption has continued in this manner for a'certain period, the cuti- cle begins to peel off in thin, whitish, scurfy exfoliations, not un- like those observed in rubeola. This desquamation has not been attended to by Dr. Moriarty or Mr. Alley, if they have not, by giv- ing the same name to the decrustation which occurs in the last stage, confounded both together. It commences in those places where the eruption first made its appearance, and in this order spreads to other parts. About this period the fauces become sore, the tongue swells, and the eyes appear somewhat inflamed. The duration of this stage is very various ; sometimes it contin- ues from ten to fourteen days, and in other cases it terminates in half that time. When the disease has appeared in its mildest form, the patient recovers immediately after this desquamation, a new cu- ticle having formed underneath ; but, if severe, he has only experi- enced the smallest part of his sufferings, and the skin now assumes a new appearance, which I have considered as the second stage. , The skin at this period appears as if studded with innumerable minute vesicles, which are filled with a pellucid fluid. These vesi- cles may be expected, if the patient, at the close of the first stage, complains of increased itching, and sense of burning heat, in those parts from whence the cuticular exfoliations have fallen. They re- main sometimes for a day or two, but are most commonly burst, im- mediately after their formation, by the patient rubbing them, in or- der to relieve the troublesome itchiness with which these parts are affected. They discharge a serous, acrimonious fluid, which pos-^ scsscs such a very disagreeable odour as to induce nausea in the pa- tient himself,and those who approach near his bed-side. The odour is so peculiar, that it can easily be recognised by any person who has once experienced it. This fluid is poured out most copiously from the scrotum, groin, inside of the thighs, or wherever the skin forms folds, and sebace- ous glands are most numerous. The serous discharge from tliese minute vesicles form, with the cuticle, an incrustation, which may be considered as the third or last stage. These crusts are generally very large, and, when detached, retain the figure of the parts from which they have fallen. Their colour is yellowish, but sometimes appears dark and dirty. This period of the disease might be termed, I think, with much propriety, the stage of decrustation, in order to distinguish it more fully from the desquamation which has been already noticed. From the use of tire two iast terms indiscriminately, those who have described tne dis- ease have introduced into their descriptions a degree of confusion, 182 OE THE REMEDIES USED Cll IV. which has caused its progress not to be well understood. When this stage appeai-s, the fauces become more affected, the eyes intole- rant of light, and the tarsi tender, inflamed, and sometimes invert- ed. The crusts formed on the face, as in other parts of the body, before falling off, divide asunder, so as to leave cracks and fissures, which produce an hideous expression of countenance; and the eye- lids are also, from the general swelling of the face, completely clo- sed. The back and hairy scalp are last affected, and, even in very severe cases, these parts are sometimes observed to escape entirely. The patient, whilst in this state, is compelled to desist from every kind of motion, on account of the pain which he experiences on the slightest exertion, and which he describes as if his flesh were crack- ing. The crusts also fall off in such abundance, that the bed ap- pears as if strewed with the cones of hops. Whilst the eruption is only making its appearance in one place, another part may have ar- rived at its most advanced form ; so that all the different stages of the disease may be present at one time in the same individual. It is attended with typhus through its entire course ; but it is very cu- rious to observe, that the appetite for food, in most cases, remains unimpaired, and sometimes is even voracious. This circumstance was particularly remarkable in a patient who laboured under thedisr case, in its worst form, for the space of three months, in the Royal Infirmary of Edinburgh; for double the usual hospital allowance of food was scarcely sufficient to satisfy his hunger. When the catarrh- al symptoms have continued during the progress of the complaint, they are, at this advanced period, particularly aggravated: the anx- iety and pain of breast are also very severe, attended with cough, and bloody expectoration, and the patient always feels languid and dejected. The pulse becomes frequent, feeble, and irregular, the tongue black and parched, and at length diarrhoea, delirium, con- vulsions, gangrene of the surface of the body, and death, super- vene. In its mild form, it only goes through the first stage, and terminates, as we have already stated, in a few days, by a slight de- squamation. But, when severe, it is often protracted more than two months, every stage of the eruption continuing proportionably longer; and when, in this manner, it has run its course, it repeated- ly breaks out on the new surface, and passes through the same stages." To the above we add an abstract of Dr. Alley's work, taken from the New-England Journal of Medicine and Surgery, for April, 1814. "The Hydrargyria," as Dr. Alley, states it, " is characterised by an eruption, which is very variable in its appearance. These va- rieties in the appearance of the eruption being usually accompanied with corresponding symptoms indicative of the medicines or pecu- liarity of the disease, justify the division of it into three species. 1. Hydrargyria mitis vel sine febre ; 2. hydrargyria simplex febri- lis ; 3. hydrargyria maligna. 1. Hydrargyria mitis. This species has at a first view nothing to characterize it further than a light rose coloured efflorescence ; an attentive observer, however, by holding the affected parts between him and the light, and keeping his eye on a level with them, may SeC. IV. IN LUES VENEREA. 183 perceive the surface to be studded over with innumerable, minute, and transparent wrinkles ; but to the naked eye the vesicular ap- pearance is sometimes with difficulty perceptible. Heat and itching attend the striking out of the eruption, and slight headach and nau- sea, in some cases, exists for a few hours. At times the smarting itching which attends the striking out of the eruption is not contin- ual, sometimes attended with accelerated pulse, and flushing of the face. The efflorescence though not close at first, is gradually diffused over the parts affected, viz. upper part of the thighs, groins, scro- tum, lower part of the abdomen, Sec. and it usually is confined to these parts. If, however, mercury be used after its appearance, it does not long remain local, the colour of the eruption in this is sometimes as dark as in the second species ; the spots are minute and distinct however, unless the use of mercury be persisted in af- ter their appearance. In this as in the other species, the colour of the eruption recedes on pressing, and suddenly returns, when the pressure is removed, and the finger will readily detect an inequality of the surface. At times the efflorescence fades away without any desquamation, when however the vesicular appearance is very man- ifest, a slight scurfiness may be observed after a few days, and the natural colour in some instances is net regained for some time after the desquamation has commenced. This species by an incautious use of mercury while it exists may degenerate into the second, and even third, or be produced in an aggravated form by a too early re- moval of the mineral. This is however, contrary to Mr. Pearson's experience who states that 'v it has even occurred where the patient has been sent out of the hospital that he might enjoy the benefit of a pure atmosphere." 2. Hydrargyria simplex-febrilis. The eruption in this species is preceded by fever, it is accompanied with itching of the skin, ansLn* considerably more rough to the touch than the efflorescence in the same species. From being distinct the spots soon become crowded together, and after the third day the natural colour of the skin can- not be discerned. This eruption may be distinguished from measles by the spots being larger in the former, and not appearing in the annular form which is the case with measles. Mr. Crampton, however, thinks it very difficult for the first two days to distinguish them, the eruption is of a dusky reddish hue, and if mercury be laid aside it is seldom darker than on the second day. The parts attacked are various, in males sometimes the scro- tum, thighs, sometimes however, the backs of the arms and hands, or the back and abdomen are first affected, contrary to what occurs however, in the first variety, it gradually spreads over the entire surface of the body. In this species at times the vesicular appear- ance of the first, may be noticed, especially on the first striking out of the eruption. When on the decline the eruption may be mista- ken for the last of scarlatina anginosa, at a similar period : the dusk- iness of colour which it always preserves will enable a careful ob- server to distinguish them. This species may be distinguished from the first, by a greater sep- !ij| OF THE REMEDIES CSED Oil. IV. aration of the cuticle. This is usually preceded by soreness of the throat and fauces. This latter symptom is of short duration. De- scuamation generally commences on the fourth clay of the eruption, and the earlier it occurs the milder in general the disease. It has been observed, that successive desquamations at times take place, and that this is chiefly observable in cases in which mercury has been vised after the formation of the disease. The febrile symptoms mentioned as the precursors of the erup- tion are followed by a considerable degree of oppression about the prsecordia, a hard cough and difficult respiration. The skin is usu- ally very dry, heat very great; from 102° to 106° and is in no dis- ease perhaps more steady or permanent. Sometimes, indeed, in this species, a very foetid perspiration takes place, where there is much attrition of surface, as in the axilla, Sec. The pulse, though full, is not in general hard and varies from 100° to 130° in the minute. The febrile symptoms, except the htadach and nausea, increase as the disease proceeds, and does but seldom abate with the desquamation. The eleventh day has hither- to been considered critical. 3. Hydrargyria maligna. This species is ushered in with the same symptoms as the last. But Mr. A. considers the following as almost certain indications of the distressing nature of its termina- tion. 1. The sense of burning on the surface is experienced to a very painful degree. 2. The actual heat of the skin becomes in- tense. 3. The soreness of the throat and fauces is extreme. 4. The colour of the eruption is darker, rising sometimes even to purple, and there is considerable tumefaction of the surface. 5. Vesicles of a larger size than jn the former species precede desquamation. It must be remembered, that the other species may degenerate into this, by continued use of mercury, and even by continuing the patient in the venereal ward of a Hospital. A most painful burning « sensation accompanies the tumefaction, and immediately preceding desquamation the heat has risen to 108°. Blisters are now formed and discharge an acrimonous lymph. So numerous are the vesi- cles that the whole cuticle desquamates from the tumefied parts, as in that species of Roseola attendant or small pox. As the disease advances, the discharge acquires a most offensive odour, one which will be readily recognized, after having been once experienced. The discharge also becomes more acrid and viscid. Desquamation is later in this than in the other species, not occuring in some cases . till the tenth day. The separation commences with cracking of the scarf skin, scabs form on the surface. The eyelids partaking of the general tumefaction are sometimes closed ; and so irritable at times is the surface, that blood instead of lymph attends the desquama- tion. The cuticle sometimes separates in large pieces, thus, that of the hand will come off, so entire as to resemble a glove. The desquamations which succeed, discover a surface less red, and exposed, and the discharge ceasing the epidermis is renewed. Painful tumours sometimes occur in different parts of the body, they suppurate acd heal kindly. While desquamation is only commciv Sec. iv. IX LUES VENEREA, 185 cing in some parts, a thin acrid matter often exudes in others. The cuticle also when regenerated at times cracks, and separates again ; and in some cases, after the disease has disappeared in every other part of the body, one particular place remains discoloured and ex- tremely sore. The cuticle, in some severe cases of this species, is not the only part separated ; but so deep does the desquamation extend, that in one patient who was very much pitted with the small pox, no pits were discoverable after his recovery. In other instan- ces the hair from the chin, axilla, 8>cc. has been completely removed by the desquamation. Dr. Alley observes, that the febrile irritation is, in general, proportionate to the severity of the external symp- tom. The affection of the lungs is among the first and most dis- tressing symptom. In some cases great sense of weight and op- pros ... ion about the prxcordia and difficult respiration are the most disrressir.L, ; in others hard and incessant cough, and a fixed pain in the chest are superadded. The pulse is hard as in pneumonia ; and during fits of coughing, severe headach is experienced. Delirium has not been observed. The soreness of the throat is very distress- ing in some cases for many days, sometimes hoarseness and hae- morrhage from sloughing of the lining membrane of the fauces has occurred. At first the tongue is white, it becomes however parch- ed, and black in the centre, towards the conclusion. The pulse continues qdick, but loses its fulness; it becomes weak and fre- quently irregular. The secondary fever is the most dangerous, and is so a proportion to the extent of the disease and the depths of the desquamation. True hectic at times occurs in these cases, and fre- quently diarrhoea supervenes, constituting the most formidable symptom of the disease. Convulsions sometimes occur, and at oth- ers the fasces, -xud urine are discharged involuntarily. As the hydrargyria has been mistaken for other diseases, Dr. A. subjoins the following brief recapitulation of its most leading feat- ures. 1. The eruption is, for the most part, at first vesicular. 2. The fever and eruption are generally synchronous in their ap- pearance. 3. Exfoliations of the cuticle usually take place, about four days after the appearance of the eruption, and is commonly preceded by soreness of the throat and fauces. 4. In several cases, blisters, sometimes large vesications pre- cede desquamation. Tne cuticle, in such cases, cracks and forms fissures; and the odour of the exudation from the surface, is strong- ly characteristic of the disease. 5. The presence of the delirium ferox has never been witnessed, however considerable the inflammation and tumefaction of the ex- ternal parts of the head ; nor has the head appeared engaged, ex- cepting where the debility was extreme and the exudation from the surface profuse. 6. When the cuticle desquamates, the parts underneath appear red, as before that occurrence. 7. The disease is never fatal unless secondary fever supervene. » vol. rr. 2-t 18(? OF THE REMEDIES USED Cll IV. Dr. Alley gives the following table of the results of all the cases that he has witnessed during the last ten years. Hydrargyii Mitis. H Simplex f'obrilis. H. Malig-na. Total. Cured. Died. Male. 6 12' 10 28 , 22 6 2 Female 4 7 4 t5 13 Total. 10 19 14 43 35 8 Mr. Pearson however, has never seen it fatal, nor has he seen it in subjects above 50, and says, that its occurrence is more common about eight or ten days after beginning a mercurial course. The remote cause of this disease, is the employment of mercury and this without reference to the quantity or manner in which it is used. " I have seen the eruption" says Mr. Pearson, " take place after the friction of a single drachm of mercurial ointment and af- ter one dose of calomel. I have known a slight degree of the ecze- ma mercuriale, induced in young children from the administration of a single grain of calomel, the touching any part of the human body with mercurial ointment will sometimes produce it and I have seen the accidental falling of a few grains cf the hydrargyrus nitra- tu*-: ruber upon the skin, succeeded by a similar effect, but under these circumstances, the eruption will be confined to the parts with which the mercurial preparation comes in contact." (London Med- ical Review, vol. 3. p. 315.) Practitioners however appear to differ on the point whether the application of cold to the body, when un- der the influence of mercury, is necessary for the production of the disease. This is the opinion of Dr. Gregory and Dr. McMulien inclines to this belief, in consequence of the constant combination pf catarrhal symptoms. Dr. Spens remarks that in all his cases, the patients had been exposed to cold, but adds that something more is necessary for the production of the disease, since its occur- rence is too rane to be the necessary consequence of a cause so com- mon. Mr. Pearson however considers the irritation of mercury to be the exciting cause, independent of the action of cold, which he denies having any effect in bringing on the complaint. For the removal of .this disease Dr. McMulien recommends the immediate discontinuance of mercury, the removal of the patient from wards, where this mineral is in use ; the frequent use of" tepid bathing ; emetics and diaphoretics, but on account of the irritable state of the bowels, he prefers theacetite of ammoniae or citrate of potash to antimonial s ; and purgatives of the mildest kind, such as oleum recini, magnesia vitriolata, &c. To allay the cough and sore- ness of the fauces, he advises mucilaginous drinks with opium. He recommends great attention to cleanliness and is opposed to lo- cal applications of an astringent kind to the eruption and also to the use of blisters. In the second stage, when the fever assumes more of a typhoid type, the cold infusion of bark with opium maybe tri- ed, but it generally disagrees with the stomach. Wine and porter K-U- IV. IV LUES VEXEREA. 187 are very useful, as are large quantities of diluents and tepid ablu- tion.^ To relieve the ophthalmia tarsi, the unguentum oxidi zinci will in general prove sufficient, and to appease the painful sensation of the skin cracking, the linimentum aquae calcis, which should be applied as soon as crusts appear. The method of cure adopted by Dr. Spens-is in general similar to the above. He observes that the external applications which he found most useful were lime water and flour. Mr. Pearson seems doubtful whether any mode of treatment has the power of interrupting the regular course of the disease, or abridging its duration. Believing however in the benefit of reme- dies to mitigate it, he recommends in the early stage, small doses of antimonial powder, with saline draughts or the ammonia acetata. A gentle purgative should be given every three or four days and opium to procure sleep, and fche latter article may be advantageous- ly combined with camphor. Sarsaparilla with bark may be given, when the discharge is no longer ichorous and the tumefaction is sub- siding. He has also found the sulphuric acid to prove grateful and '. cfreshing. The diet should be light and nourishing, but no fer- menting liquors should be allowed until the desquamation has some- what advanced. Frequent use of the warm bath and often changing the linen and sheets of the patient are indispensable. Mr. Pearson also covers every part from which the cuticle is detached, with a mild cerate of litharge plaster, yellow wax and olive oil, spread thickly on rollers, and renewed twice a day. This mode of treat- ment, he has, during twenty years experience, found successful. ^Rees' Cyclopedia, Art. Erythema Mercuriale.) Dr. Alley agrees with Mr. Pearson in the opinion, that medicines have no effect in cutting short the disease, 'but objects most decided- ly to the remark of the Jatter gentleman, that in some cases, the continuance of mercury is proper. Dr. Alley advises the imme- diate discontinuance of mercury, tepid ablution in the eruptive stage and some gentle purgatives, for the removal of the pectoral symp- toms. This plan he considers proper during the eruptive stage of each of his species. He recommends the cold affusion, but does not appear to have used it in any of his patients, blood-letting where tho inflammatory symptoms are severe; and diuretics especially digitalis, after evacuations. Emetics do not appear to be indicated, and the mineral acids although useful in the primary stages ought to be laid aside in the secondary one, unless combined with opium, as diarrhoea is generally present. The same objection occurs to the use of bark, which also aggravates the pectoral symptoms and Dr. Alley has found wine an excellent substitute in tne latter stages of the disease. As to external applications the author speaks well of the liniment: aq: calc : and also of finely levigated carbon; zinc- pp. or meal, separate or in a combined form. He deprecates the external use of lead and considers it highly prejudicial. (Lon- don Med. Review, vol. 3. p. 317. Eclectic Repertory for October, 1813 and New-England Journal for April, 1814.) w'ith respect to the controversy on the name which ought to be eiven to this disease, we refer our readers to the works quoted 18!i of the Remedies used Ch. iv. above. It is proper however to observe that Dr. Rutter of Liver- pool, has published a case of erythema not occasioned by mercury, in the Edin. Med. and Surg. Journal for A; ril, 1809, and Dr. Mar- cet of London, another in the Medico Chirurgical Transactions, vol. 2. (New-England Journal, vol. 1. p. 304) The latter gentleman suggests the term Erythema ichorosum as more suitable than that of Erythema mercuriale. It appears that this disease is not confined to Europe, since in a letter from a surgeon in Madras (Edin. M. and S. Journal, for Oct. 1806) it is stated that amor.g the natives, who never can be made to clothe themselves sufficiently, when under the use and influence of mercury, the disease occurs frequently and of- ten proves destructive. Dr. Willan in his work on the Diseases of the skin, mentions a complaint under the name of Erythema papulat-um, which he is in- clined to refer to the use of mercury-. It occurs he observes, at an advanced period of the Lues Venerea on the upper and inner part of the thighs, on the scrotum and between the nates. It is attended with heat, pain and itching, and an acrimonious viscid discbarge, which partially excoriates, but which at length forms a smooth whi- tish incrustation, ovei all the affected surface. The best remedies are washing the parts with warm soap and water, and applying toft astringent ointments. Dr. Willan has also known the Pompholyx benignus induced by the use of a few grains of mercury. (Willan on Cutaneous Diseases, vol. 1st. London, 1808..) Madness is not a very uncommon consequei.ee from the exhibition of mercury, largely and injudiciously administered. Mr. Haslam in his work on Insanity, states this among other causes, and Baron Larrey in his Relation Chirurgicale de I'Armee D'Orient observes,. that although syphilis was very easily cured in Egypt by the internal use of mercury, diaphoretics and vapour baths, yet mercurial fric- tions were not only insufficient, but produced violent frenzy in some patients, and spasms, convulsions and profuse salivation in others. (Edin. M. and S. Journal for April, 1806.) It is a fact, indeed, well attested, that in warm climates, a smaller quantity of mercury and a shorter period of time are sufficient to cure the disease. Tnis, we have observed is the case in E^ypt, and Mr. Pearson states the same to occur in Italy, Spain and the Southern parts ot France. Ed. IX. Does Mercury ever fail in the Cure of Lues Venerea ? This is a question of the highest importance, and therefore merits our attention. 1 am disposed Irom the result of my own experience to say, that mercu- ry under proper management may be considered as a certain reined} for syphilis, when not combined v.ith other diseases, or where it does not atitct patient BeC IV. IN LEES VENEREA. 189 whose constitutions are so reduced and debilitated as to prevent the quantity of the medicine that is neces- sary to destroy the virus from being employed. I know that some are of a different opinion ; but I con- clude that they are wrong from my never having met with an instance of mercury having failed when it was properly given, but where some obvious rea- son, such as 1 have mentioned, could be assigned for it. Lues Venerea as we have already had occasion to see, is often combined with diseases in which mercu- ry commonly does harm. This is particularly the case in scurvy, and in some degree with scrophula. In the higher degrees of scurvy mercury cannot be giv- en but vvith great danger ; a'nd even where it prevails in a slight manner only, mercury cannot be employ- ed in such quantities as are sufficient for eradicating any of the more formidable symptoms of Lues Vene- rea. When the two diseases therefore are conjoined we cannot expect that mercury will have much influ- ence in the cure of any venereal symptoms that may- take place; and I believe that we are often disappoint- ed in the treatment of the disease by the patient at the same time labouring under a certain degree of scur- vy, which although not so obviously marked as to in- dicate the propriety of advising an antiscorbutic regi- men, may yet be sufficient to prevent him from receiving the full advantage of a course of mer- cury. I conclude this to be the case from the frequent in- stances of the failure of mercury in the cure of many of the symptoms of syphilis, in which it afterwards proves successful when the constitution of the patient has been restored from a weak debilitated state to strength aud firmness, and which we usually accom- plish by a milk and vegetable diet, country air, and such other articles of regimen as generally contribute to remove even the high degrees of scurvy. Nay, I believe that a mercurial course when long protracted, is apt to induce a certain degree of that very slate of the system which I now aiiude to, and I9U OE THE REMEDIES USEH (Jll. VI, which I conceive to be the cause of the remedy being often found to fail where in this manner it has been long continued. Every practitioner is acquainted with this circumstance, that a variety of venereal symptoms, and more especially extensive ulcers, will to a certain length do well under mercury, when af- ter a great deal of the medicine has been exhibited ihey will begin to remain stationary, and make no progress whatever, although the mercury should he given in larger quantities than at first. Nay, in some instances they become worse. The discharge from the ulcers, instead of being mild and purulent, as ful- some time it may have been, will become thin, sharp3 and corrosive, and the sores themselves more exten- sive. In this situation a farther continuance of mer- cury very commonly doesvharm, whilst the most ob- vious advantages are derived from it after the consti- tution of the patient has been restored by the influ- ence of a proper regimen. We even sometimes find that a cure is accomplished by regimen alone, and that no more mercurv is required, but this can only hap- pen where a sufficient quantity of the medicine has been previously given for the destroying the virus of the disease, and where the ulcers which remained were kept up by a slate of the system, which mercu- ry, instead of removing, seems evidently to promote. In the commencement of a mercurial course, and for some time thereafter, it is a certain effect of mercury to excite inflammation, and to produce that state of the system which we conceive to be the very reverse of what takes place in scurvy. The pulse becomes full and frequent, and the blood is firm and sizy ; but all who have paid attention to the subject will have perceived that the contrary happens where mercury has been, long continued. The patient, however full he may have been, is for the most part much emaciated: his pulse is feeble, and any febrile symptoms to. which he may be liable are of the low or putrid kind. The particular state of the blood in this situation we have few opportunities of observing, as\fbr the most part the discharge even of a *mal! quantity'vnuld in such Sec. iv. OF EVES VENEREA. 191 circumslance prove hurtful, and therefore is not advi- sed : We have reason, however, to conclude, that it is the reverse of what takes place from inflammation, as the most effectual remedies we employ here, are a generous diet, wine, and bark. This opinion of the effects of mercury upon the system receives some confirmation, I may remark, from the putrescency which it evidently excites in the mouth; and from the peculiar tendency both of mer- cury and scurvy to excite a tender st te of the gums, and a very foetid state of the breath, we have reason to suppose that the effects of both are in some degree the same. This might be farther elucidated by various argu- ments which the extent of this publication will not ad- mit. Enough, however, has been said for the purpose of explaining the chief part of the treatment I have ven- tured to propose; particularly that which relates to di- et and other articles of regimen during a course of mercury. In speaking of scrophula as an impediment to the action of mercury in the cure of Lues Venerea I do not mean to say that the disease cannot be cured in scrophulous constitutions. We daily meet with the contrary of this : But we also find, when the same sore partakes both of scrophula and Lues Venerea, that we do not derive the same advantages from mer- cury as in sores purely venereal. In such circumstan- ces, after as much mercury has been given as is pro- ductive of any beneficial effect, and of which we judge by the sores or other symptoms making no progress towards farther amendment, our best chance of effecting a cure is to omit the mercurv, and not have recourse to it again till by the use of bark, cold bathing, cicuta, and other remedies employed for scrophula, the dis- position is corrected or removed by which the opera- tion of the mercury upon the syphilitic symptoms was rendered .ineffectual. But the most frequent cause of our failure with mercury in the cure of this disease is that which I have already had occasion to ip.<)s'j extensive ulcers which sometimes succeed to bu- b"«-'S. In some the guiacum answers by itself, but it p >ves more frequently successful, as we shall here- after have occasion to mention, when conjoined with mezereon and sarsaparilla. i . — The Lignum Guaiaci or Guiacum Wood was first employed by the natives of St. D'omingo as an antidote against the Lues Vene- rea ; the Spaniards soon acquired a knowledge of its virtues, and introduced it into Spain in the year 1508, and in a short space of time it acquired great celebrity. Its reputation as an anti-venereal con- tinued -high for two centuries, although repeated instances occurred, in which it was given in vain. Mr. Pearson observes that when he was first entrusted with the care of the Lock Hospital in 1781, it was a favourite remedy with his colleagues. The patients for whom the guiacum was directed were those who had previously used the usual quantity of mercury, but who complained of nocturnal pains, who had gummata, nodes, ozoena, and such-other effects of the ve- nereal virus, connected with secondary symptoms, as did not yield to a course of mercurial frictions. The diet of these patients con- sisted of raisins and hard biscuit; they drank from two to four pints of the guiacum every day, they were ordered to use the hot bath twice in the week ; and they commonly took a dose of antimo ial Wine and Laudanum, or of Dover's powder, every evening. Con- stant confinement to bed was not deemed necessary ; and they were seldom exposed to the vapour of burning spirit to excite perspira- tion, as only a moist state of the skin was required. This treat- ment was sometimes of singular advantage to those whose health had sustained injury from the complicated operation of the disease, combined with confinement and a long course of mercury. The strength increased, untractable ulcers were frequently healed, cari- ous bones ex oliated, and those anomalous symptoms which would have been exasperated by mercury, yielded reaciin to the decoction of Guiacum. Mr. Pearson observes that this Memcine was also 19b OF THE REMEDIES USED Cll. IV. formerly given on the first attack of the venereal disease, and from the benefit derived, a radical cure was considered to be accomplish- ed Frequent relapses however followed, and Mr. Pearson re- marks that although it may operate like a true antidote, in sus- pending for a time, the progress of certain venereal symptoms and removing other appearances altogether, yet experience has evinced that the unsubdued virus yet remains active in the constitution. In exhibiting the decoction of Guiacum for pains in the bones, Mr. Pearson rarely found any benefit, except where it acted as a sudorific, and in this respect he considers it inferior to antimony or volatile alkali. When the constitution has been impaired by a suc- cessful course of mercury and long confinement, and a thickened state of the ligaments, or periosteum, or foul ulcers still remain, these sores will heal and the enlarged membranes subside, during the administration of the decoction. It will also suspend for a time, the progress of certain secondary venereal symptoms, such as, ul- cers of the tonsils, venereal eruptions, and, even nodes, but Mr. Pearson never saw an instance, in which the venereal virus was erad- icated by the powers of this medicine*nor does he consider a com- bination" of it with mercury, as increasing the virtues of the mine- ral, nor lessening the necessity of giving a certain quantity of it. He has however administered the guiacum with good effect in Cu- ta.eous Diseases, and in the ozoena. (Pearson on the effects of ya-. rious articles in the cure of Lues Venerea) Ed $ 4. Of Sarsaparilla. Sarsaparilla has been long employed in the cure of Lues Venerea, and from the result of some trials which I made with it I am disposed to think that some advantage may be derived from it. The trials which I Lave made with ft along with mercury have been nu- merous, but it is not upon these that any judgment can be formed of its real efficacy. Neither have 1 given it often where mercury had not been previously used; but I have had many opportunities of using it in cases where mercury had not proved altogether successful, whether from being given in too small quantities, or from being exhibited without that attention to regimen which it requires, and in a great proportion of these it has been productive of evident good effects. I have found it particularly useful in those symptoms which chiefly affect the skin, such as blotches and the remains of old venereal ulcers. When mercury from either of the causes which I have mentioned has failed of com- Sec. tv. IN LUES VENEREA. 197 pleting the cure, I have in various instances known it accomplished by sarsaparilla, where otherwise there was much reason to think that mercury in a larger quantity, or given in a different manner, would have been necessary. I have given sarsaparilla in powder, in extract, and in decoction, but the latter has always appeared to an- swer best. Not unfrequently I conjoin it with guia- cum, and it answers the purpose of blunting the acri- mony of the latter.* Sarsaparilla and guiacum have both a tendency to promote perspiration. Besides any power which they may possess of acting directly upon the venereal vi- rus, they seem also to prove serviceable where mercu- ry goes too readily to the mouth, in diverting it from that outlet.* ? Vide Appendix, No. 2.3. The Radix Sarsaparilla was introduced into Europe from the West Indies as a remedy of great efficacy in venereal cases, about the year 1530, but afterwards lost its fame. It was again brought into notice by the late Dr. William Hunter, who advised Dr. Chap- man to use it in a bad case of phagedenic bubo, and from the bene- fit derived, Dr. Hunter was induced to recommend it to other prac- titioners. Sir William Fordyce in a memoir contained in the " Med- ical Observations and Inquiries, v»l. 1st." speaks highly of its vir- tues and considers it effectual in curing many of the secondary symp- * loms, without the aid of mercury. He also observes that in chan- '( cres it will be of little service, but thinks it probable that sarsaparil- ' la will always cure what resists the powers of mercury. Mr. Pear- son in opposition to the above writer, contends that this medicine has not the power of curing any, one form of the disease, and cites in favour of this opinion the observations of Cullen and Bromfield. 1 He allows however, that it may suspend for a time the ravages of the disease,—that it will alleviate symptoms, derived from the joint action of mercury and the venereal poison on certain constitutions, or such as are often the sequelae of a full course of mercury, such as nocturnal pains, membranous nodes, cutaneous ulcerations, &c.; hut adds that the combined exhibition of sarsaparilla with mercury does in no case diminish the necessity of giving a certain quantity of the latter. (Pearson on the effects of certain articles in the cure of Lues Venerea, 1st Edit. 1800.) Sarsaparilla is an important ingredient in several French prescrip- tions of high reputation. The Anti-syphilitic Rob of Laff'acteurh 198 OF THE REMEDIES USED Ch. IV one of these, and we are indebted to Dr. M'Nevin for the following receipt for preparing it. Take of Sarsaparilla $xxx. Marsh reed grass, (Arundo phragmatis) 5xxx. Flowers of Borage, $vrij. Senna and Roses, aa 5ij- Boil these for one hour in nine pounds of water, then strain the liquor ; put an equal quantity of water on the residuum, and boit it again for nearly two hours, strain this, and to both decoctions, add six pounds of sugar, as many of honey, and boil down the whole to the consistence of a rob. The dose for men is six table spoonfulls, and for women, four. For further directions, we refer the reader to Dr. M'Nevin's Paper on this subject. He observes that the effica- cy of this medicine is confined to those venereal cases which have been aggravated by the abuse of mercury, and that it is seldom ser- viceable in the primary stages. Another Medicine much in use in the French Hospitals is the Syrup of Cusinier, which is prepared as follows: Take of Sarsaparilla J^x. Senna, 5x. Flowers of Borage, 5iij. Flower of Roses, ?iij- Boil and strain and add sugar and honey each forty pounds, and reduce die whole to the consistence of a syrup. Dr. M'Nevin adds that he has found a saturated decoction of sar- saparilla and guiacum answer as well as either of the above, taking care at the same time, to confine the patient to a warm room, and to prevent costiveness. (New-York Med. and Phil. Journal and Re- view, Vol. 3d. P. 23.) •■ Eb. $ 5. Of Mezereon. The root of this plant has long been employed for the removal of schirrous tumours by whatever cause they may be produced, and many have thought thai it lias proved particularly useful in venereal nodes, as well as in some other symptoms of this disease. As I have not made much use of it where mercury was not either employed along with it or before it was given, I cannot from my own observation determine wheiher it is possessed of the power of curing syphilis by it- self or not ; but from much experience of the effects of it when conjoined with mercury, I can say deci- sively that in tiiis manner it often proves uselul. I Sec. iv. IN LUES VENEREA. 199 have never known any advantage that was sufficiently clear and obvious derived from it in nodes, but it cer- tainly tends to heal those ulcers which sometimes re- main obstinate after the quantity of mercury is given that we judge to be necessary. I have already had occasion to mention that spread- ing ulcers of this kind are particularly apt to succeed to buboes, and that they often resist all the remedies that we employ for them. As this sometimes happens after a very full quantity of mercury has been given, and as the sores often heal at last from the effects of a change of regimen alone, I conclude that they are not kept up by any remains of Lues Venerea; and as it is in this state of the disc-ase that I have chiefly observed any advantage to accrue from mezereon, I conclude that it acts particularly by correcting that state of the system which long continued use of mercury is apt to induce, and wdiich by experience we find to be very inimical to the cure of all such sores as the patient at the time may labour under. It seems to be in this manner that Kennedy's decoc- tion, and of which mezereon appears to form a consid- erable part, proves particularly useful. There is no reason to suppose that any quantity of mercury is con- tained in that decoction, and yet there is no cause to doubt of sores of this description having been often soon healed by it, which had previously resisted every attempt that was made to cure them. Of this I could mention several histories which have fallen within my own knowledge, but they are too long to admit of in- sertion in this place. This decoction, I may remark, appears to be nearly, or perhaps entirely the same with the Lisbon decoction, for which a form is given in the Appendix.* In using this root it is proper to observe, that the ligneous parts of it are altogether inert. The bark of tie root appears to be the only active part of it. An English quart, containing a drachm and a half of the hark, is a sufficient quantity to betaken in the course * Vide Vol. I- Nos. 46 and 47 200 'OF THE REMEDIES Li MO Cll. IV; of a day, and even this, when the root is in perfection^ renders the decoction so acrid that it is apt to affect the throat. With a view to lessen this acrimony we conjoin it with gum arabic, liquorice, althea, and of- ten with sarsaparilla.* * Vide Vol. II. No. 24. The Mezereon Root was recommended by Dr. Alexander Russel in the " Medical Observations and Inquiries, vol. 3," as a cure for the venereal node, but he added that it was not found of service in the removal of any other symptoms. Mr. Pearson however asserts that it has not the power of curing the venereal disease, in any one stage, or under any one form, and considers its use Unnecessary, since the good effects attributed to it are derived, without its dis- agreeable qualities, from the Guiacum, Sarsaparilla, &c. (Pearson.) As the Lisbon Diet Drink and the Decoction of the Woods are famous prescriptions in venereal cases, we give the following for- mulae in additition to those contained in our author's appendix. When the disease is doubtful, or mercury disagrees, or has been given in sufficient quantity, such remedies may often be administer- ed with great benefit. R. Sarsaparilla: concisa? Ligni santali mbri. Ligni santali citron, sing : 5iss: Radicis Glycyrrhezae. Radicis mezerei sing : £ij. Ligni rhodii. Ligni guiaci officinalis. Ligni sassafras sing : 5iss. Antimonii 5i- Aquae distillate J^ v. These Ingredients are to be macerated for twenty-four hours, and afterward^ boiled till the fluid is reduced to half its original quantity. From one to four pints are given daily. The following decoction is said to be the genuine Lisbon Diet Drink. A- Sarsaparillse concisac. Radicis Chinse sing: ?i- *f ucum juglandis cortice siccaturum No. xx' Antimonii ?ij. Lapidis pumicis pulverisati 5i. Aqua; distillate ffrx. The Powdered Antimony and Pumice Stone are to be tied in sep- arate pieces of rag and boiled along with the other ingredients.