: I £ty «>:■■■■■: >.(»»:. .. . ■ : '••!■■■. ■':-',:! HBffHffBgS&alffl j, IT irpTlntilMrtlWF^ ^ V) ^ CTiKl "^SWl t/N*M fBSnfiKft ! rli'v'--': '■• .',-.'» ■■:',--,'r'if(l'-i''',.-- :■ - r )'". - } hif.-s :■ * )?•'••■•• '• k' ' ,' < ;■/*. ■■ K!,{,i •'. t. :■•■ ;» ... MH Kfip.}I'i fftfti fclHtr i; '■ ! ', - '• tpirBil fflTi; rfj;;.;:-, ^ 1 J„ 3-1 3 $&& | Surgeon General's Office <■ ECLECTIC MEDICAL COLLEGE OF PENNSYLVANIA, N. E. cor. of Sixth and Callowhill Streets, Philadelphia, Pa. The Onhf Regular Chartered Eclectic Medical College in the State of Pennsylvania. HOLDS TWO SESSIONS ANNUALLY. Winter Session begins Oct. 9th, 1865, and Spring Session, February 1st, 1866. FIFTEENTH ANNUAL SESSION, 186S-'66. TRUSTEES PRESIDENT, ZOPHER C. HOWELL, ESQ. SECRETARY, JOHN FEST, ESQ. THOMPSON WESTCOTT, ESQ.. JOSEPH SITES, M. D., EDWARD JOHNSTOWN, ESQ./ HENRY HOLLEMBAEK, M. D-, WILLIAM BAIRD, ESQ., JOSEPH P. FITLER, M. D., WILLIAM GRAY, ESQ., JOHN BUCHANAN, M. D„ WILLIAM GILCHRIST, ESQ., WILLIAM CLARK, M. D. FACULTY. THOMAS G. CHASE, M. D., EMERITUS PROFESSOR OF CHEMISTRY AND JURISPRUDENCE. JOSEPH SITES, M. D., PROFESSOR OF OBSTETRICS AND DISEASES OF WOMEN AND CHILDREN. HENRY HOLLEMBAEK, M. D., PROFESSOR OF MATERIA MEDICA AND THERAPEUTICS. JOSEPH P. FITLER, M. D., PROFESSOR OF CHEMISTRY AND TOXICOLOGY. JOHN BUCHANAN, M. D , PROFESSOR OF SURGERY AND INSTITUTES OF MEDICINE. * WILLIAM CLARK, M. D., PROFESSOR OF THEORY AND PRACTICE OF MEDICINE AND PATHOLOGY. E. DOWN, M. D., PROFESSOR OF ANATOMY AND OPERATIVE SURGERY. EMIL QUERNER, M. D., PROFESSOR OF PHYSIOLOGY AND MICROSCOPICAL ANATOMY. ROBERT HAMILTON, M. D., PROFESSOR OF MEDICAL JURISPRUDENCE AND HYGIENE. E. DOWN, M. D., DEMONSTRATOR OF ANATOMY. The Museum and Clinic of the College will be open every Wednesday and Saturday. The regular course of Lectures will commence on the second Monday of October, annually. The Lectures will be amply illustrated by the extensive and valuable collections of Anatomical, Microscopical, Pathological, Obstetrical, Surgical, Chemical and Philosophical, Botanical. Ac, apparatus of the incumbents of the various chairs, and every opportunity will be afforded in the Clinic and Hospital for obtaining a thorough, scientific, and prac- tical knowledge of Medicine in its most advanced state. FEES. Matriculation Fee, - - - $5 00 I Demonstrator's Fee, - $5 00 Tickets for the Course, - - 60 00 | Diploma,.....30 00 For further particulars, address, JOSEPH SITES, M. D., Dean, Sixth and Callowhill streets, Philadelphia, Pa. KW Ten deserving Students, unable to pay full fees, will be taken each term for $20. 1 VENEEEAL DISEASE. THE TREATMENT OF THE VENEEEAL DISEASE. BY JOHN BUCHANAN, M. D., * 4 9 PROFESSOR OF SURGERY AiN'D INSTITUTES OF MEDICINE IN THE ECLECTIC MEDICAL COLLEGE OF PENNSYLVANIA, PHILADELPHIA ; EDITOR OF ECLECTIC MEDICAL JOURNAL OF PENNSYLVANIA, ETC., ETC. FIRST EDITION. PHILADELPHIA: W. B. SELHEIMER, 501 CHESTNUT STREET, N. W. COR. OF FIFTH. 1865. fit™ No .H$ W j™0,7- \ CONTENTS. PAGE Introduction,.......................................................... 11 General Remarks,.........................................-.........• • • 15 Gonorrhoea,.......................................................... 17 Treatment of Gonorrhoea,.............................................. 20 Local Medication,...................................................... 21 Nitrate of Silver,....................................................... 21 Permanganate of Potash,................................................ 22 Sulphate and Chloride of Zinc,.........'................................. 22 Bismuth,............................................................... 23 Iron,...........,...................;.......-.......................... 23 Concentrated Organic Medicines,..............■.......................... 23 Hydrastin,.... ......................................»---• -............ 23 Hamamelin,............................................................ 24 Rhusin,................................................................ 24 Eryngium Aquaticum,..............................•................... 24 Tannin,............................................................... 24 Chlorate of Potassse,.................................................... 24 Constitutional Treatment,...................-.......... ........... ..... 26 Senecin, Gelsemin,...................................."............... 27 Macrotin, Populin, &c,................................................. 27 Barosmin, Irisin, Erigeron,............................................. 28 Favorite Prescriptions,................................................ 29 Copaiba and Cubebs,...........................................-........ 31 Hemorrhage from the Urethra,........................................... 33 Painful Erections,................................................... 33 Chordee,.............................................................. 33 Suppuration of the Glands of the Urethra,................................ 34 Prostatitis,...................................................... ...... 34 Affection of the Bladder from Gonorrhoea,................................ 34 Ischuria et Dysuna,......;............................................... A CONTENTS. PAGE Epididymitis,.......................................................... 3^ Excoriations,.......................;..................................• 40 Excrescences,.......................................................... 41 Lingering Sensations,................................................... 41 Gleet,................................................................ 42 Stricture,.............................................................. 46 Gonorrhoeal Ophthalmia,............................................... 52 Gonorrhoeal Rheumatism,............................................... 54 Gonorrhoea in the Female,.............................................. 56 Bubo,................................................................. 57 Spermatorrhea,...................................................... 61 Pathology of Gonorrhea ,............................................. 65 Syphilitic Gonorrhoea,.................................................. 66 Non-Syphilitic Gonorrhoea,.............................................. 67 Chancre,.............................................................. 70 Soft Chancre,....................................................... 70 Treatment of Soft Chancre,............................................. 72 Nitrate of Silver,...................................................... 73 Nitric Acid,........................................................... 73 Acetic Acid,........................................................... 74 Caustic Potash,........................................................ 74 Vienna Paste,.......................................................... 75 Caustic Soda,........................................................ 75 Ricord's Caustic Paste,............................................. 7(3 Bromine,.......................................................... 7g General Treatment,............................................... 7g Serpiginous Chancre,.............................................. 80 Phagedena,....................................................... gj Indurated Chancre,............................................ g3 Treatment of Indurated Chancre,............................. gg Prevention of Infection....................................... qq General Treatment,.......................................... g, Constitutional Syphilis,.................................... ' 95 Mode of Absorption of the Syphilitic Virus,.................... 95 Progressive Symptoms,................................... y« Syphilis in America,.................................. no Syphilitic Inoculation,............................ on Secondary and Tertiary Syphilis,...................... inn Syphilitic Fever and Head-Ache,............................... 1 qq CONTENTS. 9 PAGE Significant Symptoms,.................................................. 101 Substernal Tenderness,................................................ 101 Syphilitic Afiections of the Skin,......................................... 102 Syphilitic Roseola or Erythema,......................................... 102 Lichen.......,........................................................ 104 Tubercula,............................................................ 104 Pustules,.............................................................. 105 Syphilitic Ulcers,..................................................... 106 Mucous Patches,....................................................... 106 Condylomata, Warts,................................................... 106 Syphilitic Onychia,..................................................... 107 Syphilitic Iritis,....................................................... 107 Treatment of Secondary Syphilis,.................................... 108 The Concentrated Remedies,.......................................... 109 Ampelopsin and Podophyllin,...........................................109 Rumin and Phytolacin,.................................................. 109 Irisin and Menispermin,................................................ 109 Stillingin,...........................................................110 Corydalin,.............................................................. 110 Com. Stillingia Alt.,................................................... 111 Tinct. Kalmia,......................................................... Ill Gold,................................................................. Ill Iodide and Bromide Potassium,.......................................... 112 Iodide Sodium and Ammonium,......................................... 112 Sulphite of Soda,...................................................... 112 Nitric Acid,........................................................... 113 Alkaline Permanganates,................................................ 113 Medicated Baths,....................................................... 114 Cleanliness and Hygienic Measures,...................................... 116 Syphilitic Eruptions,.................................................. 117 Progress of the Virus,.................................................. 118 Syphilitic Fever,....................................................... 118 Alopecia,.............................................................. 119 Syphilitic Diseases of the Skin,.......................................... 120 C. Syr. Celastrus,..................................................... 120 Iodine,................................................................ 120 General Treatment,........................................ ............ 121 Evils of Mercury........................................................ 121 Syphilitic Tubercles,......................................■............. 122 Pustular Eruptions,................................................--- 123 2 10 CONTENTS. PAGE Mucous Patches,....................................................... 124 Syphilitic Onychia,...................................................... 125 Syphilitic Iritis,........................................................ 125 Local Treatment,....................................................... 127 Tertiary Syphilis,.................................................... 128 Gummy Tumors,........................................................ 129 Osteoscopic Pains,...................................................... 129 Nodes,................................................................. 131 Caries and Necrosis,..................................................... 132 Local Treatment,....................................................... 133 Syphilitic Ulceration of the Throat,....................................... 134 Transmissibility of Syphilis,............................................ 135 Conclusion,........................................................ 138, 139 INTRODUCTION. In speaking of the Venereal Disease in the following pages, we mean the action of two morbid animal poisons, generated and usually communicated by sexual intercourse. We believe, and base our belief on the nature of the disease, on the statement of the earliest writers, that this aflfection was co-eval with man's primitive existence; that it was recognized and known to proceed from fornication, although we think the secondary symp- toms were not understood; but evidently confounded with leprosy. True, we grant, syphilis in the early period of man's history was mild; true, its virulence was only known when it was treated by mercury as a panacea, when famine, privation and suffering became prevalent; true, it became mild, and diminished as treatment by mercury was laid aside, and comfort, cleanliness, and hygiene pre- vailed. As to the origin of these two poisons, I believe, with that eminent surgeon, Guthrie, " that whenever prostitution is foul or unclean, restricted to few women amongst crowds of men, there the infection will be generated, which afterwards spreads through society at large. The irregularities of men are at all times punished by the generation of diseases and loss of health; and, it would be difficult to believe in a superintending Providence, if this transgression of divine and human law should be allowed to pass unpunished." 12 INTRODUCTION. If either of the specific virus be deposited upon a mucous mem- brane, we have a gonorrhoea; if upon a cutaneous surface, a chancre. Discharges and excoriations resembling a gonorrhoea or chancre, may be caused by local irritation. A person may contract a very severe discharge from a woman if she has a leucorrhoea, or an acrid vaginal secretion. The cata- menia is capable of excoriating and exciting a discharge. The question naturally arises, how are we to distinguish them. The grand .diagnostic sign is the perfect mildness of that produced by irritation, the absence of acute inflammation, the character of the patient, the existence of some of the foregoing causes. In gonorrhoea in the female, we have nearly the same symptoms as in the male; heat, pain in micturition, tenderness and soreness, muco-purulent discharge; the parts red, swollen, and it may be, sympathetic enlargement of the inguinal glands. Acute inflammation of the mucous membrane of the labia and vagina, is not at all an unfrequent complaint in very young girls, as a consequence of some irritation, as teething, worms, constipa- tion and the like; and has the same symptoms as gonorrhoea, and requires to be carefully diagnosed. In these cases the anxiety of the parents must be removed, by informing them that it is a com- mon idiopathic affection. Leucorrhoea is to be distinguished from gonorrhoea by the absence of heat, pain in micturition; pain in the back, pallid or anemic countenance, irregular catamenia, exhaustion, debility. Sometimes a gonorrhoeal discharge has the same appearances. Ulcers or excoriations due to irritation, require no specific treat- ment for their cure, cleanliness and some antiseptic astringent wash being all that is necessary; whereas, all primary ulcers, due to the action of a specific morbid animal virus, are only to be combated by specific remedies. The American Eclectic Treatment of the Venereal Disease, in all its forms, consists in discarding mercury and arsenic in any INTRODUCTION. 