A TREATISE ON THE VENEREAL DISEASE, BY THE CELEBRATED AND INGENIOUS Mr. JOHN HUNTER, of LONDON, ABRIDGED By WILLIAM CURRIE. PHILADELPHIA: Printed by CHARLES CIST, in Race-street, between Front and Second-streets. MDCCLXXXVII. PREFACE. THE following Treatise on the Vene- real Disease, is an abridgment of the incomparable, but voluminous work of Mr. John Hunter, a celebrated anatomist in London; who is confessedly allowed to have done more towards the improvement of anatomy, physiology, and medical surgery, than any other man of the present or, perhaps, any former age. This abridgment, (short and imper- fect as it may appear,) will be found to contain more practical knowledge and real instruction, than any other produc- tion of the kind, hitherto published. And, as the work from whence this is selected, is the result of very exten- sive experience, conducted by a man of superior talents; the editor thinks no apology necessary for the present abridge- ment; [iv] ment; especially, as he is persuaded it will, (on account of its size and price,) contribute to diffuse a more correct know- ledge of the nature and cure of the different forms of that just scourge of lawless embraces; than is to be expected from the work at large, or than is attainable from any other publication: and by this means correct the errors of practice, and thereby save the lives and preserve the health of numbers, who may have the misfortune to contract the dis- ease through ignorance, or who might suffer from improper treatment. Whether this abridgment is calculated to answer this desirable purpose, or not, must be left to the judgment of the discerning. Trusting solely to its merit, the editor leaves it to its fate, and only asks for justice. CONTENTS. CONTENTS. Page. the venereal disease,—1 Of the venereal gonorrhœa,—10 Of the cure,—13 Of chancre,—24 The cure of simple chancre,—26 Of buboes,—36 Of the confirmed lues venerea,—43 Of the cure of lues venerea,—48 Of the action of mercury,—50 Of the diseases of the urethra, supposed to be derived from the venereal disease,—58 Of the diseases of the urethra,—63 Of correcting some of the effects of mercury,—77 Of the form of the different preparations of mercury, when in the circulation,—85 Of gum guaiacum and sarsaparilla, in the venereal disease,—89 Of the effects remaining after the disease is cured, and of the diseases sometimes pro- duced by the cure,—90 General observations on the medicines usually given for the cure,—96 Some selected cases, to confirm part of what has been advanced in the preceding pages,—102 OF THE VENEREAL DISEASE. THE venereal poison is capable of affect- ing the human body in two different ways—Locally, that is, in those parts only to which it is first applied—and constitutionally, that is, in consequence of the absorption of the venereal pus, which affects the solids through the medium of the circulating fluids. BETWEEN the first and second, or the local and constitutional, form of this disease, certain intermediate complaints take place—In the progress of absorption there are inflammations and suppurations, forming, what are called, buboes, in which the matter is of the same nature with that of the original disease. When the matter has got into the constitution and is circulating with the blood, it there irritates to action, and from that irritation are produced A many [2] many local affections; as, blotches on the skin, ulcers in the tonsils, thickening of the periosteum and bones. The local, or first. kind, may be called immediate, because it arises immediately upon the application of venereal pus.—Of this form there are two sorts, seemingly very different from each other, but not so in fact. In the first, there is a formation of matter without a breach in the solids, called a GONORRHOEA. In the second, there is a breach or ulcera- tion in the solids, called a chancre. I am perfectly convinced, from numerous experiments and repeated observations of my own, that neither of thefe two ways in which the disease shews itself, is owing to any thing peculiar in the kind of poison applied, but to the difference in the nature, situation and pro- perties of the parts contaminated. The readiness with which the parts run into violent action, in this species of inflam- mation, is greater or less according to the nature of the parts affected; which perhaps does not arise from any specific difference in the [3] the parts themselves, but is according to the common principle of sensibility and irritabi- lity; for we find that the vagina is not so much disposed to inflammation in this disease, as the urethra is in the same sex, because it is not so sensible. However, it may be possible, there may be some specific disposition to irri- tation and inflammation in the urethra in man; and what inclines me to think so, is, that its canal is perhaps oftener out of order than any other, producing a great variety of symptoms This disease, when it appears in the form either of a gonorrhœa or a chancre, differs very much in the violence of its symptoms in different people—In some it is extremely mild, in others extremely violent. When mild, it is generally simple in its symptoms, having but few, and those of no great extent, being much confined to a specific distance, reaching from the orifice of the glans to an inch, an inch and an half, or perhaps two inches up the urethra. But when violent, it becomes more complicated in its symptoms, having a greater variety, and extending itself beyond the specific distance: this does not arise from any variety in the specific quality of the poison, but from A2 a dif- [4] a difference in the disposition and mode of action of the body or parts of the body; some being hardly susceptible of this or any other irritation, others being very susceptible of it and of every other irritation, so as readily to run into violent action. The venereal irrita- tion, however, does not always follow these rules; for I have known young men, in whom a sore from common accident healed up rea- dily, yet the irritation attending a gonorrhœa would be violent, and a chancre would in- flame and spread with great rapidity, and even mortify.—On the other hand, I have known young men in whom a sore from common vio- lence, has been healed with great difficulty, yet when they had contracted a gonorrhœa or chancre, the disease has been mild and easily curable. In particular people it is either mild or severe, for the most part uniformly. In the first stated dispositions it is not invariably so, but then, I believe, there is some indisposition at the time, I HAVE known several Gentlemen, who had their gonorrhœas so slight in common, that they frequently cured themselves; but it has so happened, that a gonorrhoea has been re- markably severe, which baffling all their skill, they [5] they have applied for assistance; but then they were attacked with the symptoms of a fever, and when the symptoms of fever have gone off, the gonorrhœa immediately became mild. I may now also observe, that when the disease is in form of a lues venerea or pox, different constitutions are differently affected, in some its progress being very rapid, in others very slow. To account for the very different effects of the same matter producing different forms of this disease, it is only necessary to observe the difference in the mode of action of the parts affected when irritated, let the irritation be what it may. The gonorrhœa always proceeds from a se- creting surface, and the chancre is formed on a non-secreting surface, and in the latter, the part to which the poison is applied must be- come a secreting surface before matter can be produced. All secreting surfaces in the body being probably similar, one mode of application is probably sufficient to produce this disease in them all; which is by the poisonous matter simply [6] simply coming in contact with them. But to produce chancre the matter may be applied three ways—to a wound—to an excoriation of the cuticle—or to a surface where the cuticle is very thin. The effects produced by the venereal poison, appear to arise from its pecu- liar or specific irritation, joined with the suscep- tibility of the living principle, to be irritated by such as cause, and the parts so irritated acting accordingly. When an irritating matter of any kind is applied to a secreting surface, it increases that secretion, and changes it from its natural state (whatever that be) to some other, which in the present case is pus. UNTIL about the year 1753 it was a re- ceived opinion, that the matter from the urethra in a gonorrhœa arose from an ulcer or ulcers in that passage; but from an accurate inspection of persons after their decease, who were known to have the disorder at the time of their decease, it was about that time first discovered that this was not the case, but that it was produced by a vitiated secretion. When [7] When a secreting surface has once received the irritating action, its secretions are increased and visibly altered; also, when the irritation has produced inflammation and an ulcer in the solid parts, a secretion of matter takes place; the intention of which, in both, seems to be to wash away the irritating matter; so that irritations have a tendency to produce their own destruction: like a mote in the eye, which, by promoting a secretion of tears, is itself washed away. But this specific irritation in gonorrhœa, is preserved and prolonged by the inflammation it produces.—It is however found, that this inflammation can sonly last a limited time; the symptoms peculiar to it vanishing of them- selves, by the parts becoming less and less susceptible of irritation. This cessation will vary according to cir- cumstances, for if the parts are very irritable, their actions will be more violent and longer continued; but in all cases it is an incon- testible fact, that the difference must arise from the difference in the constitution, or ac- cording to the patient's regimen and conduct, and the care taken to relieve or cure the disease. IN [8] IN many cases, if by a proper regimen the irritation of the inflamed state is carefully avoided, the gonorrhœa spontaneously ceases, the symptoms of inflammation gradually abat- ing, the matter discharged becoming of a thicker and more viscid consistence, as well as of a whiter colour; till at length the flow of it ceases altogether; and whether it be thus cured spontaneously, or by art, the disease often exists without communicating any in- fection to the other parts of the body; because while the urethra continues free from ulcera- tion, the absorbents have no command. But this circumstance, of the disease ceas- ing spontaneously, only happens when it at- tacks a secreting surface, and when a secre- tion of pus is produced; for when it attacks a non-secreting surface and forms an ulcer there, the ulceration goes on, continually increasing and propagating other effects, by means of absorption, till it destroys the patient's life, unless prevented by art. FROM this statement of the disease, it would be natural to expect, that whatever medicine would cure it in one form, would cure it in any form, and alfo all the varieties of every form; [9] form; but repeated experiments have taught us, that this does not hold good, especially in this disease. For mercury, which is found to be a specific for chancre and all its conse- quences, however varied, instead of contri- buting to the cure of gonorrhœa, never fails to aggravate and prolong it; and has too often been the cause of effects, much worse than the disease for which it was employed to cure. Having premised sufficient to give a ge- neral idea of the nature and character of this disease, I now proceed to consider in a more particular manner, the symptoms peculiar to each form and modification. And first— B Of [10] OF THE VENEREAL GONORRHŒA. THIS form of the disease generally makes its appearance swithin eight or ten days after the infection has been received; some- times indeed it appears in two or three days, and at other times not in less than a fortnight. Previous to the discharge, the patient feels an itching, with a small degree of pain, a little distance above the glans penis, in the urethra: afterwards a thin whitish viscid matter be- gins to discharge from the canal, which stains the linen, and occasions a small degree of ti- tillation, particularly in the time of making water; this gradually increasing, arises gra- dually to a sense of scalding and pain, chiefly felt about the extremity of the urinary passage, where a slight degree of redness and inflam- mation likewise begins to appear. As the disorder advances, the pain, ardor urinas, and running increase, while fresh sym- ptoms [11] ptoms daily ensue. In men the erections be- come painful and involuntary, and are more frequent and lasting than when natural. This symptom is most troublesome when the patient is warm in bed. The pain, which was at first only felt towards the extremity, in many cases proceeds and extends all the way up the urinary passage; and in other cases, the in- flammation spreads even to the neck of the bladder. In these aggravated circumstances it sometimes happens (but that is very rare) a more considerable inflammation is occasioned in certain parts of the urethra; and sometimes even terminates in suppuration or ulcer, by which the venereal poison is sometimes com- municated to the system, and gives rise to a general lues. But dissections prove, that the disease commonly does exist without any ul- ceration of the urethra; so that the discharge which appears, is entirely of a vitiated mucus from the follicles of the urethra. In many cases the heat of urine is so great, that the patient dreads the making water, and though he feels a constant incli- nation, yet it