-. Sec. iv. IX LEES VENEREA. 201 (R^es' Cyclopedia, Art. Lues Venerea.) Mr. Pearson appears to incline to the opinion that antimony is the important ingredient in tin above preparations, in promoting a determination to the skin. The Decoctum SarsaparilU compositum of the London and Dublin Pharmacopaeias will also be found an useful remedy. Ed. $ 6. Of Opium. Opium had long been employed for the relief of that kind of irritation which some of the symptoms ;.,/ of Lues Venerea are apt to excite, but it was not till within these fourteen years that it was supposed to possess any power of destroying the venereal virus, or of curing this disease. It was first employed with tliis view in the British hospitals in America ; and Doctor Michaelis, physician to the Hessian troops was, I believe, the first who put it to the test of ex- periment. Since that period it has been used as an antisyphilitic medicine by various practitioners in almost every part of Europe; and it has had the fate of almost "every new remedy, or of every remedy employed with new- motives. Some have spoken of it in the highest terms of panegyric, while others do not admit that it is ca- pable of removing even the mildest symptom of the disease. In matters of doubt all that, authors ought to attempt is to state clearly what they know to be matter of fact, as it is from tlie result of repeated tri- als properly authenticated that an adequate judgment on all such points is alone to be formed. As it ap- n peared to be a matter of the fir^t importance to have a * new remedy for the cure of Lues Venerea, and which was reported to act with much more ease and certainty than mercury, I was one among many who gave it a very full trial. It was used in a variety of cases and indifferent stages of the disease; but in no instance did it accomplish a cure where there was cause to sup- pose that the virus was not previously destroyed by | mercury. Sores originally produced by this virus, and kept up, as is sometimes the case, by irritation alone, and long after the venereal taint is destroyed vol. rr. 26 202 OF THE HEMEDIES USED Cll. l\ , are more effectually cured by opium than any other remedy. Sores which from this cause have remained obstinate for a great length of time, are, by the use of opium, often brought to a healing state ; and when the constitution is not otherwise diseased, they are, for the most part, soon cicatrised. It is proper, however, to distinguish between these sores and such as are vene- real. Sores in this state are not to be considered as venereal. The venereal virus, it is true, has acted as the exciting cause, but this being destroyed by mer- cury, they no longer depend upon this, and in such circumstances are to be treated in the same manner with sores of a similar nature proceeding from any other cause. In whatever way sores Ynay have taken place, if much irritation prevails, opium is perhaps the best remedy we can employ, but I have not found that it proves more effectual in sores that are the con- sequences of Lues Venerea than in such as are produ- ced by any other cause, provided the degree of pain and irritation with which they are accompanied be the same. I suspect much, therefore, that this distinction has not met with sufficient attention by many who consider opium as a remedy in the cure of syphilis. By acting as a very effectual remedy in the cure of many sores in which mercury had failed, they have been induced to attribute powers to opium, w hich I have much reason to think it does not possess, for I have never known it prove effectual where mercury had not previously been given. Antisyphilitic powers being once attributed to opi- um it was readily imagined that in proportion to the quantity exhibited it would prove more or less effectu- al. It was accordingly given in large doses, and these were more fiequently repeated than had been usual in former practice. Few, I believe, made more com- . plete trials of it, or have pushed it farther than I have in various instances done : Beginning with two grains ' bed-time, one in the morning, and another at mid- y, and adding a grain to each dose every third or urtli day, patients in this manner I have found could \ ^| Sec. IV. IN LUES VENEREA. 203 bear very considerable quantities in the course of a short time. One of my patients who could not at first bear more than a grain at once, in the course of five- weeks took three doses of fifteen grains each, daily. I did not bud, however, that any advantage v\ as deriv- ed from giving it so largely, while it frequently did much harm. It was apt to excite sickness, head-ach, and giddiness, a total loss of appetite, in some an ob- stinate costiveness, and what was more surprising, it- acted with many as a smart purgative. I never observ- ed this effect, however, till the dose came to the ex- tent of ten or twelve grains; but when this symptom did take place from it, no astringent medicine seemed to have any effect in removing it, and it was only re- lieved by emetics and purgatives. I must indeed admit that opium was taken by many, even in large doses, witiiout any inconvenience or dis- tress ; but being soon sensible that it had no effect in destroying the venereal virus; that it proved in no other way useful than by lessening or removing irrita- tion ; and that this resulted with equal certainty from moderate doses, 1 have of late desisted from giving it in larger quantities than two or three grains in the course of a day. Opium conjoined with an emetic has long been known as a very useful remedy in rheumatism^ and I have founl it prove particularly useful in those pains resembling rheumatism which occur in the venereal disease. But the relief which it procures is only tem- porary if mercury be not employed along vvith it. For this purpose laudanum may be given along with tincture of antimony, or opium may be given with ipecacuan, in the form of Dover's powder.* In some cases opium proves useful as an external application, whether employed as a wash for painful phagedaenic ulcers, or in a solid form as an ointment; butlt does not appear, even in this manner, to act in any other way than as an anodyne. ' Vid'.' Appendix, No 2t 204 OE THE REMEDIES USED Gh. IV. Opium was first employed as a specific in the Military Hospitals in the City of New-York, about the year 1779. In the opinion given by our author on its anti-syphilitic virtues, he is seconded by the unanimous voice of the profession. The utility of opium is confined to its preventing that irritable state of the bowels, or sys- tem, which mercury sometimes induces, and thus enabling the prac- titioner to administer the latter in sufficient quantity. Besides the articles enumerated in the preceding sections, as re- medies in the cure of Lues Venerea, we shall mention a few addi- tional ones, some indeed of no great reputation, while others are of considerable utility. The Cinchona or Peruvian Bark is considered by Mr. Pearson as a salutary medicine in several of the symptoms of lues venerea— He has observed incipient buboes reduced, although not cured by it; venereal ulcers in the throat become clean and heal, although the disease recurred ; and a gangrenous appearance of chancres, togeth- er with a consequent mortification of the penis, occurring in pecu- liar constitutions,' totally removed by its exhibition. There are ca- ries however he remarks, in which after the slough has separated and the ulcer assumed a clean and favourable aspect, it will become painful and foul and spread with thick and indurated edges. At this crisis, the bark is to be abandoned and mercury is to be exhibited. Mr. Pearson concludes by observing that where the tonic powers of the bark are not indispensably necessary, it ought not to be given, since the power it possesses of diminishing the several secretions may prove detrimental. Several other vegetable remedies have acquired a short lived re- putation. Among these are the Radix China whose consequence originated in the report of its having cured the Emperor Charles V.; the Cicuta, recommended by Dr. Storck, and useful in prevent- ing the spreading of irritable sores, whether connected with the venereal virus, or remaining after a mercurial course ; the Sassa- fras Juniperus, Lobelia syphilitica, Saponaria Dulcamara, Astra- galus Exscapus, and "the green rind of the IValhut, which Mr. Pearson has used for many years with advantage in cases where pains in the limbs and indurations of the membranes have remained after a full mercurial course. The Ammonia preparata, or Volatile Alkali, which was first in- troduced into notice as an Anti-Venereal by M. Peyrilhe, was found beneficial like other diaphoretic medicines in pains of the limbs and in venereal eruptions, and Mr. Pearson has also found the Muriate of Barytes, of which Mr. Bell speaks hereafter, (Chap. IV. Sect. IV. § 2.) useful in painful and ill-conditioned sores derived fror* - venereal cause, audit has proved beneficial by improving the he n in general. This medicine, along with the Muriatic and VitriA - Acids appear from Mr. Pearson's experiments, to have the po of suspending for a limited time, the progress of the disease, a. are useful in phagedenic ulcers of the genitals, of ihe penis, ando." SeC. IV. IN LUES VENEREA. • 205 the throat. The tonic power of the acids will also be found advan- tageous. The remedies however which of late vears have raised the highest expectations among practitioners, and have excited the sanguine hopes, as well as the deliberate examination of many, are the Mtric Acid and the Oxy.muriate of Gold. Valuable as these medicines are in several of the symptoms of Lues Venerea, the re- sult of the investigations concerning them has only added new proof for the opinion that mercury is the only specific. Of the Nitric and JVitrous Acids. The Nitrous Acid was first introduced into notice as' a remedy for the Lue^s Venerea by Mr. Scott, Surgeon at Bombay, in April, 1796. On transmitting an ac- count of his success to England, it was immediately used by a num- ber of practitioners, several of whom have given the result of their experience to the public. Among these may be named Dr. Beddoes, Dr. Rollo, Dr. Ferriar, Mr. Pearson and Mr. Blair. Mr. Scott is said to have caught the idea from Dr.' Girtanner, who suggested that the efficacy of the various preparations of quicksilver might arise from the oxygen which they contained. The success which he appears to have met with, in India, does not correspond with the result of Mr. Pearson's and Mr. Blair's experience in England. The former gentleman found both the nitric and nitrous acid, com- pletely able to remove the primary and secondary symptoms in sev- eral cases, whilst in a vast majority, they were nevertheless, inade- quate. He observes however that where the constitution is so im- paired, as to render the introduction of mercury improper, the ni- trous acid will restrain the progress of the disease, and also im- prove the patient's health. Another advantage which Mr. Pearson has remarked is when given in conjunction with a course of mer- curial unction, it improves the appetite, determines powerfully to the kidnies, and counteracts in a considerable degree the action of mercury on the mouth and fauces. (Pearson, 1st Edit.) Dr. Fer- riar found the nitric acid useful in removing pains in the bones and also in ulcers remaining after a mercurial course, but does not con- sider a less quantity of mercury necessary to remove the disease, even when given in conjunction with it. (Ferriar's Med : Histories and Reflections, 1810. vol. 3rd.) In further experiments on this subject, the nitric acid ought to be used instead of the nitrous. It is given in the following manner. Mix 5' of the nitric acid with a pint of distilled water and sweeten the mixture with simple syrup. This quantity is to- be drank at different times, in the course of twenty-four hours, through a small glass tube, which is used to pre- vent the teeth from being injured. If no inconvenience is felt, the dose may be increased to 5*j or even %iij. It will be found most ad- vantageous in the primary symptoms. The Oxygenated Muriate of Potash, which contains an immense quantity of oxygen, is stated by Mr. Cruikshank, to be more effi- cacious than the nitric acid, in relieving venereal symptoms. Dr. Ferriar observes that he has perceived no remarkable advantage from its use. In an able article in Rees' Cyclopedia on Lues Venerea, it is sta- ted on the authority of Ricnerand, that experiments have been made 206 OF THE REMEDIES USED Ch. IV. at the Ecole de Medicine at Paris, with the oxygenated fat and ni- tric lemonade. The former is probably the Oxygenated Cerate of Mr. Alyon, which Mr. Pearson mentions (a composition of nitrous acid and hog's lard) and which he found useless. Mr. Richerand mentions that a few cures were eftected by the above remedies, that some received temporary relief, whilst others suffered such relap- ses as to render a resort to mercury necessary. $ Gold. In addition to the remedies already noticed in the cure of Lues Venerea, we may notice different preparations of Gold, some of which were at an early period prescribed in its treatment, and as speedily abandoned. Its use has however, of late been revived, both on the continent of Europe, in Great Britain, and subsequently in this country, and has been attended with various success. By some it is considered as a specific, by^olhers as inert, while a third considers it injurious, producing troublesome ef- fects on the stomach and chylopoetic viscera. We confess on the first trials we made with this medicine (the triple muriate of gold and soda) we were incli- ned to regard it not only as a specific, but one which we fondly hoped would supersede, the more trouble- some and painful one then in use; but experience soon taught us that this hope was delusive ; for though chancres and buboes, rapidly healed and disappeared under the use of it, and the disease appeared to be totally eradicated; yet in every case where we trusted to it alone, the patient returned in the course of a few weeks with ulcers in the throat; these how- ever easil}' yielded to a slight alterative course, of mercury. From these cases we were led to the con- clusion, that though no confidence could be placed in it as a specific, it was nevertheless a most important auxiliary in the cure of Lues; and we have used it in all cases of chancre or bubo which have come un- der our care, for upwards of two years, and with the happiest effects. We commence wiih the gold and continue it till the chancre or bubo disappears ; when we immediately begin with a moderate alterative J5CC. IV. IN TjUES VENEREA. 207 course of mercury, which is continued for five, six or more weeks, unking use at tie same time of the De- coction of the Woods. T-:»is is a much less painful course for lhf> patient, and infinitely less troublesome to the physician, than when mercury alone is given, and has proved equally effectual in every case in which we have given it,—-so perfectly so, that in up- wards of two years we have not seen < r heard of a single case of its failure. In secondary affections, we have not experienced the same good effects from this remedy ; Hough we have tried it in several cases, where the patient could not conveniently bear the ac- tion of mercury. We have given it to the extent of a grain in the twenty-four hours, in the form of Pdls, The following is our ordinary prescription, viz, R. Muriat : Aur : et Sod : Gr. i. Pulv : Glycyrrhiz : Grs. x. Mucilag- : G. Arab :-q. s. M. ft. Mass : et divid : in pill: No. xij. Three of these pills to be taken, three or four times a day, and the chancres to be dressed vvith dry lint. The only sensible effects that we have observed the gold produce, are exerted on the kidneys, the quantity of urine being greatly increased; at least we have known but one exception to it-.indeed so pow- erfully diuretic did it prove, that we were induced to give it a trial in a well marked case of Ascites, in which it was attended with more than the expected success. We have not in a single instance discovered any bad effects of the gold either on the stomach or any oilier organ. For some account of Gold as a remedy in Lues Venerea Vide Medical Repository Vol. XIV. page .97. Eclectic Repertory Vol. III. page 281. 289. New-Lngland Journal, Vol.1, page 171. Vol. II. page 5. 208 OE THE CUKE Ch. IV. SECT. V. Of the Cure of Lues Venerea. $ 1. Of the Cure of Chancres. A DESCRIPTION of chancre is given in Section II. of this chapter, page 12. The first question to he determined in the treatment of chancre is, whether the cure should be trusted entirely to the internal ex- hibition of mercury ; to the use of local applications; or to both of these combined. A considerable time ago I had occasion to mention my opinion on this subject, and hitherto I have seen no good cause for deserting it.* My opinion at that time was, as it still is, that chancres should be healed as speedily as possible, and that this may be done with safety by combining the advantages of local remedies with the internal use of mercury : Many practitioners think that chancres ought not to be healed' but by the internal use of mercury alone, and they give as reasons for this, that when external applications are employed we can never be certain wheiher the constitution is rendered safe or not, while we can scarcely be deceived, they imagine, when chancres heal solely from the use of mercury. To this practice, however, there are different objections. The internal exhibition of mercury alone will not al- ways cure chancres. I have known a person kept un- der the complete effect of mercury for many weeks, and the chancres for which it was prescribed remain nearly in the same state as at first. Nay, in differ- ent instances, where this practice was pursued, and in w hich the cure was trusted to mercury alone, although the remedy was continued in all of them for six or seven weeks, and under the best management, as the chancres did not heal the mercury was laid aside on the supposition of the constitution being rendered * Vide Treatise on theTheorr r,-yi AlnTia^ment of Ulcers.. SeC. V. OF LUES VEKEREA. 209 safe ; but although in all of them the sores were soon cured by the application of caustic, red precipitate, or some other escharotic, in several, symptoms of pox appeared in the course of a few weeks; in some with ulcers in the throat, and in others vvith blotches upon the skin. From which I conclude that we cannot de- pend upon the internal use of mercuy alone for the cure of chancres; nor have I observed that it acts with certainty, unless the sores are kept up by the vi- rus having entered the constitution. But the most important objection to the practice is, that being much more tedious in accomplishing a cure, it creates a greater risk of the virus entering the sys- tem than when the sores are more speedily healed by the use of external applications. The practice of heal- ing chancres by the internal use of mercury only, ori- ginated from an opinion that venereal sores of every description proceeded from the constitution being in- fected, and were this the case, there might be cause to consider it as well founded; but now that we know that chancres at first are always local, and that they are the source of whatever matter enters the system, it is obvious that the more speedily they can with pro- priety be healed, the less will be the risk of the consti- tution being injured. Chancres might frequently be cured by the use of external applications alone, and as we know from ex- perience that the matter is not always absorbed, the cure would in a few instances prove permanent; but as we have no means of distinguishing when this is the case, while there is reason to think that in most instan- ces absorption takes place, we ought in no case to trust to it. In order to avoid the inconveniences of a course of mercury, it has been fashionable of late to trust the cure of recent chancres to local remedies, but I know from various instances in which I have been consulted, that the practice is exceedingly dangerous. The chancres may be easily healed ; but where mercu- ry is not employed the disease in a great proportion of cases soon shews itself in the system. The most certain, as well as the speediest, cure o\ VOL. II. "* 21U OE THE CURE Cll. IV. chancres is to be obtained from a due attention to ex- ternal applications conjoined with a well regulated course of mercury. By the former we are frequently enabled to complete the cure in a few davs, which otherwise would require a great length of time, and by the latter the constitution is rendered perfectly se- cure. Chancres in an incipient state are most effectually cured by the application of caustic or escharotks. If the diseased parts are completely destroyed with caustic they soon become clean, and heal as quickly as sores proceeding from any other cause and of the same magnitude usually do. This practice is now very generally adopted, and the effect of it is so remarka- ble that "it fas never probably been laid aside by any who lave given it a fair trial. None, I imagine, have pursued it more fully than I have done; but I find it necessary to remark, that in the usual way of con- ducting this practice it is liable to one very important objection : the chancres to which it is applied, if they are not of long duration, very commonly heal quick- ly ; but in a great proportion of cases the cure of the sores is succeeded by buboes in the contiguous glands. For a considerable time I was induced to suppose that the swellings of .theglands which thus took place after the cure of chancres were more the effect of accident than of the method of treatment, and that they would have occurred under whatever management the sores might have been. The frequency, however, of their appearance made me at last suspect that I was mista- ken, and farther observation made it obvious that this was the case. As experiment alone could determine the question, I was resolved to employ this test. Of the first twen- ty patients who occurred with incipient chancres, in , ten they were destroyed by an immediate and effectu- al application of lunar caustic, the remedy being em- ployed according to my usual custom at that time, in- stantly on my being called. Of the other ten, five were dressed with blue mercurial ointment, and five with common wax ointment. The sores to which cans- SeC. V. OF LUES VENF.KEA. 21 i tie were applied healed much sooner than the others, and next to these the sores that were dressed with mer- curial ointment. But to ihe ten patients to whom caus- tic was applied no less than eight had buboes, while only one bubo occurred in all the others, and it hap- pens! in one of the patients whose chancres had been dressed with mercury. I thought also that buboes ap- peared to be less frequent from the application of caus- tic where mercury had been previously given. This fell within friy observation from time to time with pa- tient :-i who had taken mercury either of their own ac- cord or bv the advice of others, and appearing to be of importance I svas resolved to bring it likewise to the test of experiment, and the result was as follows : Of forty-eight patients with chancres in an incipient state, and exactly as they occurred in practice, one half was treated in the manner I have mentioned, by destroying the chancres with caustic, immediately on my being desired to see them, while all the others were put under mercury for eight or ten days before the application of caustic. In every other circum- stance the method of treatment was the same. The difference, however, surprised me exceedingly. Of the twenty-four treated with the immediate application of caustic twenty were seized with buboes, while only three buboes occurred in an equal number to whom mercury had been previously administered. These buboes did not indeed all terminate in suppu- ration, nor did many of them arrive at any considera- ble size. Being closely watched, mercury was imme- diately applied for the purpose of discussing them, and for i ;e most part it proved successful; but there was no cause to doubt of their being venereal from their being equally difficult to manage, and from those which ended in suppuration being equally difficult to cure with buboes which occur in the ordinary course of bu- siness. At first I was induced to hope that swellings produced in this manner were not venereal, but mere- ly the effect of irritation excited by the caustic, but it soon became obvious that this was not the case, and that caustic does not destroy the venereal virus so com- 212 OF THE CURE Cll. IV. pletely as is commonly imagined, while, by the irrita- tion which it always in some degree excites, it tends often to produce buboes, which otherwise never would take place. This affords an additional proof to what has already been mentioned of the effect of irritation in exciting the action of the absorbents; and the effect of mercury in this case, by preventing the formation of buboes, tends farther to support the opinion of this medicine acting as an antidote to the syphilitic virus. In most instances buboes produced in this manner begin to form in the course of a day or two after caus- tic has been applied; in some cases even sooner. But I have known them take place where the glands had remained sound for a good many days after the chan- cres were completely cicatrised, and where there was no reason therefore to suspect that any exciting cause of buboes could remain. In these instances I conclude that such a small portion of the virus had been lodged in the lymphatics forming the gland, as required this length of time to excite that degree of irritation that is necessary for the production of bubo. The same effect appears to result from whatever caustic is employed; at least this has been the case with such trials as I have made with lunar caustic, red precipitate, blue vitriol, and corrosive sublimate ; and as the caustic is more easily applied, while it common- ly acts with more certainty, and perhaps with less pain than any of the others, I commonly give it the preference. Where caustic is to be employed, my practice now is to put my patient previously under ii.-rcury for the space of six, eight, or ten days, till there., "i ill evidence of the medicine having entered the system. Ai mis time caustic is applied over the whole surface of the chancre, however extensive it may be, in such a manner as to destroy all the diseas- ed parts, and the application is renewed as often as the sores become foul or sloughy. In some it is not ne- pessary to use it above once or twice, while in others it must be repeated in every second or third day, dur- ing a great part of the cure. Even where the sores Jnve become clean, caustic often proves useful, par- SeC. V. OI LUES VENEREA. 213 ticularly when they are stationary, and make no pro- gress towards a cure; in which case we may common- ly make them cicatrise more speedily by the reiterated application of caustic than by any other remedy. When chancres are brought "into a clean healing state a cure will for the most part be obtained by con- tinuing the use of mercury for a sufficient length of time, and by dressing with dry lint, or any simple ointment; but that fixed or stationary state "to which I allude, and in which they often remain where caus- tic is not frequently applied, is very effectually pre- vented by dressing with precipitate or calomel oint- ment; and in some cases I have employed for the same purpose an ointment prepared with verdigris.* In all cases of chancres the parts ought to be kept particularly clean, and the best ordinary wash for this purpose is a weak solution of corrosive sublimate, in the proportion of one grain to seven or eight ounces of water. Where the sores remain foul notwithstand- ing the application of caustic, but which does not of- ten happen where a sufficient quantity of mercury is given along with it, it becomes necessary to employ a* solution with a greater proportion of sublimate. In this case one, or even two grains, may be added to an ounce of water; but this being too strong for applying to the contiguous parts, care must betaken to confine it as much as possible to those that are diseased. In this foul or sloughy state of chancres, among the vari- ety of dressings which we are occasionally obliged to employ, the blue .ointment prepared vvith equal parts of mercury and hogs-lard sometimes answers well, as it does indeed in almost every state of chancre in which it is proper that mercury should be used. For the purpose too of removing this foul appearance which chancres are very apt to assume, and under which they never heal, red precipitate finely levigated is of- ten employed in powder, and frequently vvith advan- tage. Calomel applied in this manner also proves use- ful ; and it is chiefly in this state of chancres that I ' Formal?: of these ointments are given in the Appendix, Nos. 26, 27, and 28. 214 OP THE CURE Ch. IV. have perceived most advantage to be derived from mercurial fumigations. In all slight cases of chancres a free application of caustic very commonly proves successful; but where the sores are deep, extensive, and very sloughy, together with the use of caustic we are obliged to employ one or other of the articles which I have mentioned ; and when precipitate, cal- omel, and even verdigris have failed, I have in various instances found that the parts have been rendered clean, and brought into a healing state, by fumigating once or twice with cinnabar. There are two states, however, of chancre which do not admit, of this mode of treatment, viz. where the parts affected are either much inflamed, or show some tendency to mortification. In all other situations, whether the sores be upon the glans, prepuce, or fra> num, or even within the mouth of the urethra, caus- tic may be applied with freedom. It may be proper here to remark, that when a chancre is seated upon the frsenum, or beneath it, if it is not altogether su- perficial, the frsenum itself should be cut across. It is easily done, no inconvenience is experienced from it, and it tends always to forward the cure. When the parts upon which chancres are seated be- come much inflamed, such remedies should be em- ployed as prove most effectual in removing inflamma- tion. When the patient is plethoric, blood-letting in some instances is necessary, together with cooling laxa- tives, and a low diet. The parts should be dressed with any simple oint- ment, such as the common saturnine ointment and wax liniment mentioned in the Appendix.* In such cir- cumstances too, saturnine poultices prove sometimes useful; but nothing ever gives more relief than the internal use of opiates. By allaying irritation they frequently tend more effectually than any other reme- dy to lessen or remove the inflammation. In some cases, however, notwithstanding all our at- tention, this inflammatory state of chancres terminates J Vide Nos. 29, and 30. Sec. v. OF LUES VENEREA. 215 in gangrene, while in others gangrene takes place where no great degree of inflammation had been pre- viously observed. In these opposite circumstances the remedies to be employed ought evidently to be dif- ferent. Where much inflammation still prevails, blood- letting with other parts of an anti-phlogistic course ought to be pushed as far as the strength and age of the patient can vvith safety admit, while a plentiful use of bark is perhaps the best remedy where little or no in- flammation occurs. For th e removal of inflammation, besides general blood-letting, I have occasionally ventured upon the application of leeches to the diseased parts, and com- monly with much advantage. The bites of leeches may in some instances give rise to venereal ulcers, which otherwise would not have taken place, but little or no disadvantage ensues from this, as they heal by the use of the mercury that we must necessarily em- ploy for the cure of the disease, while nothing proves so effectual as local blood-letting, for carrying offthat great degree of inflammatory tension which in cases of this description we sometimes meet vvith. Whether inflammation takes place or not, gangrene, when it arises from chancres, proceeds with more rapidity than it usually does from any other cause. I have known a considerable part of the glans destroy- ed by it in the course of a day. For the most part, if not immediately checked, either by general or local blood-letting, or by a liberal use of bark, according to the nature of the case, it proceeds without our being able to put a stop to it till it comes to the urethra. In different instances I have known the urethra laid en- tirely bare for a considerable length on the mortified parts being removed ; and where it begins upon the preputium, it proceeds in some cases not only through the loose skin and cellular substance of the penis, but even into the corpora cavernosa. The most distressful symptom which takes place from the mortification of these parts is the vent which it sometimes gives to the urine by penetrating the sub- stance of the urethra. In some instances one opening 216 OF THE CURE Cll. IV is formed ; in others we meet with two, three, or more. Besides the inconvenience and distress which this al- ways occasions it adds considerably to the hazard of the patient, for the urine in this manner finds access to the surrounding cellular substance, where it not only gives much additional pain, but the irritation which it excites seems to be of a nature particularly apt to cre- ate a disposition to gangrene, so that whenever it takes place the mortification extends more rapidly than it did before, nor has bark and the other remedies usually given much influence in putting a stop to it. We derive most advantage from opium. vYhelher opium acts here as an antiseptic may be difficult to as- certain : I rather suppose that it proves chiefly useful by lessening or removing the irritation produced by the urine, for I have not perceived that its beneficial ef- fects are in proportion to the quantity that is given. Small doses, when they procure ease, seem to prove equally useful with the largest, which they would not probably do if they acted in any other manner. While by means of opiates we endeavour to lessen the pain, much care should be taken to prevent the urine from finding access to the contiguous parts. Wrhere it hap- pens to lodge, the sac which receives it should be laid freely open, and the parts bathed with a decoction of bark, an infusion of rose leaves, or some other an- tiseptic after every time the patient voids urine. I have taken the more particular notice of this ef- fect of urine upon parts in this situation as I do not find that it has been mentioned by others, and as vari- ous Cases have fallen under my care in which the most distressful consequences ensued from it. * Chancres are particularly apt to become gangrenous when combined vvith paraphymosis, but they do so oc- casionally where no degree of this symptom has ever occurred. The most alarming symptom of this state of chancre is the haemorrhagy which occurs when the mortification reaches the large arteries of the penis. No advantage is derived from tying these arteries with ligatures till the gangrene is rompletely stopped ; so that in thic S'ec. v. OF LUfeS VExVEREA. 217 situation we are obliged to trust to the uncertain ef- fects of astringent applications conjoined with mode- rate pressure. Piessure in this case is most effectual- ly applied by means of a fillet of linen or cotton, passed round the penis, after a leaden or silver tube has been inserted into the urethra. The point of most importance in this state of the disorder is to determine the propriety of giving mer- cury, or delaying the use of it till the mortification is over. It is the common practice to continue the mer- cury that had previously been given for the chancres, and many even judge it necessary to give it in greater quantities. In every instance, however, where I have known this done, it has evidently proved hurtful; and having found from various trials'that the mercury may with safety be laid aside during the progress of the mortification, I now never employ it till all the morti- fied parts are removed. The fear of the disease gain- ing ground from this, and an opinion of the mortifica- tion being of a venereal nature, and that mercury is therefore necessary to stop it, is the cause of its being in general persisted in; but the progress of mortified tion is so rapid, when compared with the usual symp- toms of syphilis, and it is in every circumstance so different in appearance from these, that I do not con- ceive it to be venereal. It is indeed evidentiv induced by this disease ; but in this respect the syphilitic virus seems to act in no other manner than as the occasional cause; and chancres being at first always local, I be- lieve, that in most instances the sore which remains af- ter the mortification is gone is not venereal, and that it would heal whether mercurv should be given or not, in the same manner as would happen with a great pro- portion of chancres where caustic has been freely ap- plied on their first appearance. But as we cannot in either case know with certainty whether the virus has entered the system or not, the safety of our patient requires in both instances that mercurv should be giv- en in such quantities as may be necessary to effect thfa purpose. While mortification continues to advance, it should be treated in the same manner with gangrene vol. n. 28 218 OF IKE CURL Cll. TV. from any other cause, and without eaiy regard to the venereal disease: but as soon as the mortified parts- are removed, the case should be considered as entirely venereal; a course of mercury should be advised and continued from a fortnight to three weeks or a month, according to the virulence and obstinacy of the symp- toms after the sores are cicatrised. I have seldom, however, found it necessary to dis- continue mercurv during the inflammatory state of chancres. Even where inflammation runs high, mercu- ry may be safely given. Bv lessening the venereal irritation, it tends for the most part to abate, and even to remove the inflammation, so that I commonly pre- scribe it immediately, and persist in the moderate use of it during the whole continuance of this symptom. After the inflammation produced by chancres is gone thev fall to be treated in the same manner as if this symptom had not taken place. W hen they are clean, and with a surface disposed to granulate and heal, any common ointment will answer for dressing them, but when foul or sloughy the application of caustic, calomel, precipitate, and verdigris are equally proper as if the inflammation had not happened. Ver- digris may not only be applied to chancres in powder, and in the form of an ointment, but in solution; and it equally tends to remove that sloughy foulness to which I allude, and disposes the sores to heal when they become stationary. It may be used in various proportions, from two grains to a scruple in the ounce of water. In this clean state of chancres, when the cure does- not advance, the application of spirit of lavender, ar- dent spirits, or even of alcohol, proves sometimes useful; and in some cases we derive advantage from bathing the parts vvith lime water, a solution of blue vitriol, traumatic balsam, or tincture of myrrh. One of the greatest impediments to the cure of chancres is their taking place whether on the inside of the prepuce or upon the glans along with phymosis; for when they cannot be kept clean and dressings prop- erly applied, the cure proves always both tedious an':! 3eC. V. OF LUES VENEREA. 219 uncertain. In all slight cases of chancre in (hi.-; situa- tion we endeavour to cure them, by injecting from time to time, between the prepuce and glands, one or other of the articles 1 have just mentioned sufficiently di- luted ; but when the sores are either deep or extensive the operation for the phymosis should always be advi- sed as the first part of the cure.* This being a meas- ure to which a patient does not readilv assent it is commonly postponed, by which a great deal of time is lost, and chancres often allowed to proceed" deep into the substance of the penis, which might easily have been healed without the hazard of this being in- cured. When an operation for this purpose becomes neces- sary the prepuce should be divided through its whole length. We are. commonly desired to carry the incis- ion only the length of the chancres, but in different instances I have perceived bad consequences ensue from this. The undivided skin is apt to inflame and become tight, and the pain from the operation being nearly the same, the other as being more effectual and not productive of these inconveniences, should be preferred. When the cure, however, is conducted without the prepuce being laid open, besides a very regular at- tention to cleanliness care should be takt n to prevent adhesions-between the preputium and glans; a cir- cumstance particularly apt to happen when much in- flammation takes place, and from which a good deal of inconvenience is afterwards experienced. This is most effectually prevented by making s«ch liquids as are injected pass freely round the whole substance of the glans, and inserting pledgits vvith proper dressings, and^placine them between the prepuce and those parts of the ghms that are affected. Chancres in the parts of generation of women re- quire the same method of treatment as in men. The parts do not appear to be so irritable, so that they more readily admit of the escharotic applications * Vide Chapter III- S ction XII. 220 OF THE CURE Cll. IV which I have mentioned. In both sexes the cure is much promoted by confinement while nothing tends more to retard it than the fretting of the parts by mo- tion in walking or riding on horseback. Where, venereal sores form upon the mons veneris and external parts of the labia pudendi, or when chan- cres spread to these parts, as they sometimes do from the nympha3 clitoris, where they often begin, they are commonly more foul and sloughy than venereal sores in any other situation: Neither are they so readily cleaned by the usual dressings. Besides a more fre- quent application of lunar caustic they require any escharotics that we employ to be used in powder in- stead of being mixed with ointments. They even ad- mit of being covered from time to time with leviga- ted verdigris; nor have the milder articles of this class, such as calomel and red precipitate, the same influence in keeping them clean that we find them to have in venereal sores in almost every other part. It is proper, therefore, in the treatment of sores upon these parts^ that this circumstance be kept in view. Lunar caustic is the best application for chancres upon the lips. In this situation ointments cannot be conveniently employed, we therefore trust almost en- tirely to the repeated application of caustic ; but in chancres upon the nipples the application of caustic creates so much pain that it ought never to be advis- ed. We are therefore in these parts obliged to em- ploy the milder dressings, and nothing answers better than the common saturnine ointment, or wax oint- ment, with a fourth part of calomel. Some advan- tage is also derived from bathing the parts affected with a strong solution of opium in water. It lessens irritability, by which the sores are more readily dis- posed to heal. Our treatment of chancre has been already detailed at some length in th^ note on " the duration of a mercurial course, &c." page 159, extracted from Dr. Francis' paper on that subject, and the section on " Gold," as a remedy in lues venerea, page 206. Notwithstanding the reasons adduced for this practice and the I !3eC. V. OF LUES VlJiEREA. 