13 preparation in the treatment of the affection, preferring and being more successful in all its varied types, in iritis, nodes, lepra, psoria- sias, deep excavated ulcers with the remedies laid down in this work. We claim for those remedies, when judiciously administered, a superiority, a success which never can be obtained by the bichlo- ride of mercury, or the most favorite preparation of arsenicum. The Eclectic, non-mercurial, or simple treatment of the Venereal Disease, consists in the employment of our indigenous remedies, with every means, both local and constitutional, without resorting to those deleterious agjents. This is the true physiological treatment of syphilis—it is the base of all rational and scientific practice, and it is the result of modern experience on the subject. It has been ably demonstrated of late years, by practical observation, that protracted, inveterate cases of constitutional syphilis, more promptly yield to thorough hygienic measures, to a well regulated diet, and the exhibition of such tonics as bark, than to mercury as' a specific therapeutic agent. In the enumeration or recommendation of our concentrated remedies, we, in all cases, refer to B. Keith & Co., New York. I have used all the agents claimed to be manufactured by the various parties throughout the country, and find the large proportion of them useless—mere inert powders. The remedies manufactured by B. Keith & Co., are the most reliable and positive medicinal agents ever introduced; and if essen- tial tinctures are the favorite form, Keith's Concentrated Tinctures cannot be excelled. In addition to remedies peculiar to the American practitioners, the sulphites or bisulphites, in various proportions, from half a scruple to one or more drachms, are eminently calculated to meet particular indications. In cases where we have eroding ulcers, foul and phagedenic, which are seen in certain constitutions, where. the dyscrasis is so great as to almost baffle the skill of our art, 14 INTRODUCTION. these remedies may be relied upon; and not only in syphilis, but in all cases of animal poisons. It is undoubtedly true that the virus of syphilis, if left to itself, and the health of the patient be carefully attended to, will wear out of itself. All contagious diseases of the blood run a certain course, and we have not, as yet, discovered a specifiocure for one of them. The intensity of all diseases in modern times, has declined exactly in proportion as their treatment by mercury has diminished. GENERAL REMARKS. The object of this work is to present, in a concise form, the American Eclectic Treatment of the Venereal Disease. The want of such a Treatise, containing the principles of the Reformed Pro- fession, has long been felt by our physicians. With a view to fill the vacuum, the author has prepared this work. The latest writers on the subject have been freely consulted, their opinions noticed; the results of the author's experience and obser- vation during a private practice of sixteen, and an extensive clinical practice of eight years, have been fully introduced; demonstrating the fact, that the Venereal Disease, in all its ramifications, can be more speedily, effectually, and permanently cured by our remedies, than by any preparation of mercury or arsenic. An apology is asked for typographical and literary imperfections. THE TREATMENT OF THE VENEREAL DISEASE. GONORRHCEA. The venereal disease consists in the effects of certain poisons, generated and usually communicated by promiscuous intercourse, including two distinct poisons, manifested both under gonorrhoea and syphilis. Gonorrhoea.—A specific inflammation of an acute form, affecting the mucous membrane of the genitals, with a copious puriform, or • muco-purulent discharge, propagated by contact. No certain rule can be laid down with regard to the time that gonorrhoea will appear after infection. In some persons it will manifest itself a few days after contact; in others again, it may be two or three Weeks. It is usually perceptible from six to fourteen days, and in the male, begins with an uneasiness about the parts of generation, such as itching in the glans penis, a tenderness and tingling sensa- tion along the course of the urethra, soon followed by an appear- ance of pus at its orifice; and, also, some degree of pungency on making water. In the course of a few days the discharge of matter increases considerably, will most probably assume a greenish or yellowish tint, and will become thinner, and lose its tenacity; the parts become red and inflamed, in consequence of which the glans will put on the appearance of a ripe cherry; the stream of urine is smaller than usual, owing to the urethra being narrower, by the inflamed state of its internal membrane, and a considerable degree of pain and scalding is experienced on every attempt to urinate. 3 18 TREATMENT OF THE VENEREAL DISEASE. When the inflammatory action prevails to a great degree, it pre- vents the extension of the urethra on erection taking place, so that the penis is crooked, denoting the presence of chordee. In consequence of the violence of the inflammation, it occasionally happens, that at the time of making water, owing to rupture of some small vessels, a slight hemorrhage occurs. In consequence of inflammation, the prepuce also becomes so swollen at the end that it cannot be drawn back, constituting phymosis; or that being drawn behind the glans, it cannot be returned, giving us paraphymosis. Now and again, from the same cause, little hard swellings arise on the lower surface of the penis, along the course of the urethra; and these may suppurate, and form fistulous ulcers. The neighboring parts sympathize with those already affected, the bladder becomes irritable, and incapable of retaining the urine for any length of time, which gives the patient a frequent disposi- tion to uiinate, together with uneasiness about the scrotum, peri- neum, &c. The glands of the groin become indurated and enlarged, or perhaps, the prostate, the testicles become swollen, inflamed, in consequence of which he experiences excruciating pains, radiating from the urethra to the loins; he becomes restless, and well-marked symptomatic fever may be developed. When there is not much inflammation, few or none of the last mentioned symptoms will arise, and only a discharge, with a slight heat or scalding in urinating, will be present. In consequence of the inflammation of gonorrhoea extending along the urethra, it occasionally happens that the mucous mem- brane of the bladder becomes inflamed, thickened, and ulcerated, and pours out a considerable amount of muco-purulent matter. If there is great inflammation, with chordee, or if the gonorrhoea has had a long continuance, or been of frequent occurrence or recur- rence, there is risk of one or more strictures in the urethra. These are sure to occasion a considerable degree of difficulty, as well as pain, prior to and during the act of urinating, and instead of it being discharged in a free, uninterrupted stream, it is forked, split in two or more streams; or, perhaps, is voided drop by drop. Strictures, from neglect, sometimes become serious and dangerous, not unfrequently blocking up the urethra, and thus inducing total suppression of urine. Inflammation in the urethra is the grand source of stricture, and, TREATMENT OF GONORRHOEA. 19 for the most part, this is excited by gonorrhoea; occasionally it has arisen from other causes, which produce irritation in the parts, such as previous disease in the bladder, or prostate gland. Th*e usual course of stricture is as follows: a gonorrhoea has arisen, gone on unchecked, or been arrested by improper treatment; at the height of the inflammatory stage there is a purulent secretion, and proba- bly chordee; the disease, which was at first seated near the orifice of the canal, has spread backwards; but, by the use of appropriate remedies, the more urgent symptoms are relieved, general amelio- ration has taken place; still, however, the irritation does not entirely subside. Some pain and heat in voiding urine are still perceived, and from time to time there flows a gleety discharge; but this gleet is not the effect of mere relaxation of the vessels allowing a profuse discharge; it is the vestige of it in a milder and more chronic form. When this state of the parts is allowed to continue, a pretty firm stricture will, in process of time, be formed. The degree and firmness of the contraction generally hold a strict relation to the length of time, and the frequency of the occasional increase of irritation, pain and discharge. When a gonorrhoea has been of long standing, warty excrescences or vegetations are apt to spring up about the parts, owing to the matter falling and lodging # thereon; and they not unfrequently prove troublesome, and acquire considerable size, and are prone to recur. If a gonorrhoea is neither irritated by any irregularity of the patient, nor prolonged by the want of timely and judicious medical treatment, in the course of two or three weeks the discharge, from having been thin and discolored at first, will become thick, white, ropy in consistence, and from having gradually begun to diminish in quantity, will, at last, ultimately cease entirely, together with every symptom whatever; whereas, on the contrary, if the patient indulges in intemperance and sensuality, indulges in excess in eat- ing, has neglected to pursue the necessary treatment, it may con- tinue for months, and on disappearing, may leave a weakness or gleet behind it, besides being accompanied with the risk of giving rfee, at some future period, to a constitutional affection, especially if there has been a neglect of hygienic measures; for when venereal matter has been suffered to lodge between the prepuce and the 20 TREATMENT OF THE VENEREAL DISEASE. glans of the penis for any time, so as to have caused excoriation or ulceration, there is always danger of absorption. Gonorrhoea in the female is more amenable to treatment, the parts being less complex in their nature, fewer in number, and not liable to many of the symptoms which affect the male patient. Treatment.—In the cure of gonorrhoea, we are to be directed by the symptoms which are present; by the age, the temperament, the severity, the habits of life, and by the stage of the disease at the time that advice is applied for; on a due recognition of these will depend the success of treatment, the character of the inflammation, its progress, its complications. These points being settled, the existing inflammation must be removed, injured tissue must be repaired, and the affection eradicated. Gonorrhoea is always most severe on its first occurrence in young and robust patients, and in depraved, irritable, and scrofulous con- stitutions. If at the commencement of an attack of this complaint, the patient should experience much pain, heat, and difficulty in making water, together with other inflammatory symptoms ; and if he is of a full plethoric habit, it is advisable to have recourse to means calculated to subdue inflammation, equalize the circulation, arouse the secretions and facilitate excretion. For this purpose, an active cathartic, such as podophyllum and bitartrate of potassa, or podophyllin and colocynthin, or leptandrin, euonymin and jalapin might be given with decided advantage. This might be beneficially followed by a free use of asclepin, macrotin and gelse- min, in alternation with buchu, marshmallow, mucilaginous drinks, as barley water, linseed tea, solution of gum acacise in milk, abstaining from too stimulating diet and spirituous drinks, and avoiding exercise; locally, packs, sedative injections. If an inflam- matory condition does not exist, it then will be unnecessary to have recourse either to the above remedies, or to cathartics. In avoiding purging when not necessary, we must take care not to run into the opposite extreme, constipation, which sometimes proves a source of considerable irritation. In every stage of gonorrhoea, it is advisable to keep the bowels perfectly regular, either with appropriate food, or by the use of some very mild laxa- tive, such as juglandin, or leptandrin, a remedy of an unirritating character, or enemas. The plan of treatment of a gonorrhoea differs little from that which should be adopted in other inflamma- TREATMENT OF GONORRHOEA. 21 tions of the urethra; but we must always bear in mind that inflam- mation of mucous membranes generally, is never benefitted by a depleting, lowering treatment—indeed, if the constitution be ren- dered irritable from weakness, these inflammations often become aggravated and obstinate. It is good practice, therefore, when we aim at preventing its development, diminishing its intensity, and abridging its duration, to keep our patients' strength unimpaired, the vital forces vigorous. Practitioners who aim at popularity, by endeavoring to make hasty cures of gonorrhoea, by what is known as the abortive treat- ment, are in the habit of employing strong injections of nitrate of silver, and exhibiting copaiba and cubebs internally, in large doses, on the first appearance of the disease. A frequent consequence, however, of this mode of practice is, that, although the discharge is perhaps speedily suppressed, the patient is soon afterwards attacked with some of the complications, or a return of the disease in a gleety or more intractable form. Such consequences too frequently arise from this treatment. Palliative treatment, con- sisting in rest, repose of the affected part, the use of a suspensory bandage when walking, attention to diet, hygienic measures, &c, &c, is always essential. Having overcome the inflammatory symptoms, if they exist, our next recourse is to eradicate the disease, which may be accom- plished by local and internal measures. 1st. Local or direct Medication.—The indications to be fulfilled in local or direct medication are: to isolate the diseased mucous membranes, by preventing their coming in contact; to oppose the stay and stagnation of morbid secretions in the parts; to neutralize and dry up the discharge. The conditions of direct treatment are specially fulfilled by injections, and most of the remedies employed in this form have a most happy effect. Nitrate of Silver.—Owe improved remedies have almost entirely superseded the use of this agent, and any predilection for it in the mmds of the older members of the profession is rapidly disappear- ing ; it undoubtedly has led to serious complications. If this agent is used, its best form is weak injections, in the proportion of one- fourth to half a grain to the ounce of distilled water. They should be used five or six times in the twenty-four hours, and the patient should be told to retain the fluid in contact with the diseased 22 TREATMENT OF THE VENEREAL DISEASE. urethra for at least a minute. To be efficacious, let nothing be injected until the urine has first been passed, not even water; and in using them, he should press the penis between the thumb and fingers of the left hand, so as to close the urethra posterior; or, he should sit on the edge of a chair, so that the urethra is con- stricted in the perineum, and thus -prevent any of the injection passing into the bladder. The meatus should be closed with the right hand as the syringe is withdrawn. It is well to enjoin upon the patient the practice, after any suspicious connection, to urinate, and perform a thorough ablution with soap and water, or inject a small quantity of cold water, or some astringent, and if there are any abrasions, touch them with some mild caustic. Permanganate of Potash.—In all stages of a gonorrhoea, the use of injections of the permanganate of potash, if properly per- formed, are alone sufficient to effect a speedy and permanent cure. It possesses advantages over all other substances—it appears to exercise a decided specific influence, by neutralizing and destroying the contagious property of the secretion from the mucous mem- brane. The best results are obtained by the use of weak injections, . one-fourth of a grain to an ounce of distilled water, and should be gradually increased in quantity up to two, three, or four grains. Six to eight injections in the twenty-four hours. Sulphate of Zinc.—Another very excellent injection is the sul- phate of zinc, in the proportion of about a grain or two to each ounce of water; one of the most active and successful of any that could be recommended. It is one of the best agents we possess, and the best method of using it is as above, by frequent and weak injections—a weak astringent solution—one grain to an ounce of distilled water, always bearing in mind, that the patient must pass water prior to the injection, in order to clear out any morbid con- tents that may accumulate in the canal., Chloride of Zinc.