is rendered with difficulty, and often only by drops. The chordee is often extremely painful and frequent, and the run- B2 ning [12] ning is copious, sharp, and of a bloody, brown or greenish colour. These alterations in the colour and consis- tence of the running are owing to the condi- tion and disposition of the parts which form it, and this disposition of the parts depends chiefly on the increase or decrease of the inflamma- tion, and not on the poisonous quality of the matter itself; for any irritation on the same parts, equal to that produced by the irritation of the venereal matter, will produce the same appearances. It often happens, after the symptoms pecu- liar to gonorrhœa have been perfectly removed, that a mucous fluid continues to issue from the urethra, and continues so to do a long time, and sometimes for a great part of a person's life. This discharge is denominated GONOR- RHOEA BENIGNA OR GLEET. In such circumstances the matter discharged rarely, if ever, contains any venereal poison, notwithstanding it sometimes has a puriform appearance. This appearance in the matter of a gleet, which before had been of a less coloured kind, has been frequently mistaken for [13] for a fresh infection: But I am certain that such appearances may be brought on by per- haps various other causes; and particularly, by intemperance in venery and drinking concur- ring together. When it was the practice to employ mer- cury and drastic purgatives freely, at the com- mencement of the virulent gonorrhœa, a gleet was a frequent consequence. Of the CURE. THE chief circumstance to be attended to in the cure of the virulent gonorrhœa, is the inflamed state of the urethra, which may be considered as inseparable from this form of the disease. And if what has already been advanced be true (as it certainly is) that the disease will always be cured spontaneously in time, with- out medical assistance, if not prevented by mismanagement or intemperance, and that the whole of the infectious matter will be entirely discharged; all that is required of art, is to remove and prevent a return of that inflam- mation [14] mation which continues the disease, and ac- casions all the troublesome symptoms that ever attend it. The sole business, therefore, should be directed to take off the inflammation ac- companying the gonorrhœa, and this may for the most part be performed by avoiding ex- ercise, by employing the antiphlogistic regi- men, by abstaining entirely from spirituous and fermented liquors, and by drinking plen- tifully of mild aqueous liquids. The scalding, which is so troublesome a symptom, and which is occasioned by the pas- sage of the urine through the irritable and in- flamed passage, should be remedied as soon as possible. This is best done by the liberal use of warm water, rendered palatable with the acid juices of ripe vegetables, and by the in- jection of tepid mucilaginous watery liquids, destitute of stimulating particles—oil of almonds—emulsion—milk and water, &c. Emollient clysters would likewise be benefit cial, much more so than the mildest purga- tives; but as costiveness always adds to the ir- ritability of the bladder and urethra, where clysters are not submitted to, the sedative or quieting laxatives may be occasionally allowed, especially Glauber's salts, soluble tartar, mag- nesia, [15] nesia, oleum ricini, lenitive electuary, &c. But every purgative of a drastic quality should be carefully prohibited, nor should any purgative be administered oftener than merely necessary to prevent or remove costiveness.—As for diu- retics, the inflamed state of the body render them absolutely improper. In this state of the parts it has been advised, to apply emollient somentations and poultices to the body of the penis; but these seldom do good, and may do harm if applied hot. Com- presses, dipt in cold lead water, seem better adapted to resist and prevent the increased im- pulse of the fluids; and as the symptoms de- pend, in a great measure, on the increased sensi- bility of the urethra and contiguous parts, it will generally be found that opium will afford more relief than any thing else, especially after the bowels have been emptied or blood has been drawn from the patient, provided he is in a condition to bear the loss of blood—a grain or two may therefore be given under such cir- cumstances at night, and half as much in the morning; and a filtered solution of the same of tepid warmth, may be injected into the urethra frequently in the course of the day. WHEN [16] When by these means the inflammation has considerably abated, the disease only now re- maining in a mild form, it may be attacked either by internal remedies or local applica- tions. If it be attacked locally, violence is still to be avoided; because as long as the diseased parts remain very susceptible of irri- tation, the inflammation may be brought back. At this period, however, gentle astringents may be employed with a prospect of success; or if the disease has begun mildly and there are no signs of an inflammatory disposition, either of the common or of the erysipelatous kind, in order to get rid of the specific mode of action quickly, an irritating injection may be used, which will increase the symptoms for a time, but when it is left off they will often abate or wholly disappear. In such a state of the parts astringents may be used, for the only thing necessary to be done, is to procure a cessation of the discharge, which is now the principal symptom. In cases of stricture or hernia humoralis, I believe astringents should not be used; for we find in either case, while the discharge lasts, both complaints are relieved. Many [17] Many injections remove the symptoms soon, and prevent the formation of matter; and this has given rise to a notion of repelling and shutting up the disease in the constitution; but this is not the case, for my experiments teach that the venereal matter is the only substance in which the poison is contained, and cannot be communicated without the formation of matter; therefore, if we can prevent the for- mation of the one, the other cannot take place, and of course there can be no room for ab- sorption, so that there can be no power of in- fecting the constitution in the same person, nor of communicating the infection to others. I SHALL divide injections, according to their particular effects upon the urethra, into four kinds—the IRRITATING, the SEDATIVE, the EMOLLIENT and the astringent.—A specific one I am not acquainted with. Most of the irritating injections have an astringent effect, and prove simply astringent when much diluted. Irritating injections should never be used where there is already much inflammation, especially in irritable con- stitutions; nor should they be used where the irritation has spread beyond the specific dis- C tance, [8] tance, which, as has already been said, reaches about an inch and an half or two inches up the urethra; nor where the testicles are tender; nor where there is a tendency in the bladder to irritation, which is known from a constant inclination to make water. In such cases I have found them do harm; they have some- times increased the inflammation, and in some cases produced abscesses in perinæo; but have often succeeded with them mmediately in cases that were mild, and in constitutions less irritable. The following is equal to any of this class: Rec. Pulv. mere. subl. corrosiv. gr. ii. Aq. pluv. vel rosar. unc. viii. M. But where that stimulates considerably, or induces an increase of inflammation, it must be weakened, and perhaps entirely omitted for a time. SEDATIVE injections will always be of service in cases where the inflammation is considerable, by lessening the diseased action of the parts, and by relieving the painful sensations of the patient. Perhaps the best sedative is opium, as well when given by the mouth or anus as when applied to the part affected in form of injection. [19] injection. But it has not this effect in all con- stitutions or conditions of the parts; but on the contrary, adds to the irritation. Perhaps if thrown up the rectum with a common penis syringe, it would answer better than any other way in cases of great uneasiness and irritation, unattended with the swelling and throbbing which characterises inflammation. THE saccharum saturni acts both as a sedative and gentle astringent, and may be employ- ed in the proportion of 14 grains, dissolved in 8 ounces of rose water. THE drinking freely of diluting liquors, may be considered as having a sedative effect, as it in part removes some of the causes of irri- tation, rendering the urine less stimulating, either to the bladder when the irritation is there, or to the urethra in its passage through it; and it is possible, that dilution may lessen the susceptibility of irritation. Water with a solution of gums, or an infusion of mucilagi- nous vegetables, is in no respect preferable to simple water, because it is only the water with which they are mixed that reaches the parts af- fected, or that can make any impression on the constitution. Perhaps therefore lemonade, C2 tamarind [30] tamarind water, toast and water, barley ptisan, &c. are equal to any other drink. EMOLLIENT injections are proper where the inflammation &c. is very great: these may be composed of milk and water, of fresh oil of almonds, or of the infusions of emollient and mucilaginous vegetables. Under such circum- stances, more active injections might do harm. It very often happens, that the irritation at the entrance of the urethra is so great, that the point of the syringe can not be suffered to enter: here it should not be attempted till the inflammation abates; this may be assisted by emollient fomentations. The astringent injections can only act by lessening the discharge, they can have no spe- cific effect upon the inflammation; but as they must affect the action of the living powers, it is possible, they may alter the venereal dispo- sition. They should only be used towards the latter end of the disease, when it has become mild, and the parts begin to itch. But when the disease has begun mild, they have been found serviceable from the beginning, for by gradually lessening the discharge without in- creasing [21] creasing the inflammation, we complete the cure, and prevent a gleet. These act by con- tracting the vessels of the urethra, and suppress secretion. DURING the continuance of chordee, no violence is to be employed in the cure, but all irritation should be avoided; otherwise that symptom will be aggravated: nor under such circumstances should any thing be done that may tend to suppress the running, either by internal or external means; because that has no effect in removing the inflammatory irri- tation which gives rise to that symptom; but the constitution is to be altered, if possible, by remedies adapted to each disposition, and with a view to alter the action of the parts arising from such disposition, and to reduce the disease to its simple form. The most speedy removal of the hernia humoralis or swelled testicle, which is only a sympathetic affection, is, by emollient fomenta- tions to the testicles and penis, the application of emollient cataplasms, by clysters, and when the inflammation has not increased the action of the vascular systerm sudorific anodynes, will [22] will be proper to be repeated occasionally after a mild laxative, &c. The strangury, which is a very common and distressing symptom of a recent infection, may be occasioned either by a spasmodic con- striction, or an inflammation of the urethra and parts about the neck of the bladder. In the former case, the patient begins to void his urine with tolerable ease; but as soon as it touches the inflamed urethra, a sudden spasm takes place, and the urine is voided by spurts, and sometimes by drops only. When the strangury is owing to an inflam- mation about the neck of the bladder, there is a constant heat and uneasiness of the part, a perpetual desire to make water, while the patient can only render a few drops: if this complaint continues any time, a tenesmus generally comes on. When the strangury is owing to spasm, the best treatment will be liberal dilution with mild aqueous drinks, and five or six drops of laudanum taken every four or five hours, and and a larger quantity at bed-time. The pec- toral [23] total ptisan is a valuable drink in such cir- cumstances. Emollient fomentations may also be applied. When the complaint is evidently owing to an inflammation about the neck of the bladder, bleeding should be copiously performed and repeated, according to the violence of the symptoms. After bleeding, mild softening anodyne clysters should be administered, if the patient will submit to them, or if that cannot be conveniently done, laxatives of castor oil, or manna and Glauber's salts may be substi- tuted, and the patient may himself inject some mild mucilaginous tea up the rectum, with a little crude opium dissolved in it, with a penis syringe. In addition to these means, flannels, dipt into a decoction of emollient herbs, such as poppies, mallows, and chamomile flowers, should be frequently applied to the pubes, groins, penis, and perinæum. If the complaint does not give way to this method, or a total suppression of urine should come on, the patient should be put into a warm [24] warm bath which should reach as high as his stomach, and when put to bed, the urine should be drawn off with a catheter. In this inflamed state, the surgeon will often find his utmost skill baffled, in attempt- ing to introduce the catheter, and when that is the case, it would be proper to try a bougie, or perhaps an operation may become neces- sary, as will be more fully specified in the latter part of this work, when treating of strictures. OF CHANCRE. INSTEAD of proceeding to give an account of the supposed effects of gonorrhœa at present, I shall defer that part of my subject till I have finished both my account of the other local affection of the venereal disease, known by the name of chancre, and of the confirmed or constitutional lues. BY [25] BY chancre I would be understood to mean a spreading venereal ulcer, with ragged, cal- lous, prominent edges, and unequal surface. This kind of ulcer may happen with or without a gonorrhœa. These are commonly seated about the glans penis and inside of the pre- puce. They first appear like a little blister or blisters, with an inflamed circumference. This vesication feels hot and itchy before it breaks; afterwards it gradually degenerates into a foul obstinate ulcer, the bottom of which is commonly covered with a viscid mucus, and the edges become hard and contracted. Sometimes the first appearance resembles a simple excoriation of the cuticle, which soon increases to a corroding ulcer. CHANCRES partake both of a specific and constitutional inflammation: hence, it is always necessary to take notice of the manner and condition in which they first appear, and also to their progress; for they often explain the nature of the constitution at the time. If the in- flammation spreads fast and diffusively, it shews a constitution preternaturally disposed to in- flammation. If the pain is great, it shews a strong disposition to irritation. It also some- times happens, that they begin very early to D form [26] form Houghs; when this is the case, they have a strong tendency to mortification.