22! success with which, (so far as our experience goes) it has been attended, there are some practitioners of great authority who ad- vocate strenuously the plan of cure « under confinement," or as it may be more emphatically called the «cure by salivation." For this mode ol treatment Mr. Howard and Dr. Adams are the two most illustrious champions, and as they have offered some very spe- cious reasons for their practice, we shall endeavour to give a short abstract of it for those who may not have been favoured with a pe- rusal of the original works. Mr. Howard in what he terms the early or aphthous chancre, ad- vises confinement, frictions, till there be fcetor of the breath, slight affection of the mouth, with or without mercurial griping, or much increase of the salivary secretion towards the close of the course, principally by the latter doses of the medicine. Every friction, from the beginning to the end of the course, must be fairly perform- ed, for the space of half an hour, by the patient himself, with his naked hands. The dose originally begun with may after a little time, be doubled, trebled, or quadrupled, as circumstances di- rect. The effects of this course, is frequently obvious in eight or ten days and often before the mouth is affected, which is known by the base and callous edges of the chancre beccming soft and clean. The medicine should be continued not only till the chancre be healed, but till it be perfectly cicatrised, without the smallest degree of hardness remaining, and for a few days after. In this species of chancre, he advises no topical applications, but water and dry lint. As to the quantity of mercury necessary for a com- plete cure, he thinks one half of what would be required for a chancre of an old date, or a secondary affection, will be sufficient, provided the general effects be fair and unequivocal. Care should be taken that the connection between the several doses be preserved entire, without the interruption of a single day till there be a con- siderable accumulation-. In the use of the remedy we are invariably to go from a small to a large dose, for if this order be inverted the course is checked, and the effects expected from it greatly weakened. The external marks of the decisive internal change are tenderness of the gums, fcetor of the breath, increased secretion of saliva, languor, pros- tration of strength, sudden emaciation ; sometimes with, some- times without a dysenteric affection of the bowels arising after a preceding costiveness. " In some cases the sore immediately heals upon the coming on of these symptoms ; when I say im- mediately, I mean in the short period of a night's time ; but in oth- ers it may be three, four or more days." When a dysenteric affection of the bowels occurs in consequence of mercury it should never be treated with any kind of purgative not even the most gentle, but the local irritation should be quieted by a warm opiate, such as the i opiate confection. This course under confinement generally takes from fourteen to twenty-one or more days. In the next species of chancre, which is the same as the forego- ing except being of an older date, the same rules are to be observ- ed- double the Quantity of the remedy employed, and for a m^h 222 OF THE CUKE . Ol. IV. longer period, at all events till all the decisive effects of the remedy are visible. In what is termed irritable chancre, the same mode of treatment is applicable. If topics can be avoided, so much the bet- ter ; if the irritation be great, evacuations, cleanliness, opium, and rest, will generally give relief. Where phymosis takes place, rest is essentially necessary, and local treatment, as lotio ex calomel, et aq: rosar. employed. This lotion should be injected between the glans and prepuce, while the specific is introduced in full doses. Opium is very useful in this stage. The last kind of chancre noti- ced by Mr. Howard is " the irritable, livid, spreading, moist kind of chancre." In this species he considers the use of topics indis. pensable, from the great irritability and uncommon acrimony of the discharge. In this case he makes use of the lotio ex calomel, and pushes the specific to the fullest extent, in order to prevent phy- mosis, and mortification of the glans and prepuce. The most pro- per time in every mercurial course for the application of a pow- erful topic to chancre seems to be only during the three or four days at the close of the course, when the medicine is quickly producing its anti-venereal effects. In this case sedatives are useful. Doctor Adams prefers the method of cure by inunction, and if the patient will not submit to that, the crude mineral reduced by tritura- tion with some iconserve, but objects strongly to all the mercurial salts. Should it affect the bowels, small doses of opium must be combined with it, and the pills taken shortly after a meal, avoiding every thing soar: The dose to be gradually increased, till the de- cisive effects are produced. This is known by the yielding of the callous edge and base of the chancre. As Dr. A. adopts the theory of Mr. Huntei, (counter irritation) he advises the excitement of the mercurial irritation, as expeditiously as the constitution of the patient will admit, for this purpose he directs the rubbing in of the ointment twice a day and tne wearing of drawers, not wiping the ointment off in order that the absorption of it may continue. Sali- vation is the usual, but not a certain proof of mercurial irritation; the first symptom of mercurial action is known by the starting of the gums before the angles of the teeth. In those constitutions, where the specific doe's not affect the mouth, the cure goes on nev- ertheless with the same regularity, as under tlie severest salivation. He thinks the chancre heals more readily by applying dry calomel to it during the frictions. When the frsenum has been the seat of chancre the patient should be careful not to indulge in venereal commerce for sometime alter recovery, as the general consequence is a rupture of the part. But the best way is to divide Are w'role fraenum at once. In phymosis, the penis should be kept in a perpendicular posture, parallel to the pubes, to prevent as much as possible the extravasa- ted lymph from subsiding and increasing the intumescence. In the mean time the gians should be frequently waslied, by means of a syringe, with a solution of oxymuriate of mercury in lime water, till the absorption of the extravasated juices, permits the denuda- tion of the glans and the treatment of the ulcers in the common way, Vide Howard on the Venereal, vol. 2, page 1.30. Adams on Poisons, quarto, page 116, VJ.6. Ed! hec. v. OF LUES VENEREA. 223 § 2. Of the Cure of Buboes. A history of the rise and progress of bubo has al ready been given in sect. II. of this chapter, p. 20. Our treatment of bubo has varied and been improv- ed by the more perfect knowledge which of late years has been obtained in the anatomy of the lymphatic system. Till this was acquired buboes were consider- ed as an effort of the system to throw off the morbific matter of the disease, so that in every instance to pro- mote their suppuration was thought to be necessarv; but now that it is known that they are not produced by any disease of the constitution; that they originate from a stoppage of the syphijitic virus in its progress to the common course of the circulation; that by bringing mercury into contact with the vnus while in this situation we can render it totally inert; and that sores the consequence of the suppuration of buboes are difficult of cure, we do not hesitate to say that it is the best practice to prevent the formation of matter, and by a proper application of mercury, combined with other means, to procure a discussion of every tumour of this kind. But although the advantages of this practice are ob- vious to all who have given it a proper trial, stil-1 there are many who have not adopted it, as thinking that they lessen the hazard of the patient by inducing sup- puration in the substance of the gland, and afterwards discharging the matter, the consequence of the inflam- mation induced by the obstruction. We must indeed acknowledge that this reasoning would .have every appearance of being well founded, and that the practice of curing buboes by discussion ouo-ht certainly to be exploded, was it to be accom- plished by forcing the matter of infection into the sys- tem, but as we have it in our power by a proper use of mercury entirely to destroy the nature of the mat- ter lodged in the obstructed gland, and as we know from daily observation, that when accomplished in this manner the discussion of buboes can never be pro- ductive of danger, it ought in all cases to be fid- vised. 224 OF THE CL'KE Ch. iv. The discussion of these tumours might often be in our power by other means than the direct application of mercury to the matter of infection; but we act with more certainty of doing no harm to the consti- tution by first destroying the active property of the matter in the obstructed gland, and trusting after- wards to a proper course of mercury for obviating the effects of any part of tlie virus that may have passed into the system. On the first appearance of a bubo mercury should therefore be applied so as that it may with most cer- tainty pass into the obstructed gland. Hence it should be chiefly applied to those parts lying between the bu- bo and the spot at whie^i the matter of infection was absorbed ; but in the ordinary seat of buboes the space lying between these points is not sufficient for the quantity of mercurial ointment that must be employ- ed. Where buboes form in the arm pit, or in the fore part of the thigh from venereal sores in the hand or feet, this may at all times be done ; but when seated in the groin, besides rubbing the ointment on the parts lying between the chancres and the swellings, we also apply it along the inside of the thigh and leg. When the practice of discussing buboes with mercury was first introduced the ointment was chiefly rubbed upon the tumour, and in many instances a mercurial plaster was kept constantly applied to it; we find, however, that the mercury passes with much more cer- tainty into the gland by applying it to those parts from whence the lymphatic vessels forming the gland take Iheir origin. But although a mercurial plaster applied upon the gland seems to do harm, by the heat and irritation which it excites, I am of opinion that a small portion of the ointment which we employ should be rub- bed upon it. Although none of it should by this route pass directly into the substance of the gland, still it will go into the system, and the discussion of the tu- mour is in many instances evidentiv promoted bv gentle friction applied to it. In our application of mercury for the purpoco oi Sec. V. OF LUES VENEREA. 225 making it pass through a particular gland it is evident that a knowledge of the course of the lymphatic ves- sels is a matter of importance; but we cannot alwavs apply it, as we have already observed, to those parts from which the greatest number of lymphatics of the contiguous glands originate. Thus in women, where thebubo is sometimes seated within an inch or so of the Beat of infection, which is the case where the glands upon the round ligaments become obstructed, as the lymphatics forming these glands arise perhaps chiefly from the tender skin of the labia pupendi, we cannot with propriety apply.the ointment to these parts ; nor can we in most instances in the treatment of buboes in men take the advantages of those lymphatics which originate in the glans penis in the internal surface of the prepuce or scrotum : at least wherever 1 have at- tempted to do so, however gently the friction was ap- plied, so much irritation was induced by it that there was an evident necessity for desisting. In the scrotum it is very apt to excite a fretful itchy eruption, and a considerable degree of uneasiness. In all these situa- tions, therefore, we must apply the ointment to the more firm skin of the contiguous parts. When the full quantity of mercury to be employed can be rubbed upon the leg and thigh of that side in which a bubo is seated, it ought certainly to be done, but the cure of the disease often requires a greater quantity of the ointment than can be used in this manner. In such cases we commonly apply it to the other thigh, but it may with equal safety and advan- tage be rubbed upon the arms or any part of the body. From what has been said, it will appear that we de- pend chiefly upon a proper applicatioii of mercury for the discussion of buboes; but we ought by no means to trust entirely to this. When the patient is plethoric he should immediately lose blood, in quanti- ty proportioned to his strength, and his bowels should be opened by a brisk purgative. It proves sometimes serviceable to repeat the purgative' once and again : Cold saturnine poultices should be applied to the tu- mour : The patient should be kept at perfect rest: His vol. ir. 29 22b OE THE CLUE Ch. rv. diet should be moderate; and where much irritation prevails opiates should be given in such doses as arc sufficient for removing it. I think it right indeed to observe, that in the treatment of buboes much advan- tage may be derived from the use of opiates, and that mercury will often fail if we do not at the same time lessen or remove the irritation and pain, for which no- thing answers with such certainty as the internal use of opiates combined with a frequent renewal of cold sat- urnine applications. In some instances I have made trial of local blood-letting by means of leeches for the discussion of venereal buboes, and in some cases vvith advantage. In others, however, it has not proved so serviceable as this remedy commonly does in swelling? of these parts that proceed entirely from inflammation. On the contrary, the irritation excited by the bites of these animals has in some appeared to do harm. By a proper application of the remedies that have been enumerated we endeavour to carry off any in- flammation that may have taken place in the tumour, while by a due continuation of mercury we secure the safety of the constitution. The length of time to which a course of mercury should extend for this purpose can only be ascertained by the effects which result from it. It ought always, however, to be continued till the swelled gland is nearly reduced to its natural size; and Avhen chancres take place along with it, the mercury cannot with safety be laid aside till the sores have been cicatrised for two or three weeks. But in atten- ding to the discussion of the tumour we have no rea- son in any case to expect that it will be reduced alto gether to its usual size; for lymphatic glands when swel- led from this cause commonly remain for a great length of time, and in some instances during the life of the patient, somewhat more full and prominent than they were before. All we have to expect there- fore is, that they should fall nearly to their natural size, and be entirely free of pain. This being accom- plished, if no chancres or other symptoms of the dis- ease exist, and if the full effect of the mercury has Sec- v- OP LUES VENEREA. 227 been kept up, it may with safety be left off at the end of a fortnight. In buboes altogether venereal we commonly suc- ceed in removing them by discussion, where the pa- tient applies in due time and gives that attention which he ought to do to the application of the remedies ; bwt in various instances we fail, and notwithstanding all our endeavours, the tumour proceeds to suppuration. This may take place from various causes, but it hap- pens chiefly from patients delaying too long to ask for assistance ; from their improper manner of living, and being allowed to walk about when they ought to be confined ; from their not applying the mercury with that care and attention which it requires; and in many instances from the patient being of a scrophulous con- stitution; by which although the syphilitic virus may be removed or destroyed by the mercury, still it is not sufficient for. the purpose of carrying off that tenden- cy to the formation of matter in the gland which the virus has produced. As soon as a bubo shews any tendency to suppurate, it is the practice with many to endeavour to promote the formation of matter as speedily as possible ; but I have not found that there is any good reason for this. By still proceeding with an attentive application of mercury, and with the use of cold applications, we frequently succeed in the discussions of these tumours after the}' have arrived at a considerable bulk, and in some instances even after some partial suppuration has taken place. Neither does any harm occur from the practice when it does not succeed ; for although complete suppuration should afterwards take place, we do not perceive that the process is retarded by the mercury having been continued, while the sores which ensue heal more kindly than they usually do where the mercury has been previously laid aside. By some we are told, that the use of mercury, during the for- mation of buboes, ought never to be advised; but al- though I have paid much attention to the subject 1 have&never perceived that in any instance it has done harm while, beside* other advantages it save<= a good 228 OF THE CURE Ch. IV. deal of time which otherwise would be lost. Even where the formation of matter has taken place to a considerable extent, and, where it is therefore proper to promote the complete suppuration of the tumour by the frequent renewal of warm emollient poultices and fomentations, still there is no necessity for desisting from-the use of mercury, which ought to be continu- ed without interruption till a sufficient quantity is em- ployed for the safety of the constitution. It does not prevent the suppuration from going forward; and the sores which ensue from the discharge of the matter heal more readily, as we have already observed, when no interruption has been given to the exhibition of mercury. When buboes have come to a stale of suppuration it is a question with some whether they should be opened or not, for many have observed that they fre- quently heal easily when they are allowed to burst, by which the pain and terror of the operation is avoid- ed. The result of my observation has been, that when buboes do not arrive at any great size we should proceed vvith the use of mercury till they burst of themselves, unless where the teguments are unusually thick; but when the substance of the gland is entirely suppurated, as the matter, if thickly covered, would be a long while in getting out, and as it might in the mean time insinuate among the surrounding parts, in order to prevent the inconveniencies which this would induce, we ought certainly to make an opening into it; and in all cases of large buboes we should not he- sitate in advising them to be opened. Our object in opening buboes should be nearly the same as in other purulent collections. Such an open- ing should be made as will afford a free vent to the mat- ter, but there is no necessity for making it larger. In very large buboes, indeed, the teguments are apt to be so loose and flabby, and the texture of the skin so much destroyed, that the cure would be rendered tedious was the skin allowed to remain. In such cases I some- times discharge the matter with caustic, applied in such a manner as to destroy any part of the teguments $eC- V' £>F LUES VENEREA. 229 that appear to be superabundant. This, however, is not often necessary; and for the most part I have found that an opening made from the centre of the tu- mour, where the matter commonly points down to the most depending part of it, is perfectly sufficient. Even a smaller opening than this would often answer; but it is belter to make it of a sufficient size at once than to be obliged to repeat a very painful operation perhaps once and again, as is often necessary where buboes of a large size are opened with small incisions. I need scarcely observe that the opening should in every in- stance be continued down to the most depending point of the collection. From want of sufficient attention to this we meet with daily instances of the matter be- ing allowed to collect, and in this manner to find ac- cess to the contiguous parts, by which a great deal of distress is induced, which, with due care at first, might easily have been prevented. This I may observe is a point of the first importance in the treatment of buboes, but it does not often meet with that attention which it merits. Patients under mercury being for the most part highly irritable, they seldom submit easily to have buboes properly opened ; so that although the lancet may be entered at the most prominent part of the tumour, which it ought always to be, the practitioner, if not firm and resolute, is of- ten prevented from carrying it to the most depending part of it, by which some space is left for the lodge- ment of matter; and however small this at first may he, it seldom fails of becoming more extensive. This again gives rise to a great extent of ulcer, or to the formation of sinuses, which very constantly prove the source of much pain to the patient, and of distress and embarrassment to the surgeon. When sinuses in this situation are superficial, and run little deeper than the skin, they are easily managed. JNo risk is incurred in laying them open, by which, if the constitution is healthy, a cure will be obtained on a sufficient quantity of mercury being given; but they sometimes run deep, and pass so near to the large blood-vessels of these parts, that no attempt of thin 230 OF T5IE CURE Cll. IV. kind can with safety be made. In such circumstances all that art can in general do is to preserve the exter- nal opening of. the sinuses sufficiently large, and by regular and equal pressure at the different dressings, to prevent as much as possible the matter from lodging. In some instances I have derived advantage from in- serting, from time to time, a piece of caustic to the bottom of a deep sinus, and applying it gently over the whole internal surface of the sore. In others, the insertion of a small portion of ointment impregnated with red precipitate has proved useful. By removing the sloughs with which the surface of these sinuses are commonly covered, they thus excite a disposition over the whole to granulate and unite. When buboes come forward to full maturation with- out much injury being done to the skin, I have in dif- ferent instances, discharged the matter by the intro- duction of a small cord or seton^ and the practice has succeeded. This requires, however, the teguments to be firmer than they commonly are when a bubo is ready to be opened. It is universally admitted that it is of much import- ance to prevent the air from finding access to sores; and as we sometimes observe buboes ooze out the mat- ter which the)7 contain by a number of small openings, and as these openings commonly heal easily, I con- clude that they do so from their being so small as to exclude Ihe air entirely. In different instances I have attempted to imitate nature, by making a number of small punctures vvith the point of a lancet over the whole extent of the bubo, and for the most part with success. The matter in this manner comes slowly off; the sides of the abscess contract gradually ; and when completely emptied, we find the whole parts that have been affected sufficiently firm without any sores or si- nuses remaining. When the patient has taken a sufficient quantity of mercury, if the constitution in other respects is sound, the sore in most instances heals easily, merely by dres- sing with common cerate, and by that attention to cleanliness which in the treatment of sores of every SeC. V. OF LUES VEXEKEA. 232 description is necessary. It often happens however that the cure of these sores proves tedious, notwith- standing all the attention that we can give to them. Their edges become hard, Hvid, and often retorted; the matter thin, sharp, and foetid; and instead of heal- ing, the ulceration gradually extends, or, if it heals in some parts it breaks out in others, giving a honey-comb appearance to all the contiguous parts. In some in- stances the tendency to this depascent kind of sore is so great that it soon spreads over all the under part of the abdomen, and upper parts of the thigh; in some cases by the matter being so acrid as to corrode and destroy all the contiguous parts vvith which it comes in contact, and in others by spreading beneath the skin, and bursting out from time to time in a variety of small ulcers. The situation of patients with sores of this descrip- tion is often very deplorable. The pain vvith which they are attended is commonly severe ; the acrid mat- ter which they afford being absorbed, hectic fever is thereby induced; the patient becomes hot and restless through the night; and almost a total want of appe- tite renders them soon much emaciated. In such circumstances cicuta has sometimes proved useful; and in different instances the sores have been healed by it when no advantage was derived from a- ny kind of ointment. In these cases it was applied in the form of poultices, commonly by mixing the juice of the fresh herb vvith emollient cataplasms. I have also observed that the recent expressed juice has, for internal use, proved more effectual than any other form of it. I have employed hyoscyamus and bella- dona fully, but [seldom with any material advantage. Neither have I in these cases observed any obvious be- nefit from sarsaparilja; but in different instances me- zereon, guiacum, and sarsaparilla combined have pro- ved useful, when exhibited in the manner I have al- ready mentioned. The most effectual course, however, which I have employed, is the application of caustic round all the edircs and hardened parts of the sores, conjoined with ^62 OF THE CURE Ch. IV. the internal use of opium. For a considerable time I trusted entirely to dressings of the emollient kind, be- ino- afraid of irritating parts already highly sensible* In some cases a saturnine ointment has proved success- ful, and in others the common calamine cerate has an- swered ; but in most instances, on those days in which caustic is not applied I have found more advantage from dressing with ointments prepared with a consid- erable proportion of calomel, red precipitate, or ver- digris.* In some cases it is necessary to sprinkle these articles over the sores in the form of powder, but for the most part they are sufficiently powerful when mixed w7ith ointments. Instead of exciting pain, as those not accustomed to use them are apt to suspect, they commonly remove it; and they seldom fail to al- ter the discharge from a thin acrid sanies, to a well digested pus. The application of lunar caustic indeed always ex- cites pain at first, but this soon subsides, especially when the internal exhibition of opium is advised a- long with it. Indeed opium of itself proves often use- ful in sores of this description, not by acting, as some have imagined, as an antisyphilitic remedy but by re-< moving, as I have already had occasion to observe, that pain and irritation with which sores discharging acrid matter are usually accompanied. By removing this state of irritability it destroys the disposition in the vessels of the sore to form that kind of matter, which, by its own acrimony, serves to perpetuate the ulcera- tion ; and this being accomplished, when no other in- terruption takes place, nature alone seldom fails to complete the cure. In some instances I have known sores in this situa- tion which resisted every other remedy soon healed by being fumigated from time to time vvith cinnabar: In others warm salt-water bathing, and afterward the or- dinary form of sea-bathing has proved useful; while in some a'cure has not been obtained but with an en' Vide Appendix, N9S, 26, 27, 28. Sec. v. OF LUES VENEREA. 233 tire change of regimen. Where the patient has pre- viously lived upon milk and vegetables a moderate al- lowance of wine and animal food has proved service- able, while those who have previously been accustom- ed to full living have derived much advantage from a diet consisting altogether of vegetables and milk. In all such cases country air proves particularly useful. Where mercurial fumigations are employed for the cure of these sores they should be conveyed to the parts affected by metallic tubes, and kept applied to them for the space of twenty-five minutes or half an hour at once, and this should be repeated every second or third day, for six or eight times. For some time past I have been making trial of the muriated barytes, a remedy lately brought into notice by the ingenious Dr. Crawford of London.* These trials have been chiefly confined to sores and tumours produced by scrophula, but I have also made use of it in some of those spreading ulcers which we are now considering, after there was no cause to doubt of the syphilitic virus being eradicated, and in some instances 1 think with advantage. I have not as yet, however, given it in a sufficient number of cases to be able to speak of it with precision. Besides this state of bubo there is another which in some instances proves very distressful, in which the tu- mour, after arriving at a considerable bulk, remains nearly stationary, and shews no tendency either to sup- purate or dissolve, notwithstanding of all the remedies we may employ. For the most* part this indolent state of bubo depends upon the patient being of a scrophulous constitution ; but whatever may be the cause, our first object should be to employ that quantity of mercury which may ap- pear to be necessary for rendering the system safe. Unction affords here likewise the best form of using mercurv ; bv making it pass through the diseased parts discussion of the tumour is more readily accomplished * Vide Appendix, No 3° 234 OF THE CUKE CIl. IV. than when the medicine is given by the mouth. Even this, however, will in some instances be continued without any advantage for a great length of time. In such circumstances I have in various cases advised blis- ters to be repeatedly applied over the tumours. They never do harm, and in some cases they have proved evidently useful. In others electricity has proved ser- viceable, but it is necessary to continue it for several weeks in order to judge of its influence ; and it ought to be continued longer at each time of applying it than is usually done. In four cases of indolent tumours Where electricity proved successful, and two of these were of the kind we are now considering, no advantage was derived from the common way of using it. In all of these it was applied for the space of half an hour at once; this was repeated three times a-day, and at each application sparks were not only taken from the surface of the tumours, but gentle shocks were passed through them. For the first two or three weeks scarce- ly any alteration was perceived in any of them, but they all decreased suddenly at last. One of them of considerable size, which had been of eight months du- ration, and in some parts of which matter seemed to have formed, was reduced to the fourth part of its bulk in the course of a few days from the period at which it began to diminish. In this state of these tumours a long continued use of cicuta proves sometimes service- able ; and I have seen evident advantages from sea- bathing, and from drinking as much salt water daily as the patient can bear without being much purged. Before entering upon the use of cold bathing I have in some cases advised warm salt water to be poured upon the swelling morning and evening, for the space of two or three weeks, and for the most part it has ap- peared to prove useful. In the course of time buboes in this state sometimes become soft, and shew a tendency to suppurate, al- though they may not have done so before. It is here that I have observed the warm gum plasters prove most. useful. By stimulating the vessels of the diseased BeC. V. OF LUES VENEREA. 25-1 parts they seem to excite that kind of effusion which. readily proceeds to a state of purulency. But the most alarming circumstance to patients vvith tumours in this indolent state, is, a suspicion which they are apt to entertain that they may some time or other end in cancer. This is, however, so rare an oc- currence, that it should scarcely give any cau^e of a- larm. The phagedenic sores which occasionally suc- ceed to. buboes, and of which we have already taken notice, sometimes put an a cancerous appearance, but the real schirrhus which terminates in cancer is rarely if ever the consequence of a venereal bubo. In dif- ferent instances I have been consulted for indolent tu- mours in these parts on suspicion of their being can- cerous, but I conclude that they are seldom or never of this nature, from all of them having done well where the patients have been persuaded not to meddle vvith them. They often indeed remain considerably en- larged for a great length of time; but when they do not ulcerate no danger is to. be dreaded. Wherever parts in this situation, however, become cancerous, they ought to be extirpated while they remain in a moveable state. With regard to the cure of this troublesome symptom of Lues, we have little to add to the observations of our author. We have frequently experienced the good effects of Epispastics, in the early sta^e of bubo, and feel confident that a judicious application of them w>lt often prevent suppurations-Should suppuration, however, take place, as it frequently will in spile of every means to prevent it, fie tumour ought to be suffered to break of itself, and that termi- nation promoted^ emollient cataplasms. If the method of cure by confinement be realty adviseable in any case, it is during the inflam- matory sta*re of bubo, when the irritability is great, and liable to be increased by the slightest degree of exercise. For further information on the treatment of buboes, we refer to Howard, Vol. II. page 3Q.~To the Dissertation of Dr. Francis, vide note page 164, and to Doctor Adams on Poisons, quarto, page Ed. i:>9. 236 OP THE CURE Ch. iv. $ 3. Of the Cure of Venereal Ulcers. In the two preceding sections we have treated of the cure of chancres, and of those ulcers which succeed to buboes, both of which, but particularly the first, may be considered as primary symptoms of the disease, as they may take place without the system being in any degree injured. At present we have to consider the treatment of those ulcers which originate from the sy- philitic virus having entered the constitution, and of which a description has been given in the second sec- tion of this chapter, page 42. In the management of these ulcers our chief depend' ence is upon a well-regulated course of mercury; and I believe, that in general it is the best practice to trust in the first instance to mercury alone, and not to has- ten the healing of the sores by any other means than the application of mild dressings and due attention to cleanliness. Under this .treatment we rest assured that the cure is altogether accomplished by the destruction of the virus, which must always be a more doubtful question where caustic remedies have been employed. There are some exceptions, however, to this, and I consider it as of much importance in practice that they be kept in view. Venereal sores may be so situated, and in such a state that their farther progress mav be attended with the loss of parts materially necessary for life, or for the future comfort of the patient, as is the case with ulcers that have already penetrated deep in the throat, mouth, nose, lips or face. In all these situations, particularly in the throat, nose, and lips, they usually proceed with more rapidity than in other parts of the body, so that by trusting to the internal use of mercury alone such a destruction of parts often takes place as proves afterwards highly distressful. On this account the eure ought to be hastened as much as possible by the use of such dressings as we find from ex- perience prove most effectual; and no harm can ensue from this being conjoined with whatever quantity of mercury may be required. Sec. v. OP LUES VENEREA. 237 In all sores truly venereal, wherever they may b situated, the parts are most speedily.brought to a heal- ing condition by a free application of caustic, but the practice has seldom, I believe, been considered as ap- plicable to ulcers in the mouth, throat, or internal parts of the nose. For many years past, however, I have been in the practice of'using caustic as well as other escharolics in the cure of these ulcers with the greatest freedom. No danger has ever ensued from it; and in various instances it has contributed to save the uvula and other parts of the throat, which other- wise were in great danger of being destroyed. Caus- tic fixed in a tube six or seven inches in length may be easily conveyed to any part of the mouth or throat, and the tube answers the purpose whether it be curved or straight. Caustic excites less pain in tliese parts than it usually does in other parts of the body, and it seldom fails to remove the irritation which accompa- nies these ulcers, and in this manner to dispose them to heal. One application seldom proves sufficient. Till the mercury has completely entered the system, it requires to be repeated once and again, perhaps every second or third day, and in the intermediate days I cause the parts to be touched occasionally either with a weak solution of corrosive sublimate or with a strong impregnation of honey with mercury, which in all sores of this description is a very useful application.* In (he description which I have given of the vene- real sore throat, page 37 of this volume, I have en- deavoured to point out marks of distinction between it and affections of the throat, the consequences of other causes, and particularly those by which it may be distinguished from ulcerations of the mouth and throat which mercury is apt to induce. Among other means of distinction may be mentioned the different effects produced upon them by caustic. In the true venereal ulcer, after the first irritation which it excites is over, a good deal of relief is obtained from it, and the parts soon assume a clean healing appearance; * Vide Appendix, No. 5. 23tt W THE CUKE Ch. IV. whereas, in sores induced by mercury the application of caustic not only gives very intense pain at first, but this is apt to continue for a considerable time, while the sores retain nearly the same appearances, however frequently the remedy may be repeated. In the nose and outer parts of the lips, these ulcers besides being touched vvith caustic, may be dressed with ointments impregnated vvith calomel, red precip- itate, and even with verdigris; but these remedies are inadmissible to the throat and inside of the mouth from the danger that would ensue from their passing into the stomach. Even in venereal ulcers of other parts of the body we are often obliged at last to employ remedies of this class. For the most part they become clean soon after mercury is taken in sufficient quantity for rendering the mouth sore, and they frequently heal, merely by continuing the course of mercury for a sufficient length of time. But this does not always happen; for al- though the sores may become clean, and even con- tract, they are very apt to become stationary at last; and do not show any disposition to heal, however long the mercury may be continued. When we perceive this to be the case, the mild dressings which we em- ployed Bt first should be laid aside. The parts should be completely touched with lunar caustic every second or third day, and at other times dressed with calomel, or red precipitate ointment. In some cases we suc- ceed by bathing with a weak solution of corrosive sur> limate, or verdigris; but the ointments for the most part prove more effectual. By thus connecting a regular attention to the exter- nal management of the sores, with a due perseverance ii» the use of mercury, we very commonly prove suc- cessful at last; but even this does not always answer. In some instances, the ulcers instead of becoming clean and putting on a healing appearance, remain foul and equally extensive as at first. In such circumstances we sometimes succeed by changing the preparation of mercury, and in others by ' making some variety in the dressings applied to the ^C. V. OP LUES VENEREA. 239 sores. We should not, therefore, rest satisfied vvith one mode of treatment, but where no advantage is ob^ tained from the second or third variation of the reme- dies, particularly if the caustic has been sufficiently powerful, and the mouth kept for a due length of time completely sore with the mercury, we may in that case be assured either that some other disease prevails in the system or that the sores are rendered obstinate by an affection of the contiguous parts. Scrophula and scurvy are the diseases of the consti- tution by which the cure of these sores i3 most apt to he obstructed. Venereal ulcers will no doubt heal in scrophulous constitutions. Of this we have daily in- stances; but it is equally certain that the contrary of- ten happens, and with such certainty does scurvy ob- struct the operation of mercury that a cure can scarce- ly be obtained as we have already observed, of any of the more inveterate symptoms of syphilis while the scorbutic diathesis exists in any considerable degree. Where either of these diseases is therefore found to be the cause of our failure, those remedies must be employed which prove most successful in removing them, but having already in different parts of this work had occasion to speak particularly upon this sub- ject, it will not here be necessary to consider it farther. The local affection which occurs as the most frequent impediment to tlie cure of these sores, is a diseased state of the bones above which they are seated, or of the membranes covering these bones. In either of these cases, although the virus of the disease may be eradicated by a course of mercury, still the sores will continue foul, nor will they show any tendency to Ileal, however long the mercury may be continued. Ulcers of this description being frequently connected with this diseased state of the parts beneath are often the cause of more mercury being employed than would otherwise be judged necessary, for wc are too apt to suppose that all such sores as were at first produced h\ Lues Venerea are to be cured by mercury alone; an | error that has been the cause of much merciuy bein:; very unnecessarily given. 240 OF THE CURE Ctl. IV. Whether the bone, or only the periosteum be at first affected, our practice muit be nearly the same; for in such circumstances, where the periosteum is so much diseased as to resist the effects of a full course of mer- cury, there must ultimately be a partial exfoliation of the bone beneath, before a permanent cure will take place. The soft unhealthy granulations with which sores in this state are apt to be covered must be de- stroyed with proper escharotics, and the exfoliation of the bone must be promoted by all such means as usu- ally prove most effectual for that purpose, and foi which books on surgery may be consulted. I may here shortly observe, that the best escharotic I have employed for the destruction of these fungous excres- cences which sprout upon the surface of the diseased bones is a combination of red precipitate and calcined alum, which proves much more powerful than either of these articles when used separately, and more ef- fectual even than caustic in the usual way of apply- ing it.