—This is even superior to the sulphate, and has many properties peculiarly wanted in this affection. The most salutary results are obtained from weak and frequently repeated injections. From half a grain to two grains of the chloride to an ounce of water, are'the ordinary limits of strength. In the above proportions, chloride of zinc has a remarkable power in curing gonorrhoea; also, in dilating the urethra, and preventing strictures. TREATMENT. OF GONORRHOEA. 23 This substance will often radically cure gonorrhoea in two or three days, at the rate of three or four injections per diem. There are various preparations or combinations of zinc quite popular; for example, we have half a grain of the sulphate of zinc to an ounce of rose water, tannate of zinc. Bismuth.—The great merits of this agent are well appreciated, and gaining a large amount of favor and extended use. The sub- nitrate has met with a very favorable reception, and the formula esteemed best is : ten grains to six ounces of water. The tannate of bismuth we can highly recommend, from an extensive experience of its use. Iron.—This is an old, but, nevertheless, a very efficient remedy in solution; the muriated tincture, the sulphate. The most effica- cious preparations we have found to be the iodide of iron, from one to eighteen grains to an ounce of distilled water; it acts well, and is a powerfully astringent substance; and the perchloride of iron, the proportion being twenty drops to four of water. The proto- sulphate of iron has a most powerful effect, and is an agent of intrinsic value. Concentrated Organic Medicines.—As a majority of the concen- trated medicines are soluble in water, we can recommend a few of them as being of great utility in the local treatment of gonorrhoea. Our experience goes to prove, that such agents as hydrastin, rhusin, hamamelin, lupulin, hyosciamin, veratrin, exercise specific influence over the malady, and are much to be preferred in certain weak, irritable, or scrofulous habits. Injections are usually divided into irritating, sedative, emollient and astringent, and we have these qualities in a pre-eminent degree in those concentrated remedies. Indeed, the introduction of these agents mark a new era in the treatment of disease. Hydrastin.—It has been successfully employed in the treatment of gonorrhoea; it acts well, either alone or combined with geranin, myricin, hamamelin, &c. The proportion of the hydrastin is from one to three drachms to a pint of boiling water, and the resinoid principle allowed to precipitate. We have used this with most excellent results. If more of an astringent property is required, rhusin, geranin, myricin or hamamelin might be added. It makes a fine combination with baptisin and trillin, and this corrects or 24 TREATMENT OF THE VENEREAL DISEASE. neutralizes the virus of the discharge. It may be resorted to three or four times daily. Hamamelin.—This is an exceedingly valuable and an admirable agent, superior to all other remedies, exercising a peculiar sooth- ing, healing influence upou the mucous membrane of the urethra. The proportion most salutary is the same as for the hydrastin. It has also been found highly beneficial in combination with other astringents, as rhusin, myricin, geranin, lycopin. Rhusin.—Among all the remedies of the Eclectic profession, rhusin may be classed as the most valuable of the astringent tonics. Its specific sanative influence over mucous membrane, renders it an invaluable agent in the treatment of any disease affecting those surfaces. It is of essential service in gonorrhoea, b(eing reliable and appropriate in all cases. It exerts a rapid controlling power when judiciously combined with geranin, myricin, lycopin; or where a stimulating action is indicated, a combination of rhusin with xanthoxylin, will be found astringent, tonic, anti-septic and stimu- lant, and superior to all others. The geranin, myricin, baptism, lycopin, lupulin, hyosciamus, &c, may all be used with very favorable results. But one of the most positive remedies, one from which the most speedy and permanent result is obtained, is the eryngium. Eryngium Aquaticum in almost any form is strikingly useful, a specific remedy in gonorrhoea, internally, and as an injection. The pulverized root, in doses of two or three grains, several times daily. Three ounces of the pulverized root in a pint of Holland gin, given in one or two drachm doses, thrice daily, will effect a cure when all remedies fail. The decoction answers well, and is to be preferred. Tannin.—A solution of pure tannin, or another, consisting of a solution of tannin in port wine, in the proportion of eighteen grains of the former to six ounces of the latter. Tannin and sulphate of zinc is a favorite formula. An injection of the tannate of alumina, five grains to the ounce. Quinine in some form has attained repute. Acetate of lead. Chlorate of potash is sometimes used'with the most gratifying results; one drachm of the salt dissolved in eight ounces of water, of which an injection may be given every two hours for two days, at the end of which time the discharge becomes changed and dimin- ished ; when, on the third day, the disease will be generally found TREATMENT OF GONORRHOEA. 25 to have ceased. So efficacious has this remedy proved, that some are in the habit of using nothing else. An excellent injection is made as follows: Rose water, two ounces; bicarbonate of potash, one drachm; M., twice daily. A solution of alum, four grains to the ounce; chloride of lime has also met with success. Chromic acid, the mineral acids, metal- lic salts, the various astringents, the extracts of many vegetables, oak bark, cinchona, tormentilla root, &c, borax. Gonorrhoea is sometimes treated by counter-irritation, such as blisters, with but indifferent success; in intractable cases of gleet they have been resorted to, small blisters, four inches square, placed high up towards the anterior and inner aspect of each thigh, (the acetate of cantharides on adhesive plaster,) have met with some success. Injections have been highly censured by some authorities, and unjustly; they contend that repeated handling is dangerous; that they have the effect of driving in the contagious matter, and pro- longing the disease; that they excite inflammation higher up in important parts; that they are the cause of strictures, &c. These objections are not sustained in practice, they are ridicu- lous, and not founded in fact. If a patient make water immediately before injecting, and empties the urethra, no contagious matter can be driven in. It is true, badly administered, highly concentrated, or made of unsuitable ingredients, may produce this effect; but in this case the fault.is not in the remedy, but rather in the method of application. The general experience of the profession is, that they do not cause strictures; but, that on the contrary, they antici- pate them, when they promptly arrest a gonorrhoea; and in certain cases of soft hypertrophy of the urethra, they may cure strictures depending thereon. The bad effects of injections appertain to their improper administration of pernicious medicinal agents. The effects of the concentrated remedies in the treatment of gonorrhoea, have been watched with much interest. With some practitioners there appears to be a deep-seated prejudice against any other than a constitutional treatment; and the pertinacity with which they adhere to it is astonishing. Local treatment is the exception, and not the rule; and whilst in most other local diseases local remedies are employed, in the early stages of this they are rarely entertained by some. Experience leads us to the 4 26 TREATMENT OF THE VENEREAL DISEASE. conclusion, that a judicious and Avell-timed employment of injections soon subdues the specific inflammation. Constitutional, or Indirect Treatment.—This should be employed from the commencement of the attack. There are a few who totally deny that gonorrhoea has a venereal origin; and there are others again, who contend that it is a peculiar species of the vene- real disease; but, at the same time, look upon it as a local com- plaint, in Avhich there is no danger of the system becoming affected by an absorption of matter. They regard it as a disease that will ultimately wear out of itself, and neglect giving much or any medicine, with the view of eliminating, neutralizing, or destroying the syphilitic virus. The impropriety of proceeding in this manner, the bad effects which frequently result from it, must be apparent to all. Well-taught experiences must have convinced the prudent practitioner, that in order to guard against any disagreeable con- sequences, and ensure a perfect cure, it is advisable, in all cases of gonorrhoea, to make use of constitutional or indirect treatment. In making this observation, we do not mean to say that gonor- rhoea can, in no instance, be effectually removed without medication. In all cases where the disease is of recent origin, perfectly mild, where neither excoriation nor ulceration has taken place, where injections have been judiciously resorted to, it may remain a local affection, and a cure be effected; but, as it is impossible to correctly discriminate those cases in which the virus may not be absorbed into the system, from those in which it will, it certainly appears to be the safest and most advisable method to have recourse to certain remedies in all cases; by doing so, we guard against all bad con- sequences, ameliorate the predominant symptoms, establish a per- fect and rapid cure. A neglect of this will be sure to hurt the practitioner in the esteem of his patient, if any unpleasant sequel should occur. Private practice offers great opportunities for the treatment of this complaint, and it will be often found when the inflammatory stage has passed, or before it has gained ground, that few cases will be benefitted by copaiba or cubebs, with the most appropriate injections. The. modern improvements consist in carefully investi- gating the cases that do not improve under such remedies. From among the numerous concentrated organic remedies, many TREATMENT OF GONORRHOEA. 27 may be selected as of sterling utility in the treatment of this affec- tion. We may enumerate a few of them. Senecin.—In any stage of gonorrhoea, senecin exercises a very beneficial power. It may be exhibited alone, or in combination, or alternated with such other remedies as the features of the case may indicate; or, it may be advantageously combined with stillingin, phytolacin, irisin or coryc\alin. Thus, if there is great scalding of the urine, populin will be appropriate. If chordee, lupulin or gelsemin. Other formulas might be indicated; but the senecin alone, well triturated, is to be preferred. Grelsemin.—This is one of the best concentrated remedies, it is the most positive medicinal agent we possess, and in the treatment of gonorrhoea it is peculiarly serviceable. It is best adapted to overcome urethral inflammation and prevent chordee, and for this it possesses specific power. It may be given alone, or combined with other remedies—for the purpose of fulfilling the indication for which it is reliable, it is best to administer it towards evening, so that comfortable repose will be procured, an essential condition in the treatment of all diseases. From one to two grains of the gelsemin, or from ten to twenty drops of the tincture may be given; some patients will be controlled with much smaller doses. In mild cases it may be given to the exclusion of other remedies. Macrotin.—This agent has been highly recommended as an auxiliary in the treatment of gonorrhoea and gleet; it is a powerful alterative, and promotes the efficiency of other remedies. Populin.—In that distressing stage of gonorrhoea, when there is a kind of sympathetic inflammation of the bladder, with vesical catarrh, great scalding of the urine, with a peculiar secretion of mucus or pus, nearly of the consistence of jelly, populin is the grand remedy. All other remedies may be laid aside, aifd this alone can be relied on. The relief it affords is usually prompt. In such cases we have found it to answer well in. large doses in solution. We would earnestly call the attention of the profession to the populin, as a remedy well calculated to fulfill the most urgent indications. A fair trial of its intrinsic merits will confirm the opinion we have formed of it. Chimaphilin.—The populin in combination with chimaphilin is very valuable in the treatment of gonorrhoea. When deemed appropriate, the chimaphilin may be joined with others, as the 28 TREATMENT OF THE VENEREAL DISEASE. senecin, irisin or gelsemin. In combination with the rhusin it is much esteemed. Caidophyllin with iron, or caulophyllin with copaivin, is an excel- lent formula; or, if chordee prevail, lupulin or gelsemin may be added. Barosmin.—This agent has attained considerable repute in the treatment of gonorrhoea. It is especially indicated in the worse cases, and its efficacy is much enhanced by combining with populin. Where irritation is very great, where the urine scalds most acutely, where you suspect abrasions, where the prostate or bladder is implicated, the barosmin may be given with unbounded success; it cleanses and heals the mucous tract—its power as a resolvent can- not be adequately estimated. The barosmin is more efficacious in gonorrhoea than copaiba or cubebs, and is not so ojectionable, on account of its smell or disagreeable taste. Irisin.—We have found irisin of reliable utility in gonorrhoea— it is excellent in combination with collinsonin or hydrastin. We have found a formula, equal parts of irisin, hydrastin and collin- sonin to be very efficacious, acting promptly, and relieving the urgency of the symptoms very speedily. Erigeron Oleum.—The oil of erigeron may be exhibited in gonor- rhoea with the best results, or it may be added to some of the mixtures used in that complaint, or its most marked and beneficial results may be obtained from it alone. It allays the scalding of the urine, and with populin and barosmin is becoming highly esteemed as a standard remedy. Hamamelin.—Hamamelin has been quite extensively tested, and found to answer well alone, or joined with some others of more intrinsic worth, and calculated to meet certain indications in the case. " ' Upon the plan of diminishing the irritability of the system, as well as the parts particularly affected, anodynes have been of late years much used in gonorrhoea, internally and locally. This prac- tice has been attended with good results, and ought to be adopted more generally- than it is; for this latter class of treatment the concentrated remedials are destined to play a very important part, such as hyosciamin, gelsemin, cannabis stativa. If the digestive powers of the patient become enfeebled under any remedy whatever, the ext. of the spruce fir or horseradish may TREATMENT OF GONORRHOEA. 29 be used with advantage. I often used in such cases the inspissated extract of the spruce fir. I now order it as follows: . R.—Ess. abietis nigr. inspiss., 5ii 5 Mag. carb., q. c.; * M.—Ft. pil., xxx. Two, three times a day. Under the influence of this remedy and anodynes, I have obtained very salutary results. I am somewhat partial in the exhibition of anodynes to their use in the form of suppository; any favorite anodyne, incorporated with the butter of cacao, introduced per rectum every evening. Copaiba and cubebs are not so much used as formerly. They undoubtedly exert some influence in diminishing the discharge, although there are inconveniences attendant upon their use. They are both equally efficacious. Various excellent formulae are in use* B/.—Bals. copaibae, §ii; Spts. etheris nit., §i; C. tinct. gelsemin, Tinct. opii, " Iodine, aa. 5i; Magnesiae, 5ii; Mucil. acaciae, 5v.—M. A teaspoonful thrice daily. Some very eminent surgeons are in the habit of giving copaiba and cubebs in somewhat full doses from the start, care being taken not to carry them to the degree of intolerance. If they cause excessive action of the bowels, combining with opiates and astrin- gents, so as to restrain that action, so that the active principle of those agents may be eliminated by the kidneys, and pass off in tlje urine. They should be suspended if they occasion uncontrollable nausea or diarrhoea, a cutaneous eruption, severe pain in the kid- neys, or general debility. Useful formulae are the following: B/.