—By these marks we may, in some measure, under- stand the future treatment. My observations convince me, that chancre never appears, in any degree, without im- mediately communicating more or less of the venereal poison to the constititution, by means of the absorbents; whereby it is conveyed into the circulating fluids. The CURE of SIMPLE CHANCRE MAY be shortened, by destroying it by caustic or excision, while the blood is well charged with mercury. THE earlier, after infection, it is destroyed, the better: the whole diseased part should be removed: the caustic should only be applied to those parts that are really diseased, and this treatment should be continued with a piece of caustic, pointed like a pencil, till the surface of the sore looks red and healthy, after throw- ing off the last slough; after which it will heal like any other sore produced by caustic. WHEN [27] WHEN the ulcer is large, it is out of the power of the caustic; but if the situation will allow, the diseased parts may be cut out, or incisions may be made round it into the cel- lular membrane with good effect. Where this method cannot be employed with proprie- ty, because of the inflamed or painful state of the chancre, it should be frequently fomented with warm water or other emollients, and dressed with the mild blue mercurial ointment, made of argentum vivum and hogs lard in equal parts; or if not inflamed, with equal parts of crude mercury and venice turpentine: but in most cases filling the ulcer every day or two with red precipitate and covering with the lead water poultice, or Goulard's cerate, is the most effectual, though not the least painful, of any other application. If the chancre be destroyed early, no other symptoms will follow; but if matter has been absorbed, its effects will appear in other parts in form of lues, as will be more fully ex- plained when on that part of the subject. When a chancre fixes on the internal sur- face of the prepuce, one of two very trouble- D2 some [28] some and distressing symptoms is generally the consequence—either a phymosis, or a para- phymosis; the first signifying such a constric- tion of the prepuce over the glans, as hinders its retraction; the last is such a constriction of the prepuce back of the glans, as hinders it from being brought forward. The phymosis and paraphymosis is a thick- ening of the cellular membrane of the prepuce, in consequence of the irritation produced by the chancre, attended with considerable and diffused inflammation. In this condition it is often impracticable to apply dressings to the chancre. A phymosis should therefore be prevented if possible, and upon the least sign of a thick- ening of the prepuce, which is known by its being retracted with difficulty and pain, the patient should be kept quiet, and the penis kept up against the belly with a linen swath, because if suffered to hang down, the extra- vasated fluids descending and remaining in the prepuce, contribute often more to prevent it from being drawn back, than the inflamma- tion itself. WHEN [29] WHEN the phymosis has taken place, the same precaution may be followed; but as the sores cannot be dressed in the common way, we must either have recourse to dressings in form of injections, or lay open the prepuce by means of a knife. If injections only are employed, they should be frequently repeated, as they are only tem- porary applications. The dressings in form of injections should be mercurial, either crude mercury rubbed down with a thick solution of gum Arabic, which will assist in retaining some of the in- jection between the glans and prepuce; or calomel and opium with the same. In the proportion of these no nicety is re- quired. But where the sensibility of the parts is not very acute, a weak solution of sublimate in water, half a grain to an ounce or two of water, will frequently be found proper propor- tions; but if it encreases the pain and attend- ing symptoms it should be more diluted. In many cases the prepuce and glans are too much swelled and too sore to admit of any [30] any injection; here a poultice made of bread and water, with an eighth part of laudanum, will be proper; but previous to this application, immediately after having cleaned the part, it would be proper to let the penis hang over the steam of hot water, with a little vinegar and spirits of wine in it, which is the neatest way of employing fomentations. WHEN to the above mentioned symptoms a bleeding of the chancre is added, I do not know a more troublesome complaint, because here the cells or veins have no great disposi- tion for contraction: the blood generally comes either from the glans, or from the spungy substance of the urethra, where the chancre has begun about the frænum. Oil of turpentine affords the best stimulus for the contraction of vessels of all kinds; but where hæmorrhage arises from an irritable action of the vessels, which is sometimes the case, then sedatives, such as opium, is the belt application.—Whatever is used in such a state of the prepuce, must be injected into the part. WHERE [31] WHERE the chancres are in a healing con- dition on the glans or prepuce, the prepuce should be moved on the glans as much as it will allow, once or twice a day, to prevent adhesions. When the parts have suppurated, the pus may be let out with an instrument, or by the lapis septicus applied on the part where the pus is collected. A mortification of the prepuce is sometimes the consequence of violent inflammation; but such cases are generally of the erysipelas; and not of the phlegmonous or true suppurative kind. When excrescencies under the prepuce are numerous or large, it commonly becomes necessary to divide the prepuce with the knife, in order to have room to apply suitable dres- sings. In those cases where violent inflammation has invaded the seat of the chancre, producing phymosis, and often so as to threaten mor- tification, a question naturally arises, what is to be done? Is mercury to be given freely, to get rid of the first cause, or does that medicine increafe the effect, while it destroys the cause? Nothing but [32] but experience can decide this. But I should incline to think it necessary to give mercury; for I am afraid, our powers, to correct such a con- stitution, while the first cause subsists, are but weak; but would give it sparingly, because it assists in disposing to such symptoms, and might, if given liberally, do injury. I am therefore of opinion, that such medi- cines as may be thought necessary for the constitution, should be given along with the specific. Bark promises to be of the most ge- neral use; and opium, administered at proper periods, will be of singular service. By com- bining the bark with mercury, they will coun- teract both diseases, the local and constitutional. WHEN the inflammation is so predomi- nant, that mercury may increase the dis- position, bark must be given alone. IN inflammations which have a tendency to mortification there remains an increase of action, but a decrease of power; and this is the cause of the mortification, by destroying the balance which ought to subsist between the power and the action of every part. Upon these [33] these principles the bark is the medicine on which we can place the most dependence; be- cause it increases the powers and lessens the action at the same time. Opium likewise, in many cases, lessens the action, but has not the property of increasing real or permanent strength of the system or of particular parts. When thes stricture from the paraphymosis threatens mortification, an operation becomes necessary. THIS operation is more difficult and trouble- some than that for the phymosis; because the swelling on each side of the stricture covers or closes in upon the tight part, and makes it difficult to be got at. THE belt way is to separate the two swellings, caused by the stricture, on each side, as much as possible, when you mean to cut, so as to expose the neck, then pass a crooked bistoury which is pointed, under the skin at the neck and divide it; no part of the swellings on either side of the stricture need be divided, for it is the laxity of the skin in these parts which admits of their swelling. It may be proper to let the prepuce remain in the same situation E after [34] after the operation, till the chancres are healed on it, or on the glans. If increased inflam- mation succeeds the operation, local treatment will be sufficient, such as fomentations, poul- tices, &c. MERCURY should be employed in every case of chancre.—If given internally and cau- tiously managed, it will seldom or never fail of curing the disease, even where local appli- cations are omitted. When employed to act internally, it should be continued the whole time of the cure, and for some time after the chancres are healed. THE quantity of mercury employed, should be in proportion to the size of the ulceration; becaufe absorption is more copious from large than from small surfaces. MERCURY employed to act internally, must be applied either to the skin or taken into the stomach, according to circumstances. The quantity, in either way, should be such as may affect the mouth slightly. WHEN the sore has put on an healthy aspect, when the hard basis has become soft, and it has [35] has skinned over kindly, it may be looked upon as cured. BUT in very large chancres it may not al- ways be necessary to continue the employ- ment of mercury, either for external or internal action, till the ulcer is healed; because the venereal action is just as soon destroyed in a large chancre as in a small one; for every part of the chancre, being equally affected by the mercury, is equally easily cured: But the skinning is different, for a large sore is longer skinning than a small one. WHEN the mercurial course is carried too high, or is too long continued, it will some- times produce sloughs and ulcerations in the tonsils, and enlarge the surface of ulcers, after the venereal virus is removed. Under such circumstances the cortex with decoctions of sarsaparilla and mezereon are found the best remedies. A GENTLEMAN whose ulcerations were ag- gravated by mercurial dressings, was cured by taking forty drops of lixivium tartari every evening and morning, in a bason of broth. E2 OF [36] OF BUBOES. BUBOES, being an inflammation and tu- mefaction of the inguinal glands, may arise from various kinds of irritation. When the fibres are in a state of preternatural tone, called an inflammatory diathesis, they fre- quently arise from the external application of mercury. But as the most frequent cause is the absorption of venereal matter, I shall con- fine my remarks to venereal buboes only. THE venereal bubo is always caused by the absorption of venereal matter, but this absorp- tion can not take place, unless the urethra, the epithelium or cuticle of the glans or pre- puce is abraded, unless introduced into a wound, &c. below the gland. Therefore, although the matter lies for many weeks in the urethra and over the glans penis, it seldom happens that any aborption takes place; and hence the reason that a gonorrhœa so seldom degenerates into a lues venerea, though the matter [37] matter of it and that of chancre are precisely the same. When a bubo is ascertained to be venereal, resolution certainly ought to be attempted if it be in a state of inflammation only—If very large and suppuration begun, this can seldom be effected. RESOLUTION is to be performed principally by mercury, and depends almost absolutely on the quantity that can be made to pass through the gland. And where suppuration has come on, the cure depends upon the same circum- stance. The quantity of mercury which can be made to pass through the diseased gland, depends greatly on the extent or size of the ex- ternal surface for absorption below the bubo: Hence it is necessary to apply the mercurial ointment to the leg and thigh of the side affect- ed, and also to the penis and scrotum, that it may pass through all the branches of the lym- phatics which lead to the affected gland; but nothing of the kind should be applied to the integuments of the gland itself, lest by its irri- tation the intention of resolution be