* On the diseased parts of the bone being removed a cure will soon take place if a sufficient quantity of mercury has been given; otherwise the sore will as- sume the usual appearances of a venereal ulcer, and will not heal till another course of mercury is advised. With respect to the quantity of mercury to be giv- en for the cure of venereal ulcers, this must at all times be regulated by the effects which result from it, and these again will in a great measure depend upon the duration of the disease. When the disease has been of short continuance, and the sores heal easily with- out the assistance of external applications, the mercu- ry, if given in full quantity, need never be continued above three weeks after they are cicatrised; but we should proceed with it for the space of a month where the system has either been long infected, or where we have judged it necessary to heal the sores quickly by the application of caustic or escharotics. Thus, in an ulcer in the throat, which we might suppose would 5 A pre^rin+'on is jrivfn for this 3rt:rl*> "No ii. ^twWW ln Vol I. BeC. V. OF LEES VENEREA. 241 require the patient to be under mercury for the space of a fortnight, merely in order to cicatrise it, and for another fortnight, Ural is, for the space of a month in all, in order to render his constitution safe, if by the application of caustic the ulcer shall be cicatrised in a week, the mercury should be persisted in for a month thereafter, or for five weeks in all. By some it has been doubted whether it is necessary to persevere in Ihe use of mercury after the symptoms for which it is given are removed; but these doubts have only been suggested by those, who, from want of sufficient experience are not capable of judging, or by otheis who in the support of a theory which they have adopted, allow their judgments to be so far per- verted that they lose sight of every fact and argument that militates against it. Theic is nothing more cer- tain than that venereal ulcers, as well as every other svmptom of the disease, may be completely removed by mercury, and yet that the disease will return in the same or some other form, if we do not persist, in the use of .mercury for some time thereafter ; that is, the disease itself may be cured while the disposition re- mains. All the symptoms may be carried off entire- ly, and yet the virus subsist in such force that they will at some future period break out again^ The length of lime to which the use of mercury should be protracted for removing this disposition it is not al- ways easy to ascertain. In this and some of the pre- ceding sections I have mentioned the result of my own experience upon this point, but this can only be done in general terms, and the quantity of mercury to be given in any particular case must in a great measure be regulated by the judgment of the practitioner in attendance. Towards the close of a mercurial course employed for the cure of venereal ulcers of long duration, de- coctions ol sarsaparilla, mezereon, and guiacum are. sometimes given with advantage. The latter I have already mentioned as the most effectual of these, but in some instances a combination of the whole has ap- peared to prove more powerful than any one of them 212 OE THE CURL Cll. IV. used separately. Many alledge that no advantage is derived from any of these; but although I was once of this opinion lam now perfectly convinced that ul- cers of this description frequently heal more easily when a mercurial course is conjoined vvith a decoction such as I have mentioned, than when the mercury is given entirely by itself. In these ulcers, when much irritation prevails, opi- um proves particularly useful. I have in various in- stances, indeed, found that all other remedies are of no avail till this irritability of the parts is removed. In some cases this may be done with hyoscyamus. Three or four grains of the extract given at bed time very commonly acts us an anodyne, and I conclude that cicuta, when it proves useful here, acts also in this manner; but when the irritation is considerable opium is the only remedy upon which we can depend. It ought therefore in all cases to be given where the sores do not soon become perfectly easy on the mer- cury taking full effect, and which they commonly do when they are altogether venereal. When the ulceration of the throat is considered venereal by the practitioner, the relief administered should be speedy, as the ulcer spreads rapidly to the uvula, and if that pat t be destroyed, an in- curable defect in the voice will remain ever after. To accelerate the action of the general remedy, fumigation with cinnabar has been advised by some writers. This, however, is not to be used in those patients whose lungs are irritable or who have a tendency to hectic. In this case, a mild mercurial in the form of a gargle may be pre- scribed and we have found particular benefit from a solution of the corrosive sublimate in water. Should the ulceration be rapid in its progress, large doses of mercury ought to be given, in order to in- duce a rapid salivation. Venereal sores of the skin, ulceration of the posterior part of the oesophagus, of the tongue or cheeks are curable by the same gene- ral means as before, and to these symptoms mercurial topics are sometimes though rarely necessary. Mr. Howard observes that he has seen a venereal sore of the skin so highly irritable, that the patient felt excruciating pain during the dressing, until the system and mouth became affected vvith mercury, when it completely sub- sided. A similar treatment is adviseable in cases of Venereal Ozae oec« T- OE LUES VENEREA. 245 4 4. O/ /Ae Cure of Venereal Blotches. A description of this symptom is given in Section II. of this Chapter, p. 50. Almost the only remedy employed for the cure of Venereal blotches is mercury, and when the course is well conducted it seldom foils. We never find it ne* cessary to have recourse to external applications unless the eruptions become hot and uneasy, in which case relief is sometimes obtained from dusting the parts withflour or starch powder, as is done in cases of ery- sipelas. Where the usual method of exhibiting mercurv has failed in the cure of these eruptions, corrosive subli- mate has appeared to prove useful; but as the medi- cine in this form cannot be given in large quantities, it requires to be continued for a great length of time. It should be regularly given for at least sis weeks af- ter the blotches have disappeared; and it seems to op- erate with most certainty when conjoined vvith the de- coction which I have just had occasion to mention. The Lisbon diet-drink is said to have proved particu- larly useful in the cure of this symptom.* Antimoni- als, from their well known property of exciting a de- termination to the skin, are frequently combined with mercury in the cure of venereal blotches. Upon this principle I conceive to be formed many of the quack remedies generally employed in cutaneous affections; and it is for tlie cure of this symptom of syphilis that Plummer's pill has been most frequently used.f Crude antimony is, in cases of this kind a favourite medicine vvith some practitioners, and when conjoined with mercurv I think I have observed it prove useful. It-mav be given either in powder or pills, to the ex- tent of fifteen or twenty grains three times a-day; and besides being given along with the mercury, it may be continued with advantage for two or three weeks after the mercurial course is over. * Vide Appendix, Vol. I No, 4 i vlde Vo1 ri No - 244 OE THE CURE Ch. IV. « 5. Of the Cure of Nodes, Swellings of the Perioste- um, £>r. A description of these swellings has already been given in Section II. page 62 : and it is of importance in the method of cure to distinguish them accurately. In all the affections to which the periosteum and bones are liable from the syphilitic virus, mercury ought to be given immediately, for it is upon this rem- edy that we chiefly depend. Where the bones are much swelled, that is, where tumours truly osseous have arrived at any great bulk, mercury alone will not prove sufficient; for although it may destroy the con- stitutional infection, these tumours will remain, but when given immediately upon their first appearance, it will prevent their farther increase ; and as they are always small at first, although they may never disap- pear entirely, no inconvenience will be experienced from their remaining in this state, even during the life of the patient. The method of throwing mercury into the system by unction is the best adapted for this symptom, as it is perhaps vvith a very few exceptions for the cure of every symptom of the disease ; but it does not appear that any advantage is derived from rubbing the oint- ment upon the tumours. On the contrary, by tending to irritate and fret the skin, it renders them more pain- ful, so that it answers better to apply it to other parts. As tlie bones seldom become affected till the disease has been of long duration, it is perhaps for this reason that more mercury is in general required for the cure of this symptom than for any other syphilitic affection. I believe, however, that we are often deceived in this, and continue to give mercury for the cure of the local affection long alter the virus by which it was produc- ed is eradicated, and for which purpose alone it was prescribed. INext to the state of the system, which we render safe by a due continuation of the mercurial course, the pain excited by the tumour is the symp- tom which chiefly requires attention. When the mer- cury is employed immediately upon the swelling tak- Bee. v. OF I.TJES VENEREA. 245 ing place the pain commonly subsides soon ; but if the tumour has previously arrived at any considerable hulk, the pain which it excites is apt to be severe, while it is not allayed or even lessened by all the mer- cury we can employ. Where the skin has become in- flamed and painful, some relief will be obtained from saturnine applications; but as the pain depends chiefly on the stretching of the periosteum by the tumour of the bone, whenever it becomes severe nothing will prove effectual but the division of this membrane. No practitioner would lay a bone bare for a moderate degree of pain, whatever the cause of it might be ; but whenever the pain produced by nodes becomes distress-' ful, and is not allayed by a course of mercury, as I know of no other remedy that will give relief, I con- clude that we are fully justified in advising an incision to be made completely through the periosteum, along the whole course of the tumour. Where the bone is not so much increased in bulk, and not otherwise diseased, if a sufficient quantity oi mercury has been given for the destruction of the vi- ms, a cure, may be obtained without any part of it ex foliating. With which view the mildest dressings on- ly should be employed, while the sore is protected as effectually as possible from access to the air. But, when the tumour of the bone is considerable, and par- ticularly when caries has taken place, as it would be vain to expect a cure but with the exfoliation of the diseased parts of the bone, so all such means should lie employed for effecting this as are known to be most powerful. Any of the soft parts covering the diseased part of the bone should be removed with escharotics. Small holes should be drilled through the carious part of the bone, and the sore should be dressed with pre- cipitate or verdigris ointments, of such a strength as to act gently as stimulants upon the contiguous parts, By due perseverance in this mode of treatment, and taking care at the same time to support the strength of the patient with a nourishing diet, the diseased parts of the bone will at last exfoliate, when the healing of 246 OF THE CURE Cb. IV, the sore not being impeded by any other cause, a cure will soon be obtained with common treatment. The next variety of tumour taken notice of in the description which I have given of nodes, proceeds, as we have had occasion to see, from the effusion of a thin fluid between the periosteum and surface of the bone. This also is apt to be accompanied with severe pain ; but as the pain is induced by the distension of the pe- riosteum, in consequence of a fluid being collected be- neath, and as this fluid is frequently absorbed on the mercury taking effect, we seldom find it necessarj- to lay this variety of tumour open. Absorption of the matter is sometimes promoted by the application of a blister to the part, or by rubbing it occasionally with stimulants, such as volatile liniment or.tincture of can- tharides. But when the swelling has been of long du- ration, as the surface of the bone is in this case com- monly injured, as the absorption of the matter does not take place so readily, and as the tumour at the end of the mercurial course is commonly larger than before, an incision the whole length of the tumour should be made through the periosteum, and the wound dressed in the manner just now advised. I think it right, how- ever, to observe, that the opening of these tumours is very seldom necessary ; and that it would in no in- stance perhaps be so if mercury was given in sufficient quantity soon after their formation. Even w here the quantity of effused fluid is considerable, the swelling, for Ihe most part begins to lessen soon after the mercu- ry has fully entered the system ; and if the effect of the medicine is kept up for a sufficient length of time we seldom fail in removing it entirely7. In those diffused swellings upon the bones which I have taken notice of in the description as a symptom of syphilis, and which also have improperly been term- ed nodes, mercury, when properly given, seldom fails to effect a cure ; but it requires to be given in as large quantities as the patient can bear, and to be continued for a considerable time, commonly for nine or ten weeks. The pain indeed soon subsides upon the mer- cury taking full effect y but when the swelling has been Sec. v. OF LUES VENEREA* 24'? of long continuance, as often happens before mercury is given, from the disease being at first apt to be mis- taken for rheumatism, in order to remove it the mercu- ry must be employed for several weeks after the pain has ceased. In the treatment of this symptom blisters prove particularly useful, and thev should be applied along the whole course of the swelling. Where the ligaments, tendons, and fascia? of mus- cles, become swelled, as sometimes happens from the matter of venereal ulcers spreading to those parts from the skin and cellular substance where they originate, we depend entirely upon a course of mercury, with proper attention to the external treatment of the ul- cers in the manner we have already pointed out. } 6. Of the Cure of Venereal Excrescences about the Anus. In section second of this chapter, a very particular description has been given of these excrescences. A full mercurial course is the remedy for these ex- crescences, under which they gradually" lessen, and at S last very commonly disappear altogether; but where we are disappointed in this, we must use the same ap- E plications recommended for the removal of the warty" excrescences which succeed to Gonorrhoea.* The disease being now entirely local, no advantage can accrue from mercury being longer continued, while we seldom fail with a proper application of es charotics. (, Where the surface of these excrescences becomes ulcerated, and yields matter, saturnine lotions and other astringents should be employed to heal them : for as the matter which they afford appears to be ve- nereal, and of which we judge from the real venereal bubo being in women sometimes produced by it, the longer that this secretion is allowed to continue the more of it will pass into the system, and the greater * Vide Chapter in. Section XIII. Vol. I. 248 OF THE CURE I h. IV. the risk will therefore be of some of the glands in its course towards the heart being obstructed. When local applications become necessary to venereal excres- cences, we would recommend the use qf the Tincture of the Oxy- muriate of Iron, as stated in the note to Chap. III. Sect. XIII.— We have found it much preferable to the remedies mentioned by Mr Bell, or Mr. Hunter, or the Pulv : Sabin : so highly spoken of by Mr. Howard. The same remedy will be found useful in warts on the organs of generation. Eel. § 7. Of the Cure qf ihe Venereal Swelled Testicle. For the description of this affection of the testicle, and of the difference between it and other tumours to which the testis is liable, I must refer to section second of this chapter. One important difference between this tumefaction of the testicle and that which proceeds from Gonor- rhoea is, that in the latter mercury very frequently does harm, while in this it is the remedy7 upon which we chiefly place dependence. Unless the swelling has been allowed to advance to a great size, from an opin- ion which some have entertained that it is always of a local nature, and not connected with diseases of the constitution, mercury seldom fails to cure it. Were it not to add considerably to the extent of the present work, this, as well as many other points, of which I have had occasion to take particular notice, might be illustrated and proved by a variety of cases which have fallen under my observation, in which the swelling of the testis to which I allude, produced altogelher by the syphilitic virus in the system, and in many instan- ces where Gonorrhcea never existed, after resisting ev ery other remedy, has at last been completely cured by mercury. Besides other views of no small import- ance in the theory of the disease, which this tends to establish, it may be looked upon as an additional argu- ment for considering the matter of Gonorrhcea and of pox as different. The swelling of the testis which oc- curs in Gonorrhcea yield* entirely to the effect's of ar SCC. V. OF LUES VENEREA. 249 antiphlogistic course and without doing an injury to the constitution, while the other in no instance has been known to do so, and gives way only to that re- medy which we know by experience is alone to be trusted for the cure of every oiher symptom of sy- philis. Mercury even proves effectual in removing those tumours in which matter has formed. I have met vvith several cases in which a partial suppuration had taken place in the body of the testis before mercury was given, and the matter has been absorbed, and the swelling entirely removed soon aftei a sufficient quan- tity of the medicine has been thrown in. In some I have thought that mercury was assisted by a decoction of mezereon being given along with it; but it is for the most part abundantly successful by itself. Where the use of mercury has been too long delay- ed the swelling commonly suppurates, and the sore which ensues from the bursting of the tumour assumes always a very ugly appearance. Even in this situa- tion, however, bur chief advantage is derived from mercury ; nor do we often fail in curing the sore if due attention is given to regular dressings, and pro-' curing a free discharge of the matter. The best dress- ings for this purpose are the saturnine and zinc oint- ments when the parts are clean, and the precipitate or verdigris ointments when they are foul or sloughy. But where matter is observed to lodge in any part of the swelling, nothing can be of advantage but mak- ing a free opening into it. This, however, is not al- ways done so completely as it ought to be. The tes- tes" being organs of much delicacy, we are apt to be afraid of opening any abscesses that may form in them, in consequence of which the matter is apt to find ac- cess into the cellular substance of the scrotum, where it seldom fails to produce very troublesome sinuses. This however, may always be prevented, either by making a free incision into the most depending part of the^abscess, without allowing it to burst, or tak ng care to enlarge the opening if it has previously made way for itself. Nor should we ever l}e afraid of doing vol. n. 32 2jO OE THE CURE Ch. IV. so, for the injury which this may do to the testicle can- not be equal to what it must suffer from matter being allowed to lodge in it. In all such circumstances I never hesitate to lay the testicle freely open, and no inconvenience ever ensues from it. As this affection of the testicle never occurs but in very advanced stages of syphilis, it requires a very con- siderable quantity of mercury to remove it, and at the same time to eradicate the virus from the system by which it has been produced. It ought to be continu- ed from ten to twelve weeks, and in as great quantities as the patient can bear. When the sores which ensue from the bursting or opening of these tumours do not heal after such a quan- tity of mercury is exhibited as we judge to be proper for the safety of the.constitution, some advantages is occasionally derived from a plentiful use of hemlock, and from sea-bathing; but in such circumstances no- thing proves for the most part so useful as dressing the parts in the manner I have mentioned with stimulat- ing ointments, and touching them occasionally with .caustic. This we are also apt to be afraid of from the natural irritability of these parts; but I have not found that there is cause for this. On the contrary, a free application of caustic to the surface of these sores renders them for the most part less painful. Where much irritation however prevails, and is not removed or much lessened by the use of caustic, opi- ates must be given in such quantities as are sufficient to allay it. The general remedy will remove this symptom, and the applica- tion of mercurial ointment to the part ought to be suspended until towards the end of the course, as it may possibly induce a metasta- sis, if applied at an earlier period. Ed- $ 8. Of the Treatment qf Alopecia, Venereal Blindness, and Deafness. A description of these symptoms was given in £ec. Hon II. of this chapter, $ 11. 12. and 13. Sec. v. OF LUES VENEREA. 25 i W hen alopecia, or the falling off of the hair takes place in any considerable degree before mercury is employed, particularly if the patient is advanced in years it never grows again but in verv small quanti- ties ; but during youth, and when mercury is given in tlie commencement of this symptom, we not onlv pre- vent it from advancing farther, but any hair that has been lost will very commonly be renewed. There is scarcely indeed any other remedy upon which we can depend but a full course of mercury; for although many external applications are recommended to re- cover or renew hair lost in this manner, there is no reason to suppose that any advantage is derived from them. Where the falling away of the hair is connected with a scurf over the head, some benefit indeed is obtained from the application of external remedies; by remov- ing the eruption we tend to prevent any farther loss of hair, and the internal use of mercury alone is not. alto- gether sufficient for this. The most effectual applica- tions for tlie removal of this are the unguentum citri- num,* and a weak solution of corrosive sublimate in water. When the.former is used the parts should be rubbed with it once a-day. The latter may be applied three or four times daily, in the proportion of half a grain of the mercury to an ounce of water ; and for the more effectual application of ihese remedies, the head should be shaved, and the hair not allowed to grow till the eruption or scurf is entirely removed. in the treatment of blindness as a symptom of Lues Venerea, we have scarcely any variety of practice. Mercury is perhaps the only remedy from which any advantage is to be expected ; nor does it prove of any avail if it be not given immediately, and in as great quantities as the patient can bear. Whether the eye is therefore affected with gutta serena, cataract, or effu- sions upon the cornea, where there is the least reason to suppose that the affection proceeds from Lues Ve- nerea, the patient should be immediately put under a * Vide iVRrcndix, Vo 14 252 ov THE -CURE Ch. IV. complete course of mercury, and his mouth kept fully affected for the space of ten, eleven, or twelve weeks, according to the effects which may arise from it. In gutta serena it may be proper before mercury is given to premise a smart purgative or two, and during the course to conjoin the repeated application of blis- ters to the temples and head, with electricity, and err- bines for the purpose of exciting a discharge by the nose, although the effects of these remedies are so un- certain that in every instance our chief dependence must rest upon mercury. Where the blindness is found to proceed from cata- racts, if mercury does not succeed in removing the opacity, our only remedy must be the usual operation of depressing or extracting the chrystallines. This will not always succeed, but where the eye is other- wise sound, and only the local affection of the lens ap- pearing to be the cause of blindness we ought in every instance to advise it. We sometimes find t' at mercury here proves so far useful as to lessen the opacity of the lens in a conside- rable degree, without removing it entirely ; and where this has happened I have found in more instances than one that a cure has been accomplished by electricity. I have nev^r perceived, ho* ever, that electricity has produced any advantage where the opacity was not previously much diminished, and even in this situation it requires to be long continued in order to prove effec- tual. In blindness produced by the humours of the eye becoming confused or turbid, where it is known that this proceeds from the system being affected with sy- philis, the patient ought no doubt to be put under mercury ; but this cause of blindness is of a very hope- less nature, for I have never known an instance of its being removed. JNeither do we prove very successful even with mercury, where vision is affected by the matter of syphilis fixing upon the coats of the eye. We may prevent the disease from advancing much farther, but mercury does not appear to be sufficient , for removing any considerable degree of opacity in the i SeC. V. OF LUES VENEREA. 253 cornea that has already taken place. Nor does this cause of blindness admit of remedy by means of a sur- gical operation ; for it is not upon the surface, but in the very substance of the cornea that it is seated. When abscesses form in the coats of the eye, we have it in our power by discharging the matter which they contain to remove in some degree the deformity which they produce, as well as the pain with which they are accompanied; but we are not to look for any farther advantage from this or any other remedy that can be proposed. Of all the symptoms of Lues Venerea, none prove more obstinate, nor are less acted upon by mercury than deafness. A certain degree of deafness, indeed, produced by venereal ulceration or swelling at the opening of the Eustachian tube in the throat is some- times relieved or even removed by a course of mercu- ry ; but no advantage is ever obtained from this or any other remedy where the disease has fixed upon the membrane or bones of the ear. In the description of this symptom, I had occasion to remark, that a tempo- rary deafness is sometimes produced in Lues Venerea by the meatus externus being filled up by a scurfy eruption ; and in some instances, 'by the membrane of the passage becoming thickened and even ulcerated. In this, as in some other symptoms of the disease, we |; depend entirely or the internal use of mercury for : removing the virus from the constitution ; but the local affection'may remain after the system is rendered safe. The best remedy I have employed for this is a cau- tious use of bougies. Care, however, must be taken that they be not pushed so deep into the passage as to ' injure the tympanum ; and they ought to be formed of the mildest materials, as they never fail to do harm when they excite much irritation. In venereal ophthalmia, the first object should be to reduce the in- creased circulation in the vessels of the part, and of the system al- so, if'necessary. Bleeding general or local, blisters and brisk mercurial purgatives ought to be administered The blister should be kept open and the specific daily given with all possible exped;- 254 «>p THE CURE Gh. IV. *ion. The eye ought to be kept from the light until the inflamma- tion is gone, and the safest way will be to confine the patient in a dark room. As a topic, tepid water applied with a sponge, or the Ung^ Hydrarg : may be used.—(Howard.) Ed. j 9. Of the Cure qf some Anomalous Symptoms of Lues Venerea. In section second of this chapter, page 81, sundry anomalous symptoms of syphilis are enumerated which could not with propriety be described in any of the preceding sections. For the cure of these we depend almost entirely upon a full course of mercury. • Scarcely any of them occur but in the later stages of the disease, and they are very apt to recur, if the medicine be not given in as large quantities as the patient can bear, and continued for a considerable time after they have disappeared. Besides this general course of treatment, some of these symptoms require a peculiarity of local manage- ment. The first that I have mentioned are those-chops or clefts in the palms of the hand and soles of the feet to ■which syphilitic patients are sometimes liable. The best dressings that I "have employed for these are the unguentum citrinum,* and unguentum e mercurio'pre- cipit. rubr. f. But while these ointments are per- haps the best that can be applied to the chops them- selves, they are too irritating to admit of being appli- ed to the contiguous parts, which for the most part are red and tender, and which are best defended by the unguentum saturninum.J For the removal of that scurf and gummy matter which occasionally forms and becomes very trouble- some upon the eye-lids of syphilitic patients, I have found nothing answer so well as bathing them from time to time with a weak solution of white vitriol, and applying over the eye-lashes and cartilaginous border 'of the eye-lids a small portion of the calamine lini- ment,? or unguentum citrinum, so much reduced with * Vide Appendix, No. 14. f No. 27. • Vide Appendix, No. 2° § >"o 31. Sec. v. OF LUES VEKEKfcA. 255 axunge as to prevent it from exciting too much irrita- tion. * The. sores which succeed to the swellings described in p. 82, are frequently healed by mercury alone, but in some instances they resist even this and all the | dressings we can employ. Caustic and other escha- [ rotics prove to be the best applications here, as we find them indeed to he in almost every variety of vene- | real ulcer. When they do not succeed, it is for the most part owing to a greater degree of irritation and pain in the sore than is consistent vvith the*process of healing. In this case nothing proves so effectual as sufficient doses of opiates. When the pains mentioned in p. 83 do hot give way to that quantity of mercury which we judge to be sufficient for the safety of the constitution, we some- times find that they may be removed by blisters appli ed directly to the parts affected, and anointing their: with set her, anodyne balsam, or volatile liniment. For the removal of these pains we are often obliged to have recourse to opium. In sufficient doses it sel- dom fails by itself, but it proves more effectual in ev- ery variety of pain when given in the form of Dover's powder. Ten or twelve grains of the powder given at bed-time, and continued for seven or eight nights , successively, very commonly affords effectual relief. The irritability, restlessness, and atrophy to which venereal patients are not unfrequently liable, are often difficult to remove, and sometimes even prove fatal. I have known different instances of these symptoms proving incurable where ulcers and other symptoms of the disease vvith which they were at first connected were easily removed, but where the patient by con slant restlessness and anxiety, having first been deprived of his'appelite, and afterwards of strength, was at last carried off, notwithstanding all the means that could be employed for his safety. I judge that these symptoms are in many instances altogether venereal, from observing them accompany- ing other well-marked symptoms of the disease, and from mercury being the only remedy that has any in- 256 OF THE CURE Gil. IV, fluence in removing them. Even mercury will not al- ways succeed ; but in various instances 1 have known it prove effectual where every other remedy had pre- viously been tried in vain. Peruvian bark, a change of diet, and country air, are commonly prescribed; but we may readily conclude that no material advan- tage can result from them if the mercurial course be not also continued till the virus is eradicated. This restless anxiety to which syphilitic patients are occasionally liable, is in some instances very effect- ually removed by opiates, while in others these reme- dies rather do harm. The only course that I have found to prove useful, is, a light, nourishing diet, a due continuance of mercury, and the patient, during the time of using it, being allowed to go daily abroad in a carriage when the weather is not cold or damp. In the use of mercury for the cure of this symptom the greatest nicety and care are required ; for in the delicacy of constitution which prevails here it con- stantly does harm, if not managed with much atten- tion. It cannot be given in large doses but vvith much risk of doing harm; nor can it be laid altogether aside without the disease gaining ground. If ever an alte- rative course of mercury, as it is termed, is proper for any of the symptoms in the more advanced stages of syphilis,' it is here. By a regular exhibition of small doses of mercui;y the virus may be kept mode- rate till the strength of the system is so far restored by attention to regimen as to admit of larger quantities being given. The most frequent anomalous symptoms in this dis- ease is fever. It is often the effect of some evident symptom, such as bubo, ulcer, or node. In such ca- ses the cause is obvious, and the fever disappears along vvith the symptom by which it was induced: But where a quantity of mercury sufficient for eradicat- ing the disease has not been given, although all the symptoms for which it was employed may be remov- ed, yet ..fever will sometimes take place, and in some instances subsist for a considerable length of time be- fore any external mark of the disease is perceived. Sec. vi. Of LUES VENEREA, &C. 257 IhisI know is doubted, and even denied by many; but I have met with it frequently, and in some instan- 9 ces distinguished in the most obvious manner. In some where from the history of the case the cause was evi- dent, the patient has been cured by an additional course of mercury, while in others, from no cause of suspicion being mentioned, the febrile symptoms re- sisted all the usual remedies, and were not removed at last till the appearance of nodes, ulcers, or some other local symptom has pointed out the necessity of a far- ther prosecution of mercury. The effect of mercury upon this fever is often re- markable. In almost every other situation it is one of the first effects of mercury in «a certain degree to accelerate the circulation of "the blood, while here it not only lessens the quickness of pulse, but abates every other febrile symptom. Even in small quantities mercury proves useful here, as it evidently does in the symptom last mentioned; and as the strength of the patient is commonly much exhausted before this rem- edy is employed it should not at first be given in lar- ger quantities than is merely necessary for mitigating the symptoms. This, however, not being sufficient to render the constitution safe against future returns of the disease, care should be taken that a sufficient quantity of the medicine is exhibited as soon as the patient's strength, restored by a nourishing diet, ena- bles him to bear it. SECT. VI. Of Lues Venerea in Infants. NO period of life is exempted from the ravages of the venereal disease. They are frequently to be der plored even in infancy, and here the same symptoms appear as in a patient of more advanced years; that is, when the virus enters the system in the usuahway from the surface of the body, the symptoms which vol. u- 33 OF 'LUES VENEREA eh. iv. ensue are nearly or entirely the same as in other peri- ods of life : but when the disorder is communicated to the foetus in utero, some variety is observed which de- ^ mand particular notice. We have already indeed had occasion to remark, that it has been doubted whether Lues Venerea can he communicated to the foetus in utero. Nay, of late it has been asserted that it cannot, and that practitioners upon this very important point have hitherto been mis- taken. But this is so contrary to general experience, and to the result of my own observation, that I cannot consider it as an opinion that will ever gain ground where the judgment is not entirely warped. A desire to support a particular theory seems to have laid the foundation of this doctrine ; but the facts which mili- tate against it are too strong and too numerous to ad- mit of being easily set aside.* Those who are of opinion that neither the blood nor any of the secretions of a syphilitic patient can commu- nicate the contagion, a!ledge, that when a child appears to have been infected in .utero, the infection must have been communicated during labour from venereal sores in the genitals of the mother. That this in some instances happens there is no rea- son to doubt. A child passing over, and perhaps rest- ing for a considerable time upon sores of this kind, may readily be infected in this manner, and this may probably be the case in most of those instances where the disease does not appear till two or three weeks af- ter birth. But where a child is instantly upon delivery found to be covered with a venereal eruption, and which I have met with in various instances, the infec- tion must necessarily have been communicated a con- siderable time before birth. It may be asked, however, in what manner eruptions appearing on the birth of a child have been known to be venereal ? In answer I * Even Mr. Hunter has unguardedly fallen into this error ; and as his au- thority would necessarily have influence with those whose opportunities for observation are not so great, I think it right, in a matter of such practical im- portance to endeavour to render the mist;.k<3 obvious : see different p:trts ot Mr, Hunter's Treatise. hec. vi. IN INFANTS. 259 may observe, that it has been ascertained in the most obvious manner, by finding on enquiry that the father had been poxed without taking such a quantity of mercury as was necessary to eradicate tlie virus : by the eruption upon the child being exactly similar to what experience in other instances shews to be venereal; by a child in this situation giving the different symp- toms of Lues Venerea, evidently'and strongly marked, to the nurse by whom it has been suckled ; by the nurse giving the disease in the first place to another child, and afterwards to her husband, and by the dis- ease in all of them being cured by a proper use of mer- cury alone, while no other remedy is of any avail. Every practitioner must have met with instances of this. I have seen many, in some of which no external mark of the disease appeared either in the father or mother, although one or other of them, and in some cases both, must have been infected. I conclude that we have sufficient evidence of this where the same pa- rents produce one, two, or more pocky children, and continue to do so till both pass through a complete course of mercury ; and hence, notwithstanding any theoretical opinion that may be advanced to the con- trary', I have much reason to imagine that the Opinion which I have elsewhere given, that the semen of a dis- eased parent will give a pocky offspring is well found- ed. No person, I believe, will doubt of other diseases being communicated in this manner. We have daily- proofs of it in gout, phthisis, scrophula, and, perhaps, in some others, in which these diseases descend from fathers to their children, while no infection is commu- nicated to the mother ; and I have met vvith very deci- sive evidence of it in Lues Venerea, at least with such as leaves no room with me for doubt. About ten years ago I was desired to visit a child seven or eight days old. It was covered with a rash, which had much the appearance of being venereal ; and finding that the only other child which the parents ever had was born vvith a similar rash, of which it died, I enquired of the father of the child whether there was: any cause to suspect that he wTas infected or not. iTe 260 OF LUES VENEREA Gil. IV. informed me that he had been poxed about six months before his marriage ; that his symptoms were chancres arid a sore throat; but that having taken as much mer- cury as was judged to be sufficient, the symptoms having disappeared while under the course, and none of them having ever occurred again, although he had pow been married nearly three years, he could not possibly believe that the child was infected vvith this disease* particularly as no symptom had appeared upon his wife. I was clearly of opinion, however, that the child was infected ; and I judged it right to say, not only that the child should instantly get mercury, but that he and his wife should also take it, with a view to prevent the same occurrence with any other children tvmch they might have, as well as to render themselves safe. He agreed to this with respect to himself, but on account of the suspicion which it might create, he would by no means consent that it should be given to Iris wife. Imperfect as this measure might be I was obliged to adopt it. Small doses of calomel were given to the child, and the father was kept under a complete course of mercury, with unction and the blue mercu- rial pill, for the space of ten weeks. The child got well ; and although the same parents have had several other children since that period, all of them have been perfectly sound. Some doubt, however; might still fiave remained of the real nature of this rash, but it happened that a very decisive, although unfortunate proof was given of its being venereal. Two nurses were infected by the suckling of this child. The first became so much distressed vvith ulcers upon her nipples, and pains in one of the mammae, that she was obliged to leave the family, and although warned of her situa- tion, and of the necessity of giving no suck to other children till the course of mercury which she was put under was finished, she foolishly took home her own child, which she had previously given out, and in the course of two or three weeks he also was poxed, and being a weakly child, he soon died, although the great- est care was taken of him. The nipples of the other purse ulcerated, and she was soon thereafter seized SeC' ™ ™ INFANTS. -61 with a venereal ulcer in the throat, for which a course of mercury became necessary. Since that period, be- sides some instances in which the disease was given to children, where there was much reason to think that both parents were infected, I have met with two other cases very similar to that which I have mentioned, in which a mercurial course given to the father proved so completely successful that all the children of both fa- milies that have been born since that time have been entirely healthy, although one of them had previously lost two and the other one from their not havino- en- tertained any suspicion of the nature of the disease. These, as well as various other facts which I mio-ht adduce, render it obvious to me that Lues Venerea may be, and frequently is, communicated in the man- ner I have mentioned ; that is, by the infection passing directly from parents to children, and where no marks of disease appear either upon father or mother. Nor would I have judged it necessary to have entered so fully into the subject, as by many the opinion I am endeavouring to establish will be admitted, had it not been vvith a view to put the younger part of the pro- fession upon their guard, till"by experience they are enabled to judge for themselves of the distressful con- sequences that would frequently result from the oppo- site doctrine being admitted. Among other baneful effects of syphilis, perhaps none prove more distressful than the frequent abor- tions which it evidently occasions. A child infected in the uterus will in some instances not come away till the full time ; but in a great proportion of cases abor- tion takes place in the sixth or seventh month, some- times sooner, but most frequently about the middle of the seventh month. Of this I have met with such a number of instances, that I am induced to consider it as one of the most frequent causes of abortion ; but as Ihe child is commonly either born dead, or so weakly that it soon dies, sufficient evidence is not often obtain- ed to lead the attendants to entertain any suspicion. Hence practitioners seldom hear of it unless the disease (las made greater progress than usual. We have it in 260 OF LUES VENEREA Ch. IV. our power, however, when this cause of abortion is discovered, to remove it with much certainty. A. well conducted course of mercury,-, very seldom fails to prove effectual. I have now met with a considerable number of instances where abortion had regularly ta- ken place in the sixth, seventh, or eighth month, and in which, from there being no mark of disease either upon the father or mother, the real cause of it remain- ed concealed ; but which being at last discovered, ei- ther by some of the children being clearly marked with the disease, or from its breaking out in an obviouj form on one or both of the parents, a mercurial course has at last been prescribed, and in no instance has it failed where a sufficient quantity of the medicine has been given. In two instances it did not answer so completely as in the others, but in both there was suf- ficient evidence of too little mercury having been em- ployed ; for the children in both instances were kept till the beginning of the ninth month, which in the one was two months, and in the other six weeks later than had been the case beiore, and both the parents having in each of these instances been made to take mercury again, and in greater quantities than before, no abor- tion has since taken place, and each family has within these few years had several healthy children. At whatever period children with this infection are jborn they are remarkably weak and delicate. The muscles over the whole body are flaccid, and the joints bave not that firmness which they ought to possess. When the disease is discovered immediately upon the birth of the child, it is usually in the form of an ery- sipelatous efflorescence over the whole body. In some instances the cuticle is either altogether or in part de- stroyed, and the skin is tender, and affords a kind of niatter. In others the nails have not formed either on the fingers or toes. Sometimes again no mark of disease will be per- ceived till the tenth, twelfth, or even fourteenth day after delivery; and in such cases the eruption occurs chiefly about the anus, on the nates, and about the pudendum. In these places irregular blotches arise, Sec. vr. iiV infants. 