—Copaibae, spts. aetheris, nitrici, aa Si; Liquoris potassae, 5ii 5 Spt. lavandulae, comp., §ii; Syrup acaciae, 5vi.—M. A teaspoonful three times a day. 30 TREATMENT OF THE VENEREAL DISEASE. B/.—Bals. copaiba, Sss ; Pulv. cubebs, §i; Potassa chlo., gr. xx.—M. A piece, the size of a filbert, three times daily. B/.—Bals. copaiba, Si; Potassa chlo., 5i; Syr. tolutantis, Siv.—M. Teaspoonful thrice daily. B^.—Cannabis indica, 5i; Macrotin, 5ss; Chimaphilin, Populin, aa 5ss.—M. Ft. three gr. pill, one four times daily. B/.—Cannabis indica, 5iss ; Oleum copaiba, " cubebs, aa 5i', i ' Terebintha alba, 5ii; Magnesia, q. s. Ft. three gr. pills, two pills four times daily. B/.—Pulv. cubebs, Sanguinis draconis, Pulv. ratanhy, Ext. Catechu, aa 5ii; Bals. copaiba, q. s.; ft. elect. Dose, three drachms per diem. B/.—Ferri iodide, gr. ii; Opii pulv., gr. i; Mucilage q. s. ft. pill. T^rree a day. B/.—Pulv. cubebs, Sss ; Bals. copaiba, 5ii', Ferri sulphate, 5i; Terebinth chiae, 5iii-—M. To be made into bolus, 10 grs. each, two per diem. B/.—Guaiaci resina, pulv., Terebinth chiae, aa 5i.—M. Ft. xxiv pills, four twice a day. TREATMENT OF GONORRHOEA. 31 B/.—Ethereal ext. cubebs, Solidified bals. copaiba, Carbonate ferri, aa 5ii 5 Podophyllin, gr. x.—M. Ft. four gr. pills, two ter die. B/.—Pulv. cubebs, Podophyllum, White pond lily, aa. Sss ; Gin, Holland, oi.—M. Tablespoonful ter die. B/.—Tinct. cubebs, Spts. ether nitrici, Oleum amygdaia dulcis, aa Sii; " juneperi, " terebinth, 5a 5ss.—M. Dose, a teaspoonful ter die. B/.—Pulveris cubebae, 5viiss ; " aluminis, 5ss.—M.; or B^.—Pulv. cubebae, 5iii; Bitartrate potassae, 5ii.—M. Either of these to be taken daily in three doses. Copaibae solidified by magnesia, (16 parts to one by weight,) and made into boluses, is sometimes a convenient mode of administra- tion. . The following combination is good. B/.—Balsam copaiba, Sii; Spts. nit. dulc, Si; Tinct. cubebs, 5ii; " lavender C, " opii, aa 5i-—M. A teaspoonful morning, noon, and evening. The extract of cubebs in fifteen grain doses, three times a day. This is beneficial when the discharge is excessive, thin, and transpa- rent. Take balsam of copaiba, two drachms; powdered cubebs, six drachms; powdered opium, two grains, mix, and add sufficient quantity of magnesia to form a paste. To be divided into six parts. One to be taken three times a day. Very prompt. 32 TREATMENT OF THE VENEREAL DISEASE. In the administration of these remedies, the stomach and bowels should be attended to, and so combined as to cause as little disturb- ance as possible. B/.—Bals. copaiba, Pulv. cubebs, aa Sss ; Lig. potassae, 5iss; Mucil. acaciae, Sss; Aq. distilled, Sviss.—M. A tablespoonful morning and evening; or B/.—Mucil. acaciae, Copaibae bals., C. tinct. lavender, ail Si; Oleinn cubebae, 5i; Sacchar. albae, Siv; Aqua cinnamon, Shi-—M. Dose, teaspoonful ter die. Copaiba acts on, the stomach, the intestines, the urinary passages, the skin, and nerve centres, and its specific action is powerful in the treatment of gonorrhoea; perhaps of equal importance we must rank barosmin and cubebs. Copaiba and cubebs together, are more efficacious than either alone, and are better borne by the stomach. B^.—Copaibae, Sii; Pulv. cubebs, Si; Aluminis, 5iss; Magnesia, q. s.—M. To be taken in boluses, in from three to six days, according as the stomach will bear it. The place of the alum may be supplied with rhein for a cathartic, or if a tonic is called, iron or populin might be added to meet the indications. The above are all powerful remedies in gonorrhoea; but they have very little efficacy in gleet; in the latter intractable affection the concentrated remedies are more to be relied on. While some of the above methods of treatment are going on, it is often advantageous to render the urine less acrid, and thus lessen the pain experienced during micturition. For this purpose we sometimes resort to demulcent drinks, such as marshmallow, flax- seed and slippery elm teas, either acidulated or not with lemon juice, citric acid, or the bitartrate of potash; or we may give the TREATMENT OF GONORRHOEA. 33 acetate of potash, in half drachm doses every four hours, or alter- nate with the spruce fir or horseradish, or buchu or uva ursi, which is quite as effectual as the balsam, and is not so objectionable, on account of its smell or disagreeable taste. The diuretic drops are also invaluable. The wine of colchicum in thirty drop doses, three times a day, with gelsemin or hyosciamus is a good remedy. Cannabis-stativa in twenty drop doses, of an average tincture, is attended with the very best results. Thuja also may be given, being a useful remedy. As the following symptoms are only occasional consequences, generally the effects of irritation on the urethra, they are to be treated upon general principles. Hemorrhage from the Urethra.—In cases of gonorrhoea, where the hemorrhage is violent, or spreads along the urethra, there is frequently a discharge of blood from the part. In such cases, where the hemorrhage is either slight or severe, gelsemin is the sovereign remedy, either alone or combined with lycopin; or oleum erigeron given internally, has been of great utility. I have also been successful with lupulin and hamamelin, and packing the penis with cloths wrung out of ice water. I have also found turpentine of advantage internally, as well as the use of local remedies, as injections of alum, matico, perchloride of iron, rhusin, &c, &c. Painful Erections.—Gelsemin, lupulin, hyosciamin, opium, inter- nally, all have the effect of preventing painful erections in many cases. The cannabis indica taken at bedtime, has produced most satisfactory results. The cicuta, also, is a good remedy. In that painful, neuralgic condition, the local application of gelsemin with our vegetable alteratives internally, is of decided benefit. Chordee.—At the commencement of this complaint full doses of gelsemin and veratrum. Packing the penis is excellent; relief is experienced by exposing that organ to the steam of hot water. Poultices of belladonna or lobelia, or stramonium, have beneficial effects, so have fomentations ; all assisting in removing inflammation by the addition of gelsemin. Lupulin, gelsemin, camphor and opium, are of signal efficacy, lessening pain, removing inflammation, preventing erections, and obviating the immediate cause of the complaint. When the chordee continues, after the inflammatory or spasmodic 5 34 TREATMENT OF THE VENEREAL DISEASE. symptoms are gone, we often have a deposition of extravasated lymph in the urethra, coagulated and organized, and the absorp- tion of this must be our aim; for this purpose we may continue the lupulin with podophyllin and phytolacin, or irisin. Beache's discu- tient ointment, or a combination of oleum of erigeron, stillingia and lobelia in alcohol; this latter combination is extremely useful applied to the parts, will promote the absorption of the extravasated lymph; or an ointment of phytolacin, veratrin and gelsemin, answers well. Iodide of potassium, iodine ointment, equal parts of tinct. iodine and belladonna. The local application of gelsemin is esteemed a specific remedy here. Stramonium leaves are excellent. Experience has shown that these agents have considerable power in exciting absorption. Friction alone, or with any of the above agents, will be of service. In some intractable cases considerable benefit is derived from the exhibition of remedies, C. tinct. cin- chona, C. syr. stillingia, bromide of potassium, conium; galvanism may also be tried. When extravasation has occurred, the process of cure is progressive and uniform, as happens in a case of ordinary inflammation. For the relief of chordee there are no remedies superior to the gelsemin, lupulin and camphor; if spasmodic, lobelin and cinchonine. Depleting measures must be avoided, as they are invariably injurious, always do harm. Suppuration of the Grlands of the Urethra.—This affection, though rare, occasionally occurs, and when it does, it heals kindly under the influence of rest, cleanliness, alteratives and tonics; meet- ing the indications as they present themselves. Prostatitis.—Inflammation of the prostate gland is caused by extension of the morbid action from the urethra. It is recognized by the constant desire which exists to pass urine, by the dull pain pre- sent in the perineum. Barosmin and populin are the best remedies. Affection of the Bladder from Gonorrhoea.—When the disease extends as far the bladder, it produces a most troublesome com- plaint, from which serious consequences seldom arise; but it has frequently laid the groundwork of future irritation, which irritation has often given rise to ischuria, dysuria, &c, which have proved very troublesome, intractable, and in some cases dangerous. In such cases, the exhibition of populin, barosmin, hamamelin, hydras- tin, iron, quinine, gelsemin, and nux vomica, are attended with unbounded success. Suppositories are excellent made of bella- TREATMENT OF GONORRHOEA. 35 donna, so are anodyne enemas if nothing forbid their use. The warm bath is very beneficial; warm fomentations to the perineum have a good effect. Depleting agents must not be resorted to— gelsemin is the sovereign remedy; next, mucilaginous diuretics, such as marshmallow with an alkali, or minute doses of nitric acid, or flaxseed tea, uva ursi with populin, or barosmin, or iron. As this affection of the bladder often continues for a considerable time, producing irritation in the neighboring parts, and is not in the least mitigated by ordinary treatment, I would recommend the following method of treatment in such cases: gelsemin is very valuable in alternation with bark, cinchonine, irritating plaster over the region of the kidneys, counter-irritation on the perineum, and the local application of stramonium, over the region of' the blader, following with alteratives; small doses of nitro-muriatic acid well diluted in water. In the treatment of affections of the bladder, after gonorrhoea, our concentrated remedies are of striking utility; such a combination as B/.—Stillingin, Irisin, Barosmin, Hamamelin, aa, in full doses, in some mucilaginous vehicle, is of great service. If we have strong inflammatory symptoms, tinct. gelseminum and asclepias in an infusion of verbascum, may be freely adminis- tered. Mucilaginous diuretics, with acetate or citrate of potassa might be given in alternation. After controlling the acute symp- toms, more stimulating diuretics, as the uva ursi, with nux vomica, buchu, pareira brava. If we suspect morbid accumulations, wash- ing out the bladder with tepid injections of water, or glycerine, chlorate of potassa and water. Some preparation of zinc or nitric acid, or hamamelin, make an excellent injection in these cases. Constitutional treatment must not be neglected. Ischuria et Dysuria.—The causes which give rise to these diseases are an inflammation of the urethra, occasioned'perhaps by venereal sores, or acrid injections, or by inflammation of the bladder or kidneys, spasm of the neck of the bladder, excessive indulgence in spirituous drinks, gravel, irritation in the rectum. Perhaps a more frequent cause of both dysuria and ischuria is an enlargement or diseased state of the prostate gland, a complaint exceedingly com- 36 TREATMENT OF THE VENEREAL DISEASE. mon among the old men of our large cities. It is usually excited by full living, inebriety, excess with women, frequent excitement of the seminal vessels by masturbation, severe attacks of gonorrhoea, constipation, exposure. Indeed, whatever increases the circulation of the blood in these parts beyond the normal standard may cause an impairment, the blood-vessels lose their tone in advanced life. In ischuria, it is always advisable to guard against inflammation; gelsemin and aconite should be given in sufficient quantity, besides having recourse to the warm hip bath, emollient fomentations and mild enemas. If the suppression does not give way to these means, the patient should be put into a warm bath, if convenient, and if not, gelsemin in full doses in asclepias, might be given internally, with a suppository of belladonna or lobelia; then a catheter, well warmed, should be tried. When there is retention of urine, the introduction of a catheter is sometimes prevented by an enlarge- ment of some part of the prostate gland; various manipulations must be resorted to; if a catheter cannot be passed, bougies may be tried with some hopes of success. In every instance of the complaint, whether arising. from stric- ture, gravel, inflammation or spasm, gelsemin will prove highly beneficial, and ought to be given in some form; it is extremely serviceable administered internally—doubly efficacious in an enema repeated frequently. Some cases of spasmodic stricture are relieved by cold, placing the feet on a marble slab, dashing cold water over the thighs and legs, the effect of which is almost instantaneous. If due to any lesion of the spine, strychnine and gelsemin. An excel- lent combination is equal parts of tinctures of gelseminum and macrotys, in doses of thirty drops every hour, until the full influ- ence of the remedies are obtained. In retention from spasmodic stricture, ergotine, lobelia, belladonna, galvanism, warm bath, &c. Dry cupping to the superior and internal part of the thigh is often successful. Placing a patient under the influence of ether or chlo- roform will at once relax a spasmodic, and even if permanent, will allow the catheter to be passed. In cases that come on suddenly, dry cups to the loins, the hot stimulating hip and foot bath, tur- pentine, sweet spirits nitre, tinct. juniperi, in an infusion of hair cap moss, pulsatilla, lycopodium, and nux vomica. If all means fail, such as the warm bath and remedies mentioned, the most patient and cautious manipulation with the catheter or TREATMENT OF GONORRHOEA. 37 bougies, anaesthetics, relaxing agents, such as lobelia, belladonna, should have a fair trial in alternation; or combined with gelsemin, internally and locally. Lobelia in marshmallow tea, three times daily, has proved an excellent, remedy in many cases of dysuria. The tinct. ferri chloride is a remedy that often proves efficacious in suppression of urine arising from spasm, and may be given in ten drop doses, repeated frequently, until some sensible effect is produced. After a few doses the urine usually flows freely. The good effect of this remedy in cases of spasmodic suppression can hardly be overrated. In ischuria, more especially of a chronic nature, camphor, lupulin and populin, make a most excellent combination. In morbid con- ditions of the bladder, in which a suppression of urine is apt to arise, and recur frequently, the cypripedin, populin and hyosciamin, prove an excellent combination, beginning in medium doses and gradually increased, according to the distress of the patient, and the effect produced. If we have a diseased condition of the bladder, depending upon some venereal taint, or otherwise, stillingia, irisin and populin, will be of great service; but to derive their best results, we must give them in large doses and often repeated. Corydalin, phytolacin, gelsemin and barosmin have proved bene- ficial in these cases. Nitric acid in minute doses is excellent. Injections of soothing ingredients in the urethra, milk and water, anodynes; relaxing agents will afford relief, especially if the sup- pression has been occasioned by small pieces of gravel which have stuck in the canal. In both ischuria and dysuria arising from gravel and stone, besides adopting palliative measures, radical means should be adopted for their removal. In desperate cases, where all measures are ineffectual, where no catheter or bougie can be passed, where no remedies are effectual, where imminent danger is apprehended from enormous distension of the bladder, recourse must be had to puncturing the stricture. As a prophylactic measure for those troubled with such affections, all exposures to vicissitudes of temperature, all excesses, all inordinate exercise, and every pre- caution against the venereal taint should be rigidly attended to. Those who are liable to suppression or difficulty of the urinary apparatus, either from stricture, real or spasmodic, will act pru- dently in wearing a bougie for an hour daily, and in attending carefully to the general health. 