defeated. WHEN local inflammation runs high, bleed- ing and lead water poultices, with the addition of [38] of a paste made with opium and water, should accompany the application of the mercurial ointment. THESE poultices should always be applied cold. In this way they have very powerful effects, in diminishing the action of the arte- ries of the part, while the mercury alters the specific irritation. BUT, if the constitutional irritation is very great, that is, if the solids are in preternatu- ral tone, and the globules of the blood dense and compact, evacuations and topical seda- tives hould always precede the employment of mercury. ON the contrary, in relaxed habits, the bark and a nutritive regimen, should be combined with mercury. MERCURY, taken into the stomach, cannot act immediately on the bubo; the ointment should therefore always be preferred. IN WOMEN, buboes are seated sometimes in the ligamentum rotundum; sometimes be- tween the labium and thigh; and sometimes in the groin. WHEN [39] WHEN seated between the labium and fe- mur, the mercury, that it may pass through it, should be rubbed about the perinæum, nates and inside of the thigh, as all the absorbents of those parts appear to pass that way; at least, they do not pass into the pelvis by the anus, but go by the groin. IN the resolution of buboes, mercury should be pushed as far as possible, without inducing salivation. HALF a drachm of ointment, made of equal quantities of crude mercury and fresh hogs- lard, has been generally sufficient to apply at a time; and if the mouth does not become sore, but only tender, then pursuing this course, till the gland is reduced to its natural size, will be sufficient, and will probably secure the constitution, provided the chancre, which gave rise to the bubo, heals at the same time. If the mouth is not affected in six or eight days, then two scruples or one drachm may be rubbed in along the course of the lympha- tics every night, till it accomplishes the pur- pose. WHEN [40] WHEN there are two buboes, the quantity of ointment should be proportionally greater. WHEN the buboes are so seated, or so cir- cumstanced, that the mercury cannot be con- veyed to them through the lymphatics, it must be employed either externally or internally, as may be most proper, so as to cure, by acting on the constitution in general. And in such cases, the mouth must be affected. BY following this method, I have had but three buboes to suppurate, since the year 1761. BUT if they should come to suppuration, they are then to be treated in some respects like other abscesses. WHEN suppurated it will be best to let the bubo break itself: but if that is not allowed, it should be permitted to go on thinning the parts as much as possible before it is opened. The great advantage arising from this is, that these parts having become very thin, lose the disposi- tion to heal, which gives the bottom of the abscess a better advantage for healing with the superficial parts; by this means too large an opening [41] opening is avoided, and the different modes made use of for keeping the skin from healing, till the bottom is healed, become unnecessary. I am of opinion that mercury should be con- tinued through the whole suppuration: for though the parts cannot become disposed for a cure, till the abscess is opened and the pus let out; yet I think, they will have a greater ten- dency that way. THE abscess may be opened by simple inci- sion, in preference to any other way. AFTER the abscess has been opened, mercu- ry should be employed in the same manner as directed for the resolution, and for the same reason. IN general, the system should be kept charged with mercury till the bubo is healed; or, till it has for some time lost its venereal or diseased aspect. But venereal ulcers, some- times, assume other aspects and dispositions, different from venereal. In some such cases, when the system has been much reduced by long confinement, and a tedious course of mer- cury, and the ulcers continue without shewing any disposition to heal, but perhaps even grow F worse; [42] worse; under such circumstances, in general, the most effectual remedy is a light nourish- ing diet, with fresh air and moderate exercise, to restore and invigorate the constitution. The bark and wine, or Huxham's tincture, will likewise contribute to the same purpose. And, as old sores of this kind, are generally covered with a glossy slough, some degree of local sti- mulus will be always proper. An ointment formed of Precip. rub. two drachms, and Ba- silic. flav. one ounce, affords one of the best dressings. When by the application of this ointment, the sloughs have all cast off and a proper pus is discharged, the ulcer may after- wards be dressed with lint, and covered with common cerate, so as to exclude the air. OF [43] OF THE CONFIRMED LUES VENEREA. I HAVE now finished my account and me- thod of treatment of those affections, in which the venereal poison is supposed to be confined chiefly to the particular part by which it was received; and shall next treat of the disease, in its confirmed state; that is, when the poison is actually received into the blood, and thereby conveyed to every part of the body. The first symptoms of this form of the disease, appear either on the skin, throat, or mouth. It appears on the skin, in dry scabby erup- tions or pustules, covered with a yellow scab, and most numerous among the hairy parts. If the scab is picked off, the skin underneath appears of a reddish brown or copper colour; the pustules are usually covered with a dry branny scurf, or else with a hard dry scab, of a tawny yellow colour. The parts of the F2 throat [44] throat and mouth principally affected, are the tonsils, uvula, and fauces, from whence they often spread to the ossa nasi. IN the second stage of this disease, it affects the deeper seated parts, the conglobate glands, the tendons, the fasciæ, the ligaments, the pe- riosteum, and the spongy parts of the bones. WHEN these last parts become irritated by this poison, the progress of the symptoms is more gradual than in the first; and have very much the character of scrofulous swellings, or chronic rheumatism, When the periosteum is affected, the swelling has the appearance of an enlarged bone; because it is firm and closely connected with it. ALL these symptoms go on increasing in violence, and additional ones continue to arise, till the miserable patients fall into an hectic and atrophy, and die miserably, unless preserved by the powers of medical art. HARD indolent swellings, however, resem- bling venereal nodes, exostoses, &c. some- times arise independent of the venereal poison, and may depend on a scrofulous constitution. We [45] We ought, therefore, to examine other sym- ptoms well, before we pronounce these to be venereal. When these swellings are not owing to venereal poison, they are very sel- dom painful, or have a great tendency to inflame or suppurate; whereas those that are venereal, generally do, and if they lie upon a bone, generally bring on a caries. THESE carious ulcers are most commonly met with on the ulna, tibia and bones of the cranium; and when accompanied with nocturnal pains, we need never hesitate in considering them as venereal. THESE, then, are the principal and most evident signs of the confirmed lues—there are others enumerated by authors; but as they are more equivocal, shall for the pre- sent be passed over in silence. BEING thoroughly convinced, that the case is venereal; before we apply our remedies, we should consider first of all, whether it be of longer or shorter date, and then the age, sex and constitution of the patient—because this disease is much more difficult to ma- page, when it has been of long continu- ance [46] ance in weakly persons, and in persons la- bouring under any chronic disease, than in one of a sound and healthy constitution—Not because two diseased actions of a different nature can exist in the same part, but because the predominant action will operate with more violence, in consequence of the parts affected being more susceptible of impres- sion by the weaker diseased action. The more symptoms that arise, and the more that they affect the bones, the more difficult will be the cure. THE condition of the patient should al- ways be considered, before he enters on a course of the grand specific, mercury. It is superfluous to observe, that it would be rash and dangerous to administer mercury in an acute fever, in the hectic fever, derived from internal ulcers or abscesses, and in the last stage of a consumption, except when in the last mentioned cases there is convincing evidence, that the hectic is derived from the lues. In many chronic diseases, or morbid con- stitutions, mercury may be administered un- der certain limitations, with perfect safety and advantage, especially in the scrofula, the asthma, &c. IF [47] IF the patient's strength has been much exhausted by labour, abstinence, or sickness, or any other cause, the employment of mer- cury should be postponed till by time, rest, and a nourishing diet, it can be sufficiently restored. IN the application of mercury to pregnant women and to infants, much caution will be requisite. MERCURY should always be guardedly given to patients afflicted with the scurvy, and to such as are subject to habitual diarrhœa or dysentery. WHERE any of these disorders prevails, it should be cured, or at least alleviated, before the patient enters on a cure of the lues. THE patient's regimen should be in some measure conformable to his former habits; and if he has been accustomed to live full and to drink free, the quantity of his aliments and drinks may be reduced with propriety, but not their quality: otherwise mortal diarrhœas, palsies, or some other disease of a debilitating nature, will be apt to be the consequence. It is [48] is however of much importance, to avoid all manner of excess, and to avoid the common causes of inflammation on the one hand, and those productive of putrefaction on the other—"In medio tutissimus ibis." OF THE CURE OF THE LUES VENEREA. TO cure the local and visible effects of the lues, we must attack it through the medium by which it was communicated, that is the blood, without however considering the blood itself, as a diseased part, or containing the poison, but as the vehicle of our medicine which will be carried by it to every part of the body, where the poison was carried, and in its course it will act on the diseased solids. WITH regard to the preparation of the medicine, and the modes of administering or applying it, we are to consider two things. 1st. THE [49] 1st. THE preparation and mode that is attended with the least trouble or inconveni- ence to the patient; and, 2d. THE preparation and mode of admi- nistering it, that most readily conveys the necessary quantity into the constitution. AND when in every form it acts locally, instead of generally, it will become necessary to join such medicines with it, as will lessen or prevent its violent local effects, without affecting its specific ones on the constitution at large. WHEN it can be thrown into the constitu- tion with propriety, by external application, it is preferable to the internal, because the skin is not near so essential to life as the sto- mach, and is therefore capable in itself of bearing much more than the stomach; it also, in this way, affects the constitution much less. THE visible effect of mercury on the con- stitution is, to produce universal irritability, that is, make it more susceptible of all im- G pressions; [50] pressions; it quickens the pulse, increases its hardness, and produces a kind of tempo- rary fever, &c. EXPERIMENTS prove that evacuations, pro- duced by mercury, retard the cure, especi- ally if the secretory organs are too susceptible of this stimulus, for then the quantity suffi- cient for the cure cannot be taken in. On the other hand, if given with care and judg- ment, so as to avoid violent evacuation, any quantity may be introduced, sufficient for the cure of the disease. OF THE ACTION OF MERCURY. MERCURY can have but two modes of action—one upon the poison; the other on the constitution. IF [51] IF it acted upon the poison only, it might be supposed to be in two ways, either by destroying its qualities, by decomposing, or by attracting it, and carrying it out of the constitution. IF the first were its action, the quantity alone would be the thing to be depended upon; if the second, the quantity of evacu- ation would be the object. BUT if it act upon the principle of de- stroying the diseased action of the living parts, counteracting the venereal irritation, by producing another of a different kind, then neither quantity alone, nor evacuation, will avail much; but it will be quantity, joined with sensible effects, that will pro- duce the quickest cure, which, from ex- perience, we find to be the case. MERCURY losing its effects upon the dis- ease, by constant and habitual use, is a proof that it neither acts chemically, nor by carrying off the poison by the excretions, but by its stimulating power. G2 THE [52] THE best preparation of mercury, for ex- ternal application, is made by triturating equal weights of crude mercury and hogslard to- gether, till perfectly incorporated, without any other addition. THE preparations I employ for internal application, and which I believe to be equal, if not superior, to any other form, is, mer- curius calcinatus, calomel, and argentum vivum, incorporated with thick mucilage of gum arabic. OF the first, I commonly give one grain, with a third of a grain of opium and a drop of agreeable essential oil, for one week or upwards; and if by that time, that quan- tity has not made a visible alteration in the mouth or throat, I repeat the same