263 of a light strawberry colour, and somewliat elevated above the contiguous surface. Although a thin acrid serum in some instances oozes from them, if not pre- vented by a timeous exhibition of mercury, the dis- ease is apt to spread quickly over the whole body; but excepting in the parts which I have mentioned, it usu- ally appears in the form of a crusty eruption, which in some cases is dry, and falls off in small scales, while in others it is kept together by the exudation of a vis- cid matter, particularly upon the forehead, eye-lids, arms, and breast. I have already had occasion to observe, that in sup- porting a favourite theory some have denied that the foetus in utero ever receives this disease from the par- ents, and assert, that wherever it occurs in new born children they must have received it from the mother in the time of delivery. But while the fallacy of this opinion is rendered obvious, as we have just had occa- sion to observe from the foetus being in many instances perceived directly after birth to be covered vvith a ve- nereal efflorescence, we also find that the syphilitic virus is in this state of a more deleterious nature than it ever appears to be in any other form of the disease. Besides, being more particularly apt to communicate the infection, it proceeds with more rapidity to destroy the constitution, insomuch, that if mercury be not employed immediately on the disease being perceived, it usually makes such quick progress that a fatal termi- nation can scarcely be afterwards prevented. In all such circumstances the child ought to be nurs- ed by the mother; and as mercury is necessary for both, they should both be put immediately under it. As it has been found that a diseased child may be cur ed by sucking the milk of a woman under mercury, some have advised that new-born children should al- ways be treated in this manner. But I can say from experience, that it is not to be trusted. In some in- stances this practice will no doubt succeed. In all it will perhaps accomplish a temporary removal of the symptoms, but for the most part they return again, or Hie disease breaks out in some other form, At the 264 OF LUES VENEREA Cll. IV same time, therefore, that the mother begins to take mercury, it ought to be given to the child, and it may- be done with no inconveniency ; for even at this early- period it excites less distress than it usually does after- wards. The cause of this may be difficult to assign; but I have in various instances found that mercury in early infancy, is not so apt to excite either salivation or violent effects upon the stomach and bowels as it af- terwards does, and that it may be given with safety in sufficient quantities for curing the disease. Calomel is often employed for this purpose. The dose should be the fourth or fifth part of a grain three times a-day, and when rubbed with a small quantity of sugar, the child takes it easily. Mercurius alkalisatus is a preparation that answers particularly well in the dose of half a grain three times a-day; and I sometimes employ the com- mon blue pill prepared with triturated quick-silver. A pill containing a grain of mercury, being rubbed into a powder, and divided into four, one of these is given evening and morning. Any of these being continued for the space of a month, will, in most instances, re- move every appearance of the disease; but a com- plete cure will not be accomplished if the use of the medicine is not persisted in for a considerable time thereafter. When the child is healthy, and not of a delicate form, this should be done with no interrup- tion, otherwise it may be laid aside occasionally for eight or ten days together; but upon the whole, it should be given for the space of fifteen or sixteen weeks, and never discontinued so long at once as to al- low the effects of the mercury upon the system to be entirely gone at any one time. When a child in this situation cannot be suckled by its mother, either from her want of milk or any other cause, what are we to do ? ^Another nurse is common- ly procured ; but this resource ought never to be adopted, for it seldom fails of giving the disease in the most virulent form to whoever is so unfortunate as to be employed for this purpose. All such children ought to be nourished and brought up on spoon meat, nor should the restriction be confined to the first weeks 3eC. VI. IN INFANT-. "2&V of infancy only. No child infected in this manner should be put to the breast of a sound nurse till a couise of mercury has been continued for three months at least after every external mark of the disease is gone. In one instance, where a child in this situation had for seven weeks been nursed by the mother, and where mercury had been regularly continued for the space of three weeks after every external mark of the disease had disappeared two different nurses were in- fected, who were employed to suckle the child during a temporary fever with which the mother was attacked, And in another the disease was given in the same man- ner where the child was three months old, and where every symptom of syphilis had disappeared upwards of eight weeks. Hence I conclude that the greatest attention is required for preventing similar occurren- ces, and that nothing will prove effectual but a regu- lar and long-continued use of mercury. In addition to what I have already said on the sub- ject of syphilis producing abortion, I may observe, that when a woman has suffered one or more abortions, and has reason to think that they proceed from vene- real infection, she, as well as her husband, should immediately be put under mercury. It is a prevailing opinion that mercury is apt to occasion abortion, and it is therefore seldom given during pregnancy. Much experience, however, has convinced me that this opin- ion is not well founded, and, when managed with cau- tion, that it may be given in sufficient quantities at every period of pregnancy, for curing every symptom of syphilis, and without 'doing the least injury either to tlie mother or child. We would not indeed from choice give mercury during pregnancy; but when a woman in this state is evidently poxed, or when there is good reason to think that she is so, I would not hesi- tate to advise a course of mercury. In different in- stances I have done so, and always with much advan- tage. Where obvious symptoms of Lues Venerea break out during pregnancy scarcely any will doubt of the necessity of giving mercury, but «omc explanation voi* it. :'l 266 OF LUES VENEREA Cll. IV. may be required for advising it to be given where there is onlv ground of suspicion. In illustration of the propriety of this, the follow- ing, among several cases, may be recited. Five years ago I visited a lady in the fourth month of pregnancy, on account of a simple fracture of the os humeri. The patient being young and healthy I prognosticated a speedy cure. She had been married four years, and bad suffered two abortions, one in the sixth, the other in the seventh month, and her friends were anx- ious lest this accident should produce the loss of an- other child. This induced me to enquire into the cir- cumstances attending the previous abortions, when I found that both children were born dead, and entirely destitute of nails and cuticle. Wo obvious symptom of syphilis had appeared upon the parents, but the husband had occasionally been attacked with a dry scaly eruption upon the breast and shoulders. I also discovered that he laboured under the venereal disease a few months before marriage; and it did not appear to me that he had taken mercury either with the regu- larity or to the extent necessary for removing the symptoms which took place. This led me at once to say that both he and his wife should immediately un- dergo a complete course of mercury. To this they submitted, and in less than a year from the commence- ment of the course the latter was delivered of a heal- thy child. Nowhere was only ground for suspicion ; but the event gave cause to imagine that if this kind of proof was to be set aside where direct evidence cannot be procured, and which often happens in cases of this kind, many constitution- would be irreparably injur- ed, and many ch.iuien lost which otherwise might be saved. Luring pregnancy mercury ought in every instance to be used in the form of unction, as we thereby vvith most certainty prevent it from acting upon the stom- ach and bowels, and thus avoid the hazard of abortion taking place as the effect of irritation upon these parts. Notiiing indeed more readily excites abortion than purgatives, when severe in their operation upon the / ^ec- Vi. IN INFANTS, 26/ bowels, or when they even only produce any consid] erable degree of tenesmus ; and as the internal exhi- bition of mercury is frequently the cause of this, it can- not but with much hazard begiven in any considera- ble quantity during pregnancy. Among the peculiar opinions entertained by Mr. John Hunted, on the Venereal Disease, those relating to tlie communication of the infection to new-born infants, are not the least singular. He maintained that the child while in the womb cannot be affected with syphilis by either parent, that after birth it cannot be diseased by 3uckingan infected nurse, and also that if it have received the con- tagion in passing through the vagina, it cannot transmit the disease to the nipples of the nurse. Contrary tenets are upheld by our au- thor, and we believe by a large majority of the Medical Profession. The question is however far from being decided, and as Mr. Bell has stated the important arguments in favour ot the idea that the disease may be communicated in utero, we will now add what are advanced against it. It is urged in the first place, that parents de- cidedly infected, often produce children who are born and continue perfectly healthy. This is allowed by the opposite party and par- ticularly by a late writer, (Mahon on the existence, nature and com- munication of venereal infection in pregnant women, new-born in- fants and nurses,) as is also the fact that the symptoms as detailed by Mr. Bell, wili often appear on children soon afterbirth, in whose parents, no symptoms of syphilis have existed for years. To both these, it is however replied, that the venereal poison-may lurk for a length of time in the constitution of the infant or parents, before it discovers itself, an observation of but litde weight, since it is evi- dent that there must be a general contamination of tlie secretions, in order to affect the offspring. The Editors of the London Annual Medical Register remark, that they have seen children born of del- icate an'd sickly mothers, attacked with a disease resembling that described by Mr. Hunter, and they have been much pleased to find it described by Dr. Wiilan under the name of Pemphigus Infantilis. The symptoms, they add, are very similar to those named by Ma- hon as distinctive of lues in new-born infants. An aphthous state of the mouth and fauces, although not named by Willan, is a com- mon attendant, and the aphthous discharge deposited on tlie nipples of the nurse might produce a train of symptoms resembling syphi- lis. Many points in this important subject, require elucidation, and we hope they will claim the attention cf thosi* who have had exten- sile experience in hospital practice. E> 268 OF LUES VENEREA IN Cll. IV, SECT. VII. Of some Peculiarities of Form under which Lues Venerea has appeared in Scotland and Canada. I HAVE already had occasion to remark that this disease has appeared vvith some peculiarities both in Scotland and in Canada. By the accounts received of it from Canada it seems to have appeared in that coun- try in the same manner, and under the same form as it had a considerable time before done in Scotland ; and as few have had more opportunities of seeing it here than I have had, I mean to give a short description of the appearances which it exhibits, and to mention the method of cure which hitherto has been found most ef- fectual. In the Highlands of Scotland this disease is usually termed si wens or sibbens : In Dumfries shire and Gal- loway it is commonly called the yaws, from a reseo> blance which if is supposed to bear to the African and West Indian disease of that name ; but over the whole kingdom it is known to be the venereal disease. That this is so is" certain from those afflicted with it in every district where it has yet appeared having been able to trace it to such an origin as left no room for doubt, as well as from the symptoms which take place in it bear- ing an exact resemblance to those of the later stages of Lues Venerea in the ordinary form of the disease, and from mercury being the only remedy upon which we can place any dependence for a radical cure. It never appears, as I have elsewhere had occasion to observe, in the form of Gonorrhcea, nor seldom at first in any form upon the genitals, owing to the man- ner in which it is most frequently communicated. The infection being for the most part received by eating or drinking out of the same utensils with those labouring under the disease, it often appears at first in the throat or some part of the mouth* In the mouth the sores have the usual appearances of venereal ulcers. This is likewise the case in the throat when the disease Sec. VIL SCOTLAND AND CANADA. 269 has been of some duration; but at first, and often for the space of several weeks, although the patient com- plains of a good deal of uneasiness in swallowing, and of a constant hoarseness, there is nothing perceived upon inspection but a degree of tenderness accompa- nied with an erysipelatous redness of the amygdala?, uvula, and velum pendulum palati. If not prevented, however, by the use of mercury, ulcers at last form ' upon these parts, and commonly spread more quickly than venereal ulcers usually do in other parts of the body ; insomuch that the uvula and amvgdalse will sometimes be entirely destroyed in the course of a few days, and a degree of hoarseness and loss of voice produced, from which the patient never afterwards re- covers. It is particularly apt to affect the internal parts of the nose ; and when the sores penetrate to the ossa spongiosa these soon become carious, and come away in small pieces along with the matter, which is always exceedingly foetid. When not prevented byr mercury the ulcers spread to the hard bones of the nose, and from these to the bones of the cheeks. -In this manner the whole face becomes ulcerated, for when these bones are affected the contiguous soft parts likewise & become soon diseased. It is not uncommon for these ulcers to attack the eye-lids. When the infection is not received by ihe mouth the disease appears in a variety of forms in different parts of the surface of the body. Wrhen the virus has entered the system the parts upon which it first com- monly breaks out are the genitals, the parts contigu- ous to the anus, the anterior parts of the thighs and legs, the under part of the abdomen, the breast, arms, fingers, and toes, and hairy scalp. It does not so readily fix upon the fleshy parts of the legs or thighs, or on the back. In some the parts become covered with an infinite number of small pustules, and, as they are itchy, the disease is at first often mistaken for itch. This happens the more readily from its prevailing al- most entirely among the common people, who, from want of cleanliness, frequently labour under itch ; and 270 OF LUES VENEREA IN Cll. IV* so much is sibbens confined to this set of people, that excepting children, who are more particularly exposed to receive infection from servants, those in the higher ranks of life are scarcely ever attacked with it, at least few instances of their being so have fallen within my observation. This eruption, however, soon assumes appearances which sufficiently distinguish it from itch. The skin* upon which it is seated becomes thickened and somewhat elevated, and acquires the characteristic mark of venereal blotches, a peculiar copper-colour appearance. The late Doctor Gilchrist of Dumfries, in a paper upon this subject, in the Physical and Literary Essays of Edinburgh, remarks, " that these scabby eruptions are often met with on the scalp, forehead, inside of the thighs, groins, and parts contiguous. Inflammation and excrescences about the fundament are frequent; and it sometimes appears in the form of a herpes exe- dens, healing in one part and breaking out in another." Some have small tubercles, or hard elevated knots upon the face,-arms, and breast, somewhat resembling small pox at the height, but of a red or copper-colour, and accompanied vvith a painful degree of heat. If mercury is given early these tumours gradually subside, otherwise they.become large and discharge a foetid vis- cid matter, which forms into crusts or flakes, and on ' their falling off, the parts beneath are red, tender, and in some cases in a state of ulceration. ■"Instead of this more numerous eruption, some are at- tacked with small inflammatory boils, which do not readily suppurate, but remain for a considerable time hard and of a copper-colour, and at last discharge a thin bloody ichor. These at first resemble the com- mon anthrax or carbuncle, but soon after bursting they assume all the appearances of the true venereal ulcer. But the most characteristic symptom of this variety of syphilis is a soft spongy excrescence, in size and colour resembling a common rasp, which is apt to ap- pear on all such parts as either become ulcerated, or that are attacked with any kind of eruption; sivven or SeC. VII. SCOTLAND AND CANADA. 271 sibben being in-many parts of the Highlands the name of a wild rasp, and this being a very frequent symptom of Ihe disease, is the cause of its'being distinguished by this appellation. In some instances this spongy substance rises to a considerable height, nor can it be kept down by any of the common escharotics; for al- though entirely removed, if the virus of the disease be ..not eradicated by the use of a full course of mercury, if,soon returns to a greater extent than before; but as mercury is commonly given as soon as this symptom becomes evidently marked, the excrescence is seldom so much elevated as it otherwise would be. These fungous productions are occasionally met with in every part of the body ; but they are particu- larly apt to form on such parts as have become tender whether from previous eruption or from the cuticle having separated and come off from the skin beneath ; a circumstance which sometimes takes place in this dis- ease, and when to any considerable extent, always vvith much inconvenience and distress. In the treatise which I have mentioned, Doctor Gil- christ observes that this disease does not attack the large and solid bones, and very rarely anyT of the others. I have however seen several instances of the contrary, in which both the bones of the legs and arms have been affected ; and it is by no means un- common to find this disease fix upon the bones of the head. I have seen it indeed in every part of the body, and in every form under which Lues Venerea usually appears, except in chancres upon the genitals. I have seen it produce sores resembling chancres upon the lips and on the nipples of nurses ; and where an infec tion has been of long duration I have known ulcers form upon the penis, but I have not known an instance of its producing chancres either in men or women from coition, owing, I imagine, to all who are attacked with ulcers upon these parts from this cause avoiding venereal intercourses, which they very universally do till a cure is obtained by a course of mercury ; but al- though sibbens is not usually met vvith in the form of chancres upon the penis, this, as well as other parts of 272 OF LUES VENEREA IN ^h. IV. the genitals, are particlarly apt to be attacked with such ulcers as appear from the virus having entered the constitution. In different instances I have known the whole penis and scrotum destroyed with it, but this has commonly happened from the patient having neg- lected too long to call for medical assistance, or from mercury being given in too small quantities. These ulcers, like the usual form of venereal ulcer^ proceeding from the constitutional form of the disease, do not commonly produce buboes. This, however, is not universal; for buboes sometimes take place in sib- bens, not only from the primary ulcers of the disease, as I have in more than one instance perceived in the arm-pit from sores produced upon the nipple in nursing an 'infected child, but also from those which appear upon the penis and other parts of the genitals from the virus having entered the system, and the appearance of buboes produced by sibbens, whether in their swelled or ulcerated states, is in every respect the same vvith that of the ordinary form of venereal bubo. Syphilis, in whatever way the infection is communi- cated, is readily transmitted, as we have already had occasion to see, from parents to the feetus in utero, and Ibis is particularly apt to happen in sibbens. Sibbens therefore proves a frequent cause of abortions, al- though in some instances children are born with it at the full time, and in a few it breaks out in the course of the first month after delivery. In the treatment of sibbens, as of every variety of Lues Venerea, mercury is the only remedy upon which we can place dependence. Sarsaparilla, guiacum, and mezereon have occasionally proved useful, but we trust to mercury alone for a radical cure. The obser- vations we have already had occasion to offer on the employment of mercury apply with equal propriety to the treatment of every symptom of sibbens. It is therefore unnecessary to consider the subject farther at present; but while we refer for this purpose to differ- ent parts of the preceding sections, I think it right to observe, that a greater quantity of mercury is in most ^-tances required for the cure of sibbens than we usu- Sec. vn. SCOTLAND AND CANADA. 1273 ally find to be necessary in the ordinary form of the disease. Relief is obtained with perhaps equal ease, and a stop may be put to the'tarther progress of the disease by the same quantity that we employ for the common symptoms of pox, but it is more apt to return if the medicine be not given in larger quantities, and Continued for a considerable time after every appear- ance of infection is removed. When the disease has been of long, duration mercury ought to be continued for seven or eight weeks after every symptom has dis- appeared. A practitioner of experience and observation, and who had many opportunities of seeing every symptom of sibbens, informed me that mercurius sublimatus borrosivus frequently proves successful in the cure of the more inveterate symptoms of the disease when the milder preparations of mercury fail. He gave it in the form of drops. Sixteen grains were dissolved in an ounce of water vvith the addition of eight grains of crude sal ammoniac, and of this ten drops were given three or four times a-day. When ulcers in the throat and other parts do not readily yield to the use of mercury, we have recourse to caustic and escharotics, and they prove equally useful here as in every variety of sore proceeding from Lues Venerea. In various instances they have been rendered clean and brought into a healing condition by fumigating with cinnabar, when they had previous- ly resisted every other remedy. The public, however, are equally interested in the prevention of this disease as in the cure of it, particu- larly in those districts where it has long prevailed, and with proper attention there is much reason to suppose that it might soon be eradicated. In some parts of Scotland this has already indeed been accomplished, and the means by which it has been done are simple, and easily practised. They consist entirely in a due attention to cleanliness and in preventing nurses and other servants from being employed vyhere there is the least reason to imagine that they are infected. ^ In the choice of a nurse this is a point of the utmosUmporU vol. n. ^5 271 QV LUES VENEREA IN Ch. iv ance ; for in sibbens, as in every other form ot syphi- lis, I have had many proofs of the disease ^ being com- municated by the milk alone, and as this is almost the onlv way by which it has found access to families of rank, they are particularly interested in prevent- ing it. The chief difficulty which occurs to the prevention of this disease proceeds from those who ought most anxiously to wish for it. The infected are so much afraid of a discovery being made to injure their repu- tation that they do all in their power to conceal it, by which they are often prevented from taking mercury in that complete manner by which alone a cure can be accomplished. I know, however, that this anxiety for concealment may be removed, and, with proper atten- ion, that those poor people who otherwise would fall victims to the baneful effects of the disease may be easily induced }o apply for medical assistance. The clergy have this so much in their power, that through their "interference the sibbens might soon be eradicat- ed. In one parish this was actually done. The dis- ease had spread to such an alarming height that more than three-fourths of the inhabitants were infected, and many of tlie more delicate, particularly young chil- dren and females, died under it.. This had gone on for many years, when by the exertions of the clergy- man of the parish it was entirely removed in the course of a short time. He went personally to every individual of his parish and convinced them of the propriety of applying for medical assistance immedi- ately on the disease breaking out, which they agreed to the more readily from their being sensible that all of them had got the disease in the most innocent man- ner. In this way it was soon carried off, and by due attention to cleanliness, and avoiding all kind of in- tercourse with those who they suspected to labour un- der it, the disease has now for a considerable time been entirely subdued. This has in some degree in- deed been the case in every district of Scotland where sibbens ever prevailed. In some situations it has been nearly eradicated, and in none is it now so frequent Sec. VII. SCOTLAND AND CANADA. 27.) as it was some years ago. There is much cause there- fore to hope that by the superior attention to cleanli- ness, which of late years has prevailed among our common people, it will soon become every where un- known. If the disease as it prevails in Canada is the same with the sibbens of Scotland, and from all that I have heard of it there is no cause to doubt of its being so, the same method of cure will prove effectual, and the same means of prevention must be observed- The first account of Sivvens or. Sibbens was published in 1771, by Dr. Ebenezer Gilchrist, of Dumfries, in the third volume of " Es- says and Observations, Physical and Literary, by a Society in Edin- burgh." This Essay was however read in 1765, and printed during the same ye&r for general distribution. In 1767, an Inaugural Dis- sertation De Syphilitide venerea was published at Edinburgh by Dr. Adam Freer, to which was added an appendix on Sivvens, and in 1772, Mr. James Kill, Surgeon in Dumfries, published an account of the same disease in which he controverted several of the opinions maintained by the former writer. If, in addition to these are men- tioned the notices of our Author and Dr Swediaur in their works on the Venereal Disease, a Paper by Dr. Paterson of Air, in Dr. B«ddoes' " Contributions to Medical Knowledge," an Inaugural Dissertation De Syphilitide Insontium, published at Edinburgh, in 1805, by Dr. M'Leod, together with a Chapter in Dr. Joseph Adams's work on Morbid Poisons, 2nd Edition, 1807, they will comprehend, we believe, the whole of the literary history of this remarkable disease. Dr. Gilchrist's description of Sivvens as quoted by Dr. Adams, is similar in every material point to the account given by our author. In Dr. Freer's Dissertation, a most whimsical opinion is introduced concerning its origin. Supposing Syphilis to arise from an insect and adducing the authority of Mead that the itch also originates from one, " the author suggests the probability that coition of the " male and syphilitic insect'w ith the female itch insect, may have pro- u duced an hybrid race of animals, the cause of sivvens." Imperfect as his description of the disease is, says Dr. Adams, we may col- lect from it the following facts. That it was frequently spread by smoaking with the same pipe—that it is more easily cured by mer cury than syphilis—and that some women have been permanently cured, without the use of any remedy, during the alteration that: their constitutions have undergone in gestation or parturition.— (Adams on Morbid Poisons, 2nd Edit. p. 179.) Mr. Hill states that the Sibbens was brought into the Highlands of Scotland not by Cromwell's men, but by diseased soldiers about fifty vcr.rs preceding the nme at which he wrote, He considers it 276 OF LUES VENEREA IN Ch. I\ . the same disease as syphilis, and in proof of its not being peculiar to Scotland, adduces extracts from various standard writers giving an account of Lues, communicated in the same way and exhibiting similar symptoms, which in general are those stiled secondary. He further states that the disease is not more infectious, as he is unac-* quainted with any instance where it was communicated except thro? an abraded skin, and by sweat or exhalation. Allowing the truth of the fact as stated by Dr. Freer, that sivvens may be more easily cured by mercury than syphilis, he attributes this to the temper- ance, vegetable diet and healthy constitutions o£ the inhabitants, but adds that he has observed cases, in which the disease remained even after salivation, particularly in the throat. This latter affection says Mr. Hill, is a consequence of an universal taint of the blood, if the disease is not communicated by the mouth, but where the infection is given by a foul spoon or pipe, the angles of the mouth, the lips, gums, &c. are first affected with ulcers, resembling a piece of white soft velvet, which gradually becomes broader and deeper. Mild mercurials are apparently preferred as remedies by Mr. Hill, and he observes that he agrees in every material respect with Dr. Gil- christ in his mode of cure. (Hill's cases in Surgery, to which is added an account of Sivvens. Edinburgh. 1772.) Dr. Adams, not being satisfied with the accounts that had been published, undertook a journey into Scotland, for the express pur- pose of viewing the disease. After examining several cases in their various stages, he arrives at the following conclusions which we give in his own words. " From all the above accounts, it is evident that sivvens is different from the venereal disease, though approach- ing nearer to it than any other morbid poison with which we are ac- quainted. The venereal gonorrhcea differs from the throat inflamed by sivvens, in the appearance of the discharge, and in the great dis- position sivvens shows to excite the effusion of coagulated lymph. The ulceration differs—the venereal being attended with callous edg- es and base,and sivvens consisting only of the clear phagedaenic ulcer. Secondary local symptoms differ—the venereal retaining longer its copper appearance, and afterwards becoming more elevated, retain- ing more the colour of the skin, and the scab, when formed, being more scaly. In sivyens, the appearance is very early pustular, though I never could detect pus under the cuticle : .1 should there- fore, conceive the pus still less in quantity than in syphilis. It is probably thinner, that is, more truly lymphatic, as it hardens into an irregular dark brown crusty or stony scab. There is nearly the §ame difference between this and the venereal scab, as between the cow-pox and the small-pox scabs. Lastly, it is now universally ad- mitted, that sivvens never attacks the bones but by spreading from the soft parts, and that it yields earlier to mercury than syphilis." An interesting case by Mr. Halliday, is given in which it appears that vaccination caused a suspension for six weeks, of this disease, which for twelve months before, had kept possession of the skin and constitution. With respect to the tubercles from which the flame of Sivvens is derived, Dr. Adams observes, that the practi- tioners with whom he conversed, agree with Dr. Gilchrist, is not SeC. VII. SCOTLAND AND CANADA. 277 insisting on their appearance, as a mark of the disease. From the rapidity ot the ulceration and the high inflammation in sivvens, itis evident, that it could not be generally propagated by the genitals, although the primary symptoms may, according to Dr. Adams, oc- cur in that situation. He observes, that if Cromwell's soldiers in- troduced the smoking of tobacco among the inhabitants of Scotland j the commonly received opinion concerning its origin may be rightly dated, even if the soldiers were free from the complaints, since a custom prevails in several districts in Scotland, of a whole familv using a single pipe. Dr. Adams concludes, by suggesting a prob- ability, that sivvens may be among the morbi in cole mentioned by Celsus, and cites from Astruc, the statements of various authors proving that similar complaints have been noticed previous to the introduction of Syphilis, among the Diseases of tlie genital organs. A similar opinion is entertained by Dr. M'Leod in the Dissertation referred to above. The following extract from Professor Frank's ( a German Physician of eminence) Travels in France and England, as quoted in the Edinburgh Med. and Surg: Journal for July, 1807, is worthy of notice, particularly as the Author observed several ca- ses of Sibbens in the Hospital at Edinburgh. " In 1800, a disease appeared in Dalmatia, which had the characters of Syphilis, but was rather considered as a kind of Lepra, as it was communicated not only by sexual congress, but also by every kind of intimate con- nexion. Several thousand persons were already infected, when Dr Cambieri, District Physician at Fiume, pronounced the disease, which was called by the natives Scherlievo, a venereal affection, and the same with the Sibbens of Scotland. His official communication on the subject, was transmitted by the court to my father, who per- fectly coincided with Dr. Cambieri in opinion. In consequence of which, the malady, when present, was not only treated with corro- sive sublimate, but also its farther propagation so completely check- ed, by the erection of hospitals, and the adoption oi other regula- tions, that in the course of three yedrs it was almost exterminated. On this occasion, Dr. Cambieri suggested the opinion that the Sibbens or Sherlievo is the original form of the venereal disease, as it first appeared in Europe. For it is well known, that it existed long before it was supposed that it communicated itself by sexual intercourse. Even the rapidity of its diffusion over all Europe, renders it probable that this was not the only way by which syphilis was then propagated." With respect to the complaint of a similar nature prevalent in Canada, according to Dr. Adams' examination, instead of the ac- count being written by a Dr. Bowman, and found among the papers of Governor Hamilton, as Dr. Swediaur states, itis more probable that the investigation was undertaken by a Mr. Beaumont a French Surgeon, who had been sent from Quebec by Governor Haldiman, to ascertain the nature of a disorder prevailing at the Bay of St. Paul, Canada. In one respect, according to the papers which Dr. Adams read, it agrees with sibbens, which is, that the contagion is oficn conveyed by smoking with the same pipe. We have been informed by Dr. Lc Baron, Apothecary General to the Army of 278 OF LUES VENEREA 1A Ch. IV. tbe U. S. that for the space of seven or eight years, during which he was stationed as Garrison Surgeon at Fort Mackina,he met with repeated instances of disease resembling Sibbens, among the Fur Traders and Natives. We add to this article, the following account of a disease resem- bling in some respects those which we have noticed, and particu- larly so in the mode of cure. It is extracted from the Edinburgh Med: and Surg: Journal for Oct. 1809, and is entitled An Account of the Pseudo-Syphilitic Cutaneous Disease, Radesyge, prevalent in some parts of Sweden and Norway. By Hugo H. Booker, M. D. Upsal. This distressing disease, known in Norway and among some Swe- dish practitioners by the Norwegian name Radesyge, and in some parts of Sweden called Saltfluss, has not, till of late years, attract- ed particular notice, and is still most commonly confounded with the confirmed venereal lues, to which it, in many points, bears the strongest resemblance. Its being a degenerated form of the true syphilis, or a complication of that disease with scurvy, which has been suggested, has not been confirmed by any well-founded obser- vation ; and it is now, by all those who have made this matter a sub- ject of their investigation, thought to be a peculiar disease, per- fectly distinguished from both. The characteristic marks of this-, disease are, ill-conditioned sores, with excavated uneven bottoms and hard edges, arising either from reddish spots, or from copper- coloured tumours on various parts of the skin, without any previous venereal infection or primary symptom; accompanied, during the progress, by swelling of the bones, sometimes by caries, and, un- less checked by proper remedies, ending with destruction of vari- ous parts, and total loss of health and life. Hardly any part exposed to the, air has been found free from the disease. However, it seldom^affects the face, the hands, and the private parts ; but most frequently the throat, inside of the mouth, upper and lower extremities, shoulders, neck, and trunk, and more particularly those places where a bone lies close to the skin. When it affects parts covered with a constantly moist skin, such as the fau- ces, it never begins with tumours, but with spots of a brighter co- lour; whereas, on the skin of the exterior surface of the body, it either begins with spots or tumours, both of a darker appearance. Previously to the eruption, the diseased sometimes complain of ill- ness, general languor, pain in the limbs, exacerbated.towards night, 8cc; but frequently it comes on without any precursory symptom, and may, for some time, proceed under no alteration in the general state of health. The first symptoms often shew themselves in the throat, preced- ed by a sense of soreness, and a difficulty of swallowing. On ex- amining the parts, these will be found swelled, and a dark reddish colour spread somewhere over the surface, from the midst of which a whitish ulcer sooner or later breaks up, spreading somewhat in depth, and eroding the tonsils, uvula, or palate, with all the conse- quences of hoarseness of th-e voice, nasal pronunciation, &c. usual* Sec. vir. SCOTLAND AND CANADA. 