38 TREATMENT OF THE VENEREAL DISEASE. In enlargement of the prostate gland, the best means to resort to are the frequent exhibition of aconite and gelsemin, dry cupping, assisted by such remedies as podophyllin and irisin from time to time, enemae of lobelia or belladonna, the use of the hip bath at 96°; rest, avoidance of all means of irritation. The introduction of bougies or catheters should be dispensed with, as they are liable to produce disturbance, inflammation and retention. In a more advanced stage of the disease alkalies should be given, in such remedies as buchu, queen of -the meadow, marshmallow, the bowels regulated by the neutralizing mixture, the diseased parts soothed by suppositories of hyosciamus, or belladonna, or opium. Relief is frequently experienced by a tonic course, iron, quinine and nux; or cypripedin, hydrastin and populin; the hip bath, of common salt water at a low temperature, is an excellent adjunct. In cases of irritation of the neck of the bladder and urethra, and in sympathetic irritation from disease of adjacent organs, we find an injection of opium is in many cases sufficient; an excellent formula is the following: B/.—Tinct. opii, 5ss ; " gelseminae, " lobeliae aa. gtt. xxx; Aqua, Sii-—M.; use as an enema and repeat frequently if necessary. Internally, no remedies are more effectual than gelsemin, macrotin, and tinct. chloride of iron, rhus radicans, arnica; locally, stramonium. Epididymitis.—The testicle frequently sympathizes with the urethra or bladder; generally, however, it does not occur till the acute stage of the gonorrhoea has passed. It is not due to metas- tasis, but to an extension of the inflammation along the ejaculatory ducts to the epididymis. At first the inflammation is limited to this structure, but it may extend to the body of the testicle. Epididymitis in the early stages, is most advantageously treated by perfect rest in the recumbent position. This is a good remedy— the horizontal position is not only the easiest, but it is the best for equalizing the circulation. If the patient cannot confine himself in having recourse to that desirable expeolient, the scrotum must be kept in a suspensory bandage. In this complication, no particular method of cure can be laid TREATMENT OF GONORRHOEA. 39 down. It must be treated on general principles. The course of treatment that I have found to be the best and effectual is, an emetic at the start, and if the affection does not yield rapidly, a repetition of it on the third day. An emetic of lobelia I can recom- mend as of great service, and have known it to remove a swollen testicle almost instantaneously. The effect of emesis probably arises from some sympathy between the stomach and the testicle, and the peculiar nature of the lobelia. The exhibition of the C. podophyllin pill every night should not be neglected. At the same time discutient lotions, of which the chloride of ammonium, or acetate of lead and opii in solution, or tinct. of arnica, or equal parts tinct. belladonna and iodine, or muriate of ammonia, one ounce to six or eight of water are the best, and one of them kept constantly applied. I have also found clematis, cicuta, belladonna and thuga useful. If induration occurs, the C. syr. stillingia et sarsaparilla, with the iodide of sodium or potassium, is to be admin- istered internally, and the iodized glycerine applied externally. Some cases get along well by compression with adhesive strips, or by means of collodion. Some cases again require not only the exhibition of the lobelia and podophyllin, but we must, where we have great constitutional disturbance, resort to aconite, gelsemin or veratrum, and apply anodyne poultices, such as stramonium, the patient maintaining the recumbent position. During the continuance of the inflammation and swelling I have derived good results from the acetate of potash, always giving an opiate at bed-time, such as lupulin. Almost every case of inflamed or swollen testicle will terminate favorably by attention to the above treatment; but when, either from improper treatment, neglect, or any unfavorable circumstances, suppuration has occurred, the matter must be discharged by making an incision into the most dependent part of the abscess, and the remainder of the treatment must be the same as in collections of pus in other parts of the body. If there be effusion into the tunica vaginalis, and the above reme- dies be not sufficient to create absorption, it must be drawn off* In cases of true orchitis, where the body of the testicle is involved, the pain severe, I have derived excellent result from irrigation, the continual dropping of cold or ice water on the part. Cold applied to the scrotum by compresses dipped in water is a powerful remedy T 40 TREATMENT OF THE VENEREAL DISEASE. assuaging pain, preventing effusion, and hastening absorption; if it induces an uneasy sensation, the temperature must be raised from cold to cool, and continued till the cure is complete, at the same time giving nux vomica, pulsatilla and aurum. Clematis is also a good remedy in the treatment of orchitis. % After reducing the inflammation and relieving all complications, hardness very frequently remains; poultices of hemlock or bella- donna every night, and the use of stillingin and irisin internally, together with compression during the day by means of collodion or adhesive strips, will be the remedies most likely to remove it. In scrofulous cases, iodide of iron, with cod liver oil, answers well. Epididymitis frequently follows a sudden suppression of the dis- charge, and experience has amply taught us that it is useless to recall the discharge from the urethra, as it exercises no bearing on the future progress of the cases. The evacuation of the effusion into the tunica vaginalis in this affection is best performed by the ordinary hydrocele trocar plunged perpendicularly into the bulging mass of the fluid above and in front, and a few strands of silk allowed to remain, and one removed daily. Lotions of the acetate of lead and opium, or stramonium, applied after the operation. Excoriations.—The matter discharged in gonorrhoea being in all instances of an acrid and virulent character, is apt, by lodging between the prepuce and glans penis in men, and on the labia in women, to occasion an excoriation and ulceration in these parts. To prevent such consequences, it is right and proper to pay strict attention to cleanliness, by washing the parts twice daily with soap and water, following with a lotion of sulphate of zinc, or tannin, or alum, or permanganate of potash. When such excoriations take place, they are best to be touched with nitrate of silver, or calc. alum, or sanguinarin, then use one of the lotions above mentioned, suspending the penis at the same time to the abdomen, by means of a proper bandage. The inflammation of a gonorrhoea may spread to the glans penis and prepuce, producing balanitis, posthitis, and balano-posthitis. If these do come on, washing with castile soap and water, the appli- cation of strips of lint moistened with a solution of permanganate of potash, or with glycerine, or with hydrastin in solution. If the disease persists, lotions of hamamelin, rhusin, sanguinarin, tannin, alum, sulphate of zinc, will be more efficacious. TREATMENT OF GONORRHOEA. 41 Excrescences.—Warty excrescences or vegetations now and then appear about the external organs of generation in both sexes, as a consequence of gonorrhoea. They are caused by the direct appli- cation of the gonorrhoeal discharge to the parts in the vicinity of the genitals. They are of various sizes, appearance and consist- ence, adhering sometimes by a narrow base, and sometimes by a broad one. They occasionally attain an immense size, and are troublesome, from the pruritus they excite and their weight. Wherever one or more ligatures can be applied, it is a good method for their removal—where, from the broadness of the base, or their being extremely numerous, they may be removed by chromic acid made into a paste and applied. This I have found to be the best agent for their removal. Sanguinarin has succeeded well, and its use is often to be commended. Cause a slight abrasion on the surface of excrescences, and apply it morning and evening. It acts as a mild escharotic, produces a considerable discharge from the surface, by which the excrescence is gradually sloughed off without leaving an eschar. It gives no pain, and is seldom produc- tive of inflammation, which not unfrequently follows the use of caustic potash, caustic soda, muriate of ammonia, bromine. Next to chromic acid as a local application, I know nothing better than nitric acid. If the patient be scrofulous, Or of the sanguine tem- perament, cutting them off with the knife and cauterizing the surface with the acid is often resorted to. Cleanliness is essential to their complete cure. In some cases, washing the vegetations with a solution of tannin, and then applying a layer of equal parts of savine and calc. alum, is attended with the most happy results. Lingering Sensations.—The lingering sensations, the disagreeable feelings which sometimes continue in the urethra and glans, occur most frequently when the bladder has sympathized during the disease. These shooting neuralgic pains, and other bad symptoms, are merely a consequence of the original disease. These lingering symptoms vary much in their essential features; no one mode of treatment will be always proper. I have found a course of altera- tives of decided value, stillingia, irisin, phytolacin, &c.; good results also follow cinchonine, strychnin and iron; and in irritable subjects, anodynes have magical power, hyosciamin, lupulin, gelsemin. Stimulation, positive nerve tonics, such as xanthoxylin, cypripedin, scutellarin, electricity; in weak hysterical patients, hygienic mea- 6 42 TREATMENT OF THE VENEREAL DISEASE. sures are of value; the medicated bath, the shower bath, friction to the entire surface, exercise in the open air, agreeable associations: counter-irritation is of great value applied to the perineum, over the region of the loins, sometimes over the entire spine. For the purpose of counter-irritation I have used the following for a basis for plasters, it being more cleanly and more suitable of adaptation about the perineum. B/.—Glycerine, Si; Maranta, gr. xv.—M. Heat to a temperature of 240°, and allow to cool. This is a plastic mass of extreme cleanliness, and one in which podophyllin, cantha- rides, sanguinarin, veratrin, quinine, morphia, &c, mix well, and one also that has remarkable adhesive properties. The insertion of a bougie often gives relief, dry cupping over the loins. Neuralgic pains along the urethra are often relieved with compression, either with strips of adhesive plaster or collodion. If scrofula be a com- plication, our alterative syrups, iron, glycerine, with iodine, inter- nally, which is superior to cod liver oil, must be resorted to. Locally, gelsemin is one of the best remedies in the materia medica. Crleet.—In consequence of repeated attacks of gonorrhoea, and the debility of parts occasioned thereby, it not unfrequently hap- pens that a gleet or small discharge remains behind, and proves more tedious and difficult to cure than the original disease. It would seem to have its origin in some constitutional defect, (aside from improper teatment of the original disease,) such as the scrofu- lous diathesis, inherent weakness, relaxed, depraved, or broken down constitution; if no evident cause, it may be due to stricture, diseased prostate. The cure depends chiefly on the removal of the cause. In recent cases the disease is easily removed; but in lon<* standing cases, where the mucous glands have suffered much relaxa- tion, or where there is a stricture or callosity, it is usually intract- able. One of the most important points in the treatment of gleet, consists in ascertaining the cause of the discharge. Supposing that the gleet has been troubling the patient for some time, the most important proceeding consists in passing a bougie, to ascertain the condition of the canal of the urethra. It is now a well-established fact, that long standing inflammation of the urethra will produce thickening of its walls, as well as an irritable granular condition of 4 TREATMENT OF GONORRHOEA. 43 certain portions of the canal, resulting in stricture, attended by purulent secretion from the surface. Now no internal medication will cure this local complaint. Experience having taught these facts, the first thing to do in all cases is to ascertain if, in any given case, this morbid condition of the mucous membrane exists. The common bougie may be employed for this purpose. The instrument previously warmed and oiled, is passed along the canal until it meets with resistance; gentle force should be employed in the attempt to pass the obstruction. If the instrument does not pass, smaller siz*es are used until the stricture is passed. The instrument is then withdrawn gently, and a stricture is thus detected by the instrument being held firmly from behind by the contraction. In slight cases of stricture, in the granular and in the spongy con- dition of the urethra, of which we are now speaking, no plan can succeed as well as this. Moreover, by measuring the distance on the instrument, we are enabled to judge of the exact length of the change of structure of the canal. The form of gleet depending on this condition of the passage becomes now one of the most tractable of affections, and readily yields to the introduction of bougies. This is the form of gleet usually esteemed incurable, and which has so frequently baffled the disciples of dogmatism. The introduction of bougies every day, or every other day, is commendable. I would strongly insist on their continuance in alternation with injections, dilatations with injections. If need be, medicated bougies, injec- tions of permanganate of potash. In the cure of a gleet by this method, we have no certain rules to guide us, six or seven weeks may be sufficient. With reference to medicated bougies and injections, it is better not to continue one remedy longer than a week; as injections, permanganate of potash, chlorate of potash, alum, hydrastin, rhusin, hamamelin, sulp. zinc; > for medicated bougies, zinc ointment, black salve, balladonna oint., &c. If gleet is not due to some local cause, such as we have described, then we must look for some constitutional defect, impair- ment, peculiar diathesis, want of tone; and, the primary thing in treating gleet is to remove this defect or impairment, alter or modify this diathesis, and to impart tone; to strengthen the vital forces, and by no means depress; improve the tone of the constitu- tion in every way. If physicians would give tonics, build up their patients, there would be little time wasted in effecting a cure; our motto is to 44 TREATMENT OF THE VENEREAL DISEASE. strengthen, invigorate the vital forces, avoid depletion, trust to tonics. If this state of things exist, one of the first things that must be done is to put the affected individual upon a nutritious diet, find some pleasing occupation for his mind, gentle exercise in the open air. The greatest benefit will be derived from cold plunge baths, shower bath, followed by frictions to the skin, with coarse towels or the hair brush. Internal medicines may be given with decided advantage, iron and quinine, hydrastin and iron; a pill, composed of two grains of sulphate of iron, and half a grain of quinine, may be taken three times a day; the Yerri et quass. et nuc. vom., or oxalate, or citrate ferri, may be substituted. I have derived very excellent results from the concentrated agents; populin, hydrastin and hamamelin is a combination that has seldom failed; other remedies according to the indications. In the strumous diathesis, those remedies which are usually given in scrofula, stil- lingia, irisin, phytolacin, ampelopsin, collinsonia, with iron, or in alternation with some preparation of iodine, change of air, the sea shore, the sea bath. The eryngium aquaticum will meet our best anti- cipations in gleet. Hamamelin in gleet cannot be too highly rated. Some cases will disappear immediately upon the use of some of the agents we have recommended in gonorrhoea, although, as a general rule, they have no great power. Tonics, general and special; attention to everything which aims at invigorating the system generally. If the attempt of cure is to be effected by injections, permanganate of potash is the best. I have used the same remedy internally with great success; it is a potent blood tonic, imparting an immense amount of oxygen to the blood. The following I have found a good prescription : • B/.