quantity twice a day, for another week; or till it gives evidence of having pervaded the sy- stem; in which condition I endeavour to keep the system, without bringing on a salivation, till all the symptoms of the disease are removed. ABOUT three grains of calomel are equal in strength to one of mercurius calcinatus; and [53] and fifteen of crude mercury are equal to three of calomel. IT has of late years, been the common practice, to give corrosive sublimate, in solu- tion; but from many trials I have made with it, I am convinced it seldom performs a perfect and radical cure. It is true, it removes ulcers of the mouth sooner than any other preparation; but this I suspect is, by its acting locally as a gargle. A grain, or less, dissolved in any agreeable liquid, particularly distilled spirits, is the common dose and form of administering it. It passes readily off by the skin, owing to its being in the form of a diffusible stimulating salt; hence has considerable effect on simple cuta- neous eruptions. But it disagrees more with the stomach and bowels, than any other preparation; therefore, generally requires to be combined with opium, to abate their sensibility. GUM guaiacum, in doses of a scruple, is sometimes a good auxiliary to these prepa- rations, especially in old debauched constitu- tions. MANY [54] MANY of the local affections, besides the application of mercury, require other assist- ance. NODES have given way frequently to blis- tering, but oftener to an incision down to the bone, through the periosteum—by these means the violence of pain, which is so in- supportable to the patient, while warm in bed, is perfectly relieved. VENEREAL warts may be considered as ere excrescences from the cutis, and ought not to be considered as a part of the animal, because not endowed with the common or natural animal powers, for which reason the cure becomes easier—hence many trifling circumstances may occasion them to decay. Electricity will produce an action in them, which they are unable to support. An in- flammation excited round them, will often make them drop off.—Many stimuli applied to their surface, make them wither and die.— Any caustic frequently applied, will destroy them—or, where the base is slender, they may be cut off with a pair of scissors, or by a waxed thread drawn so tight, as to prevent the entrance of any fluid into them; and afterwards [55] afterwards their base should be touched with caustic; merely as a stimulant, the rust of copper and powder of Savine leaves is one of the best. WHEN the caustic is employed to remove venereal excrescences, they should not be applied over a large surface at once, lest they induce inflammation, and do injury. WHEN the bases of excrescences are large, a needle, with an eye in the point, armed with two pieces of waxed silk thread, should be thrust through the middle of it, at its base, with which each half is to be sur- rounded, and tightened close, increasing its tightness daily, till the whole drops off. WHEN part of any gland, after suppura- tion, remains indurated, and cannot be brought to suppurate, it will be proper to destroy the indurated parts, by the repeated application of the lunar caustic. VENEREAL ulcers of the mouth and throat, are best relieved by gargles made of vegeto- mineral water, and a weak solution of subli- mate, combined together. And when, by mis- management [56] management or other cause, a salivation has taken place, a gargle of opium has good effect, by taking off soreness and irritability on which the discharge depends.—Laxatives and sudorific anodynes will likewise be proper in such cases. FROM all the observations I have been able to make on the operation of different preparations of mercury in the human system, I am of opinion, every preparation of that metal, when it acts on the circulation at all, becomes specifically the same; either before or after its entrance, so that the less stimu- lating and more simple the preparation is, in irritable temperaments, the better. Every preparation appears to act, by producing an irritation, which counteracts and destroys the venereal irritation. I SHALL conclude this part of my subject with the following facts, in support of what I have advanced, reflecting the venereal virus in gonorrhœa and chancre, being the same.—Both gonorrhœa and chancre are very generally consequences of the same re- mote cause, that is, communication with an affected person of a different sex: from a single [57] single instance of exposure to infection, a patient has contracted both these local forms of the disease. FROM the same female, who it was ascer- tained beyond controversy, had only a go- norrhœa, two different men were affected, one with gonorrhœa, the other with chancre; and several in whom the affection had begun in form of gonorrhœa, have (in consequence of inflammation, terminating in an abscess and ulceration,) had it converted into a confirmed lues. TO put the matter out of all dispute, I prevailed on more than one patient in an hospital, to permit experiments to be tried on them in different ways, with matter in each form of the disease; all of which con- firmed the fact. H OF [58] OF THE DISEASES OF THE URETHRA; Supposed to he derived from the VENEREAL DISEASE. BEFORE I enter upon this part of my subject, I deem it proper to give a short description of the urethra, &c in a sound and healthy state. BY the urethra, I understand that canal, by which the urine is conveyed out of the bladder. I CONSIDER all that part of the canal, con- tinued from the bladder and incumbent on the prostate gland, the neck of the bladder; and, at the termination of the neck of the bladder, the membranous part, called the urethra, has its origin. The muscular fibres, which act as a sphincter, are implanted into the prostate gland: for, although what has formerly been called the neck of the bladder, after the expulsion of the urine, is more like a canal [59] a canal than the body of the bladder, till the canal has arrived at the prostata, it has not the least power of resisting the efflux of the urine. THE commencement of the urethra ap- pears to be truly membranous, but soon after it receives a covering, called corpus caver- nosum; the origin of this cavernous sub- stance is by much its largest part, both as to number of cells, as well as form; which is not unlike a pear, whose basis is next to the prostata, and is imperforate at its basis: this spongy or carvernous substance is con- tinued round the urethra, throughout its whole extent; and when it gets beyond the extremities of the corpora cavernosa penis, it becomes a cap to them, and forms what is called the glans penis; though it cells have not the least communication with the corpora cavernosa penis, but only with the corpora cavernosa urethræ. The extremity of this canal has an aperture of an oblong shape, for the exit of the urine and sperm. If we examine the internal surface of the urethra, after dividing its superior part, lodged in the sulcus between the corpora H2 cavernosa [60] cavernosa penis, and continue the incision quite through that part of the canal which is lodged within the prostate gland, till the neck of the bladder is laid open, we shall discover a sort of caruncle, called caput gallinaginis, or veru montanum. This carun- cle has two or three orifices, opening into the cavity of the urethra, which are the ducts from the vesiculæ feminales, and are so directed as to serve as valves, to hinder the urine from entering when discharged from the bladder, and are furnished with some fibres, which act as sphincters, to pre- vent the semen from escaping, till wanted in time of coition. ON each side of the veru montanum, we observe ten or twelve orifices, which are the terminations of the excretory ducts from the prostate gland. IF we blow, with a small pipe, on the inner surface of the urethra, obliquely to- wards the neck of the bladder, we may observe the appearance of many semilunar valves, which cover the excretory ducts of the mucous glands, lodged in the caver- nous substance of the urethra: these ducts do [61] do not open into the urethra, immediately, on their being sent off from the glands; but, passing between its coats for some short space, and advancing obliquely for- ward, terminate in the urethra, and are called lacunæ: by the direction of these lacunæ, their orifices must be always closed during the discharge of the urine; and by this me- chanism, the orifices are not stimulated at that time; but the glands being acted on by the column of urine, discharge their mu- cilage which, lubricating the internal surface of the urethra, prevents offence being given by the salts of the urine, which would otherwise happen from the great sensibility of the internal membrane. NEAR to the bulb of the urethra, we remark two lacunæ, much more conspicuous than the rest, which are the openings of the excretory ducts, from two glands, com- monly called Cowper's glands, from the name of the discoverer; they are situated on the outside of the urethra, and acted on by the muscle, called accelerator urinæ and seminis. The whole internal surface of the urethra is villous. THE [62] THE urethra is a cylinder, as far as it is contained within the sulcus of the corpora cavernosa penis; but after that, it is extended towards the glans penis; its sides approach- ing each other, it becomes rather a flat tube, but remarkably depressed just within the glans; which depression is called fossa navicularis; after that the canal terminates by a sort of oblong slit, called the orifice of the urethra. WHAT we have now advanced may serve to convey a general notion of the anatomy of the parts; the diseases whereof we are about to treat. OF [63] OF THE DISEASES OF THE URETHRA. THERE are five modes of obstruction, to which the urethra is subject; four of which are diseases of that canal itself, the fifth is the consequence of the diseases of other parts. THREE of the former modes are a lessen- ing of the diameter of the passage; the fourth is an excrescence in the canal; and the fifth is derived from contiguous exte- rior swellings, or from a swelling of the prostate gland. STRICTURES are known by the lessening of the diameter of the stream of urine. SOMETIMES the stream is forked or scat- tered. Under such circumstances, if a bou- gie, of a common size, passes with tolerable case, [64] ease, the fifth cause of obstruction is to be suspected, which will most probably be a swelled prostate gland. THE spasmodic obstruction will com- monly explain itself, when the symptoms are well investigated; for the obstruction arising from this cause, will not be perma- nent or constant, but will sometimes inter- mit or be absent. THE bougie, with its application, is per- haps one of the greatest improvements in surgery, which these last thirty or forty years have produced. FORMERLY the bougies were either a piece of lead or a small wax candle. WHEN lead was used in place of bougies, it has happened that a piece of the end has broken off in the bladder, which has been dissolved and brought away by injecting quicksilver into that viscus, I SUSPECTED (a priori,) that quicksilver could not come in contact with lead, in water, so as to dissolve it; but upon making the experiment found, it did. DARAN [65] DARAN was the first who improved and brought the bougie into general use. MANY place great faith in certain com- positions of which the bougie is formed; but it is of no consequence what are the materials of its composition, because any extraneous body of the same shape and consistence, will act in the same manner. THE permanent stricture is only to be cured by local applications. The cure is either a dilatation of the contracted part, or a destruction of it, by ulceration or escha- rotics. THE dilatation is effected by the bougie, but this is seldom permanent. THE ulcerative process is also effected by the bougie; and the destruction by escha- rotics, is by means of caustics. THE bougie should be increased in size, according to the facility with which the stricture dilates, and the ease with which the patient bears the dilatation. I THE [66] THE time each bougie should remain in the passage, must be determined by the feelings of the patient; for it should never give much pain: going beyond this point, is destroying the rational intention, and produces irritation; which for a time renders the further introduction of the bougie im- proper. When the use of it is first com- menced, perhaps it should seldom be lest in, more than from five to ten minutes at a time; till the irritation ceases from habit. IT sometimes happens, that some patients cannot bear it to remain in the passage for ten minutes together, at the end of several weeks; and yet in time, they come to bear it without much inconvenience, for hours. THE belt time of introducing the bougie, is in the morning before the patient leaves his bed, or when he has no occasion to use exercise. SYMPTOMS of inflammation, are to be pre- vented, by temperature and vegetable regi- men; but when they take place, by general and sedative evacuants, and the antiphlogistic regimen,—which consists in avoiding every thing [67] thing possest of irritating powers, and by emol- lient watry liquors copiously drank, with a view of relaxing and diminishing the action of the distended fibres and diluting the salts of the urine. IF the smallest bougie which can be con- trived, with any degree of strength cannot pass, dilatation becomes impracticable, and it becomes necessary that something else be done for the relief of the patient. SO circumstanced, the stricture is to be destroyed some way or other. Here then the caustic is the best application. THIS may be performed, by fixing a lunar caustic, in form of a slender pencil, to the end of a wire or small flexible probe, by means of melted sealing wax; which is to be passed to the part most affected with the stricture, through a small silver cannula or catheter. THE application of caustic need not ex- ceed a minute at a time, and may be re- peated every day, or every second day, only allowing time for the slough to come off. I2 WHEN [68] WHEN this method excites inflammation and pain, which is sometimes the case, and sometimes a total suppression of urine— the application is to be suspended a while, and those effects removed by cool injec- tions of vegeto-mineral water, and a solu- tion of opium in water—fomentations to the region of the bladder—saline purga- tives, succeeded by an anodyne draught at bed time, joined with thirty or forty drops of antimonial wine; but, if the inflamma- tory irritation comes to be communicated to the system, anodynes will not be pro- per, till that circumstance has been re- moved by blood-letting, &c. TO prevent those effects of the caustic, the patient should make water, or inject warm milk and water into the urethra, to wash out any part of the caustic, that may have been dissolved. THE cure of strictures, in the urethra of women, is similar to that in men. The bougie must be prevented from passing into the bladder of women, by bending part of it over the orifice of the vagina, and should be prevented from falling out, by [69] by the (T) bandage. The bougie should always be introduced for women, as it is almost impracticable for them to do it themselves—but happy for them, they have very seldom occasion for such an applica- tion, as the vagina, in females, is much of- tener the seat of the venereal disease, than the urethra. A COMPOSITION, which answers very well for the consistence of bougies, is the fol- lowing: ol. Olivar. lb. iij.