279 ly to be met with in syphilis. Not seldom, however, such inflamed spots disappear spontaneously, but are, in such case, always suc- ceeded by fresh symptoms of the disease on some other part of the body. Ulcers on the tongue, similar to those in the throat, are sel= dom met with except in children, where the infection has been con- veyed to them through the nipples of a diseased person, or some- times in elderly persons, where the tongue previously has been in- jured by a decayed tooth. In the inside of the cheeks, and on the lips, the first ulcer sometimes breaks up from a red spot, with an ash colour in the midst, but mostly in children, only previously to the next and usual symptom in them, an eruption round the anus, When the nose is attacked, the disease usually begins like a, com- mon catarrh ; one of the nostrils becomes obstructed, and at length an ulcer penetrates the alae, communicating with the inner cavitv of the nose, parts of which, in the course of time, sometimes will be corroded away. On the surface of the body the cubitus, olecra- non, and tibia are the parts mostly affected; less frequently the thighs, humerus, shoulders, neck, and trunk ; and still more sel- dom the forehead, face, and hands. In all those places the ulcers may be preceded either by the above mentioned tumours, or by small spots of a copper colour, somewhat similar to an herpetic eruption, dispersed here and there, and covered with scales, which at length run into each other to larger spots, and ulcerate. This is the most usual progress on the trunk. On the extremities, espe- cially where a bone is underneath the skin, tumours are the most prevalent. When any of these parts on the trunk or extremities are the first affected, the throat will remain unattacked, but not the contrary. If the parts round the anus are the seat of the eruption, this will take the form of small dark humecting excrescences, re- sembling warts, which at length ulcerate, but are not diffused to any extent. On the penis and scrotum ulcers sometimes, though seldom, occur; they begin with tumours, but do not spread far. No instance, that I know of, has ever been found of the scalp being attacked, or any part covered with hair, except the scrotum. Whatever may be the seat of these ulcers, varying in size from the smallest spot to that of a hand's-breadth or more, they always are surrounded by a cdpper colour, considerably diffused ; they gen- erally have a round form, or somewhat approaching to that, and an appearance as if dug out of the substance; they never suppurate, but discharge a thin, though seldom fetid, matter. Most frequent- ly they give no pain, except the larger ones ; but when they grow old, or occur in irritable constitutions, they are extremely painful, They often heal up spontaneously, but are soon followed by fresh ulcers in other parts. The marks which they leave behind upon the skin have a peculiar appearance, a shining white surface, with elevated strings running across ; an appearance which they never will lose in any length of time. The tumours which this disease sometimes occasions in the bones, where these are covered only with skin (on the tibia, &c), are fre- quently without pain,, and the skin above them unaltered. They 230 OF LUES VENEREA IX Cll. IV. are seldom followed by caries; but, when this happens, the ulcer never will heal till after an exfoliation of the injured bone. The disease often continues for a long while under appearance of health, and the general constitution seems but little impaired. Some irregularity, however, in the menstrual flux, sometimes occurs in consequence of the disease. But when it is suffered to proceed, and after its having affected the bones, it evidently will shew its in-< fluence upon the body by loss of strength, disturbed functions, and general emaciation. However difficult it often may be, from the mere appearance of the symptoms, to distinguish this disease from the confirmed lues venerea, practitioners have thought themselves fully justified for appropriating to the radesyge a peculiar place among diseases, by the following diagnostic marks : That the radesyge never has been found to begin with primary symptoms, like the virulent gonorrhcea, a chancre, or bubo ; that it very seldom affects the parts of genera- tion, and not those places which are liable-to the syphilitic infection (the glans and inside of the prepuce,) but the skin of the penis and scrotum; that, to be effectual, the poison does not require to be brought into contact with such parts as are covered only with epi- dermis, excoriated or wounded, but to any part almest of the whole body; that being applied to a secreting membrane, it does not pro- duce an increased or contagious discharge, similar to that in a go- norrhcea, but an ulcer ; that it does not affect the parts so speedily as the venereal poison, but requires to be kept in contact with them a longer time ; that it does not, like the syphilis, attack parts cov- ered with hair; that the ulcers often heal spontaneously; that the spots on the skin in radesyge are larger, but less dispersed and of a deeper colour than those in syphilis ; that the tumors of the bones are of a less aggravating nature, frequently occasioning neither noc turnal pain nor caries ; and, lastly, that the ulcers themselves, aris- ing sometimes to fungous excrescences, present some difference from the syphilitic, the matter adhering to the bottom not being so thick and yellow, but thin and white, and after its having been re moved, the bottom shows itself not so red as in syphilitic ulcers- but with a deep purple colour ; nor are they, as these, offensive to the smell when kept clean, besides, that they spread less in the depth, and do not so easily affect the bones with caries. A contagious matter, brought into contact with the skin by various means, seems to be the only cause which gives rise to the disease- It appears to be of a less infectious nature than the syphilis, being almost solely confined to the lower order of people, who live close- ly together, but still leaving many unaffected during frequent inter- course with the diseased. Generally, however, it spreads among whole families. No kind of diet (fish-eating or suchlike) seems to have any material influence upon the origin ot" the disease, nor is it propagated by hereditary infection. Both sexes of every age are liable to it, but seemingly more females and children. The cure of the radesyge will sometimes prove very difficult when it has been of long standing; and in certain constitutions, or when complicated vith r^'ir- disorders, especially with the syph'li*r sec. vli. SCOTLAND AND CANADA. 281 it will hardly yield to any treatment. In children the disease makes faster progress, but generally is much easier cured than in elderly persons. When the symptoms are confined to tumours, or to the before mentioned eruptions on the skin, the cure will be less diffi- cult than after the ulcers have broken up. These, as well as the former, are more tedious upon the lower than the upper extremi- ties, and on the extremities more than the trunk. The ulcers in the throat and upon the neck are the most easily removed. The only remedy hitherto found effectual against this disease is mercury. The symptoms will sometimes very easily yield to it, but as speedily return, and prove more difficult to cure the oftener mercury has been used. A variety of preparations have been used; and, among combinations, that of mercury with hemlock with suc- cess, where mercury alone had proved ineffectual. The prepara- tion mostly, and with success, used in that part of Sweden where the disease has occurred to my observation, has been the corrosive sublimate, in usual doses, assisted by some diaphoretic decoctions, by bathing, &c. and occasionally by the internal use of the nitrous acid. The external treatment of the ulcers have seldom been of material consequence, and stimulating applications have often done harm. Whatever may be the preparation of mercury used in this dis- ease, it ought not to be introduced hastily into the system, or in large quantities, but the symptoms should be suffered to disappear slowly, and the remedy be continued for some weeks after. The combined use of mercury, internally and externally, with success resorted to in syphilis, has proved improper in this disease. When too hastily removed, it will sooner or later return, becomes more difficult to cure, and at length mercury will have no effect whatever upon the disease. But even when much care has been taken of this circumstance, the diseased not seldom has a relapse, and patients, apparently cur- ed, returning to the hospitals after months or years, give frequent and distressing proofs of the uncertainty of the cure. The foregoing account of the radesyge is chiefly founded upon observations made upon it, such as it has appeared in the north of Sweden, confirmed by what I have had an opportunity of seeing myself in Norway when travelling there. Whether any thing else, or materially different, has been remarked there, or on the west coast of Sweden, where the disease is perhaps more prevalent, my knowledge at present does not enable me to decide, nothing but some few observations from Denmark having been published upon the subject. Edinburgh, 3d August, 1809. VOL. II 3S 282 OF PROPHYLACTICS Cll. IV*. SECT. VIII. Of Prophylactics in Lues Venerea. TO prevent infection is an object of the first im- portance in all diseases, but there is none in vvhichout endeavours have proved less successful than in this. As the pleasures and safety of mankind are both inter- ested, Prophylactics in Lues Venerea have long been an object of attention; but hitherto, notwithstanding all the boasted specifics with which every kingdom of Europe abounds, nothing has been discovered upon which any dependence can be placed. At first view one would not doubt of ablution alone proving sufficient for preventing infection. As the parts to which the matter of infection is applied are alto- gether external, and as a considerable length of time commonly elapses before any effects are produced by it, we might vvith confidence expect that bathing the parts in warm water, or any other liquid, could scarce- ly fail of removing the contagious matter. This, how- ever, is not the case ; for although some advantage may occasionally be derived from careful ablution we have daily proofs of its failure, even when practised with all manner of attention. This must probably arise from the virus being ei- ther exceedingly subtile, or so very adhesive that it cannot be separated from parts to which it has found access by any means that have as yet been employed. In this View, therefore, two objects present themselves. Any application to be made use of should not only be of a very penetrating nature, but capable of deslro) ing that connection by which the virus is thus made to adhere to the parts to which it is applied. I also think it probable that some advantage may be derived from combining mercury with whatever is best adapted to these purposes. By acting as an antidote it may serve to destroy such parts of the venereal poison as the oth- ers have not been able to remove. Crude mercury, triturated with honey and with tur Sec. VIII. IN LUES VENEREA. 283 pontine, and mixed with a sufficient quantity of water, has been used as a wash for this purpose; but the in >st convenient way of employing mercury here is in the form of a watery solution of corrosive sublimate. It may be used of various degrees of strength, from the quantity of one grain to three grains of mercury in the ounce of water. More than this proves irritating and corrosive. As it is probable that the virus proves more adhesive than it otherwise would be by combining vvith the mu- cus of the parts to which it is applied, all such articles as prove solvents of mucus, or that in a more particu- lar mariner destroy its tenacity,*may vvith propriety be employed in the composition of an antisyphilitic wash. Upon this principle lime wate* may be used with ad- vantage ; also the caustic fixed alkali, and even the caustic volatile alkali so diluted with water as to ad- mit of their being applied with safety. No harm can ensue from the external use of any of these articles in tlie form of a wash, and more advan- tage, I have reason to think, may be derived from them than is commonly obtained from the use of those secret specifics which the interest of individuals and credulity of our young people have occasionally brought into no- tice. I think it right, however, again to remark, that none of them can with certainty be relied upon, and ti at in no instance ought any of them to be injected into the urethra, as preventives of Gonorrhoea. When the disease has actually taken place, they may, when much cjiluied be used vvith freedom ; but they cannot be employed but with much risk of inducing inflam- mation when of such a strength as can have any influ- ence in dislodging the virus, by dissolving or destroy- ing the mucus with which it is combined. Whether these specifics to which I allude have any of the arti- cles which I have mentioned for their basis or not I cannot determine, but when used as injections they of- ten do much harm by exciting pain, and such a con- stant inclination to pa<-« urine as proves exceedingly distressful. 284 OF LUES VENEREA Ch. IV. The best Prophylactic in Lues Venerea, is circumcision. " Jews and Mahometans," observes Mr. Howard, " from the constant ex- posure of the glans and loss of the prepuce, have the cuticle of the balanus (glans penis') of much firmer texture than those who have not been circumcised, and they are from this circumstance, much less subject to gonorrhcea and chancre, than the rest of mankind." In proof of this, he quotes Fallopius, who states that even in his day, scarcely two out of a thousand persons were infected, whose preputia were short and whose balanci were kept constantly uncov- ered. Ratio est quoniam detecta glandis durius corium redditut atque callosius. Persons who have short preputia and hence liable to abrasion in coitu, are very subject to be infected. SECT. IX. Of Lues Venerea as inducing other Diseases. AS the virus of syphilis is often difficult to eradi- cate, and the disease being-frequently known to break out again long after a cure has been supposed to have been accomplished, the fears of patients have induced them to suspect that it cannot vvith any certainty be removed after having'appeared as a general disease of the system, and even to consider it as the cause of ma- ny other diseases. Even practitioners have been divided in their opin- ions upon this. The result of rny observation has al- ready been given on the power of mercurv in curing the disease. In section fourth of this chapter I have endeavoured to show that where failures have happen- ed they must in a great measure have arisen either from the misconduct of patients when under mercury or from too small a quantity of the remedy being given, But while I am clearly of this opinion I at the same time think that Lues Venerea is often the cause of other diseases, winch frequently prove fatal from want of a proper application of mercury, by which a cure of all of them might be easily obtained. See. IX. AS INDUCING OTHER DISEASES. 285 In the preceding parts of this work a description Is given of all the ordinary symptoms of Lues Venerea, and of the method of treatment appropriated to each; but if the opinion vshich I am now endeavouring to support is well founded, this disease, it is evident, must occasionally appear under other forms. We have already had occasion to observe that Lues Venerea, when not interrupted in its course by the use of mercury, usually makes a certain progress, and that the symptoms make their appearance with some regu- larity : But when mercury is employed, and not given in quantities sufficient for eradicating the virus, al- though all the svmptoms may thereby be suspended, the disease will certainly appear either in the same or some other form at some future period. In this case the disease generally shows itself by one or other of the symptoms that have been described, but occasion- ally we meet vvith it under a variety of other appear- ances; the virus, instead of producing the ordinary symptoms of Lues Venerea, tending rather to induce other diseases. This I know is denied by many, who alledge that syphilis is never productive of other diseases; but I have met with it in such a number of instances, and these so evidently marked, that I consider the fact as certain. The virus of syphilis will not produce any disease that depends upon a specific contagion, such as small-pox, measles, itch, and some others, but I have much reason to think that a great, variety of other dis- eases are induced by it. It may be asked in what manner can syphilis act in producing other diseases, and what evidence can be given of its ever having done so ? In answer to this I may observe, that it is often difficult, and sometimes impossible, to explain the action of causes in producing diseases. We may easily, however, suppose, where the virus of syphilis exists in the system, but not in sufficient force to show itself by the usual and more obvious symptoms of the disease,' that it may, however, in various instances be capable of exciting a great deal of derangement, and even many diseases which otherwise might not take 286 OF LUES VENEREA Cll. T\*i place, and that it will more especially be apt to pro- duce those diseases to which the constitution is predis- posed, or those to which the patient is rendered liable by exposure to particular occasional causes. If the virus can exist in the system for a considerable length of time without shewing any external mark of disease, and of this few I believe will doubt, it is difficult to conceive that it should not produce both general de- rangement and particular organic affections; and ac- cordingly I believe that it more frequently does so than we are usually led to imagine. The evidence which I could give of this would be exceedingly am- ple, as I could relate ft very extensive collection of cases in a great variety of diseases in which it actually happened; but the extent of this publication renders it necessary to confine the proofs of it within narrow- er limits. The diseases induced by the venereal virus, of which I shall give instances, are phthisis, asthma, rheumatism, dropsy, head-ach, epilepsy, and mania. In the month of October 1783 £ was desired to visit a gentleman at some distance from town, with an ex- tensive foul ulcer upon his left shoulder. This was mentioned as the most material part of his distress; but I also found that he had for several months labour- ed under all the most alarming symptoms of phthisis, such as severe cough, spitting of purulent matter, pains in the breast and sides, night sweats, quick pulse, and an emaciated state of the body. These symptoms, however, did not excite the attention of the patient nor of his friends so much as the ulcer upon his shoul- der, which, from the great quantity of matter which it discharged, and the great length of lime which it had en- dured, was considered as the cause of his weakness as well as of all the other symptoms. The appearance of the sore giving cause to think that it might be venereal, I mentioned this to the sur- geon in attendance, as well as to my patient, vvith a view to discover whether from the history of the case, and - from his previous course of life there was any ground for suspicion. The answer which I received to this inquiry was, that soon alter the first appearance of this Sec. ix. AS INDUCING OTHER DISEASES. 287 ulcer about three years before the time of my being consulted, an ulcer had appeared in his throat, accom- panied with some other symptoms of syphilis. For the removal of these he had been put under a long course of mercury, which had proved successful ; and as he had not since that period run any risk of being infected he did not suppose it possible that the ulcer upon his shoulder, or any of his other symptoms could be venereal. Having found, however, that the mercu- ry, although long continued, had never been given in greater quantities than to render the mouth moderately sore, and that for a considerable time an eruption re- sembling venereal blotches had prevailed over his breast and arms, I did not hesitate to say that the infection had not been eradicated, and that*he ought immedi- ately to enter upon a full course of mercury. The chief objection to this was the debilitated state of our patient, and the quickness of pulse, vvith other symptoms of fever, which prevailed in a very conside- rable degree, the pulse at this time beating upwards of 130 in a minute. Even these considerations, however, did not deter me from advising the use of mercury ; having even at that time seen more than one case of a similar nature, where the lungs were evidently affected, and in which a cure was obtained by mercury; and judging from the whole history of the case that the phthisical symptoms might be kept up by the syphilitic virus, I observed to my patient, that if my conjecture was well founded, these symptoms, as well as the oth- ers, would gradually abate on the mercury taking ef- fect. I also said to his friends, that in such circum- stances the mercury could not add much to his hazard, however severely it might operate ; the nature and se- verity of his symptoms being such as gave no cause to imagine that he could live above a few weeks if some unexpected alteration did not take place. The patient himself having readily acquiesced a course of mercury was immediately prescribed. At first he rubbed in a drachm of strong mercurial oint- ment every evening. This came to be repeated morn- ing and evening ; and as his cough and fever were not 288 01 LUES VE-NfcKLA Ch. IV, increased by it, and the state of his mouth enabling him to bear it, the quantity at each application was increas- ed at the end of eight days to a drachm and a half. The ulcer was dressed vvith common wax ointment. About the end of a fortnight it became clean, which it had never before been, and any uneasiness with which it had previously been accompanied was now removed. The blotches upon his skin had begun to yield, and even the febrile symptoms, instead of being increased by the mercury, were somewhat abated. His mouth became exceedingly sore ; but although a good deal of salivation was excited the same quantity of mercury was continued. This I was induced to insist upon from our having now very satisfactory evidence of all his symptoms being venereal, for even the cough and purulent expectoration became moderate in proportion to the quantity of mercury that was exhibited. By the end of the sixth week the cough was nearly gone ; the blotches were almost entirely removed ; the ulcer continued perfectly clean and much contracted, and his pulse did not now beat above ninety strokes in a minute. In the course of a fortnight from this time, that i?. after he had taken mercury for the space of eight weeks, scarcely any remains of the blotches could be perceived : The sore was reduced to the fourth part of its original extent ; but about this period it became nearly stationary, for which it was touched every se- cond or third day vvith lunar caustic. At the end of another fortnight it was completely cicatrised ; but the infection having been of long duration, I judged it proper to continue the mercury three weeks longer, being thirteen weeks in all. He had now been many weeks entirely free of cough. His pulse was about its natural standard ; and as he had been allowed nour- ishing diet during the whole course, he was even con siderably improved in appearance and strength. By the beginning of the ensuing summer he was equally strong as he had ever been at any period, and when I last saw him, about three years ago, he had continued entirely free both of Lues Venerea and phthisis. Sec. ix. AS INDUCING OTHER DISEASE;. 289 In the beginning of January 1784 I vyas desired to Visit a patient newly come to town, with sores on dif- ferent parts of bis body and limbs, and he had also for a considerable time been distressed with asthma. It was chiefly however for the sores that he applied for advice, as he had been led to consider asthma as a dis- ease for which there was no remedy. There was one large ulcer immediately above the great trochanter of the right thigh; one upon the middle and most promi- nent part of each leg, both of which penetrated to the tibia; one upon the breast, where the sternum appear- ed to be thickened, although not carious; one upon the right side, upon the seventh and eighth ribs; and a small sinous ulcer upon the middle and outside of the right arm, which, upon probing, was found to run to the surface of the ulna, which was rough for the space of an inch. Besides these there were several small ulcers upon the toes of both feet. These, as well as the others, were all foul, and discharged a thin, foetid matter; and being accompanied with that erysipelatous kind of redness which frequently surrounds the mar- gins of venereal ulcers, I was thereby led to suspect them to be of a venereal nature. The patient men- tioned, as reasons for thinking that I was mistaken, that these ulcers were now of seven years continuance, and on Ihe suspicion of their being venereal that he had taken mercury to a considerable extent at three differ- ent times, each course having been continued for nine or ten weeks; and although he had from all the three derived benefit, that none of the sores had healed by the effects of any of them, and that some of them had even become worse soon after the last course of mer- cury was left off'. The asthmatic symptoms were now of five years duration. They began without any ob- vious cause, and had gradually become more violent, nor had any remedy that had been employed for them given him relief, excepting opium, and even this was merely temporary. Besides a constant difficult breath- ing, he was liable to periodical attacks of a more se- vere nature, which occasionally came to such a height as to endanger suffocation. These occurred most fr& vol. n. It ->90 OF LUES VENEREA Cll. IV. quently .during sleep, and, for the most part, with much regularity, about three o'cjock in the morning. The patient, who was now about forty-five years of age, acknowledged that in his earlier years he had suf- fered much from Lues Venerea, but having been led to suppose that he had already taken more mercury than was necessary, it was vvith difficulty that I per- suaded him to enter upon a farther couise of it. The more, however, that I heard of the rise and progress of his complaints the more I was convinced of their being venereal; for besides the appearances of the sores which I have mentioned, I found upon enquiry that he had never taken a full course of mercurv, fop although it had always rendered his gums sore, he had never used it in such quantifies as to require confine- ment. Neither had any of the attempts which had been made to cure the sores by external applications proved successful. A great variety had been employ- ed, but although some of these had rendered them more clean than they had been before, and procured a discharge of better matter, no permanent advantage had been derived from any of them. These considerations determined me to give a deci- sive opinion on the propriety of his taking mercury in larger quantities than he had ever as yet done. This induced him to agree to it, and he entered upon the course on the 14th of January. At first he rubbed in a drachm of mercurial ointment every night, and took one of the blue pills evening and morning. In the course of eight days he used two drachms of the oint- ment daily, and the same number of pills were con- tinued till his mouth became exceedingly sore, and a good deal of salivation induced which happened at the end of a fortnight. At this period the pills were left off, and only a drachm of the ointment employed dai- ly. The common wax ointment was applied to the sores and renewed morning and evening. Till he entered upon this course the sores had at all times given him much uneasiness. They had never produced acute pain, but they were accompanied with an uneasy, itchy sensation, which frequently deprived Sec. IX. AS INDUCING OTHER DISEASES. 29J him entirely of rest. Before the end of the third week this was completely removed; the sores were become clean, and the discharge of a better consistence; at the same time that his asthmatic symptoms were by no means so severe. As by this he was convinced of the propriety of the course of mercury, he readily'submit- ted to the distr ssand inconveniency which it produced, and kept his mouth fully affected during the whole time of it. By the beginning of March, that is, after having taken mercury for nearly seven weeks, all the sores were entirely healed excepting that upon the outside of the thigh and those upon the legs. Even these were much diminished, and the cure in all the three seemed to be retarded only by the state of the bones beneath, which were found to be denuded of .the peri- osteum, and even in some parts rough. These, as well as the others, had been dressed vvith mild wax ointment from the first, and excepting the laying open the sinus upon the fore arm, no farther attention had been given to any of them. He now breathed easily and had not experienced any severe fit of asthma from the time that his mouth became first fully affected vvith the mercury. The course was carried on in the same degree to the end of the thirteenth week, when judging from the quantity of mercurv employed, and the regular man- ner in which it had been taken, that the virus by which his disease seemed to have been produced must be eradicated, I caused him to leave it off. The asthma was entirely gone, and all the sores continued firm and well excepting the three I have mentioned. I now supposed, however, that these were kept up entirely by the carious boues on which they were seated ; and a« a cure could not be looked for till the diseased parts exfoliated, and as this might probably be tedious, I advised him, as soon as he could with safety venture upon a journey, to go home, and to do nothing with a view to the sores but dressing regularly with red pre- cioitate ointment in order to prevent the growth of a fiLus with which all the three were covered. This, with the occasional use of calcined alum, prevented the funo-us from being considerable ; but it was not till 292 OF LUES VENEREA Oh. IV. a year had elapsed that any of the sores healed. About this period an extensive exfoliation appeared to be coming away from the tibia of the right leg. He now came to town, and by cutting into it I sot it easily out, and the sore healed in a fortnight. The sore on the other leg healed in a similar manner at the end ofthree or four months after a small spiculated portion of the tibia had come away, but the ulcer upon the trochanter has not healed. Several small pieces of bone have from time to time come away, but I conclude that more must be thrown out before a firm cicatrix will form ; for although now reduced to the appearance of a nar- row sinus, which frequently heals, it always bursts out again. It is not, however, productive of much incon- venience. ; and on account of the situation of the bone, 1 think it better to trust to time alone than by means of any operation to attempt to promote the exfoliation of the diseased parts. No return of asthma has taken place, and he is now in good health. In the month of May 1789 I was desired to visit a pa- tient, by trade a brewer, aged forty, and very corpu- lent. For several years he has been liable to periodi- cal returns of asthma, and during all that period his breathing had been difficult, insomuch that he had for the most part been obliged to sleep nearly in an erect posture. He had been liable to frequent and very dis- tressful palpitation of the heart, and his pulse was at all times frequent and irregular. Other practitioners had previously been called, and, as is usual in such cases, different opinions were formed of the cause of the disease. By some it was considered as gout; others judged it to proceed from hydrops pectoris, while by some it was supposed to constitute what of late has been termed angina pectoris. The patient himself, however, was of opinion, that all his symptoms ori- ginated from what he termed an ill-cured pox. He informed me that in his earlier years he had suffered much from frequent attacks of syphilis, and not hav- ing taken mercury in a regular manner ; particularly from the last attack, and to which this affection of his Sec. IX. AS INDUCING OTHER DISEASES. 293 breathing had succeeded: From this he was convinced that the virus had not been eradicated. No evident symptoms of Lues Venerea, however, could be discovered; so that I could not venture to advise a course of mercury as my patient wished me to do. Purgatives, diuretics, and blisters, were re- peatedly employed, but with no advantage; and some relief being derived from opiates, he was at last induc- ed to trust entirely to a large dose of laudanum taken at bed-time, and a lesser dose in the morning. In this situation I left him in the month of September, nor had I again occasion to see him till the month of April 1790, when I was called on consultation vvith the sur- geon of the family for an ulcer which two months be- fore had appeared upon the right side of the nose. At first this ulceration was so inconsiderable as scarce- ly to excite his attention; but, as it soon began to spread, various applications were employed, from the mildest to the strongest escharotics; but although these, vvith the occasional use of lunar caustic, had proved useful, by preventing the growth of fungus which had previously prevailed, still the sore continu- ed to extend, and at this time had spread to the oppo- site side of the nose. Upon inquiry I found that in the month of November, some days after exposure to infection, a chancre had appeared upon the glans pe- nis; but as it healed by being twice touched with caustic, and which he had done without the know- ledge of his surgeon, he had not thought it necessary to enter upon the use of mercury. At this time the difficulty of breathing and distress- ful palpitation of the heart were more severe than they had ever been at any period; but the account which I had received of this recent infection, the progress which the ulcer was daily making, and the inefficacy which had already been experienced of local applica- tions, determined me to advise an immediate and full course of mercury. Being informed that mercury did not readily affect him, both the internal and external use of it was advised ; so that in the course often days his mouth w^ rendered as sore as he could possibly 294 OF LUES VENEREA ^h. IV. bear it, and he salivated to the quantity of between two and three English pints a day. The sore was dressed with common wax ointment. In the course of three weeks from his entering upon the use of mercury the sore was considerably dimin- ished, and at the end of six weeks it was entirely heal- ed ; but to the surprise and satisfaction of all concern- ed all his other symptoms became better on the mer- cury taking effect. The difficulty of breathing was soon much relieved, the palpitation vanished entirely, and the pulse fell to its natural standard. It was seve- ral weeks before the asthmatic affection left him entire- ly, but this happened before the end of the course, which was continued to the end of the third month; and he has not since that period experienced any re- turn of his disorder. In this last case it may be a question whether the patient laboured under syphilis at the time when I first saw him or not: He himself imagined that he did; and on finding afterwards that the disease in his breast was completely removed by mercury, when rendered necessary by the presence of a more obvious symptom of the disease, I came also to be of the same opinion, and this induced me to give the mercury in large quan- tity, and to continue it longer than would have been necessary for the cure of a more recent infection. In March 1787 I was consulted by a gentleman of fortune in the south of England. His case was de- scribed to be a severe rheumatic affection, vvith which he had been afflicted for the space of eighteen months. After much exposure to cold and wet weather in the course of hunting, he was attacked vvith severe pains in all his joints, particularly in the shoulders, wrists, knees, and ancles. These continued in some degree from the first approach of the disease, but he had oc- casionally been distressed with severe pains in his back, loins, and hip-joints, to such a degree as not to be able to move for two or three weeks together but with an unsupportable increase of pain. His fingers and toes also became swelled and painful; and as the balls of the great toes had been particularly affected »ec. IX. AS INDUCING OTHER DISEASES. 295 his disorder by some had been considered as gout. At the time of my being consulted the joints of his fin- gers were so much swelled that he could not even sign his name, but the chief cause of his distress at that time was a swelling of his right knee. The swelling and pain in his other joints bad at different periods pre- vailed in various degrees; they even at times left him entirely ; but the right knee had continued swelled and painful from the first, and at this period it was repre- sented as being nearly double the size of the other. There was accordingly much tension, and a very ex- tensive fluctuation had for seven or eight weeks been discovered in the superior part of the tumour. The skin, however, was no where discoloured. He was at this time thirty-two years of age. When first attacked with the disorder he was full and vigorous, but now much emaciated. His pulse, however, was good, for although for a considerable time a good deal of fever prevailed, it had now left him entirely, his skin was cool, and his pulse between seventy and eighty in a minute. The remedies he had employed were these : At first he was repeatedly blooded ; the pained parts had been rubbed vvith a variety of stimulating applications, such as volatile liniment and tincture of cantharides, and blisters had been frequently^ applied. He had taken James's powders, camphors, and opium ; but the lat- ter being the only remedy from which he derived re- lief, the others had long been disused. Sixty drops of laudanum taken at bed-time, and twenty-five in the morning kept him for the most part tolerably easy, but he experienced much distress whenever these were omitted. The following is the advice which I propos- ed to him: . . 1. That two drachms of a weak mercurial ointment, containing only a fifth part of mercury, should be rub- bed upon the swelling of his knee evening and morn- incr for the space of twenty minutes each time, and continued five or six weeks if it did not excite saliva- tion. 296 OP LUES VENEREA Ch. IT. 2. That he should use a warm bath of sea-water ev- ery second night: The whole body to remain immers- ed for the space of twenty-five minutes, or half an hour, and a quantity of the warm water to be poured from the height of three or four feet upon the swelled knee at each time of using the bath. 3. Instead of laudanum at bed-time, that he should take fiiteen or twenty grains of Dover's powder. 4. That he should wear flannel next his skin, not only upon the diseased knee, but over bis whole body. 5. If by these means the swelling did not abate in the course of four or five weeks, that blisters should be applied to it; the first to be applied upon that part of it in which the fluctuation was discovered, and the others alternately on each side of the joint. I heard again from him in the month of June, when he informed me that he had been prevented from using the mercury by a physician who had been con- sulted on the receipt of my opinion. Being afraid that his debility might be increased by the mercury, he had desired that it might not be used, but all the other parts-of the course which I had pointed out had been complied with. His general state of health was better, and by the use of the warm bath and Dover's powder his pains had been much relieved, but they always recurred on rhe.se remedies being laid aside, and the swelling of the knee was nearly in the same state as when he first applied to me. Besides this, he had been attacked with a painful swelling on the up- per part of his right shoulder, which, after becoming red and tender, had ended in an extensive foul ulcer. This giving rise to much anxiety, for the sore was dai- ly becoming deeper, he was particularly anxious to have some remedy pointed, out for it. In return to this, I desired that the mercury might still be employed with a view to remove or lessen the swelling of the knee, and I gave him formulae of dif- ferent ointments as dressings for the sore on the shoul- der. I said, however, that he must depend chiefly on the surgeon in attendance for the treatment of this ' «ore : but being within forty or fifty miles of London, ^ec. ix. AS INDUCING OTHER DISEASES. 297 I advised him, if he did not soon get better, to go there for the advantage of a consultation. 1 did not hear of him again till the month of Sep- tember, when he arrived in Edinburgh. He now in- formed me that he had gone to London on the receipt ot my second letter, and that he had been advised to the .use of guiacum ; a deep-seated pea issue had been inserted on the inside of the swelled knee ; and differ- ent ointments had been given him to apply in succession to the sore on the shoulder. Having continued, how- ever, under the regular application of these for up- wards of two months, and no advantage accruing from them, he determined at last on coming here. The pains over his joints were still very universal, almost every joint being more or less swelled, but they were not any where so severe as they had at first been. The swelling on the knee was very considerable, and a fluc- tuation was perceived, reaching from the patella, be- neath the rectus muscle, nearly to the middle of the thigh. The skin, however, was not discoloured, and the joint was still in some degree capable both of flexion and extension. But the symptom which gave him most uneasiness was the ulcer upon his shoulder* which had now extended from the top of the shoulder over the clavicle, and down to the middle of the hu- merus. It had already destroyed some part of the del- toid muscle, by which the motion of the arm was mwch impeded, and a considerable portion of the cla- vicle was become carious. This ulcer he had lately been informed was of a scrophulous nature, but as to me it had many of the appearances of a venereal sore, I decidedly said so, and on inquirv I found that there was still farther cause of suspicion. About three months before he was first attacked with rheumatism two small chancres appear- ed upon the penis, which were removed in the course of eio-ht or ten days by the application of caustic, and the use of a very small quantity of mercury. The quantity he could not exactly ascertain, but he knew that he had not taken it for a week, and that his mouth had never been sore with it. I also found, that nearly vol.. ti. 38 298 OF LUES VENEREA CI). 1V„ about the time at which his shoulder became sore an eruption had appeared upon different parts of his body, particularly among his hair and on his breast, but which till now he had not mentioned, as he had not supposed it to be of any importance. This, how- ever, along with the other circumstances of his situa- tion, determined me to advise a full course of mercu- ry, and which he the more readily agreed to from eve- ry other remedy which had hitherto been tried having proved ineffectual. He entered upon this course on the sixth of Octo- ber. At first half a drachm of the blue ointment was rubbed in evening and morning, and one of the blue pills, with two grains of opium were given at bed- time. The opium was necessary not only for pre- venting purging, but from the patient having been in the habit of taking it. At the end of ten days, as the mouth was not affected, nor any other symptom pro- duced by the mercury, the quantity both of pills and ointment was doubled. This, in the course of a fort- night, rendered the mouth exceedingly sore, and pro- duced some salivation; but the uneasiness excited by this was amply compensated by the relief which he had obtained. Although the pains in his joints had abated they had still given him much distress. This was almost entirely removed in the course of a day or two after his mouth became evidently affected, and being anxious to avoid the habit of taking opium, I found at the end of another week that he had left it off, and that he slept better without it than he had done for two years before. Still the knee continued nearly of the same size, but the sore on the shoulder was much better. Under the same dressings which he had for some time been using the surface of the sore soon became clean, the discharge was of a better con- sistence, and much less offensive, and in some parts new granulations had begun to appear. The mercury was continued in such quantities to the end of the third month as was necessary to keep tbe mouth completely sore during the whole period, and during the couise of the last of these months he Sec. ix. AS INDUCING OTHER DISEASES. 299 drank daily an English quart of a strong decoction of sarsaparilla, guiacum, and mezereon.