—Potass, chlorat., oii; Potass, acetatis, Sss; Liq. potassae, 5iii; Pulv. rhei., 5ss; Aq. dest., Sviii.—M. Si ter die. B/.—Tinct. cantharides, 5i; Tinct ferri scsquichloride, oii; Sulph. quinine, Acid sulph. dil., aa 5ss; Aqua dest., Sviii.—M. Si ter die. TREATMENT OF GONORRHOEA. 45 Sedatives come in as useful adjuncts, and, in irritable subjects, may sometimes be depended on entirely; the best of this class that I have used are cannabis indica, gelsemin and hyosciamin. The specifics commonly spoken of have very little effect; irri- tating applications, either as injections or bougies, are not good; neither are irritating agents internally of any great value. Can- tharides may be a solitary exception, given with some agent to modify it, such as B^.—Tinct. cantharides, Con. tinct. xanthoxylin, aa Sss ; Gelsemin, Strychine, aa gr. i; Syr. limonis, Siv.—M. Dose, a teaspoonful morning and night. Blisters, or counter-irritation to the penis, along the course of the urethra, are not attended with much good, and are not to be recommended; although counter-irritation, in another part of the body, is almost invariably successful, and, in obstinate cases, is deserving of a fair and prolonged trial. Old gleets, that have baffled the ordinary methods, are often cured in this way; electricity has been successful in some cases. The cure of a gleet must be made on general principles, by toning the constitution, and altering the disposition of the part. If all remedies fail, I would recommend thuga as a last resource; it has succeeded well with-me. In whatever way a cure is effected, rest or quietness, agreeable associations, regularity and moderation in all things in diet, in mode of living, in sexual intercourse. There is sometimes, after the patient is cured, a slight remaining chordee; to cure this, lupulin and camphor, electricity, the discutient ointment; if spas- modic, bark, hydrastin, gelsemin, &c. The irritation of the bladder sometimes continues, which is annoying. This troublesome affection may be kept up by the bladder itself, by the prostate or urethra. If the disease is in the bladder, the pain is felt, after making water, for a short time after. The cure of this symptom consists in the exhibition of small doses of nitric acid, alternating with gelsemin, in suppositories of ano- • 46 TREATMENT OF THE VENEREAL DISEASE. dynes, tonics, bark, nux, populin, and counter-irritation in the perineum and loins. The tinct. ferri muriate, when steadily employed, produces great benefit in gleet; it is best given either with, or in alternation with a tonic, such as hydrastis, cinchona, frazerin, &c. Stricture.—In consequence of inflammation and its effects, ulcera- tions, hypertrophy, engorgement, the folds of the urethra are apt to form projections; certain parts of it are liable to become con- tracted, and to occasion strictures, which cause the urine, instead of flowing in a free and direct stream, to split into two or more, or to be voided drop by drop. Various diseases, or mechanical violence, may produce inflammation of the urethra and cause stric- tures. Strictures of the urethra are sometimes simply spasmodic, due to affections external to the canal; sometimes due to organic changes in the canal. Strictures, properly speaking, may be divided into two classes: true permanent stricture, arising from an alteration in the stricture of a part of the urethra; the other to spasmodic action, although in some cases both are combined. In permanent stricture, the patient seldom complains until he has some difficulty of micturition, symptoms analogous to stone or gravel. The disease generally occupies no great length of the passage, does not arise from an equal contraction of the urethra all round, generally from a contraction on one side. In some cases there are more strictures than one; three, four, and as many as six have' been detected. They are more troublesome in cold than in warm weather. Sometimes the whole calibre of the canal is diminished in size. The usual way to get rid of strictures of a permanent character is by a regular and persevering use of bougies; and were all such as are afflicted with these complaints not to neglect this remedy, we would seldom, if ever, meet with those dreadful cases of sup- pressed urine Avhich sometimes occur. We have found a bougie, made of the dry bark of the slippery elm, to possess very many advantages. By holding it in warm water for a few minutes it becomes mucilaginous, passes with great facility, and, by permitting it to remain a few minutes, it expands and dilates the stricture. In making use of bougies, it is indispensable for success to attend to general rules. Begin with one of small size, and increase it very gradually; but, TREATMENT OF GONORRHOEA. 47 previous to its introduction, have it warmed and oiled, bent in the shape of a catheter, so as to adapt it to the curvature of the urethra, by which means its passage will be facilitated. Employ no force in introducing it; but, where we meet with great resistance, be content with merely suffering its point to press against the stricture for a short time daily, with the hope that, by a persevering effort in this plan of dilatation of the contracted part, may at last be effected. To wear it at first for about half an hour daily, gradually increasing the time as the parts can bear it without irritation. Never pass it into the bladder, unless it be to ascertain the extent of the disease; merely carry it a small distance beyond the stricture or strictures. Guard against it slipping into the bladder; avoid all exercise during its introduction. Continue to use it for a considerable time after the disappearance of the stricture; have recourse to it again on the least return of obstruction. As an invariable rule, the knife should never be employed in any case when a thread cat-gut bougie can be introduced, in any stric- ture that is pervious. If a bougie can be passed into the bladder, stricture can be cured without cutting. There is not one case in three hundred, of very bad strictures, where the knife need be used at all. Dilatation by bougies must be combined with proper medical treatment; give remedies to promote absorption, such as iodide of sodium, or ammonium, and give barosmin and cannabis indica to relieve irritation, give it alone or combine it with gelsemin, or irisin, or lobelin, according to the indications. Passing the bougie as far as the stricture, and allowing it to remain half an hour, with gentle pressure, will excite the absorbents. If the stricture produces complete retention of urine, we must endeavor to pass bougies, in conjunction with the exhibition of lobelia or gelsemin, warm baths, an enema of tobacco, or a supposi- tory of belladonna, with a strong solution of the extract painted over the penis; should these means fail, press a small catheter against the obstacle for an hour, and probably a small sized bougie may be afterwards inserted. Arnott's method consists in the use of a tube of oil silk, lined with india rubber, to render it air tight, and attached to the 48 TREATMENT OF THE VENEREAL DISEASE. extremity of a small canula, by which it is distended with air or water, from a syringe at the outer end, with a stop-cock to keep it in Avhen received. The canula may be of gum elastic, or of flexible metal used to make metallic bougies. The instrument is easily passed, and as soon as the bag is sufficiently within the stricture, as much water or air is to be injected as the patient can easily bear. The great secret in the use of a bougie is to handle with the utmost delicacy, and twirl it gently between the thumb and finger when it meets Avith obstruction. The golden rule as regards the employ- ment of dilatation, which must guide us, both in regard to its extent, its duration, the interval between each repetition of it, is to exercise just as much pressure and dilating poAver as can be exerted without producing pain or uneasiness, or more than slight irritation, and not to repeat the process until any excitement produced by the previous catheterism has completely subsided. Attention to this rule will conduce to a quick, safe, and successful result. In my own private practice I invariably treat stricture by simple dilatation, and avoid the use of caustics and incisions. So fully persuaded am I of the efficiency of the catheter, that I believe there is no stricture, however narrow, Avhich will not admit of an instru- ment, provided it be sufficiently small, and be employed with proper care and patience; even in those cases which have been termed impermeable stricture. Having employed dilatation, and if I find the stricture rapidly reappearing in spite of treatment, I am partial to slight stimulation with sanguinarin, as an agent possessing many advantages in the treatment of this disease. A bougie is selected, the' finer at the extremity the narrower the stricture. By heating its extremity, it is so far softened, that on immersing the instrument in sanguinarin, it adheres to the entire heated surface. The bougie, when thus armed, is passed into the stricture, and left there for twenty minutes or an hour, according to the period of treatment, the sensibility of the patient. After a few minutes a slight smart- ing is felt, but no other apparent effect is perceived. The day after this application, bougies of considerable size can usually be introduced, and a permanent cure effected in a short time. This stimulation of the urethra is attended with excellent results. Gradual dilatation should be preferred in all cases; experience has proved that the result is more permanent. As a radical means of cure, dilatation has a permanent effect in hypertrophy, TREATMENT OF GONORRHOEA. 19 combined with softening of the tissues. If induration is well marked, callous, fibrous degenerations, true cicatrices or vegeta- tions, success is less durable; we only stretch the parts, which soon recover their former state when Ave cease to separate them by dila- tation. Gradual dilatation acts like compression, and produces simple resolution of the tissues, or excites a kind of purulent dissolution. Gradual dilatation should be preferred in all cases. Caustic bougies, we think, have no advantage over common bougies in respect to the permanent cure of the malady. Experience has fully proved that after a stricture has been removed, caustic bougies are still neces- sary. For these and other reasons, the treatment by caustic bougies has, of late years, lost much, nay, all of its former repu- tation. Surgeons of the Reformed profession generally prefer the treatment by bougies, which effects the same object, more slowly it is true, but on the whole more certainly, with less inconvenience and more decided, permanent results. There are cases, however, that resist all treatment, the stricture being so complete as to cause a complete retention of urine; cases Avhere the urethra is thickened and contracted, and often compli- cated with fistulous openings ; cases of bad strictures in an extremely irritable urethra; cases in AA'hich it might be advisable to relieve by operation, by means of the lanceted stillette, or urethral perforator. This instrument is passed down to the stricture, the exact distance of which from the extremity of the urethra is first ascertained. When the point of the instrument rests upon the contraction, which is known by measurement, &c, &c, the stillette is then gently pressed forward, when the lancet is protruded out of its point, and is thus made to incise the stricture. The lancet must be imme- diately drawn back, and the instrument pushed through. Various modifications of this plan are in use. I do not recommend this plan of treatment in cases where there is any passage, however small, through the stricture; but in every case where the contraction is so great as not to admit of the intro- duction of an instrument, this plan, in my opinion, offers a safe, speedy, and effectual mode of cure. Various operations for the relief of stricture are in use, but none of them of any practical utility, and their introduction into the limits of this work would only tend to confuse and lead away the 7 50 TREATMENT OF THE VENEREAL DISEASE. mind from what is really beneficial, to something fanciful and worth- less. When a spasmodic constriction of the urinary passage ensues in or after gonorrhoea, which is usually known by its suddenly taking place, sudden interruption of the floAf of urine, we are to have recourse to emollient application, such as fomenting with cloths wrung out of hot water, or an infusion of chamomile flowers, or poppies, or rubbing the penis with equal parts of tinct. opii and belladonna. Where these fail, a warm bath, together with the internal use of opium, or belladonna, or dioscorein, or belladonna as a suppository should be employed. Belladonna, with proper auxiliary treatment, has been, and still is, a good remedy in cases of retention of urine in gonorrhoea from spasmodic strictures in the urethra. A few grains of the extract, either alone or with the dioscorein in a suppository, is the best plan of exhibition. To prevent a return of the complaint, a combination of gelsemin, dioscorein and nux vomica, may be given night and morning with very excellent results. In suppression of urine from spasm, we have several very effica- cious remedies, such as gelsemin, dioscorein, lobelin, strychnine, cannabis indica, &c, and an old but still a good remedy, muriate tinct. of iron, which given in ten drop doses every ten minutes, until some desirable effect is produced. Enemas of lobelia, tobacco, Indian hemp, &c, produce good effects; opium with the hot bath and an enema of belladonna. In obstinate cases of mixed stricture, counter-irritation in the perineum with the above remedies are indicated. Rhus rudicans has succeeded in my hands. There are certain diseases, or morbid conditions, that are apt to occur in consequence of stricture of a permanent character. The urethra, beyond the stricture, is frequently enlarged, dis- tended in proportion to the force with which the bladder acts, and the resistance of the stricture. Its internal surface becomes irregu- lar and fasciculated, and, if not relieved by some of the methods for the removal of stricture, nature endeavors to relieve herself by making a new passage for the urine; a source of much incon- venience and misery to the patient. Ulceration takes place near the stricture; the internal membrane and substance of the urethra are removed, the urine gets into the cellular tissue, diffuses itself, becomes the cause of suppuration wherever it is diffused, a breaking doAvn, first in the cellular tissue, then in the skin, making a free TREATMENT OF GONORRHOEA. 