—ceræ flav. lb. j. minii lb. iss. which are to be boiled to- gether over a slow fire for six hours. THE cure of the excrescence, or caruncle in the urethra, is to be conducted in the same manner as directed for the destruc- tion of impervious or contracted stricture, already described. IN cases of diseased urethra, where the urine diffuses itself into the cellular mem- brane of the scrotum and penis, unless foon relieved, the patient sinks, and a mor- tification comes on. IF, [70] IF, before he sinks, a separation of the slough takes place, this separation performs the operation of opening, and the patient may recover. We should not however, I think, wait for such separation of the mortified part, but make an opening early, upon the first knowledge of a diffusion of the urine into the cellular membrane; and we should be guided as to situation, by introducing a staff into the urethra on to the stricture. As in such cases there is great disposi- tion to violent action, attended with great debility of the moving fibres, in the part locally affected, it is adviseable to give the bark early and liberally, accompanied with such medicines as have the property of acting on the perspiratory vessels, such, as the saline draughts, Mindererus's spirit, antimonial wine, or other antimonial pre- parations; as there is generally a stricture on the surface, and considerable fever. THE cortex gives strength, and also, in some degree, lessens irritability, and by that means, [71] means, lessens action.—Opium will often assist its effects. ABSCESSES sometimes take place in the urethra, in consequence of violent inflam- mation, and frequently break and discharge on the outside of the perinæum or inferior part of the penis, through which the urine is discharged, rendering the wound callous and fistulous. IN cases of fistulous ulcers in the perinæ- um or penis, a bougie or the catheter, is almost the only remedy necessary to be em- ployed. By a proper and long continued use of either of these, the obstruction will be removed.—But I prefer the catheter for the most part to the bougie, because when necessary to make water, the catheter need not be withdrawn.—When the catheter is employed, it is to be secured from coming out, by a suitable contrivance. WHEN the cure of the urehtra is effected, it will be known by the instrument passing in without impediment, and by the urine following in full stream when withdrawn, and the orifice of the external sore is com- pressed. IF [72] IF this preternatural opening does not now heal, in the course of a short time by simple dressing, it will be found to be pre- vented by its edges having become callous, and by their being covered with a morbid production of the surrounding cuticle. TILL this obtacle to the progress of the cure is removed, it is evident no advantage can be derived from any means which can be employed. We are, therefore, to attempt the destruc- tion of the callous edges of the sore, as soon as it is found that the bougie or cathe- ter, after removing the obstructions in the urethra, have not proved altogether effectual. And the method of doing it, is this. The patient is to be placed on a table, in the same posture as is used in the ope- ration for the stone; and a staff being in- troduced into the urethra and pushed gently along till it has passed the opening; at which the urine is discharged. In this situation it is to be held firm by an assistant, while the operator, intro- ducing [73] ducing a small probe, at the external open- ing of the ulcer; and cutting upon it in the course of the sinus, is then to lay it open through its whole length; till it terminates in the urethra or in the bladder itself, if the fistula or sinus reaches so far. WHEN there are more openings than one visible externally; they must all be laid open, in the same manner. IN some instances, there are two or three sinuses in the cellular membrane, leading from openings in the urethra; but in others, there are as many openings in the urethra, as there are sinuses or sores, externally. THIS, however, is not a frequent occur- rence; but is a matter of importance, as the same method of treatment answers equal- ly well in both cases: for, whether the dif- ferent sinuses originate from one common opening in the urethra or not, they ought all to be laid completely open, from one extre- mity to the other. THE blood being spunged off, the ori- fice in the stricture of the urethra is to be K searched [74] searched for, and when discovered, is to be dilated. The catheter is then to be pushed forward into the bladder, and secured from coming out, and the wound to be distended with lint. AN anodyne may be given, after the ope- ration, and another at bed time. THE catheter or a bougie, as may be thought most adviseable, is to be left in the urethra; unless succeeding inflammation makes it necessary to withdraw it, till the wound becomes stationary; then left it should prevent healing, it should be with- drawn, and only used occasionally. THE substance of the urethra being mus- cular, it is subject to diseases, peculiar to muscles in general. IN a paralysis of the urethra, the bladder is hardly allowed to be filled so as to give the stimulus of repletion, but the urine dribbles away insensibly, as fast as secreted by the kidneys. THERE [75] THERE is great difference in the degrees of violence of this disease. THIS complaint is to be cured by stimu- lants; as a blister to the loins, or to the perinæum. PUTTING the feet in cold water may be serviceable. CANTHARIDES taken internally, fifteen or twenty drops of their tincture, twice a day, according to their effects, are of singular service in many cases. THIS sometimes brings on a spasmodic affection of the urethra, but an emollient clyster with the addition of opium, soon relieves. SPICES and steel medicines are of service, and from what has been said of the bark, should suppose it a good medicine. ELECTRICITY sometimes succeeds—and washing the adjacent parts with cold water, may probably have a good effect. K2 WHEN [76] WHEN carnosities are discovered in the urethra, caustic is the only remedy. STRICTURES are too often mistaken for carnosities and execrescences, which are but rare occurences. A SWELLING, or induration of the pro- state gland, is often the proximate cause of the strangury, and frequently prevents the catheter from entering the neck of the bladder: such cases require small bougies to bring on suppuration, &c. INVOLUNTARY seminal discharges, are oc- casioned by relaxation, and preternatural irri- tability of the testicles and contiguous parts; and are sometimes to be cured by opium, given in small doses, night and morning, twelve or fifteen drops of Tinct. Thebaic, at bed time, and half as many in the morning; aided by bark, cold bath, flesh brush, and exercise in the open air. Of [77] OF CORRECTING SOME OF THE EFFECTS OF MERCURY. FORMERLY, when the management of mercury was not so well understood, nor its effects in this disease so well known, as they are at present, it was generally supposed to act by evacuation from the salivary glands, and was therefore always given, till that evacuation took place; and as its effects in the cure were imagined to be in proportion to the quantity of this eva- cuation, it was pushed as far as possible, with- out bringing on a danger of suffocation. From this treatment it often happened in those constitutions which were very susceptible of the mercurial irritation, and in which the medicine produced much more violent ef- fects on some particular secretions than could be wished, that recourse was obliged to be had to medicines, correcting the effects of mercury; as these effects were often [78] often an hindrance to its being given in suf- ficient quantities for the cure of the disease. I mentioned, when treating of the effects of the mercury, that the sensible increase of the secretions produced by it, were in the following order; first of saliva, then sweat, then urine; and often of the mucus of the intestines, producing purging. I also ob- served, that when any of these secretions became too violent, that the hand of the surgeon was tied up, till they were mode- rated. Attempts have been made, to les- sen those effects in two ways, either by the destruction of its power on the body in general, or by its removal, but neither of these means have succeeded. IT never has once been thought neces- sary to attempt to lesen its powers on the organs of secretion, so as still to retain the same quantity in the constitution, or even to throw in more, which if it could be effected, would be sometimes of great service; but, as we are not yet acquainted with power sufficient for these purposes, we are obliged to observe great caution in our mode of giving the medicine. I have en- deavoured to show that this medicine need not [79] not be given with a view to procure those evacuations, and that it may be given in any quantity, without increasing either of those secretions, in any evident degree; however after every precaution, we may be still deceived; and the medicines will, every now and then, produce greater effects than were intended. It is very necessary, there- fore, to seek for a preventive of the effects where they have already taken place. The common practice when mercury produced violent effects upon the intestines, was to counteract these effects; but this was not done with a view to retain the mercury in the constitution, but to relieve the bowels that were suffering by the action of the medicine; whereas the proper practice would be to stop its progress here, as in every other outlet, that more mercury may be retained in the constitution. Although these increased secretions arise from the constitu- tion being loaded with mercury, yet there is no danger in stopping them: for they do not arise from an universal disposition becoming a local or critical one; and therefore, if such an action be checked or stopped in one place, it must necessarily fall upon some other; but it is from the part being more susceptible of this [80] this irritation than any other, and the quan- tity, now in the constitution, being equal to the susceptibility of the part, and, therefore though its effects are stopped here, it does not break out any where else; every other part being capable of supporting this quantity and of remaining unaffected till more is thrown in. When the mercury attacked the salivary glands, it increased that secretion so much, as in some cases to oblige practition- ers to administer such medicines, as were thought likely to remove this new complaint. This susceptibility of the glands of the mouth, and the mouth in general, to be easily put into action by this medicine, was generally supposed to arise from a scorbutic constitution, to which most complaints of the mouth are attributed. I am of opinion, that scrofulous people, and those of a lax and delicate habit, are more subject to have it fall on the mouth, than those of a contrary temperament. PURGES were given, upon a supposition that mercury could be carried off by the evacuation produced by them; and they were repeated according to the violence of the effects of the medicine, and the strength of [81] of the patient: but I can hardly say that I ever have seen the effects of mercury upon the mouth, lessened by purging; whether it arose spontaneously, was produced by purging medicines, or even when arising from the mercury itself. As this method was not found sufficient for the removal of the complaint, other medicines were tried; sulphur was supposed to be a specific, for the removal of the effect of mercury. Whether this idea arose from practice, or reasoning, is not material; but I think I have seen good effects from it, in some cases. If we can suppose purging of any service, purging with sulphur, would an- swer best, as it would exert its effects, both as a purge and as a specific. SULPHUR, certainly, enters the circulation as sulphur, because our