* At the end of six weeks all the swellings of the smaller joints, parti- cularly those of the fingers, were entirely removed, and even the fulness of the knee was considerably re- duced. The sore on the shoulder was already con- tracted to one half of its former size, and at the end of another fortnight the whole of it was cicatrised ex- cepting those parts seated upon the carious part of the clavicle. At this time too the knee had assumed a very different appearance. It was not only much lessened but the flucU.ation above the patella was en- tirely gone. No application had been made to it but a portion of the mercurial ointment, which, morning and evening, was rubbed upon it. In the course of the tenth week a thin, long exfoliation took place from the clavicle, and the small sore which remained healed in a few days thereafter. He continued here for several weeks after the course was over, and on going away, although the knee was about an inch in circumference larger than the other, it gave him no uneasiness, not even in walking; but a very consider- able degree of stiffness remained in the joint of the right shoulder, and which I informed him might pro- bably continue for a great length of time, perhaps even for life, owing to a considerable portion of the deltoid musclehaving been destroyed by the ulcer. In order to lessen this stiffness as much as possible, I desired, as soon as the skin was sufficiently firm to admit of it, that the whole shoulder and arm should be rubbed evening and morning with some emollient oil, and if no relief was obtained from this, that he should go to Bath, and have the warm waters of that place pump- ed upon it. I found, however, after two years had elapsed, although in every other respect he continued well, that his shoulder remained in nearly the same Many cases have fallen under my care of venereal pains which resembled rheumatism so much that it was • Vide Appendix, Vol. I No. 46 300 OF LUES VENEREA ^b» 1V- difficult to distinguish of what nature they were ; but in a great proportion of these, circumstances were dis- covered upon enquiry, by which the distinction was sufficiently well marked. In this, however, as well as in some others which I have met with, the symptoms were for a long while so evidently rheumatic that there was not the least cause to suspect them to be venereal Venereal pains almost universally fix upon the middle parts of limbs ; very rarely upon the joints only. Now in this case the joints only were affected, as very com- monly happens in rheumatism, and the patient having beenmuch exposed to the most frequent cause of that disease, while no symptom occurred that had any ap- pearance of being venereal till these pains had contin- ued upwards of twenty months. The ulcer on the shoulder was the first symptom that created suspicion ; for when I prescribed the mercurial ointment, it was not, I must acknowledge, from thinking that the patient was infected with Lues Venerea, but from experience of its utility in similar affections of the joints proceeding from other causes. An officer of the navy, who had been exposed to hard service both in the East *and West Indies was seized vvith severe rheumatic pains in spring 1782. At first they were confined to the large joints, but after- wards a soreness prevailed over his whole body. He was about forty years of age, and till this time he had been strong and healthy. All the remedies usually employed in rheumatism were advised. Flannel was applied, and the pained parts were rubbed with a variety of stimulating appli- cations ; blisters were applied to the parts that were most painful; sudorifics were used in various forms ; and in the course of the first three years he had used a great variety of baths. He bathed at first in warm salt- water, and afterwards went both to Buxton and Bath ; and he had last of all used the cold bath. No advan- tage, however, was obtained from any of these ; and at last the only remedy which he employed was a large dose of laudanum at bed-time. He had frequently been liable to pain aud some de Sec. ix. AS INDUCING OTHER DISEASES. 301 gree of fulness in the region of the liver, which he at- tributed to his residence in India. This, however, never gave him much uneasiness, till the winter of 1785, when a soft diffused swelling, larger than it had ever been, and accompanied with some pain, was perceived exactly on the site of the liver. The tumour became larger, and at last a fluctuation of matter was perceived in it. In this situation I first saw him in the month of April ; and the chief reason of my being called was to judge of the propriety of discharging the matter by an operation. This, however, I found to be inadmissible. The matter lay so deep that it did not point any where, and the fluctuation was very obscurely felt. I there- fore in the mean time advised, that mercury, which he was then taking, should be given in greater quantities, so as to render his mouth completely sore, and, as he was much reduced in strength, that his constitution should be supported with light nourishing food. As he lived at a considerable distance I did. not ex- pect to see him again, neither did I hear any thing of him till the month of February thereafter when I was again desired to visit him. A considerable change had taken place in the nature of his complaints, and the following is the account which I received of it. His mouth had been rendered moderately sore with mer- cury, and in this situation it was kept for three wreeks; but as it then gave him severe pains in his bowels, ac- companied with purging, he did not afterwards use it in such quantities, nor was it judged necessary to do so, as the swelling, for which it was prescribed, was almost entirely carried off by what had already been done. It was therefore given in such quantities, as his stomach and bowels could easily bear; and this being continued for the space of a month longer, that is, for six or seven weeks in all, it was then left off. During this course of mercury the pains which had so long dis- tressed him were much less severe, and at one period they had left him almost entirely. While the weather continued mild in summer and harvest they did not re- cur ; but about the end of October they became more severe than they had ever before been. A few weeks. 302 OF LUES VENEREA Ctl. IV. however, previous to this, symptoms of a more hazard- ous nature had made their appearance. In the month of September he was attacked with anasarcous swell- ings of his legs, and soon thereafter vvith ascites, which, notwithstanding the usual remedies employed in such cases, increased so quickly, that in the course of seven or eight weeks from the first approach of the swelling, it became necessary to draw the water off from the legs by punctures ; and by the middle of December the distension of the abdomen was so considerable that the operation of tapping was judged adviseable. These operations, however, had procured only a temporary relief, for although the punctures had been frequently repeated, his legs, at the time of my being called to him, were much swelled, and his abdomen was more distended than at any period before the operation. The chief reason, however, of my advice being fa- ken at this time, was the appearance of some hard pain- ful tumours upon his forehead, legs, and arms, one of which upon his right arm on the outside of the ulna, and another on the upper part of the os frontis, had burst some weeks before, and were now discharging a considerable quantity of a thin foetid matter. The others, viz. two upon his forehead, one upon his left arm, and one upon each leg were become very painful, and those on the head were discoloured, and contained such a quantity of matter as gave reason to think that they would also burst. The patient was at this time much emaciated, but he had no fever, and his skin was softer and his discharge of urine more plentiful than they generally are in dropsical complaints. As the tumours resembled venereal nodes, and as the peculiar fcetor of the discharge from the ulcers, to- gether with their sloughy appearance, gave farther cause of suspicion, I found, upon enquiry, that in Sep- tember 1781, about six months before he was attacked with rheumatism, chancres appeared upon his penis, and a bubo in each groin, but that these symptoms were easily removed by the use of a small quantity of mercury, and a short confinement of eight or ten days, and that he had not since that period run any risk of AS INDUCING OTHER DISEASES. 303 being infected ; that no other symptoms of the disease had appeared upon him, and that the onlv mercury he had used was that which was prescribed'for the affec- tion of his liver. 1 now began to suspect even that the rheumatism with which he had so long been distressed was of the syphilitic kind, and my reasons for doing so were ap- parently conclusive. There was full evidence of in- fection being communicated while it did not appear that he had taken half the quantity of mercury which the nature of the symptoms that ensued would have re- quired. These pains occurred at such a distance from the other symptoms as tended to confirm the suspicion. They had not been relieved by any of the remedies which in the ordinary form of rheumatism prove for the most part useful, while they were for some time almost entirely removed by the mercury employed for the diseased state of his liver. These considerations, connected with the present appearances of the tumours and ulcers, determined me to say that he was poxed, and that he should begin to the use of such a quantity of mercury as his present situation would admit imme- diately upon the water in his abdomen being taken off, and which wras done that very day. Being afraid in his present state of debility of irri- tating his bowels by the internal exhibition of mercu- ry, he was desired to use it in the form of unction on- ly; and his legs being still much swelled and tender, he was made to rub it upon his arms and abdomen. In the course of a few days his mouth became sore, and at the end of a fortnight he discharged three or four English pints of saliva daily. This was more than we wished for, and he was desired to lessen the quantify of mercury ; but as his pains were soon almost entire- ly removed, and the distress which he had experienced from the tumours and ulcers being also much lessened, he was thereby so much convinced of the propriety of his present treatment that it was with some difficulty- he was prevented from carrying the course of mercury too far. Care, however, being taken, to support him with a light nourishing diet, and with a liberal useiof 304 OF LUES VENEREA Ch. IV. wine, of which he took a bottle daily, he was enabled to bear the effects of mercury better than one in his state of health might otherwise have been expected to do. At the end of eight weeks, during which period his mouth had been kept constantly and fully affected, he had used twelve ounces of strong mercurial oint- ment. His pains were now entirely gone; the ulcers were cicatrised; and the tumours were so completely removed, that excepting those on the fore part of the legs, none of them had left any fulness by which their former situations could be discovered. The matter contained in those upon the forehead, and which at one period was just ready to burst out, was entirely absorbed, and only a slight discolouring of the skin remained; but what was still more remarkable, no swelling had as yet. occurred in the abdomen, and the anasarcous fulness of his leg3 and thighs was almost entirely gone, although the punctures last made in them had been healed upwards of three weeks. The mercury was continued for five weeks longer, during which period four ounces of ointment was rubbed in, by which the mouth was kept as sore as the patient could possibly bear it; and when at the end of the thirteenth week the mercury was left off no collection could be perceived in the abdomen ; and excepting a slight degree of oedema on the upper part of the feet, they were altogether free of swelling. Even this dis- appeared in the course of a few weeks; and at the end of three years, when I had last an opportunity of hearing of him, he remained in good health. The circumstances of this case, while they give much cause to think that hydropic symptoms may be induced by the virus of Lues Venerea, tend also to shew that mercury given in sufficient quantity acts with equal certainty in removing them as in the cure of any symptom of the disease. They also evince the power of mercury in the cure of that affection of the liver to which many are liable who have resided in the East Indies ; and that even the most advanced sta- ges of that disorder may be removed by a quantity of mercury that will not be sufficient for the cure of Sec. ix. AS INDUCING OTHER DISEASES. 305 Lues Venerea. It also appears, from the result of this case, that the matter which sometimes forms in venereal nodes may be collected in considerable quan- tity, and yet carried off by mercury. It may be pro- per, however, to remark, that where this takes place the tumours in which the matter is contained begin to diminish almost as soon as there is. evidence of the mercury having entered the system; and that when they do not diminish the matter should be discharged by a proper opening, in order to prevent it from af- fecting the bone beneath. About two years ago I was desired by a gentleman to visit his wife, who I found had been liable for more than a year to what she considered as scorbutic spots upon different parts of her body, one of which, seat- ed on the sternum, had about three months before ended in an ulcer. At first the sore did not exceed the size of a sixpenny piece ; but at this time it was very extensive, reaching from one mamma to the other, and almost from the inferior point of the ster- num to the top of it. It was foul, and discharged a thin foetid sanies. For upwards of three years she had been distressed with almost a constant head-ach, which occasionally was so severe as to deprive her entirely of sleep for many days together, and on some occa- sions nearly of her reason. It did not, like the aguish head-ach, fix upon one spot, but affected every part of the head alike. She was now about thirty years of age, and her menstrual flux regular. Till attacked with these head-achs she was healthy and rather cor- pulent ; but now she was much reduced, being almost entirelv confined to bed with the violence of the pain, and she had scarcely any desire for food. Blood-letting, blisters, bark, cold-bathing, and a variety of nervous medicines, had all been tried in vain. The eruption upon the skin, as well as the ulcer on the breast, having the true venereal aspect, I enquired of the husband whether he had of late been infected or not: He said that he had not, but he candidly in- formed me, that soon after his marriage, which hap pened more than four years before, and when he had 206* OF LUES VENEREA CJh. IV, no reason to think that he was infected, for he had no connection with any woman for a fortnight before marriage, and after having remained well for a fort- night thereafter, a chancre had appeared upon the pre- putium. Immediately upon this being perceived he applied to a suigeon and was cured; and he had eve- ry reason to think th#t his wife had escaped; for al- though she had complained of a soreness in the puden- dum about the same period, it had gone so entirely off without any mercury being given, that the surgeon, by whose advice he was directed, had assured him, it must have proceeded from some other cause. He also recollected that soon thereafter a painful tumour had formed in one of her groins; but as it also went off without coming to suppuration, and without the assist- ance of mercury, he had supposed even that this symptom could not be venereal, particularly as she con- tinued in perfect health till attacked with the head-ach ; and no symptom of pox had ever appeared upon her, unless the eruption and ulcer already described should be of that nature. From the whole of this history, the probability of the wife being infected with the venereal disease, and the necessity of a mercurial course were abundantly evident. Mercury was accordingly exhibited. Opi- um, which she had hitherto employed for lessening the violence of her head-ach was continued, while the sore was dressed with common wax ointment. Her mouth became sore in the course of a few days, and before the end of a fortnight she was under some de- gree of salivation. The eruption soon began to les- sen, and the sore from being exceedingly foul became dean and florid, at the same time that the head-achs, 4or which no cure was expected, left her entirely; the mouth was kept completely affected; the blotches dis- appeared altogether in the course of six or seven weeks, but the ulcer was not cicatrised fill the end of the eleventh week. The mercury being continued three weeks longer was then laid aside, and neither the bead-ach or other symptoms have since recurred. SeC. I A. AS INDUCING OTHER DISEASES. 307 In the month of July 1781 a young man about seventeen years of age was put under my care in a Very miserable situation. The account which I re- ceived from his parents was, that till his fourteenth year he was remarkably strong and healthy, and ex ceedingly clever. About that period he became deli- cate, and was taken from school, in order to have full attention paid to his health. Worms, and a variety of Other causes were suspected to give rise to this state of delicacy, and various remedies were employed without effect, when after two years had nearly elapsed sores appeared on different parts of his body; his eyes be- came tender and inflamed, and at last he lost the use of one eye entirely, and about a year before I saw him he had been attacked with severe fits of epilepsy, which for the last two months had recurred several times a-day. .He was now much emaciated, but his pulse was good, and the fits had not impaired his judgment. Till this time he had been under the management of a physician, a relation of his own, who considering the complaint to be scrophulous, had prescribed bark, steel, cicuta, and sea-bathing ; all of which, as well as differ- ent remedies for the epileptic fits, having been tried in vain, all hopes of a cure were lost, and for a long while nothing had been employed. My opinion was asked on account of the ulcers, some of which had of late become so painful that large doses of laudanum were required to procure rest. Besides several small Ulcerated spots, there was at this time seven large foul ulcers on different parts of his body, none of which had given him much uneasiness while not deeper than the cellular substance ; but having in different parts penetrated into the substance of muscles, they began now to impede the motion of the parts, on which they were seated, which added much to the distress which thev excited. His left eye exhibited a very singular appearance. It was somewhat enlarged and that part of the tunica conjunctiva, which in a state of health is white was of a deep red colour, while all the promt* nent part of the cornea opposite to the pupil was much 308 OF LUES VENEREA Cll. IV. thickened, and vvhite like paper. He still retained the sight of his right eye, which, however, was much in- flamed, and in a state of great irritability. As the ulcers had a venereal appearance, particu- larly one upon the right side of his nose, and another on one of his temples, where it had penetrated to the muscle, I said so to the young man himself, and he confessed that he had all along been afraid of his dis- ease being of that nature, but-not being certain of this being the case, and afraid of incurring the displeasure of his parents, he had never till now, that inquiry was made concerning it, had the resolution to speak of it. The information he gave me was, that when he was about fourteen years of age he was infected by a wo- man with whom he had connection, and that his symp- toms had been sores upon the penis and a swelling in the groin. These, by the use of mercury, which he received from a young man, at that time a student in the university, were removed ; but as he had not taken it in a regular manner, and only in small quantity, he had always entertained suspicions of the symptoms which ensued being tlie consequence of this infection. 1 now decidedly said that he ought immediately to take mercury, and he entered upon the use of it that very evening. It was employed in the form of unc- tion, and all the sores, excepting that upon his nose, were dressed with common cerate, the only applica- tion which he had hitherto made to them. As the ul- cer upon his hose had already begun to disfigure his face, I advised it to be touched with caustic every se- cond or third day, in order to stop the progress of the disease as quickly as possible, and besides this it was dressed with basilicon and precipitate. As the mer- cury did not readily aff'eet his gums he was desired to take two of the blue pills every night at bed-time, and to continue to rub in the same quantity of ointment which he had used from the first, viz. a drachm evening and morning. In the space of three weeks from the commencement of the course a considerable salivation was induced, which was afterwards kept up by the unction alone till the end of the fifteenth week, The SeC. IX. AS INDUCING OTHER DISEASE^. 309 ulcers had become clean, and put on a healing apnear- ance soon after the mouth became sore, and by the end of the ninth week they were all cicatrised; but the infection having been of very long duration, and the symptoms more inveterate than usual, I did not think it proper to advise the use of mercury to be sooner left off*. The most remarkable circumstance, however, in this case was, the cure which took place during the course of mercury of the fits of epilepsy. In less than three weeks they became less frequent, and not so violent as they had been before, and by the end of the sixth week they did not recur above once in three or four days. Long before the course was finished they van- ished entirely, nor was he ever distressed with them afterwards. His left eye still continued white and opake, but the inflammation of the other being remov- ed, he soon recovered the free power of vision of which he had long been entirely deprived. A married lady, twenty-six years of age, after being for some time distressed with severe head-achs, was attacked with epileptic fits, which at first were neither frequent nor severe, but recurred at last so often that she was commonly seized with three, four, or even more, daily. . Preparations of copper and other reme- dies were employed without effect. In other respects her health was good, till at last, after the fits had been more than usually severe for eight or ten days, she became suddenly lunatic, from which time the epilepsy did not recur. In this situation she was kept at home for three or four months, but there being no prospect of her re- covering, she was at last put under the care of a fami- ly accustomed to take charge of lunatics. As her keepers were desired to apply to me in the event of her health requiring any particular attention, I was called to her after she had remained with them about two vears, in order to give directions for the manage- ment of some sores which had appeared in different parts of her bodv a considerable time before. Besides several small foul ulcers upon her toes and feet, there 310 OF LUES VENEREA Ch. iv. was a large one upon the wrist of her right arm; one upon her side, which had penetrated nearly to the ribs, and two upon the upper and back part of her head, where the cranium was found to be carious. These ulcers, they informed me, were preceded by an erup- tion, which they considered to be scorbutic, but which I found upon inspection to be venereal. On this being stated to her husband, he acknowledged that she might have been infected by him, but as she had never com- plained of any of the symptoms of Lues Venerea, he had hoped that she had escaped. A course of mercury was advised, but as her lunacy ■was of the most unmanageable kind, she could not be made either to take the medicine inwardly, or to ad- mit of the external application by unction. The latter might have been done by force, but the trouble of se- curing her twice a-day for that purpose would have been considerable. Finding that she was fond of oatmeal porridge, she was allowed to take them both to breakfast and sup- per, and vvith each meal her keeper was desired to mix a spoonful of a watry solution of corrosive subli- mate, in which was contained three quarters of a grain of this preparation. No obvious effect appeared from it till nearly the end of the third week, when her breath became affected, and her gums sore and spon- gy ; but although the same quantity of mercury wa? continued, no salivation took place. Simple dressings were applied to the sores. It became necessary, how- ever, to make an incision along a considerable part of the left parietal bone, in order to-discharge a quantity of foetid matter which bad lodged between the tegu- ments and a portion of that bone which was cnriou? All the rest of the sores soon put on a healing appear- ance'. In the course of nine weeks they were com- pletely healed, and during this period the maniacal symptoms also abated. In less than three weeks from the above period she became perfectly well, and no ap- pearance of lunacy has since taken place, although Feveral years have elapsed. The sore upon the left side of the head continued open for eigh* o»- nine rec. ix. AS INDUCING OTHER DISEASES. 311 months after the mercurial course Was finished, owing to an extensive exfoliation from the parietal bone, which could not possibly be accomplished sooner. These, as I have already observed, are only a few of a considerable number of cases of a similar nature which I might relate ; but as the evidence which these afford, of the opinions which I have suggested being well founded, may be considered as sufficient; any farther argument would be unnecessary. The histo- ries which I have given are in proof, that the syphili- tic virus may remain for a great length of time in the system, without producing any of the ordinary symp- toms of Lues Venerea: That other diseases altogether different from Lues Venerea in the form under which it usually appears, are, in some instances, induced by this virus. That the quantity of mercury commonly given in what is termed an alterative course may be sufficient for curing the existing symptoms of Lues Venerea, and yet altogether inadequate, however long continued, for removing the disposition. And lastly, although a course of the alterative kind may repeated- ly fail, that the syphilitic disposition, as well as the worst symptoms of the disease, may be removed by the proper exhibition of a full quantity of mercury. As a Supplement to this section, we intended to give an analysis of the works which of late years have been published on Diseases resembling syphilis, or more properly, on those complaints which originate either from an improper administration of the specific, from a failure in eradicating the virus of the disease, or from both combined. After however attentively perusing the writings of Aber- nethy, Mathias, &c. we have found the subject treated so exten- sively, and the opinions of surgeons so diversified, that it would be difficult to include a complete analysis within the compass of a few pages. The sterling merit of the above writers entitle them to a distinct perusal, and the reader will find much information both in the reasoning and cases of each.—The following works are among the most important. . Abernethy's Surgical Observations on Diseases resembling Sy- philis. Philadelphia. 1811. Mathias on the Mercurial Disease. Hunter's Chapter on Diseases resembhng Lues-. 312 OF LUES VENEREA, &C. Ctl. IV. Pearson, 2nd Edit. This distinguished Surgeon styles the dis- ease Cachexia Syphiloidea. Remarks on Diseases resembling Syphilis by Dr. Channing of Boston, in the New-England Journal, Vol. I.—together with Re- views of Abernethy and Mathias, in the London Medical Review, VoJ. 3rd. Ed.^ APPENDIX TO VOL. I. THIS Appendix contains formulae of injections and other reme^ dies tor Gonorrhoea, enumerated in the preceding work, No. 1. R. Calomel, pptt 5 ii. Mucilag. gum. arab. 5 ii. et adde Aq. rosar. 5 iv. No. 2. R. Calomel, pptt. £ ii. Balsam, copaib. 5 i- Vitell. ovi. ^ ss. M. et adde paulatim. Aq. rosar. 5 iv. No. 3. R, Hydrargyr. puris. Z ii. Mucilag. arab. 5 ii. M. S. A. et adde. Aq. distillat. 5 iv. These formulas of mercurial injections seem to act, as I have else- where observed, altogether as astringents. They excite little or no irritation and when they prove successful they commonly do so in the space of a day or two. In all of them the mixture requires to be shaked when used; for even with the assistance of mucilage the mercury subsides so quickly that scarcely any of it will enter the syringe, if this precaution be omitted. Instead of mucilage, prescribed in No. 3, I have sometimes em- ployed honey. This proves more expeditious for extinguishing the mercury, but the injection prepared with it excites more pain. Whether mucilage or honey be employed, the mercury should be Very completely tritured. No. 4. R. Lap. calamin. pptt £ ii. Balsam, copaib. J i- Mucilag. arab. 5 ii. M. S. A. et adde Aq. fontan. ? iv. No. 5. R. Lap. tutiae pptt. 9 ii. Mucilag. arab. 5 ii. M. et adde. Aq. fontan. 5 iv. No. 6. R. Lap. calam. pptt. ? iv. Camphor, in pauxil. spirit, vin. rect. solut. ? i, Mucilag. arab. 5 iv. M. et adde aq. fontan. lb. vj U"t fiat injectio. VOL. II. 40 314 APPENDIX. In No. 4, the quantity of the astringent earth is so small that it may be well mixed vvith the liquid at the'time of using it, but in Nos. 5 and 6, where there is a greater proportion of earth, after shaking the phial, it should be allowed to subside for the space of a minute before filling the syringe. In this manner the finer particles only of the earth are thrown into the urethra; and it commonly proves a,. effectual as when the whole of it is used. No. 7. R. Alumin, J iss. Solve in aq. distillat. 5 viii. No. 8. R. Cortic. quercus ? i- Coq. in aq. fontan. 5 xx. ad. 5 xvi. colatura: adde Pulv. alumin. 5 ii- No. 9. R. Gall, quercus contus. ? i. Coq. in aq. fontan. 5 xxx. ad. 5 xx. cola et adde. Pulv. Alumm. J m- No. 10. R. Kin. pulv. 5 ii. Mucilag. arab. 5 i. M. in mortario et adde aq. fontan. bul ? x, No. 11. R. Kin. pulv. J ii. Pulv. alumin. 5 i- Opii. 9 ii Mucilag. arab. 5 i. M. et adde. Aq. fontan. bul. 5 x. No. 12. It. Opii. 5 i- solve in aq. font. ? vi. No. 13. R. Aq. rosar. ? vii. ss. Tinctur. thebaic. 5 ss- M- In a great proportion of cases opium dissolved in water answer? the purpose ; but in a few instances I have found the spirituous tinc- ture, in the proportions here mentioned, prove more effectual. No. 14. R. Balsam, canadens. Vel. copaib. 5 *"• Vitell. ovi. 5 ss. M. et adde. Aq. rosar. 5 vi. When the balsam and yolk of an egg are previously well rubbed together, tne water may be mixed with them so completely that no great degree of separation will afterwards ti>ke place; but to pre- vent any inconvenience which might ensue from the balsam getting to the top of the mixture, it should always be well snaked imme diaiely before the syringe is filled with it. No. 15. R. Ceruss. %, ii- Mucilag. arab. 5 ii- M. et adde. Aq. fontan. distil, z vi APPENDIX. 31') No. 16. R. Sacch. saturni. ^ i. Solve in aq. distil. ? viii. No. 17. Aq. distil. 5 viii. Acet. lythargyr. gutt. xxiv. M. When saccharum saturni, or cerussa acetata, as it is now termed^ can be obtained pure, it is perhaps preferable for every purpose to vinegar of litharge, as being of a more determined strength ; but it 's frequently so much adulterated that it will not dissolve but in very snuiil quantities, even in distilled water. Some of it indeed is so very insoiuole, that an ounce of water will not dissolve above a grain of it. By the addition of vinegar this may, it is true, be part- ly remedied ; but vinegar, for many purposes, is not admissible in such quantities as would be necessary for rendering this article much more soluble than we usually find it. Two, three, or more drops of the vinegar of litharge may be used in every ounce of in- jection. Two drops often prove sufficient, but many can bear eight or ten. The following method of preparing vinegar of litharge is the best I have met with. It is not very different from the extract of lead of Goulard, but the strength of it is more certain. • R. Lythargyri fe iii. Acet. distillat. J-^ x. coq. leni igne ad. fjj vi Cola. Besides boiling on a slow fire, during which time it ought to be well stirred with a wooden spatula, tiie whole should be allowed to cool, and the faeces to subside before straining. ' Lead dissolved in this manner is easily mixed with water, and it proves to be a very convenient, as well as a very effectual method of using it. No- 18. R. Zinci vitriolat. vulgo vitriol, alb. 3 ss. Solve in aq. font, distillat. r xvi. No. 19. R- Zinci vitriolat. 7} i. Solve in aq. distulat. ~ x. et adde. Acet. lythargyri gutt. xx. ut. f. mjectio. In some cases, where these articles have excited pain when used in tnis manner, they have been rendered perfectly mild by the addi- tion of mucilage of gum arabic, and in others by camphor. Cam- phor does not dissolve completely in any watery fluid, but being previously well rubbed with a few drops of spirit of wine, as much of it may be mixed with the water as to render the other articles much less pungent than they otherwise would be. The camphor, however, separates in such quantities as renders it necessary to fil- ler the solution before using it. 316 APPENDIX. Although a precipitation necessarily takes place from a mixture of vitriol and saccharum saturni, the following combination of these two articles with opium' gives a very useful form of injection. No. 20- R- Vitriol, alb. Sacchari saturni. aa 5 ss- Camphor, 5 i- Opii. 9 ii. Solv. in aq. fontan. bul. 5 xvi. Cola. No. 21. R. Fol. rosar. rub. 5 ss. Alumin. pur. 5 n- infund. in aq. bul. ? xvi. Cola. ut. f. in: jectio. No. 22. R. Balsam copaib. Vitell. ovi. aa 5 ss. M. et adde. Infus. rosar. rubr. ? xvi. No. 23. B. Cap. papaver. alb. 5 iv. Rad. althese incis. 5 i. Inland, per noctem in aq. bul. Jf> ii. Cola. No. 24. R. Hydrargyr. muriat. vulg. mercur. bublimat. corrosiv gi*. I . Solve in aq. fontan. 5 x. No. 25. R. Mercur. sublim. corros. gr. 1. Acet. lythargyr. gutt. xvi. Aq. fontan. 5 viii. M. S. A. No. 26. Mercur. sublimat. corros. gr. 1 Mucilag. arab. 5 h. Aq. fontan. 5 vi. M. Corrosive sublimate dissolved in water proves to be the most cer- tain, and perhaps in every respect the best form of a stimulating injeetion. Some have advised a much stronger solution than any of the^e, even to the extent of a grain,of mercury to three or four ounces of water I suspect, however, that those who recommend it of this strength have never made use of it, at least I hare never met with any who could bear it. When the mercury is combined with water alone, as in No. 24. one grain to ten ounces proves suffi- ciently stroiig; but when mixed with saccharum saturni, with ace- turn lythargyri, or with mucilage, as in Nos 25. and 26. a grain may be added to six or eight ounces of water. When mixed with either of the two first of these articles, some part of the mercury precipitates, and is therefore lost, and in the other the mucilage tends evidently to render it less active. No. 27. R- Sal. ammon. crud. gr. x. Solve in aq. font. § x, APPENDIX. 317 No. 28. R. Aq. fontan. g x. Spirit sal. aromat. gntt. lx. M. No. 29. R. Aq. fontan. | x. Spirit, corn, cervi gutt. lx. M. No. 30. R. Formul. inject. No. 23. § viii. Lixiv. caustic, gutt. xx. M. I have frequently found both the volatile and caustic alkali prove useful where other injections had failed, but we cannot with any cer- tainty point out the strength for any individual. While one is able to bear ten drops to every ounce of water, others cannot bear above three or four: The strength I have advised in the three preceding formulae proves to be the best for general use, but patients are more easily affected with variety in the strength of these injections than of any other I have ever tried. The caustic alkali may be used in water alone ; but may be ventured upon in larger quantities, and with more safety, when combined with a mucilaginous infusion= No. 31. R. iErug. pptt. gr. viii. Ol. oliv. Opt. 1 iv. M. Ho. 32. R. ^rug. pptt. 5 i. Spirit, corn. cerv. § iv. Digere et cola. R. Solut. supr. parat. gutt. xl. Aq. distillat. § x. M. Verdigris mixed with dil may be used with perfect safety of the strength mentioned in No. 31, but as injections prepared with oil prove dirty and disagreeable in the application, I commonly prefer the form of the remedy No. 32. A much larger proportion of verdigris is commonly advised, but when more is employed, it precipitates immediately on being added to the water. Even of this strength the precipitation cannot be pre- vented entirely but by adding about a half more of the volatile alka- li to the filtered solution of the verdigris. After filtrating through paper, if two ounces of volatile alkad be added to it, no precipita- tion will take place if distilled water is employed ; but in this case, a greater quantity of the solution may be added to the same quantity of water. Instead of forty drops, forty-eight or fifty may be added to-ten ounces of water. No. 33. R- Aq. fontan. § x. Timctur. cantharid. gutt. xx. ad xxx. M. The three following are prescriptions for bougies. No. 34. R Emplast. diachyl. simpl. § iv Cer. puriss. § iss. Ol. oliv. opt ^ iiJ 318 APPENDIX. No. 35. R. Emplast. commun. Spermat. cxt. aa § iv. 01. oliv. opt. § ss. Minii. g ss. M. No. 36. R. Emplast. commun. § vi Cerse flavx puriss. Spermat. cxt. aa § ii. Ol. oliv. opt. | i. Antimon. crud. pptt. § ss. M. S. A. Any of these prescriptions afford a good composition for bougies, They require to be slowly melted, and the different articles" to be well mixed together. No. 34. is the simplest and perhaps the best, the red lead in No. 35. and antimony in No. 36. being added chiefly for the purpose of affording variety of colour. No. 37. is a com- position for bougies recommended by Mr. John Hunter,* and No 38. by Mr. Sharp.f No. 37- Take oil of olives three pints, Bees wax one pound, Red lead a pound and a half. Let them be boiled together on a slow fire for six hours. No. 38. R. Diachyl. cum pice burgund. § ii. Argent, viv. g i. Antimon. crud. pptt. g ss. The quicksilver to be previously dissolved in balsam of sulphur, or in honey, and added to the plaster when melted in a moderate heat. Any of these compositions, when boiled to a proper consistence, will answer for the formation of bougies, which is done in the fol- lowing manner: While the liquid still continues warm, let a piece of fine old linen be dipped in it, taking care vvith a spatula to cover the whole of it. If the melted liquor be of a proper heat, no more of the plaster will adhere to the linen than is necessary; but as air bubbles are apt to rise and produce inequalities on the surface of the cioth,the spatula made use of should be somewhat warmer than the plaster, and by means of it the whole should be made as smooth as possible. The plaster might indeed be spread entirely with the spatula ; but this is not only attended vvith more trouble, but it does Hot cover the cloth with sufficient equality. The cloth being sufficiently cold, may be immediately formed in- to bougies, and the whole should, in the first place, be cut into the number that is meant to be made. The most exact method of doing this is by means of a sharp pointed knife directed by a rule. Tne pieces should be eleven inches in length for bougies of a full size; but they should likewise be kept of all the variety of lengths for strictures of different heights in the urethra. * Sec Treatise on the Venereal Disease, p. 137. j See Critical Enquiry by Samuel Sfiarp, F. R. 6. &c. AM-ENDrX. ^19 A ■variety of directions have been given for the iorm of bougies. Some ar'vise them to be made nearly of an equal thickness to within an inch of their smallest end, and to taper from that to the point, while a great proportion of them are made to taper to within an inch or two of the point, and the rest of them are cylindrical. I once thought that thjs last form of bougie was the best; but altera long course of experience in this branch of business, I am now con- vinced, that bougies, which taper equally irom one end to the oth- er, are the best, and that this form answers equally well for every variety of size. They arc introduced more easily, and with less pain than any of the others; the linen should therefore be cut in such a manner as to give this form to the bougies. When rightly spread, and the linen sufficiently fine, a well shaped bougie will be form d of a slip of about five eighths of an inch broad at its largest end, and somewhat more than three eighths at the smallest end. This forms a bougie of a middle size ; for particular purposes they must be considerably larger, and for others not so large by a great deal. These slips of linen are now to be rolled up as rieatly as possible with the fingers ; and in order to give them a smooth polished sur- face, they should be smartly rolled between a piece of smooth hard timber, and a plate of fine polished marble : This being continued till the whole are rendered perfectly smooth and firm, and their points being properly rounded in order to facilitate their introduc- i tion, they are in this state to be kept for use. These directions will convey an idea of the method of preparing bougies, but no surgeon can ever become so expert in forming them as those artists who are daily accustomed to prepare them in large quantities. I must here again observe, however, in addition to what I had occasion to remark in a former part of this work, that bougies, properly prepared with resina elastica, are preferable, in many circumstances, to such as are made with any kind of plaster. They not only prove much more durable, but more force can be em- ployed with them, and as they do not break or crack by remaining in the urethra, they remain in it with less pain and inconvenience than any otherbougie that has yet been invented. Cat-gut has frequently been used as a bougie; but after various trials being given to it, I do not find that it answers the purpose : It cannot be made sufficiently smooth, and it sometimes swells so much as to excite a good deal of irritation ; and lead, which was one of the first articles used for bougies, is so firm that it always creates much pain, while at the same time it is so apt to break that different instances having occurred of this happening in the urethra, it has now been long laid aside. The six following prescriptions are meant for the removal cf warts and other excrescences, and they answer equally well whether they proceed from Gonorrhoea or Lues Venerea. It would appear, how- ever that there is a material difference between the warty excres- cences which occur as a consequence of these diseases, and such as 320 APPENDIX. we usually meet with from other causes; for while the former are for the most part easily removed by any of these applications, even by the pulvis sabinae alone, the latter are seldom acted upon by any of them, if it be not by the strong solution of corrosive sublimate in No. 40. and of mercury and spirit of nitre, No. 41. both of which are possessed of a strong degree of causticity. No. 39. R. Sal-ammon. crud. ? i. Solve in acet. distillat. ? ii. Aq. fontan. § iv. No. 40. R. Hydrargyr. muriat. vulgo. mere, sublim. corros. Sal-ammon. crud. aa § ss. Solve in aq. fontan. § iv. No. 41. R. Argent, viv. § i. Solve in spirit, nitr. fort. oz. ii. No. 42. R. Pulv. fol. sabin. Calomel, aa g i. M. No- 43. R. Pulv. fol. sabin. Mercur. sublim. corros. aa J hi- Mercur. precip. rub. J i- M. No. 44. R. Alumin. ust. Mercur. precip. rub. aa J i- M. The following form of decoction of sarsaparilla and mezereon is of a strength which most people can bear; when a greater propor- tion of mezereon is added, it excites sickness, and a very disagree* able sensation in the throat. I mention it here as I have had occasion to speak of it in the preceding work ; and I shall also have cause to refer to it when treating of Lues Venerea. No. 45. R. Rad. sarsa. § ii. Cortic. radic. mezer. J iss- Coq. in aq. fontan. lb. hi. ad. lb. ii. Colaturje, adde. Syrup, althea § i. The following is the Decoctum Lusitanicum, or Lisbon diet*drink. No. 46. R. Rad. sarsaparil, Santal. alb. Rubr. aa. § iii. Rad. glycyrhiz. Mezerei. aa. oz. ss Ligni rhodii. Guaiaci. Sassafras. 