51 communication between the urethra and external surface, and pro- duces a fistula, which is extremely troublesome to cure. The best treatment in these cases: first try the actual cautery and injections, or touch with the caustic potash, and, if these fail, an operation must be resorted to for its relief. I have found, in some cases, the use of bougies, and drawing off the urine with the catheter, successful in the cure of fistulae. The caustic bougie is often of undoubted utility. There are numerous methods of operating for this fistulae, all worthy of attention. Always bear in mind, that it is not always enough to restore the urethra to its former size, but that, to effect a cure, it is indispensable to destroy the organized fistula. The passage should be laid open like other fistulae, so as to substitute for them simple wounds, susceptible of cicatrization. The method of using stimulating injections, say of nitric acid, chloride of zinc, sanguinarin, in the fistula, in order to excite adhesive inflammation, and in this way obliterate the sinus, is often successful, and, as conservatism in surgery is highly com- mendable, it is worthy of a trial. Spasmodic affection of the urethra is a diseased or preternatural action, arising from some irritation. If the urgency of the symp- toms are not great, it is proper to try internal remedies and external applications to remove it. The internal remedies consist of gelsemin, hyosciamin, belladonna, opium, bark dioscorein, nux vomica, &c. The external applications are belladonna, lobelia, the warm bath, warm pedeluvium, bladders of warm water, counter- irritation, the occasional introduction of a bougie. Paralysis of the urethra must be treated with counter-irritation to the loins or perineum, alteratives, with cypripedin, xanthoxylin, or with tonics, as populin, hydrastin, frazerin, &c. Belladonna and nux vomica as a suppository. Excrescence or caruncula cause obstructions, and it is to be cured by the bougie. This is the only good method of treating this affection: bougies smeared with alum, immersing the instrument in finely pulverized alum. In the treatment of enlargement of the prostate gland, C. syr. stillingia, irisin, phytolacin, Avith iodide of ammonium, are valuable, Avith tonics, such as populin, barosmin and iron. In the strumous oliathesis, hemlock, iodide of iron, salt water bathing, possess con- 52 TREATMENT OF THE VENEREAL DISEASE. siderable advantages. Counter-irritation and suppositories are indicated; for the latter, conium or belladonna. In the treatment of paralysis, of the bladder, from obstruction and pressure, cathartics, emetics are not to be neglected. Remedies acting on the nervous system, strychnine, gelsemin, cypripedin, cantharides, ergotine and arnica are the most potent; the tinct. of arnica, in doses of from forty to sixty drops daily. Electricity is sometimes of singular service when applied in such cases to the perineum. Benzoic acid, with populin and gelsemin, is a formula of some value. Iron, in the form of sesquichloride, three times a day, in infusion of quassia, stimulants, and counter-irritation are useful, dry cupping over the loins. Through the whole process of treatment, the urine must be drawn off, the bladder not allowed to become distended. In cases of suppression of urine, where it is impossible to draw it off, or any remedy to mitigate or bear on the case, paracentesis vesica' must be performed. There are three methods of performing this operation, viz.: puncturing above the pubis, puncturing through the rectum, and cutting through the perineum. Of these three, we exclude the first as being the most dangerous, the most liable to lead to extravasation of urine, &c. If the stricture has existed for a long time; if the walls of the urethra have become thickened and cartilaginous, so as permanently to constrict and destroy the function of the canal; if, from the circumstances of the case, the stricture be likely to persist, I recommend cutting through the perineum as the operation that is most successful; but we must, in all cases, be guided by a consideration of the nature of the case. Gonorrhoeal Ophthalmia.—The treatment of this affection should be both local and general. Of all remedies in the materia medica, permanganate of potash has succeeded best in my hands; washing and injecting the eye three times daily, soaking a piece of lint in the same, and keeping it applied. In some cases, however, it is especially necessary to make injections or irrigations every half hour or hour, when the suppuration is very abundant, so as not to alloAv the pus to remain in the eye, which has become, in a great measure, an abscess, and requires incessant evacuation to prevent maceration of the cornea, and all the trouble which results from retention of nus. The TREATMENT OF GONORRHOEA. 53 chlorate of potassa is excellent, used in the same manner, so is the tinct. of myrrh. Frictions, with extract of belladonna around the orbit and nostril of the affected side; or, what answers well, one square of the atropia gelatine paper, dissolved in the eye, morning and night. I do not like the nitrate of silver, unless it is to repress granulations that may arise. I have often found the sanguinarin a better remedy. I have used, with some success, carbolic acid in glycerine, made stronger or weaker as the patient can bear it. A little of this applied three times a day. I have found equal parts of hydrastin, hamamelin, rhusin and baptism effect a speedy and complete removal of the inflammation and morbid sensibility. Our concentrated agents are peculiarly adapted to meet the indication of this affection, and are indeed invaluable, but particularly so if dissolved in glycerine instead of water. West India molasses, dropped into the eye every two hours, is successful. The Allopathic practice of using acetate of lead, nitrate of silver, ung. picis, sulph. zinc, iodine, copper, &c, is attended with but poor success. Chloride of zinc, of the strength of one grain to the ounce, is a good formula. Irrigation, in addi- tion to other remedies, cannot be too highly recommended; irriga- tion is attended with the greatest success. If we have great inflammation, incisions, leeches, and counter-irritation may be beneficial. Unfortunately there are cases, however, where no known method lessens the symptoms; evacuations produce no relief; the strengthening plan has not been unsuccessful; sedatives have procured no relief; and time is wanted. In such cases the soothing plan is the best. In addition to local treatment of gonorrhoeal ophthalmia, I lay great stress on general or constitutional treatment. The system sympathises—is less or more deranged—a stimulating emetic is indicated; it excites or rouses up the liver, it stimulates the secre- tions, and acts powerfully on the nervous system. By this pre- liminary treatment we relieve the stomach, give it stimulus, correct or restore the secretions of the liver, kidneys, &c. If debility exists, it must be removed with good diet and stimulants, and, as soon as possible, the patient should be put at once on our vegetable alteratives, such as 54 TREATMENT OF THE VENEREAL DISEASE. B/.—Stillingin, Irisin, Phytolaccin, aa.—M. In full doses. B/.—C. syr. stillingia, Oss ; Con. tinct. iris versicolor, " ". corydalis, aa 5i; " kalmiae, Iodide potassium, aa. Sss.—M. A teaspoonful thrice daily. In those bad cases the above is often successful, following with tonics, such as hydrastin and iron, frazerin and cinchonine, cornin and gentian, &c. If it assume an intermittent form, bebeerin, quinine, or salicin will answer well. If there appear to be anemia—a want of a due proportion of red globules in the blood—iron may be pushed with more vigor; and an excellent form is the lactate of iron, being easily assimilated. Gonorrhoeal Rheumatism.—The pathology which considers rheu- matism as a blood disease, may be considered upon the whole as correct, although we are not able to explain it by the symptoms. Our treatment of rheumatism is purely empirical. There is no doubt of the existence of gonorrhoeal arthritis, gonorrhoeal rheu- matism, &c, and it has been frequently attributed to a suppression of the discharge, although this is not essentially true. It is more frequent in males than in females. I have tried the effects of special remedies in this disease, and watched a series of cases. I have tried aconite, and believe that that alone is of little service. I have used veratrum, colchicum, tinct. of blue cohosh, and believe that these alone "have no utility. My favorite and successful method of treating rheumatism is by alkalies, asclepin, or sudorific drops in some stimulating tea, full doses of the acetate of potash, with an anodyne at bed time; locally, warm alkaline packs. The employment of the acetate of potash, with diaphoretics, gives the most decided results. Col- chicum and quinine, in full doses, every two hours, will often cut short an acute attack. The iodide of potassium, in the stillingia) syr., ansAvers Avell. Bathing the entire surface daily, with an alka- line AA'ash, is always of benefit. Within this last year, I have been TREATMENT OF GONORRHOEA. 55 experimenting with the bisulphate of soda, in cases of gonorrhoea! rheumatism, with very good success. Gonorrhoeal inflammation of the iris frequently supervenes in cases with that peculiar species of rheumatism which frequently attends gonorrhoea. It very commonly alternates with affections of the joints, and an acute attack of synovitis frequently relieves the inflammation of the eyes. It is more frequent in scrofulous patients, laboring under gonorrhoea or gleet. The extreme frequency of the disease, its dangerous character, and the facility with which adhesions of the iris take place, render it necessary to keep the pupil dilated with atropia. The treatment most successful consists in equalizing the circula- tion with aconite, podophyllin, irisin and bitartrate of potassae, so as rapidly to affect the system, and the application of atropia. Our chief reliance is to be placed upon our alteratives, combined with quinine and iron; if there exists a rheumatic state of the system, acetate of potash, asclepin, colchicum, counter-irritation to the back of the neck. Conium, lycopodium, staphysagria, clematis may be tried. A chronic enlargement of the testis, sometimes occurring alone, sometimes complicated Avith hydrocele, occasionally remains after the subsidence of the more acute symptoms accompanying a swollen testicle. For this affection, compression is of little use. The proper remedies are alteratives, iodide of ammonium, or potash, and the external application of the tincture of iodine, or the iodide of lead ointment. Irisin, pushed, is occasionally of great service in these consecutive diseases of the testicle and its envelopes. In some constitutions, gonorrhoea leaves behind it a general Aveakness and irritability of the organs of generation, and an alteration in the character of their secretions. The semen is affected; there is a vitiated secretion, or a general want of power. With these symptoms there commonly exists weakness, trembling of the legs, general lassitude of the whole system. In all cases of this description, before beginning treatment, it might be well to introduce a bougie, and examine the passage. A general course of alteratives and tonics, with salt water baths, shower bath, counter-irritation, &c, and attention to hygienic measures, are often successful. As regards gonorrhoea of the rectum, I have never seen but tAvo 56 TREATMENT OF THE VENEREAL DISEASE. cases in my large private and clinical practice, and the treatment adopted appeared to me to be the only one applicable to the cases, namely, injections of cold water, weak solutions of sulphate of zinc, thrown up by a common syringe. Such remedies as iron, podo- phyllin, permanganate of potash, exert a specific action. Gonorrhoea in the Female.—The internal remedies in the treat- ment of gonorrhoea are the same as the male, although their action upon the vaginal forms of the disease is very feeble. The use of powerful tonics, such as cinchona, C. tinct. tamarack, hydrastin, iron, &c, act well. The local treatment consists in fomentations and injections. In the chronic forms of the disease, unattended by change of structure, as local applications or injections, we may employ solutions of permanganate of potash, or tannin, or bark, or alum, or chloride of zinc, hamamelin, &c. When the discharge is offensive, and accompanied by ulceration, the solutions of the chlorides of soda, or lime, or baptism, chlorate of potassae. When the chronic state of gonorrhoea in the female is accom- panied by any alterations of tissue, these changes demand our first attention, since it is useless to attempt to check the discharge as long as these conditions remain upon which it depends. Ulcera- tions, or papulous granulations, should be cauterized by the nitric acid, followed with injections of hamamelin, hydrastin, or perman- ganate of potash. As secondary symptoms may occur if the gonorrhoea has been syphilitic, and, as it is not always possible to say whether it is so or not, it is good practice to give the patient such remedies as will cause the eradication of the disease. No rule can be laid down on this point. A month or six weeks, perhaps, would be a suitable period to subject a patient to an alterative tonic course. This is the rule that I adopt: advising the patient, when he leaves off, to live regularly, to attend to the secretions, a bath three times a week, and to avoid all exciting causes, such as cold, or anything which interferes with the general health. Irisin is my favorite remedy here; it eliminates the virus through the proper channels, thus ridding the system of the poison. BUBO. Between a local and constitutional affection there often arises a kind of intermediate state, and that in consequence of irrita- tion and absorption of venereal matter, the glands situated nearest to the parts affected, are apt to become indurated, swollen, and inflamed, and so give rise to bubo. There are two kinds of bubo recognized: one Avhich attends simple gonorrhoea, arising from common inflammatory action, extending in the course of the absor- bent vessels of the penis to the glands of the groin, constituting , non-virulent adenitis due to irritation; the other, a specific abscess, marked by the same characteristic as chancre itself, and the pre- sence of this inevitably gives rise to the question of the virulent or non-virulent nature of the disease—always caused by the absorp- tion of pus from the chancre. The former, capable of resolution; the latter, always suppurating. Simple bubo from irritation or leucorrhceal discharge, may terminate in resolution ; while the viru- lent bubo, arising from a soft chancre, always suppurates. The chief points in diagnosis are : 1st. Adenitis or Simple Bubo.-^-The nature of the affection, it advancing slowly and being unattended with pain. The gland enlarging and remaining stationary. It is soft, and if it suppu- rates, it does so indolently. Its pus is not inoculable. 2d. The virulent bubo is invariably of rapid growth; suppuration is early, the inflammatory action is accompanied Avith great pain. The integument covering the abscess, if not punctured, sloughs, leaving a large open sore—a true chancre. The pus from this bubo is inoculable. The treatment for the first, consists either by repellents for the purpose of preventing the formation of matter, or by fomentations or poultices to produce suppuration, when that termination is threatened by nature. For this purpose discutient lotions'; such as belladonna, subacetate of lead, chloride of ammonium, acetate of lead, sulphate of zinc and borax in solution, should at first be tried. 8 58 TREATMENT OF THE VENEREAL DISEASE. These may be conjoined with pressure of a well regulated character by a truss. A very excellent method of applying pressure is by means of collodion: it should be applied layer after layer, until considerable compression is produced. The collodion has one objection, it does not admit of any other local application. It must be associated with rest. The tincture and the ointment of iodine are valuable applications, and are more frequently successful than any other agent in causing restoration of the entire gland. For some years I have employed a combination of equal parts of tincture iodine and belladonna, applied by wetting a small piece of linen with it, and renewing morning and night. Another preparation which possesses decided advantages, is a solution of iodine and glycerine. The best formula is, to one ounce of glycerine add twenty grains of iodide of potas- sium, and then dissolve in it forty grains of iodine. These propor- tions may be altered as it is wanted, stronger or weaker. The advantage of the iodide of potassium is, that it increases the solu- bility of the iodine, and should be in all cases about half as much in quantity; or an ointment made of phytolacin. In obstinate cases the clematis erecta may be tried with advantage. The iodide of lead ointment is also a very valuable application to be made to these inflamed glands, so is the discutient ointment, so is an ointment made of phytolacin and lobelin. Ext. of belladonna with iodide of lead in ointment, or ext. cicuta may be tried. The muriate of ammonia in solution is valuable. A good prescription is the following, kept constantly applied: B/.