sweat and urine smell of it; if it does not combine with the mercury, and destroy its properties as mer- cury, it is possible, agreeably to the opi- nion of those, who first thought of giving it with this intention, that it may so com- bine, as to form sethiops mineral, or something similar; for we know, that the æthiops mineral, however formed, does L not [82] not in general salivate. It is possible too, that sulphur may act as a contrary stimu- lus to mercury, by counteracting the effects of it in the constitution. SULPHUR has even been supposed to hinder the mercury from entering the cir- culation. Upon the whole, as these pre- parations of sulphur and mercury, are still supposed to have good effects, and as I think I have seen good effects in other cases, we must either allow that they enter the circu- lation, or that their whole effects are on the stomach, or intestines, with which the rest of the body sympathises. The good effects of sulphur, in lessening or altering the imme- diate effects of mercury, can only take place, when that medicine is really in the constitution; therefore a distinction is to be made between such as arise immediately from mercury, and one continued from habit, after the mercury has been evacuated from the constitution; a case that sometimes happens. THE taste in the mouth, from the use of mercury, has been known to go off, and not be perceived for a fortnight, and the same [83] same taste has recurred; this I am informed, has happened twice to a gentleman, from the first quantity of mercury taken. To account for this is not easy; in whatever way it happens, it is a curious fact. SULPHUR united with any of the metals, probably destroys their solubility in the juices, or at least their effects, in the circu- lation; none of the cinnabars act either as sulphur, or mercury. Crude antimony, which is regulus of antimony and sulphur, has no effect. Arsenic when joined with sulphur, has no effect; nor has iron. WHEN the mercury has fallen upon the mouth or throat, washing those parts with opium, has often good effects; for opium takes off irritability and of course, the sore- ness, which is one means of lessening the secretion. A drachm of Tinctura Thebaica to an ounce of water, makes a good wash or gargle, MY using opium, in this way, was from analogy, finding that opium quieted the bowels, when a purging came on, in con- sequence of mercury: I tried it by way of L2 gargle, [84] gargle, to the mouth, and found good ef- fects from it; but not equal to those which it produced in the bowels. WHEN mercury falls upon the skin, it is neither so disagreeable, nor so dangerous as when it falls upon the mouth; however, it may often happen, that it will be proper to check such a discharge, both on account of its being troublesome, and of its lessen- ing the effects of the medicine, in the con- stitution, by carrying it off. The bark is, perhaps, one of the best correctors of this increased secretion. WHEN the medicine attacks the kid- neys, and increases the secretion of these glands, it is not so troublesome as when it produces sweating, though it is possible that it may carry off the mercury too soon; but as we have but few medicines that can lessen that secretion, in most cases it must be allowed to go on. The bark may in such cases be given with advantage. WHEN the mercury falls upon the bow- els, it proves often more dangerous and troublesome than in any of the former cases, [85] cases, especially the two last; but it is perhaps more in our power to prevent or palliate. Opium should be given in such quantities, as to overcome the complaint, and I believe will seldom fail in removing all the symptoms. OF THE FORM OF THE DIFFERENT PREPARATIONS OF MERCURY, WHEN IN THE CIRCULATION. IT would appear from reason and many circumstances, that mercury must be in a state of solution in the juices of the body, before it can act upon the venereal disease, and indeed, before it can act upon any [86] any other disease. That mercury is in a state of solution in our fluids, and not in the state of any preparation of mercury, that we know of, is very probable, from the following facts. FIRST, crude mercury, every salt of mer- cury, and calx of mercury, is soluble in the spittle, when taken into the mouth, by which means it is rendered sensible to the taste; from thence it may appear, that it is capable of solution in some of our juices. SECONDLY, crude mercury, when divided into small parts by gum Arabic, &c. so as to be easier of solution when taken into the stomach, generally purges; but crude mercury taken, without such division, has no such powers, not being so readily dissol- ved in the juices of the stomach. The simple calx of mercury has the same ef- fect, purging, and much more violently, from being, I suppose, readier of solution in the animal juices; for if it only purged from its union with the acid, which hap- pened to lie in the stomach, it most pro- bably would not purge more than crude mercury, although it is very probable, that the [87] the calx is easier of solution in a weak acid, than even the crude mercury. THIRDLY, every preparation of mercury producing the same effect in the mouth, and also having one and the same effect in the constitution, shows that they must all undergo a change, by which they are reduced to one particular form. WE cannot say what that form is, whe- ther it is the calx, the metal or any other, that we are acquainted with; but it is pro- bable, that it is not any of them, but a new solution in the animal juices. This is rendered still more probable by this circum- stance that every preparation of mercury, put into the mouth, undergoes the same change, and the spittle has the same taste from every one of them. If every different preparation of mercury had the same properties in the constitution, that it had out of it, which we must suppose, if it enters and continues in the same form; in that case, the venereal poison must be eradicated, in as many different ways as there are preparations. CRUDE [88] CRUDE mercury would act mechanically, by increasing weight and momentum of the blood; the calx would act like brickdust, Or any other powder that is heavy; the red precipitate would stimulate, by chymical properties, in one way, while the corrosive sublimate would act in another, and the mercurius flavus in a third; this last would most probably vomit, as ipecacuanha does, which vomits, whether thrown into the cir- culation or stomach. FOURTHLY, all the preparations of mer- cury, when locally applied, act always in one way, that is, as mercury; but some have also another mode of action, which is, chymical, and which is according to the spe- cific nature of the preparation. THE red precipitate is a preparation of this kind, and acts in both these ways; it is either a stimulant, or an escharotic. FROM what has been said, and from many experiments which I made on myself, for the purpose of ascertaining the fact, it ap- pears to be immaterial, what preparation of mercury is used in the cure of the ve- nereal [89] nereal disease, provided it is of easy so- lution in our juices; the preparations ea- siest of solution, being the best. of GUM GUAIACUM, and SARSAPARILLA, IN THE VENEREAL DISEASE. I HAVE hitherto only recommended mercury, in the cure of the venereal disease; and indeed it is the only medicine to be depended upon. THE Guaiacum, I have found, possesses some power over the disease; consequently it may be of service in slight cases, where it may be improper or inconvenient to give mercury, on account of some other dis- ease; these cases, however, I have not yet M been [90] been able to ascertain; or it may be given in those cases, where it is apprehended, that the quantity of mercury, necessary to subdue the disease, would be too much for the constitution to bear; cases, which sometimes occur. The sarsaparilla appeared to have no ef- fect at all. OF THE EFFECTS REMAINING, AFTER THE DISEASE IS CURED; AND OF THE DISEASES SOMETIMES PRODUCED BY THE CURE. IN treating of the local effects of the ve- nereal disease, the gonorrhœa and chan- cre, as also the bubo, I observed that after the virus was destroyed, there remained in many cases, some of the same symptoms, end [91] and particularly after the gonorrhœa. It was also observed, that though all the symptoms were entirely cured, yet they were liable to break out again. A gleet will appear, sometimes attended with pain, so as to resemble a gonorrhœa; after chancres there will be sores, resembling them; and buboes, after the virus is gone, will not heal, but spread. In the lues venerea, the same thing often happens, especially if the inflammation and suppuration, have been violent in the parts. THESE cases puzzle considerably, for it is difficult to say when the venereal virus is gone. In such doubtful cases, the treat- ment to be followed becomes more undeter- mined. SUCH complaints are more common, in the tonsils, than any other part; for we often find, that while a mercurial course is going on, and, the ulcers on the tonsil healing, or even healed, they shall swell, become excoriated, and the excoriations shall sometimes spread over the whole pa- latum molle; which renders the disease doubtful. M2 I BELIEVE [92] I BELIEVE these excoriations, as well as such other appearances of the disease, as come on during the use of mercury, are seldom or never venereal. In all such cases, I would recommend, not to continue the mercury longer than what appears necessary or sufficient, for overcoming the original venereal complaints; not considering those changes in the case, as venereal. The bark is often of service here, and may be given either with mercury, or after the venereal course is over. IT often happens, that venereal abscesses will not heal up, although they have gone a certain length towards it; for while the venereal action remained in the part, the mercury disposed that part to heal; but under that course, the constitution and part had acquired another disposition, proceeding from a venereal and mercurial irritation, af- fecting a particular habit of body or part, at the time, which new disposition, differs from the venereal, mercurial and natural, being a fourth disposition, arising out of all the three. I SUSPECT [93] I SUSPECT, however, that it depends chief- ly on the constitution; because, if it was owing to the other two we should always have the same disease; and what makes this opinion more probable, is, that it dif- fers in different people, at least it is not cured in all by the same means. The con- stitution being predisposed, the other two become the immediate causes of action. AS soon as the venereal irritation is de- stroyed by the mercury, or becomes weaker than the other two, then the effects of the others take place. While the venereal ac- tion prevails, the mercury is of service, and the sore continues healing, but when it is lessened to a certain degree, or destroyed, the mercury not only loses its powers, but becomes a poison to the new disposition that is formed: for if mercury is continued the sore spreads; it should therefore, be im- mediately left off. SOME of the sores, formed in this way, not only resist all means of cure, but often inflame, ulcerate, and form hard callous bafes; so as to put on the appearance of a cancer, and are often supposed to be really so. WE [94] WE find also, that new diseases arise from the mercury alone. The tonsils shall swell where no venereal disease has been before, the periosteum shall thicken, and also pro- bably the bones, and the parts over them shall become cedematous, and sore to the touch; but as these complaints arise, while under a mercurial course, they are not to be reckoned venereal, but a new disease; al- though they are too often supposed to be venereal, and on that account the mercury is pushed as far as possible. IN such cases, if the complaints for which the mercury was given, are nearly cured, and the medicine has been continued a suffi- cient time after, to complete the cure of these complaints, then of course, it should be left off; and if there be any doubt, it should be left off rather sooner than if no such complaint had taken place, because it is probably producing a worse disease than the venereal; and, if after the cure of these complaints from the mercury, the ve- nereal disease begins again to come into action, mercury must be given a second time, and now the constitution will be better able to bear it, especially, if attention has been paid [95] paid to the restoring the strength of it. Those diseases of the tonsils and perioste- um, I suspect, have something scrofulous in them. BESIDES local complaints, arising from the combined action of the mercury, the disease and the constitution, there is some- times a constitutional effect, which is a weakness, or debility, a languor, want of appetite, frequent sweats threatening hec- tic; but these happen mostly in those con- stitutions, with which mercury disagrees. THESE complaints, local, as well as con- stitutional, arise in some measure from weakness. They are difficult of cure, whe- ther arising from a venereal chancre, bubo, or the lues venerea. STRENGTHENING medicines are of the most service: the bark is of great use, though in general not sufficient, as it can only more or less remove the weakness, the specific qualities still remaining. What these are is, I believe, not yet known; but I suspect, that many partake of the scrofula; and [96] and this opinion is strengthened, by their frequently giving way to sea-bathing. IN a case of an ulcerated rib, from a venereal cause, and five nodes on the shin- bones, of twelve months standing, a deep salivation of six months was undergone, af- ter fruitless attempts by gentle friction. None of the sores