55. oi. r APPENDIX. 321 Antimon. erud. ? h- misce, et infunde in aquae foivtanx bul- lientis. lb. x. per horas xx.v. d^eii, coqite ad lb. v. cola-: turx capiat, a lb. iss. ad. lb. iv. quotidie. Vel R. Rad. sarsaparillae. . Ligni sassafras. Ligni santal. rubri. Guaiaci aa. -jt iii. Cortic. rad. mezer. % i. Semin. coriand. X vi. Coq. in aq. fontan. lb. xx. ad. lb. x Sumat lb. ss. ter quaterve indies. Unguentum e calce zinci. No. 47- R- Olei olivarum opt. 5 iii. Cerae albae. Sperm, cetac aa. J iii. Leni calore hquesc. dein adde. florum zinci 5 ss Unguentum e lapide calaminare. No. 48. R- Olei oliv. opt. ? iii. Cerae alba. 5 iss. Sperm, ceti. $ ss. Lapid. calamm. pptt. 3 v. M. S. A, VOL. II. THE following Appendix contains formulae of all the medicines erumerated in the second volume, as well as of some others occa- sionally employed by other practitioners in the cure of Lues Vene- rea. No. 1. Emplastrum hydrargyri,vulgo, Emplastrum cteruleurn, vel mercuriale. Ph. Edin. R. Olei olivarum. Resinae albae utriusque partem unam. Hydrargyri partes tres. Emplastri lythargyri partes sex. Cum oleo et resina, liquefactis simul, et dein refrigeratis, teratur hydrargyrus, donee evanescant globuh ; turn paulatim addatw eroplastrum lythargyri hque. factum, et omnia accurate nusceantur. V©L. H. 41 322 APPENDIX. Unguentum hydrargyri fortius, vulgo, Unguentum mercuriale. Phann. Lond. No. 2. Hydrargyr. purif. P. libras duas. Adipis suula preparatae P. uncias tres et viginti, Sevi ovilh preparati P. unciam unam, Tere primum hydrargyrum cum sevo et tantillo adipis suillae, donee globulj visum fugerint; dein adde quod rehquum est adipis, ut fiat unguentum. Unguentum hydrargyri mitius. R. Unguentum hydrargyri fortioris partem unam. Adipis suillae preparatae partes duas, misce. No. 3. Pilule, hydrargyri, vulgo, Pilulte mercuriales. Ph. Edin. R. Hydrargj'ri. Manna, utriusque unciam unam, pulveris gljcyrrhizae uncias duas. Tere hydrargyrum cum manna in mortario vitreo, donee illius globuli visum penitus effugennt, addito prout opus fuerit, mucilaginis gummi arabici idi quantum; dem pulverem glycyrrhiza: adject, et aqua fiatmassa, statimdivi- denda in pilulas quadnngentas octogmta aequales. No. 4. Solutio mercurii gummosa, vulgo. Plenk's solution. R. Mercurii vivi depuratissimi X i. Gummi Arabici J ii. Terantur invicem in mortareo lapideo, addito medio, coclileari aquas fumariar, donee mercurius penitus dispareat in mucum. Exacte subactis admisce sen- ijttm conterendo. R. Syrupi kermesini 5 ss. Aquje fumanae 5 viii. Sum. mane et vespere, cochlearia duo. Solutio Mercurii Alia. R. Hydrargyr. puriss. J ii. Gummi Arabici 5 ss. Terantur invicem in mortareo lapideo, addito medio, cochleari aqus, donee Jiydrargyrus in mucum dispareat. Huic subacto adde. Aquae fontanae 5 ix. No. 5. Mel Mercuriale, R. Mellis ; Hydrargj'ri, utriusque unciam. 1ZT™ ^ mortareo marm°i'eo donee hydrargyri giobuli non amplius appa- APPENDIX. 323 No. G. Hydrargyrus cum creta, vulgo, Mercurius alkalisatus. Ph. Lond. R. Hydrargyri purificati uncias tres. Cretae preparata uncias quinque. Tere simul, donee globuli visnm fugerint. No. 7. Hydrargyrus calcinatus, vulgo, Mercurius calcinatus, Ph. Lond. R. Hydrargj'ri purificati libram unam. 11 j drargyrum in cucurbita vitrea, cui fundus planior sit, in balneo arena caloris 000°, cxponc, donee in pulverem rubrum concrevcrit. No. b. Hydrargyrus muriatus corrosivu*, vulgo, Mercurius sublimatus corrosivus. Ph. Ed. R. Hydrargyri. Acidinitrosi diluti, utriusque uncias quatuor. Muriae exsiccata, Ferri vitriolati exsiccati, utriusque uncias quinque. Solvatur hydrargyrus in acklo nitroso, et vaporet solutio in massam albam penitus siccam ; dein adde inuriam et ferrum vitriolatum. Bene contrita et commixta mdantur phiala, quam fere dmudiam impleant; et ex arena, primum igne leni, postea sensim aucto, subhmentur. No. 9. Hydrargyrus muriatus mitis, vulgo, Cdlomelas, sivc mercurius duicis. R. Hydrargyri muriati corrosivi, in mortarib vitreo triti un» cias quatuor, Hydrargyri uncias tres cum semisse. IVrantur simul in mortario vitreo ad extinctionem hydrargyri; pulvisque pin da oblonga, cujus tertiam tautum impleat partem, inditus, ex arena cahda subhniatur. Sublinuitione peracta confractaque phiala, pulvis rubens c.rca fundumet albicans circa collum ejus pariter rejiciendus est, massa vero rehqua, ter quatuorve denuo sublimando, ct in pulverem tenuissnuum torenda. j«j0# io. Solutio mercurii spirituosa. TX. Mercur. sublimat. corros. gr. x. Solve in spirit, via. gallic ^ *vi- No. 11- pilulcz e mercurio sublimato corrosive*. R. Mercurii sublimati corrosivi. S.Jhs ammoniaci, utriusque grana decern. Aqua distillata drachmam. Conscrva rosarum scrupulos duos. Pulveris nuLc: • giycjiTluza,-q. s. ut. f. massa in pilul.i; octaginta dividetukt 321 APPENDIX. No. 12. Aqua phagadenica. R. Mercurii sublimati corrosivi scrupulum unum. Solve in aqua calcis hbram unam, No. 13. Hydrargyrus ?iitratus ruber, vulgo, Mercurius preci- pitatis ruber. Ph. Edin. R. Hydrargyri. Acidi nitri diluti, utriusque libram unam. Solvatur hydrargyrus, lentoque igne vaporet solutio in massam albam sic- cam ; qua in pulverem contrita, et cucurbita vitrea indita, torreatur igne- sensim aucto, materia assidue bacillo vitreo agitata ut aquahter incalescat, donee ejus paiixillum, cochleari vitreo exemptum et refrigeratum, squamidas spiendentes rubras exhibeat. Turn vas ab igne removeatur. No. 14. Unguentum Hydrargyri JV'itrati, vulgo, unguentum CU trinum. Hj'drargyri unciam unam. Acidi nitrosi, uncias duas. Axungia porcina libras duas. Digere hydrargyrum cum acido nitroso super arenam calidam, ut fiat solutio, quam cahdissimam adliuc misce cum axungia porcina liquefacta, et denuo frigescente ; stienue dein nusturam subige in mortario vitreo, ut fiat unguen- tum. No. 15. Hydrargyrus precipitatus cinereus, vulgo, Pulvis mer- curii cinereus. Ph. Edin. R. Hydrargyri. Acidi nitrosi diluti, paria pondera. Misce ut solvatur hj'drargyrus, solutum aqua pura dilue, et adde aqua am- monia quantum satis sit ad hj'drargyrum penitus ab acido liberandum ; pulvis dein aqua pura lavetur et exsiccatur. No. 16. Hydrargyrus vitriolatus favus vulgo, Turpethummi- neralc. Ph. Lond. R. Hj'drargyri purificati libram unam. Ac.di vitriolici uncias quindecem. . Mista in vase vitreo, gradatim incalcscant donee coeant, et materia igne acri penitus exsiccetur. Hac, plurima aqua distillata cahda afliisa, statim flaves- cet, et in pulverem fatiscet, pulverem tere cum hac aqua in mortario vitreo. Postquam pulvis subsederit aquam effunde, ct aqua distillata lava matericm donee saporis expert fuerit; \o, 17. Pilulx e mercurio acetato, vulgo, Trochisci Kcyseri. R. Mercurii acetati. Manna puris. Pulv. gum. arab. utriusque 3 '• Aqua rosa, q. s. ut. f. massa in pilulas sexaginta dividenda. APPENDIX. 325 >Jo 18. Pilulx e mercurio tartarisoto. R. Mercurii tartarisat. 5 i- Pulv. rad. glycyrrhiz. Conserv. rosa. utriusque 3 n- ... Mucilag. gum. arab. q. s. ut f. massa in pilulas sexaginta $31' denda. No. 19. Gargarisina e borace. R. Borac. pur if. 5 i. Solv. in aqua iontana bullienti9 libram unam, et ftdjte- Mellis optim. uncias duas. }j0, 20. Pilulx Plummeri. R. Calomelanos. Sulphuris aurat. antimon. utriusque unciajt}. Conserv. Rosar. q. s. ut fiat massa. .No. 21. Decoctum ligni guaiaci. R. Rasur. ligni guaiac. ^ iss. Rad. glycyrrhiza 5 ss. Coq. m aq. fontana lb. ii. ad. lb. iss. Colatura adde. Saccari, q. s. j^0i 22. Decoctum sarsaparilla. R. Radicis sarsaparilla fissa ^ iii. Aqua bullientis libras tres. Infundantur per horas quatuor, dein expresso liquore probe-^jj^^ cm iterum adjice liquore m. Macera per horas sep.em, postea coque ad IjDrtt duas, et fortiter exprimendo cola. jj0# 23. Decoctum rad. mezerei. R. Corticis radicis mezerei, drachmam. Radicis glycyrrhiza, drachmas duas, Aq. fontana libras tres. Coque ad libras duas. Colatura adde. SjTup. althea unciam unam. No 24 Pulvis ipecacuanha composite, vulgo, Pulvis Dover:, ? ' Pharm. Lond. R. Ipecacuanha, Op;, purificati duri, singulorum in pulverem tritorem drachmam unam. Kali vitrwlati in pulverem tnti unciam unam Misce. 326 APPENDIX, No. 25. Unguentum mercuriale albulu.. R. Unguent, simphc. Ph. Edin. uncias duas. Calomelanos drachmas duas. Misce. No. 26. Unguentum mercuriale rubrum. R. Unguent. Basilic. Pharm. Edin. unciam unam. Mercur. prec.p. rub. pptt. drachmas duas. Misce.- No. 27. Unguentum ex JErugine. R. Unguent, basdic. Pharm. Edin. unciam unam. iEmgims pulv. scrupulum unam. Misce. No. 28. Unguentum saturninum. Pharm. Lond. R. Cerussa acetata drachmas duas. Cera alba P. uncias duas. Olei oliva M. libram dimidiam. Cerussam acetatam, in pulverem tritam, cum aliqua olei parte contere ; dednde cam C* 'a, cum oleo rehquo liquefacta, adde. Misturam agita donee refnxerit. No. 29. Lirdmentum cere. Pharm. Lond. R. Cera alba P. uncias quatuor. Spermatis ceti P. uncias tres. Oiei oliva M. libram unam. Lento igne liquefacta assidue acriterque agita, donee refrixerint No. 30. Linimentum lapidis calaminaris. R. Olei olivarum M. libram unam. Cera alba P. uncias duas. Lapidis calaminaris praparati, P. unciam unam. M.S. A No. 31. Emplastrum lithargyri, vulgo, Emplastrum commune. Pharm. Edin. * R. Lithargyri partem unam. k Olei olivarum partes duas. Ajjecta aqua, ccquc, assidue agitans, donee oleum ct Llthargjrus cocan' la emplastrum. No. 32. Muriated Bar-jies. This preparation is obtained by dissolving aerated barytes in the muriatic acid. The process is not difficult, and I meant to ,'uive ^iven a form of it; but as this article has never til! of late been used us a medicine, as some varieties of the terra ponderosa have lately keen discovered, and as it requires some discernment to distinguish Uicm, I think it better, m a point of such importance, to refer to a APPENDIX. 327 more particular account of it than could be inserted in this place. This is the more necessary, as the medicine, even in its purest state, is f a nature that requires to be used with much caution ; and particularly as many specimens of barytes are found to contain considerable quantities of lead, copper, and arsenic. The paper to which I allude is written by Doctor Adair Crawford of London, and is inserted in the second volume of Medical Com- munications. Doctoi Crawford, besides giving an accurate detail of the effects of this medicine in several cases of scrophula and cancer, gives directions for detecting the admixture of other sub- stances, and for regulating the doses. The close ought at first to be very small, not more than four drops for an adult, and two for children of eight or ten years. I have found, however, that when increased in a gradual manner, thirty drops maybe given to an adult, and repeated two or three times a day ; but as Doctor Crawford very properly observes, the quantity should not be farther augmented, after it begins to excite nausea or any disagreeable symptom. I even think, that in such circumstances, it should, for a few days, be omitted, and the dose lessened on beirg again entered upon. In the trials that I have made with it, no harm has ever been done by it, while in different cases of obstinate sores, proceeding from scro- phula, as well as other causes, it has evidently proved useful. Since I had occasion to mention this remedy in a former part of this work, I have given it in twelve different cases; but as most of these are still under cure, I cannot, with propriety, give a detail of them. I may remark, however, in general, that the more experience I have had of it, the more I am pleased with it. Where no effect has been produced by it on the disease for which it was prescribed, it has sel- dom failed to excite appetite, and to improve the strength and gene- ral health of the patient. I therefore consider it as an important ad- dition to our list of tonics. Hitherto the solution which I have em- ployed has been procured from London; but as I expect soon to be supplied with a quantity of terra ponderosa, I mean to have it pre- pared here- Mate I. * l'u/. »*;P£#V* * * Jtlaccli. -Ftp4. 2ry. 4. X.Fi&.3. Fig. 3. Fig. 4 Fu/ 2 Fiff 7 EXPLANATION OF THE PLATES. We have added to this edition, the plates of Mr. Charles Bell, il- lustrating the morbid anatomy of the urethra and also delineating the instruments which he prefers in removing strictures in the ure- thra. See Note to chap. 3d. sec. iv. vol. 1. p. 170. Plate V. is taken from Mr. Whately's Essay on an improved method of treating strictures in the urethra, and represents the form of the bougies which he uses and also the manner in which he introduces his fa- vourite remedy, the Kali purum. PLATE I. Fig. I. In this figure is represented a firm stricture with an irregu- lar ulcerated surface. The whole penis is not represented, but only the spongy body of the urethra, and a few inches of the canal. A A. The corpus spongiosum urethrae. 13. The urethra cut up to show the lacunae and the stricture. C. The part of the urethra below the stricture. D. The stricture with a peculiar reticulated surface, the effect of ulceration. E E. A callous portion of the spongy body of the urethra. The cells being condensed and closed, and now forming the principal seat of the stricture. Fig. 2. This figure was tal^en from Mr. Hunter's work before I had ascertained its incorrectness. I thought that the form of the spongy body at the place of stricture was a c< nsequence ot ihe stricture, but on examining the preparation, I find it to be a pure example of the stricture, by a bridle or small filament, as ex- pressed in plate II. fig. 1. B. A A. Corpus spongiosum urethrae. B B. The internal surface of the urethrae. C. The stricture. Fig. 3. In this rough etching there is represented a stricture of the oesophagus, to shew that the narrowing of the passage was not a consequence of the muscular coat contracting, but a deposition of coagulable lymph betwixt the inner coats: the oesophagus is cut directly across at the contracted part. A. The muscular coat, or tunica vaginalis gulae. B. The thickened internal coats. C. Tne passage diminished, so as not to admit a crow quill. Fig. 4. This represents the effect produced upon the urethra, by a stone sticking in it. A A. The body of the penis. . B B. The corpus spongiosum urethrae. C. The place of the urethra in which the round stone stuck. D D. Shreds of coagu.'ablc iymph which were thrown out on all the surface of the urethra, a sufficient proof of the violence VOL II. 12 330 EXPLANATION OF THE PLATJ-.S. of that infiammation, which reaching the bladder, occa- sioned the patient's death. PLATE II. Fig. 1. This plate represents a considerable portion of the urethra^ with its surrounding spongy body and the prostate gland. A A. The urethra. B. Two filaments forming a stricture, which during life power- fully resisted the introduction of a large bougie. C. Another stricture of the same kind, behind which there is the appearance of a little sac into which the bougie is often hitched.* D. Another little cord on the nearer side of the urethra : it will be observed, however, that this cord did not stand across the urethra, as might be imagined from the appearance presented here, it was like B or C; but to demonstrate the firm nature of it, I cut away the membrane of the urethra.t E. Little warty excrescences, which, however, the engraver has but very imperfectly represented, they ought to have been more agminated and prominent. F. The ducts of the prostate gland enlarged into great cells, which would very readily receive the point of the largest catheter. Such cavities I believe to be the source of the worst kind of fistula in perinaeo. G. The caput gallinaginis. Fig. 2. Represents the point of the bougie, as it often appeared when introduced during the patient's life. I saw the danger of forming a false passage in this indication of a sharp line cutting the point of the wax bougie. Fig. 3. The bougie, as it often appeared when withdrawn from the urethra of the same patient. In this case the point had not enter- ed the proper passage, nor struck against the ligamentous fila- ment, but had gone betwixt the filament and the side of the ure- thra, so as to make a sac (c. fig. 1.) If this had been persevered in, a false passage would inevitably have been formed. To avoid this, I was careful never to allow the bougie to remain, unless the resistance to withdrawing it proved it to be wedged in the proper canal. * This is of the nature of the folds of tlie membrane of the urethra, re- sembling the valve of a vein which has been described by Goulard and De sault. | After much doubt of the accuracy of my first observations regarding the nature of this stricture, and at last having repeated opportunities of satisfying myself, both of its existence and its very frequent occurrence, I find by turning my attention to Desaidf traite des ^Maladies des voies urinaires, that I mignt h;ive saved myself any anxiety on this point, for there I find a very accurate description of this obstruction to the urine, ''par des brides' But he considers these ligamentous filaments to be an effect of ulceration, condemns the use 0.1' the caustic, and recommends the use of tlie elastic gum bougie. EXPLANATION OF THE PLATES. 331 The appearance of a valve is probably formed by the point of the bougie pressing betwixt the filament and side of the urethra. The kali purum was applied three times to this stricture, but no sloughing or erosion, or effect of any kind is apparent. Fig. 4. This represents the urethra slit up to show the effects of the lunarcaustic on stricture. A A. The glans penis. B B. The body of the penis. C C. The spongy body of-the urethra. D. The urethra behind the stricture. E. The stricture. F. Coagulable lymph accumulated behind the stricture, a certain proof of their having been much inflammation there. G. Loose shreds of a very fine membrane, where the caustic had been applied. It would appear from this case, that if the proper stricture had been destroyed, still the coagulable lymph accumulated behind, would have been a cause of obstruction to the urine. The inflammation on the part of the urethra behind the stricture, and on the inside of the bladder, produced such irritation that the patient died. PLATE III. This etching represents the effect of stricture on the bladder. A A. The walls of the bladder greatly thickened. B. Much coagulable lymph behind the stricture of the urethra, and at the neck of the bladder. D. Membranes formed of coagulable lymph hanging from the inside of the bladder. E. E. Firmer masses of coagula attached to the inside of the bladder. These are sufficient indications of the degree of infiammation and the suffering of the patient. Disease to such an extent as this reduces the patient to a state of irritability that will permit nothing to be done. PLATE IV. Fig. 1. The urethra cut open to shew a long contraction in it, and a wasting of the spongy body. A. The urethra anterior to the stricture. B C. The urethra contracted for near three inches in its extent. D. The urethra very dilatable behind the contraction. Fig.'2. Urethra sounds of different sizes: the wire is made of sil- ver, and of the length of a common bougie, the ball is rivetted on, a perfect globe, and highly finished; the balls ought to be of various sizes, from the diameter of the largest to the smallest bougie, but four sizes will generally be found sufficient. Fig. 3? The urethra sounds having the balls perforated for the lodge- ment of a small portion of lunar or alkaline caustic. The intention of this instrument is to introduce the caustic upon the dilatable stricture, or to a common stricture, where the rib- 332 EXPLANATION OF THE PLATEfc. ject is to let a certain portion of caustic dissolve and come in contact with the urethra in solution, the advantage of the ball probe or sound, in this case, over the bougie, as employed by Mr. Whately is, that we are better enabled to ascertain the place of the stricture, and therefore to apply the caustic more accu- rately. Fig. 4. This is a urethra probe, where, instead of a ball, there is a pyriform knob; the curve given to the wire enables us to intro- duce it into the neck of the bladder, and I have used it with much advantage in allaying the irritation at the neck of the bladder; for this purpose I have gently introduced it along the canal, and then moved it several times through the further part of the canal. PLATE V. Fig. 1. Represents a bougie bent at the point, for the purpose of being passed through an irregular stricture. The bent point should be passed down the urethra on that side of it to which the aperture of the stricture is supposed to be situate. Fig. 2. Represents a bougie having the proper degree of curvature given to it, before it is armed with kali, in order to be passed through a stricture at seven inches distance from the orifice of the urethra. Fig. 3. Represents a large flexible gum catheter, with a thick iron wire inserted into it, and of a proper degree of curvature, in order to be passed into the bladder with the wire, in cases of an enlarge- ment of the prostate gland. Fig. 4. Represents a flexible gum catheter very much curved, by means of a small wire inserted into it, in order to give the catheter ^,•3 degree of curvature of a common silver catheter, when the wire is withdrawn, in which state it is to be passed into the blad- der. The degree of curvature I have represented, is particularly necessary in new instruments, but it may be afterwards varied a little, according to the stubbornness or flexibility of the instrument. Fig. 5. Represents a bougie a size largerthan one of the finest kind, for applying the caustic to a very contracted stricture. Fig. 6. Represents a cioth bougie of the vepy finest kind. It is gene- rally necessary that bougies of this slender make should be of a conical shape, otherwise they would not be firm enough for intro- duction. Fig. 7. Represents a very fine catgut bougie. INDEX. A. ABORTION a frequent consequence of Syphilis ------------ observations on - Abscesses in permao --------- in the corpus cavernosum penis ■-------- in the substance of the urethra Absorption, promoted by friction iErugo, form of using in injections - iEtlier, useful in spasms of the urethra Alkali Volatile, forms of using in injection Alum, used in injections for Gonorrhcea •------form of using ... and - Alopecia, description of --------- method of treatment of Anomalous Symptoms, description of ---------.------------- method of treatment of Antidote, definition of tlie term Antimony Crude, useful in venereal eruptions Aqua Phagadenica, form of - - Asthma Venereal, cases of cured by mercury Atrophy, a symptom of Lues Venerea ---------described ... -------— venereal, method of treatment of B. Balsams Astringent, used in injections - - - - I. 63 -------------------their use in Gleet ... - 116 -------------------form of using in injection - - II. 314 and - - - 316 Bark Peruvian, useful in Gonorrhcea - - - L 75 ______.----------------in swelling of the testis - 205 Barytes Muriated, its effects in sores succeedmg to buboes n. 233 _________________observations on die use of 326 Bladder, inflammation of .... - I. 86 Blindness, from Lues Venerea .... II. 77 --------- description of ----- ib. --------- venereal, method of treatment of ... 251 Blisters, use of in Gonorrhcea - - - - I. 73 ------- useful in Gleet - - - - - - 119 ------- their utility in deranged sensations of the bladder and perineum 188 -------- sometimes useful in hernia humoralis ... £05 _________________________in certain kinds of swellings - II. 247 Blood-letting, when indicated in Gonorrhcea - I. 78 -------------useful in Chordee - - - - - 92 -------------local, useful in the treatment of bubo - II. 225 Vol. Page. II. 265 ib. I. 75 ib. . ib. II, 23 . 317 I. 141 n. 317 i. 63 u. 314 316 . 75 251 . 81 254 . 108 243 . 324 289 . 83 ib. . 255 I INDEX. Vol. Page Blotches, venereal - - . - . - II. 50 ■----------------■ most frequent seat of 51 ■—----■----how distinguished .... 53 -.——-----------cure of - - - . . . 243 B01 i.x, its utdity in removing mercurial salivation - - 171 Boughs --*.... I. 115 -------often useful in gleet - - - - us ——— observations on - - _ . 151 ■ chief objects in the formation of 153 ■-------du-ections for the use of - - - - - 154 -------sometimes slip into the bladder ... 157 ■-------tune of remaining in the urethra - - - - 158 -------should not be allowed to remain long in the bladder - 160 ------— much perseverance necessary in their application - - 165 ------— formula for preparing - - - - H. 26 Bubo, definition of - . 26 ---- may take place without chancre, or any previous mark of infection 51 ---- produced by the absorption of the syphilitic virus - - 21 —— seat of --.-.._ 26 ---- frequently more than one - 27 ---- cause of being always external .... 28 ■---- description of - - - - - 29 ---- suppurates more quickly than other glandular tumours - 30 ---- how distinguished from other tumours in the groin - - 31 ---- often connected with scrophula - - - - ib. ---- sometimes connected with erysipelas 32 ---- in women, situation of 35 ■ at first, always local ...... ib. ---- method of treatment of 223 ----suppuration of, never to be encouraged - ib. ---- discussion of, always to be attempted - ib; ----------------remedies to be applied for 224 ■----suppurated, treatment of - - - - II. 228 ■■ ---- object in opening - ib. ------------•----different methods of opening - - - 229 ----Indolent, state of described ----- 233 c. Calces of Mercury, activity of - -----------—-----differences between the Calaminaris Lapis, form of using in injection Calomel, used in injections in Gonorrhcea -' forms of using in injection ■------- observations on ■------- frictions with, in the inside of the mouth Camphor proves useful in chordee ■ ■ form of using in injection and Cantharides, useful in gleet ---------- form of using in injections Caruncles, or fleshy excrescences in the urethra Cataracts, from Lues Venerea • — effect of mercury upon Catheter, observatjons on the use of the Caustic, danger of introducing into the urethra II. lor> - 134 313 I. 62 II. 313 - 142 146 I. 92 II. 313 - 316 I. 114 11. 317 I 144. II. 77 - 252 I. 193 . 167 INDEX. Caustic, caution, in applying to chancres ------ experiment concerning .... —-----method of using - —---- its utility in sores succeeding to buboes ■---------------in venereal ulcers ... Chancre within the urethra, instance of ----- the matter of does not produce Gonorrhcea —----- does not always precede buboes —:--- described ..... ■----- different periods of appearing ... —--- seat of ..... _ ■----— matter of ..... ------varieties of ..... •----— in some instances, rapid progress of ■----- remarkable instances of - ■-----in women ...... ------ cure of ..... ------ should be healed speedily ... ------ the cure of, not always to be effected by the internal use of mercury never to be trusted to local remedies alone ------ most quickly cured by the use of caustic ------ inflamed state of, relieved by leeches -----■ dangerous hamorrhage from ... ------ inflamed state of, not hurt by mercury -----clean state of various applications for —^--- treatment of, when conjoined with phymosis ----- in women, method of treatment of - Chops in the hands and feet described - ----------------------mediod of cure of Chordee, definition of - - - ------- produced by inflammation Cicuta, sometimes useful in sores succeeding to buboes Circumcision, observations on the operation of - Cold Badiing, useful in Gonorrhcea -----------------in Gleet ■-----------------in swelling of the testis Cold and Dampness, dangerous effect of in Lues Venerea Consequences of Gonorrhcea Virulenta Cord Spermatic, swellings of ----------------------remedies applied for Corona Veneris, what .... Cowper's Glands, affections of - D. Deafness, from Lues Venerea . - .. - - II. 80 -------- method of treatment of - - - - - 253 Decoctum Lustianicum, or Lisbon diet-drink, formula of - - 320 -------- Ligni guaiaci, form of - - - - 325 -.------- Sarsaparilla ------- ib. ------- Mezerei -...._ ib. Deranged Sensations in the bladder and urethra I. 183 ----------------- not easily accounted for - - - 186 -----------—---- remedies to be used in - - - - 187 Diarrhcca excited by mercurv, remedies for - - II. 174 Diseases, diflerent, may exist at the same time on the same part - 58 Dropsy, syphilitic, case of cured by mercury . . - 304 TJuncan, Dr. his opinion of the action of mercury - UF> Vol Page. 11. 210 ■ ib. 212 . 232 237 I, 26 32 . 215 II. 12 . 13 ib. . 14 ib. . 16 17 . ib. 208 ib. lercu ry ib. - 209 210 . 215 216 - 218 ib. . 219 ib. 81 254 I. 91 ib. II. 234 I. 226 - 75 116 . 206 II. 63 I. 104 208 - 209 H. 52 I. 72 INDEX. E. Vol. Electricity, its utility in the indolent state of Bubo - ll. Elephantiasis, a symptom in Sj-philis ... Emetics, their utility m Hernia Humoralis - - • - I. Emplastrum Mercuriale, form of - - . - II. __________Lithargyri, form of - ... Epilepsy Syphilitic, case of, cured by mercury ... Eruption induced by mercury, description of —■-----------------------— remedies for ■ - - - Escharotics, their utility in chancres .... Excoriations from Gonorrhoea do not require mercury - - I. ^—--------in the parts of generation of women - Excrescences Venereal, about the anus - - . II. . --------description of - -—--------------in women, sometimes produce buboes ■--------——— cure of ... F. Pever, as a symptom of Lues Venerea II. -----Venereal, observations on ... Fistula in Perinao, most frequent cause of - - • I. Fluor Albus, its resemblance to Gonorrhoea ... ----------how to be distinguished from Gonorrhoea .----------cured by astringent injections ... Frenum, sometimes necessary to cut - - - H. Fumigations with Mercury, m what manner applied ■- i ----- sometimes useful in chancres - - - - — their utility in sores succeeding to Buboes G. Gangrene induced by Chancres, rapid progress of - H. ■----------------------------opium the best remedy for ——-------------------------mercury does harm in Gargarisma e borace, form of ..... Gilchrist, Doctor, his Essay on Sibbens Glands in the Groin, swellings of I. ■ ------------remedies employed in - - Glans and Prepuce, excoriations of - Gleet, import of the term ..... —— remarkable case of ---- arises from different causes ... ---- often the effect of local relaxation —— seldom of general debility ... ■ ■ remedies useful in .... ---- inflammation useful in - > - . diet recommended in v ---- relieved by a seton in perinao ... — a frequent consequence of strictures in the urethra — sometimes relieved by opiates ... Gonorrhoea and Lues Venerea appeared at different periods ■■— a much more frequent disease than pox INDEX. Yd. Pag, Gonorrhoea translation of the matter of - «■ - 1. 2b — the matter of, does not produce chancres - 3'? — and syphilis sometimes remain long distinct - - 33 — time of appearing ----- 37 — symptoms of - - - - 38 — sympathetic pains in '• - - - - .39 — in women - !■ - . - - - 41 matter of ----- - 42 — manner of.infection in ... - 43 — remarkable f^ct in 44 — matter of, not produced by ulcers ... 46 produced by inflammation ... - 46 •— resemblance of to catarrh ... - 47 — prognosis in ..... 48 — general observations on the cure of - ■ - 50 — first stage of .... - 57 — regimen in ------ 68 — low diet improper ia .... ib. — second stage of - - - - - - 70 — third stage of 77 — fourth stage of - - - - - • * 85 — in women ------ 95 — always a local disease - - , - - - 99 gonorrhoea spuria, what - - - - - 217 — Observations-on - * - - 218 — means of distinguishing from Lues Venerea 219 — method of curing - 220 — excited by savme applied to the urethra - 23.i ■Gonorrhoea simplex ------ 236 — observations on Jh_ — remarkable case of 23. __ may be produced by the matter of fluor albus 239 , # — may .excite swelling of the testis - - 241 __ — swellings of the inguinal glands ib — necessity of discriminating - - - 24?' — method of cure .... ib Guaiacum, observations on - - - - in __ proofs of its power as an anti-syphilitic Gutta Serena, from Lues Venerea - - H, Hamorrh&ges from the urethra ... - I 94 __ produced by chancres, remedies for . II -*!& Headach, sj'philitic case of, cured by mercury 305 Hernia Humoralis, what - - - r I- 19| __ femoralis, sometimes mistaken .for bubo - - tl. J J Herpes, similar to Venereal eruptions - - - - 53 Hunter Mr. John, some of his opinions examined, A ol. H. pages 23. 08. M 103. & 175 Hj'drocelc, sometimes induced by hernia humorahs - I- 199 Hyoscyamus, proves useful in chordee - <■ 9-. I. Impotency, what » ' .-*' •—-----causes of * - ■ ., VOL. II *3 193 INDEX. Vol. Page. I. 127 128 12tf . 130 132 - 134 ib. . 197 H. 23 I. 59 . 61 64 . 6S ^66 . 75 102 . ib. 118 n.. 313 Ifmpotcncy frequently induced by local weakness --------- seldom the effect of general debility w-------- two stages of .... ■---------first stage of ■--------- second stage of ... - --------- relieved by electricity .... ---------by hyoscyamus .... —-------may occur from swelling of the epidydymis Inflammation, slight degree of, necessary for the production of bubo H Injections, their early application recommended ■----not to be used while the testes are swelled --------- strength of - - - - . ---------manner of using - . - ■---------frequency of using .... ---------sometimes do harm .... ■---------general observations on the use of ---------stimulating, useful in gleet - "' ' --- astringent sometimes useful in gleet "■--------formula of - - ' - - - K. Kidneys sometimes affected in Gonorrhoea - - I. 47 Kmo, an useful ingredient in injections - - - 63 ----- useful in hamorrhagies - - - ' - - 94 -----forms of using in injection - - - - II. 314 ■----- its utility in Diarrhoea ..... 175 Lapis Calaminaris used in injections I. 61 Lavender, spirit of, an application for chancres • - II. 218 Lead, used in injections - - - - I. 63 Leeches, then- utility in hernia humoralis ... 198 ------- their bites, observations on .... 221 L:me Water, when useful in gleet .... 122 Lhumentum Cera, form of - - - - . II. 326 Lips, method of treating chancres on - - - 220 Lixivium Causticum, form of using in injections, ... 317 Lues Venerea, sometimes takes place without chancres - I. 24 -------------appeared in Europe before Gonorrhoea -. 33 —----------appeared at Otaheite before Gonorrhoea - - ib. ------------when first accurately described - - II. 7 ------------- in what manner communicated ... 8 --------——- often given by an infected nurse to a child, and vice versa ib. ----------— may be communicated by the milk in nursing - 9 ------------matter of, may be absorbed from any part of the sur- face of the body ... ib. ---------p-— matter of, is not readily absorbed from the stomach 10 ------------- symptoms of ----- 12 -------------the cause of its breaking out sooner in some than in others 25 -------------cannot be cured by evacuants ... 107 ------------ in infants ...... 257 --------,----proofs of - - - . - 259 INDEX. Vol. Lues Venerea, how to be treated - - - -II. ------------remarkable case of - ------—----some peculiarities of form of —----------its power in inducing other diseases - Lymphatic vessels of the penis; swellings of . - - I. — — — remedies useful in — — — two cases of LiUiargyri acetum, form of H. M. Mur.ia Syphilitic, case of* cured by mercury Mel Mercuriale, form of , - Mercury not necessary in Gonorrhoea --------useful in a thickened state of the bladder ■--------never proves useful in gleet ... ————— apt to do harm in hernia humoralis ... —------ crude, form of using, in injection Mercurius sublimatus torrosivus, form of using in injection Mercury, partial use of, a remarkable effect of --------general observations on . - . . --------general effects of on the system --------stimulating effects of .... 1-------- distressful symptoms induced by - - ————— operation of in the cure of sj'philis — irritation excited by, not necessary in the cure — does not cure syphilis by the evacuation which it excites — antidotal powers of, proofs of — acts as an antidote in the cure of syphilis — preparations of . - _ - - — in what manner rendered active — different methods of exhibiting — fumes of • - . - • — — in some cases an useful remedy Mercurial preparations from triture, observations on Mercurius alkalisatus, observations on — calcinatus, observations on — — form of • — sublimatus corrosivus observations on - — — form of ... — cinereus, observations on — — form of - - - - - — acetatus, observations on - - - . Mercurial frictions, observations on - - - Mercury absorbed, quantity of difficult to ascertain - Mercurial course, duration of - Mercury alterative, course of described - ..__'.----_____________■ ■ observatibns*on - - . - _______________I..----—— not to be depended on for the cure of syphilis - — quantity of necessary to be employed ... — course of regimen to be observed in — patients taking, ought not to go abroad — course of, a caution previous to - - - - - — how far to be considered as a certain cure for syphiiis — course of, its failure in the cure of syphilis — how to be applied for the discussion of buboes • I INDEX. Mercury shouid be given in every stage of bubo — Van Swieten's solution of Me*curius duicis, form of .—______pracipitatus ruber, form of Mezereon, observations on — method of exhibiting — useful m hernia humoralis Morbid state of the system induced by mercury Mucus, attraction between and mercury N. Ixodes,, definition .of — most frequent situation of — description of — cause of their being painful —- cure of — when they ought to be laid open o. Obstructions in the urethra - ------ spasmodic of the urethra Ointment mercurial, strength of - ------observations on the use of ------ absorption of, promoted by friction Onanism, the baneful effects of - Opiate Clysters useful in Gonorrhaa Opiate Clysters useful, in Gleet Opiates useful- in chordee - - - .. - r — their utility in mortification -' Opium used in injections in Gonorrhoea — proves hurtful in impotency - — its utility in spasms of the urethra — an useful remedy in swelling of the testis - — forms of using in injection - — its utility in removing salivation — observations on - - - .— when first employed in the cure of syphilis — proves chiefly useful by allaying irritation .— large doses of given in Lues Venerea — external application of ... — its utility in irritability of the bladder and urethra —- jn sores succeeding to buboes ,— Soften particularly useful in venereal ulcers P. Pains, venereal, "now distinguished from rheumatism Paraphymosis, what . . - . ■ observations on ---- operation for - - - Phthisis Venereal, case of, cured by mercury • ZNDEX. Phymosis, what ..... — observations on ... — remed es employed in — operation for described Pilula e Mercuric* Sublimato Corrosivo — Plummeri .... ------constitution in which they prove useful " their utility in venereal blotches Plenk's solution, form of - . . . Powders Escharotic, formula of Pox, no stage of ever induces Gonorrhoea Pregnancy, not always an objection to the use of mercury Prophylactics observations on - . . Prostate Gland affections of Pulvis Doveri, form of .... R. Remedies used in Lues Venerea, general observations on Resina Elastica, the best material for bougies, Rheumatism Syphilitic, case of, cured by mercury Ring Worm, what ..... Routine of practice to be guarded against s. Saccharum Saturni, form of using in injections Sal Ammoniac, form of using in injections Salivation not necessary for the cure of syphilis — method of preventing . ... — method of removing - — mest effectually relieved by local applications — not always increased by more mercury Sarsaparilla, observations on .... — method of exhibiting - Savine, its influence in removing warts Scrophula, observations on - „ - Scrotum, thickening of Scurvy, observations on - - - - - — and a course of mercury induce similar effects Sea Bathing useful in certain stages of bubo — its utility in venereal swellings of the testis Semicupium proves useful in deranged sensations of the bladder SibbenB, what - - - - - . — description of - — method of cure of — method of preventing - Sinuses in perinao, bow to be treated ... — produced by buboes, distressful effects of Solutions Escharotic, formula of Sore Throat, venereal ...... -— description of ... — often accompanied with erjsypilas — sometimes productive of deafness — sometimes penetrates to the bones — sometimes mistaken for other affections Vol Pagr I. 218 - 223 ib. . 227 n. 323 . 325 - 172 - 241 . 322 II 320 I. 31 II. 265 . 282 I. 77 IL 325 II. 98 I. 153 II. 294 53 - 130 II. 315 . 316 169 . ib. 170 . ib. 3 171 . 196 197 I. 234 II. 191 . 82- 189 . 191 234 . 250 I. 188 IL 268 ib. . 272 273 I. 76 II. 230 . 320 37 . ib 38 . 39 40 41 INDEX* Spasms of the urethra relieved by blood-letting — by blisters . — by electricity — by bougies Strictures in the urethra, observations on — seldom the consequence of ulceration — — nor of the rupture of blood-vessels — — nor of the use of injections — most frequently induced by relaxation — not to be cured by mercury ■ — cured with most certainty by bougies Sweating induced by mercury, method of preventing Symptoms, from the sudden stoppage of Gonorrhoea not venereal Syphilis, remarkable cure of • - . - Vol. Page. - I. 141 . 142 . ib • 143 - 146 . 148 ■ . ib. . 149 - 150 . 151 . ib. H. 176 ereal I. 23 n. 173 T. Tendons and ligaments not often affected in Lues Venerea Testicle, swelling of, from Lues Venerea ... — difference between it and hernia humoralis — how distinguished from sarcocele Testes, both, sometimes swell in Gonorrhosa —- swelled, symptoms produced by — sometimes swell from sympathy — swelling of, most frequently the effect of inflammation — — seldom end in suppuration —* remedies employed for removing ... — decay of ..... — — induced by onarfism ... — — stopped by a blister applied over the scrotum Throat, ulcers in, cured by caustic Trochisci Keyseri, form of r Tumours in the substance of the urethra Turpethum Minerale, observations oh n. 69 . 72 73 . 74 I. 194 . ib. 196 . 195 197 . 198 205 . 206" ib'. n. 237 . 324 i. 135 H. 143 U. and ¥. Vas Deferens, swellings of the - Venereal swelled testicle, cure of ... Verdigris, useful in Gleet ..... — an useful application in chancres Vinegar, steams of, useful in swellings of the testis Virus Venereal, observations on ... — first acts upon the fluids ... — its action in inducing other diseases — may remain long latent ... — not to be removed by an alterative course of mercury Vitriol used in injections - - - - - Vitriolum Album, form of using in injections Ulcers Venereal, old, when they do not readily produce bubo — distinguishable into two kinds — description of in the nose and mouth -— in the mouth, how distinguished from other affections — venereal, some parts of tlie body more liable to than others —. rise and progress of - I 22 II. 248 I. 114 II. 218 I. 201 II. 86 . 88 284 . 312 ry ib. I 64 IL 315 23 24' 42 45 56 • INDEX. Ii leers Venereal, peculiar appearance of the matter of — ordinary seat of — succeeding to buboes described — a frequent cause of their obstinacy — venereal, cure of - - - - __ frequent cause of difficulty in curing Unguentum e Calce Zinci, form of __ lapide calaminari __ mercuriale, form of _ citrinum — mercuriale album __ — rubrum — ex JErugine — saturninum Urine, remarkable effect of in gangrene Uva Ursi, its utility in Gonorrhcea —— in affections of the bladder Vol. U Page. 56 57 61 62 236 239 321 ib. 322 324 326 ib. ib. ib. 216 89 103 w. Warts on the genitals — observations on - - - — produced by irritation • - - __ sometimes the consequence of syphilis ,, __ more frequently of Gonorrhoea _ removed by escharotics __ _ by stimulants - Weeping eye, how produced by ulcers in the nose Women not so susceptible of Gonorrhoea as men — not liable to strictures in the urethra I. 232 231 232 ib. ib. 234 ib. II. 44 I. 95 125 FINIS.