were healed by the mer- cury, and the patient was ordered to bathe in the sea, and take the bark. In three or four months the sores all healed up very kindly; but the side last of all. GENERAL OBSERVATIONS ON THE MEDICINES USUALLY GIVEN, FOR THE CURE. A DECOCTION of the woods, among which are commonly included guaia- cum and sarsaparilla, is one of the first medicines in the cure; and many of the cases yield to it: and this gave them the credit [97] credit of curing the venereal disease, while such diseases were supposed to be venereal. This sarsaparilla was often given alone, and was found to produce nearly similar ef- fects. A diet drink, discovered at Lisbon, was also of considerable service; and as it cured cases similar to those cured by sar- saparilla, it was imagined, that the diet drink consisted principally of a decoction of this root. This was still on the suppo- sition, that all those cases were venereal; but it was observed at last, that those me- dicines did not cure this disease, till mer- cury had been given, and in tolerably large quantity. This was sufficient to lead some thinking minds to doubt, whether they were venereal or not; and their being cured by different medicines, ought to produce a conviction of their being different from the venereal disease, and that they are them- selves of different kinds. THE mezereon has also been found to be of service in some symptoms of the lues venerea, such as nodes of the bones; but their being venereal, was taken for granted. The mezereon is seldom given in venereal ulcers in the throat, or blotches on the N skin, [98] skin which, of all the venereal symptoms, are the most certain, and the most easy of cure; yet it was conceived, that it re- moved such symptoms as are the most dif- ficult of cure; but, from what I have seen of its effects, I am convinced that all those cases, in which it has been given with suc- cess, have not been venereal. HEMLOCK has been tried in some such cases, with apparent advantage; but, like the sarsaparilla; it appears to have no effect, till mercury has done its best or its worst. OPIUM has been long a favourite medi- cine of mine, not only as relieving pain, for that is its common effect; but as a me- dicine, capable of altering diseased actions, and producing healthy ones. In all sores, attended with irritability, a decoction of poppyheads, made into a poultice, is an ex- cellent application. Bleeding sores, that do not arise from debility and laxity, but from irritability, have the bleeding stopped im- mediately, by this application. Mr. Pott is, I believe, the first who shewed the world its use in mortifications. MY [99] MY first mode of applying it was lo- cally, in which I found it had salutary ef- fects in some cases, and it was ordered in- ternally afterwards on the same principle, and in this way it was also found to have salutary effects. In two cases, that had been long suspected to be venereal, its effects were very remarkable, but its having cured them, it confirmed me in my opinion, that they were not. But when I was inform- ed, that they cured the venereal disease in America by opium, I then began to ques- tion myself, whether I had formed a right judgment of the nature of those two cases, which were cured by opium. To ascertain, whether opium would cure the lues venerea or not, I made the following trial at St. George's hospital. A WOMAN was taken into the hospital, with blotches on her skin, which had ar- rived to the state of scabs, and with well marked venereal ulcers on both tonsils. A grain of opium was ordered to be taken the first night, two the second, and so on; increasing a grain every night, unless some- thing should arise to forbid it. This was closely followed, till the nineteenth night, N2 when [100] when she was ordered a dose of physic, as she had become costive, and the opium was omitted. On the twentieth she began again, and continued encreasing the dose, as before, till it amounted to thirty grains, no alteration being produced in the sores, except what arose from loss of time. I concluded, that if she had taken mercury to affect the constitution, as much as the opium did, the venereal disease must have been cured, or at least much lessened; but as that was not the case, it convinced me that opium had no effect whatever on the disease. I then put her under a course of mercury, by friction, and in a short time it affected her mouth, the sores soon began to look better, and they went on healing without interruption, till the disease was cured. She found very little inconvenience from the opium; it kept her quiet, but she was not particularly sleepy. OPIUM was afterwards tried on a man in the same hospital, gradually increasing the dose till he took four grains, three times a day; whereby apoplectic sym- ptoms were brought on, and the patient lost his life by it. THIS [101] THIS proves that it is a medicine, ca- pable of producing very violent effects in the constitution, requiring therefore, great caution in the mode of administering it. IT was also tried on one Morgan, in the same hospital, with an ulcerated leg, in doses of twenty-four grains, a day, for twenty-three days; and for the three last days, he took seventy-two grains a day. THIS experiment went near to depriving him of life, without doing any remarkable service to his leg, however he escaped; and, his leg healed in about a month after. THE [102] THE FOLLOWING CASES ARE SELECTED, TO CONFIRM PART OF WHAT HAS BEEN AD- VANCED IN THE PRECEDING PAGES: I. A GENTLEMAN twice contracted a gonorrhœa, of which he was cured, both times without mercury. About two months after each, he had symptoms of the lues venerea; those in consequence of the first infection were ulcers in the throat, which were removed by the external appli- cation of mercury; the symptoms in conse- quence of the second were blotches on the skin, for which also he used the mercurial ointment, and was cured. We have too many examples of chancres, producing the the lues. II. The gonorrhœa continued on a young woman, in the Magdalene hospital two years, at the end of which, she gave the disease to one, who had connection with her. This appears [103] appears to have been owing to the effects of habit, by which the parts lost their suscep- tibility of the specific irritation. This opinion of parts being so habitu- ated to this irritation, as hardly to be af- fected by it, is strengthened by observing, that in the gonnorhœa, the violent symptoms shall often cease, and the disease shall still continue spinning itself out to an amazing length, with no other symptoms than a dis- charge; yet, that discharge shall be vene- real: this I have frequently seen. III. GREAT attention should be paid to the inflammation, which arises in consequence of the urine, being diffused in the cellular membrane. Where this inflammation is at- tended with suppuration and mortification, it will be necessary (whether the case re- quires an incision into the urethra, to re- move stricture, or not,) to scarify the parts freely, to give an opening both to the urine and pus.—Where mortification has taken place in the skin, the scanfications should be made in the mortified places, if it [104] it can be done with equal advantage, and this to prevent irritation. Perhaps dressing the part with opium, might be of service. IN total suppressions of urine, from what- ever cause, the urine should never be allowed to accumulate; but should be drawn off frequently, or a catheter should be left con- stantly in the urethra and bladder, because if allowed to distend the bladder beyond an easy state, it always brings on debili- tating and alarming symptoms, as paralysis of that viscus. Little regard is to be paid to the urethra, in comparison of the bladder; but in many suppressions, as in cases of strictures, it becomes impossible to draw off the water, without making an incision be- tween the stricture and the bladder. IN some cases, where the urethra is ul- cerated, and the urine gets into the cellu- lar membrane of the penis and prepuce, so as to distend them much, producing a phymosis, it becomes impossible to find the orifice of the urethra. THE [105] THE FOLLOWING CASE WILL ILLUSTRATE THESE FACTS. A GENTLEMAN of a scrofulous habit, had often had venereal gonorrhœas, which were generally severe, and commonly produced swellings, or knobs, along the urethra, upon which account he was advised to avoid getting this disease, as much as possible. WHEN in the country, in November, 1782, he was attacked with a slight cold or fever, and a small discharge from the urethra; which he could not determine to be venereal or not. In this condition he sat out for London, but was taken ill on the road, with a suppression of urine, which detained him two days at an inn. WHEN he came to town, I found him with a good deal of fever, he spoke to me only of a discharge of the urethra; but as I did not conceive that the fever could arise from that cause, I desired him to be easy on that account. I ordered for that night, six grains of James's powder: his physician, saw him afterwards, and ordered for his fever what he thought proper. He O was [106] was taken with a shivering fit, which made us suspect it might terminate in an inter- mittent, and we waited for the result. He still complained of the discharge, and men- tioned a soreness in the perinæum, both when he made water, and when he pressed it externally. On examining the perinæum, I found a fulness there, from which I sus- pected a stricture, and enquired particu- larly, how he made water in common; he declared very well; by which he led me off from the true cause. We looked on this swelling as proceeding from an inflamma- tion, either in consequence of the fever, the disposition of the part, or both; increased by sitting in a post chaise, for several days. The part was fomented, poulticed, and leeches applied several times. He had another shivering fit, three days after the first, which, if his disease had been an in- termittent, would have constituted a quartan; but he had another, some hours after, which made sis give up our suspicions of an intermittent. We now began to suspect, that matter was forming, in this part, al- though I could never feel any thing like a fluctuation; nor was the pain of a throb- bing kind, or so acute as we commonly find [107] find it in the suppurative inflammation, What in some degree surprised me, was, that the swelling came forwards along the body of the penis, towards the os pubis, while it seemed to be diminishing. in the peri- næum. HE now began to find a difficulty in making water, with a frequent desire, which increased till there was a total suppression, I pressed on the lower part of the belly, to see if the urine was secreted and accu- mulated in the bladder, but I could not find any fulness, nor did he then feel pain on such pressure; however about twenty- four hours after, he began to complain of a vast desire to make water, and a pain in the lower part of his belly; and on placing the hand there, a fulness of the bladder was readily felt. It was now clear that the water should be drawn off; but as I still suspected mischief in the urethra, as a cause in his complaint, I took the necessary precautions. I provided myself, with catheters and bougies, of different sizes, and to be as much upon my guard as possible, I introduced a bougie of a small size first, and found a full stop, about the O2 bulbous [108] bulbous part of the urethra. I then took a small one, which passed, but with diffi- culty. I afterwards passed a small cathe- ter on to the stricture, where it stopped; but, as it was abfolutely necessary the wa- ter should be drawn off, I used more force than I otherwise should have done; it went on, bur; with difficulty, and I was not certain whether it was in the natural passage, or was making a new one. When I had got so far, as to be in the bladder, (if I was in the right passage,) I found no water come, I therefore pressed on the lower part of the belly, and the water immediately came out, through the cathe- ter, which shewed that the bladder had lost its power of contracting. The water was drawn off, every eight hours; but still it was necessary to press upon the belly, as before; and it was two weeks before the bladder recovered its power of contracting, in any degree. THE swelling now encreased down the body of the penis, and made it evident, that it had arisen from the urine having insinuated itself into the cellular membrane of the perinæum; and as the urine passed out [109] out of the urethra, it was pushed forward, where the cellular membrane was loosest, till it got to the very end of the prepuce, and formed an enormous phymosis. BY this time he was become extremely low and irritable—was apt to be sick and fainty on any motion, attended with total loss of appetite, and great prostration of strength. The bark was now administered freely, with madeira wine, and cordial diet. Incisions were made through the integu- ments to the cellular membrane; and the prepuce deeply scarified, from whence issu- ed bloody froth, and air. Blisters began to rise on the skin, and in a short-time, the whole prepuce sloughed off, leaving the glans bare. The whole penis was kept wrapt up in a soft cataplasm, made of a solution of opium in water, and thickened with white bread; having been previously fomented with a decoction of bark and chamomile flowers, with the addition of a little spirit of wine. In a few weeks, all the mortified parts separated, a great portion of the cellular membrane came away, and the patient recovered. FINIS. ERRATUM. Page 60, line 9, after the word feminales, in- sert the words improperly so called, and then reading on to the word bladder, expunge the re- mainder of the paragraph.