—Chloroform, Si; Oil hemlock, Sss; Tinct. iodine, 5ij-—M. There are various other repellent remedies and methods of appli- cation in use, such as the application of small blisters, and then applying remedies ; counter-irritation by means of a strong solution of nitrate of silver three drachms to the ounce, of distilled water with twenty minims of strong nitric acid, applied with a glass rod or stick. The black eschar peels off in a few days, when it should be reapplied. Sedatives are often of utility, producing a marked effect upon the inflammatory swelling. I have also derived good results from mild purgation—podophyllin and leptandrin. If, TREATMENT OF BUBO. 59 however, all efforts to effect dissolution should fail, are we to allow it to open spontaneously, or are we to incise it ? There can be no doubt that the latter is the best course to be adopted, and it should be done early, in order to save as much of the integument as possible. If the abscess is allowed to break, the skin sloughs extensively, an ugly sore is left, which is usually tedious in healing. There are several methods of incision resorted to. A Free Incision—a method which cannot be too severely con- demned. I would never advise to open by free incision, for, almost under every circumstance where this is resorted to, there is a quantity of integument in the edges, which will not unite with the granulating surface of the sore thus produced. By opening an abscess in this way, the whole anterior wall of it is destroyed, and the cure must be performed by the cicatrization of a granulating surface, which springs from the floor or posterior wall of the abscess. The great object is to evacuate the matter first, then to diminish the disposition to its re-formation, and to procure union of the two sides of the cavity. The method of Vidal, I esteem the best, which is practiced with a fine lancet, making several very small punctures over the thinnest part, perhaps six, eight or ten; through these the matter will ooze out till the cavity of the abscess is empty. Through one of those punctures the point of a very small glass syringe may be introduced, and a weak solution of the sulphate of zinc injected, in the proportion of two or three grains to the half pint of water, or the permanganate of potash in solution. When the abscess is quite empty, place over it a large compress of lint, and use moderately tight pressure by means of a roller. In the majority of instances, if the patient is kept quiet for twenty- four hours, either partial or- total adhesion of the sides of the bubo, and a speedy cure will be the result; in some cases, however, this may not occur; but by the daily use of injections through one of the punctures, which should be kept open for this purpose, a cure will be effected in a few days. Various substances may be used for injections besides the sulphate of zinc and permanganate of potash, such as solutions of iodine, of sulphate or acetate of copper, alum, port wine, sanguinarin, tannin, nitric acid, &c.; they should be varied in strength to suit the feelings of the patient; a gentle warmth and slight irritation should be experienced, and if one remedy does not succeed, quickly 60 TREATMENT OF THE VENEREAL DISEASE. have recourse to another. The great advantage of this method is, the healing process is more rapid, no formation of sinuses, and the best results attend it. The danger of opening a bubo by the free incision is, pyaemia following, purulent absorption, which if it occurs, must be treated on general principles, and full doses of the bisulphate of soda. Pyaemia has followed in certain cases. There is another method even better than the foregoing, and which has been used with very excellent results. It consists in passing two or three small setons through the base of the swelling. Several strands of silk are inserted with a common needle. The pus drains slowly off, a mild inflammatory action is produced by the setons in the walls of the abscess. Pressure is applied, and as the pus escapes, the walls of the cavity are brought into apposition. The setons are removed one by one, and it usually happens that adhesion takes place, and the cavity is oblite- rated. If this method is resorted to, pass the seton through the base of the abscess, not through its summit. So much, then, for the treatment of simple adenitis, non-virulent bubo, the pus of Avhich is laudable with no specific properties; therefore not inoculable. A Virulent Bubo is marked by the same characteristics as chancre itself; a chancrous bubo, the pus of which is specific, from which true chancres are formed. A direct inoculation of the lymphatic gland with chancrous matter, carried to it by the lymphatic vessels. The bubo is a depot of chancrous pus.. The main facts in regard to its symptoms and pathology are, that it progresses rapidly, is attended with pain, not only has a- tendency to, but invariably suppurates. The treatment of this must essen- tially differ in every particular from the other variety. There is no use in attempting to discuss, no use of balladonna, nor iodine, nor pressure, nor purgation; all are injurious. What we most want is to hasten suppuration, which is accomplished by heat and mois- ture ; for this purpose various agents are used. Warm Avatcr applied by means of several folds of flannel, and covered with oiled silk relieves the pain, hastens suppuration. The carrot poultice answers well, so does the flaxseed, or bran in a linen bag frequently dipped in hot water, and applied constantly. Chamomile flowers make an excellent application. After pus has formed in sufficient quantity, or in other Avords, Avhen the Avhole lymphatic gland has TREATMENT OF BUBO. 61 suppurated, lay the abscess open so as to allow the freest channel for the escape of pus. Now arrives the main point in the treatment. We have said the virulent bubo goes on to ulceration; but this is not conclusive, for strumous ulceration often occurs in persons of a scrofulous diathesis. How are we to distinguish between the virulent and non-virulent, so as to be guided to a correct treatment. If you do not see the bubo at the start, if its history is unreliable, the best test is inoculation; charge the point of a lancet with a little pus from the bubo, and insert it into the thigh of the patient. If you have a chancrous bubo to deal with, a chancre will be produced at the point of inoculation, which must be destroyed with the caustic soda, or nitric acid, or Vienna paste,-or sulphuric acid, or charcoal paste. In my practice, when the bubo puts on all the characters of a virulent or specific action, I com- mence with the following formula, at the same time hasten suppu- ration : B^s.—Stillingia et sarsaparilla, C. syr., Oss; Con. tinct. iris versicolor, " " phytolacca de., aa oii; Iodide of sodium vel potassium, Sss.—M. S. A teaspoonful every three hours. Having obtained positive evidence of the nature of the bubo from the inoculation, free incision, the application of the escharotic paste freely to the bottom and edges of the sore, or nitric acid, or bromine. After the application of the caustic, the part should be covered with lint, spread with the black salve, and bandaged. Another dressing which is good is the aromatic wine or tannin in solution, or solution of sulphate of copper and zinc, or weak solutions of the chlorides of lime or soda. Carbolic acid in glycerine, or permanganate of potash, is useful as a local applica- tion. In eight or ten days the slough will come aAvay, leaving a healthy non-specific ulcer, Avhich heals without difficulty under an ointment of the oxide of zinc, or the black salve. The treatment of the virulent bubo consits in hastening suppuration, opening with a long incision, and the total destruction of the affected parts by the application of caustics to the interior. Buboes in scrofulous habits, or in debilitated or depraved con- stitutions, are very apt, if the treatment be erroneous, or diet meagre, or the patient subject to depressing agencies, to degenerate 62 TREATMENT OF THE VENEREAL DISEASE. into phagedenic ulcerations, which extend, in a short time, over a considerable space, and frequently lay bare a large portion of the thigh and lower part of the abdomen. There is really something very cheering in the beneficial effects of energetic measures in these cases. Nothing seems to be of any avail but a complete change of action; the part must be profoundly modified, an entirely new stratum must be brought to light, the old one annihilated, and powerfully detersive and energetic constitutional measures pushed with activity. Nothing can supercede the free application of bromine in phagedena. If this agent is not convenient, strong nitric acid, followed by a douche, or what I like~ better, irrigation with cold water. This is an excellent application for phagedenic ulceration, followed with hydrastin, chlorate or permanganate of potash. Creasote and carbolic acid are excellent adjuncts in the treatment; best used in glycerine. After complete destruction, the parts should be fomented with an anodyne lotion, following that, permanganate of potash, or nitric acid lotion, with powerfully antiseptic poultices and anodynes at bed time; in phagedena, let the patient have sleep, which is essential to success. Phagedena occurs always where some depressing influence is at work in debilitated constitutions, and requires a special treatment on that account—it is not sufficient here to exhibit our stillingin, smilacin, irisin, phytolacin, corydalin, &c, in alternation with the bisulphite of soda, or the permanganate of potash internally; the latter agents acting as decided blood tonics. Potent tonics are demanded— blood-elaborating diet is pre-eminently requisite—essence of beef, milk punch, cod-liver oil, &c. If there is great adynamia, with skin cold and clammy, rubbing the body twice a day with a coarse towel till the skin is red, bathing with whiskey and salt, or dilute tinct. capsicum, will help to promote a flow of blood to the surface. ■Quinine and iron have met with success; iron is the remedy, its «effects are magical. The following is a good formula: potassio- tartrate of iron, one ounce; water, six ounces.—Misce. Two tablespoonfuls three times a day. Whenever iron is used, it appears to be essential that the metal should be in a state of the protoxide. Phagedena depends upon a constitutional defect; rectify this by good diet, plenty of fresh air, attention to all hygienic measures, and mineral acid baths. Everything depends upon prompt and decided action. SPERMATORRHEA. Spermatorrhoea is sometimes a consequence of gonorrhoea, and when so, its treatment must be on general principles. In the treatment of spermatorrhoea, it is well to examine the genital organs to determine if we have increased sensibility, or any irritation of the urethra and other parts. The bowels in these cases should be kept soluble by very mild cathartics, or enemas of cold water, thus removing any cause of irritation about these parts. If we have irritation of the bladder, from increased secretion of mucus, we must remove it by exhibiting the barosmin with nitrate of potassae, in alternation with gelsemin, counter-irritation, the injections of tepid water, or slightly medicated with nitric acid. The warm hip bath, and the passing of a bougie, medicated or otherwise, together with diuretics, will often relieve the increased sensibility. If we have any form of calculus to contend with, its removal will be indispensable to success. Some remedies are peculiarly indicated, such as the bromide of potassium, in five grain doses, three times daily, and, if we have great irritability of the organs, it might be advantageously com- bined with lupulin, camphor, &c. Mucilaginous diuretics, such as marshmallow, hair-cap moss, or verbascum, might be given with acetate of potash. Instead of the above combination, we might combine the bromide of potassii with gelsemin and conium, in suitable proportions, or enemas of lobelia, gelsemin and opium. Certain tonics seem to have an excellent influence in this disease. Cornin, hydrastin are peculiarly applicable; such a formula: B/.—Cornin, Hydrastin, Bromide potass., aa. In syr. simplex. In alternation with the following pill: B/.—Extract nux vomica, gr. v; Hydrastin et quinine, aa 5ss.—M, Ft. thity pills, one thrice daily. 64 TREATMENT OF THE VENEREAL DISEASE. In some cases iron, cod-liver oil, the phosphates or phosphorus, will prove advantageous. But the best remedy that Ave can recom- mend to the profession is the eryngium aquaticum; we can put forth this as one of the best in the cure of spermatorrhoea, but its exhibition is best borne, and more successful when given with small doses of nux vomica and hydrastin. From whatever cause the spermatorrhoea has originated, this remedy is the one calculated to give the best, most permanent results. It may be given in from ten to thirty grain doses, in powder, or in tincture, or decoction, or syrup. As an adjunct to successful treatment, the patient should have the disease explained to him, his mental anxieties must be allayed, his associations must be of the most agreeable description, his confidence must be gained; moderate exercise in the open air, daily bathing, friction to the skin, confine himself to a most nutritious diet, and sleep on a hair mattress. He must abandon sexual excitement as far as possible; and it cannot be too impera- tively impressed upon him not to let his thoughts turn in such a direction. He can aid materially the treatment, and assist in the cure. In a large proportion of cases the defect is rather in the mind than in the body, and it is usually rectified by attention to the above rules, Avith the administration of a few drops daily of equal parts of tincture of nux vomica-, chloride of iron and can- tharides, with the assurance of speedy recovery. In this way confidence is restored, and the difficulty soon vanishes. PATHOLOGY OF GONORRHOEA. The term gonorrhoea is applied to a muco-puriform discharge from the urethra of the male, or vagina of the female. There are two varieties of gonorrhoea: one proceeding from the action of the secretion of an indurated infecting chancre on a mucous surface; the other from the action of the pus of a soft chancre on such a surface. These are the sources of origin of contagious gonorrhoea, not the only sources of infection. It has long been the opinion of the profession that gonorrhoea and syphilis were different manifestations of one disease on different surfaces. This is now the opinion of the most eminent pathologists, and is very generally concurred in by the more advanced members of our profession. Laying aside all unnecessary discussion, and all the opinions and dogmas that have been published, we are inevitably led to the following conclusions: "1. That the virus of an infecting chancre, when deposited on a secreting mucous surface, may give rise to an inflammation of that surface, attended with a muco-purulent discharge, without a chancre being necessarily formed, unless an abrasion exists; in which case, if the chancrous virus comes into contact with it, a chancre will, in all probability, be produced, and will co-exist with the general inflammation. That this is, essentially and properly, a syphilitic gonorrhoea, followed by constitutional contamination, and is contagious, and must be treated Avith the remedies which we nave noted in systemic syphilis. "2.- That the virus of a soft, non-infecting chancre, when deposited on a secreting mucous surface, upon which there is no abrasion, generally gives rise to a muco-purulent discharge, and, if there be an abrasion, the liability to chancre; that both diseases may exist in one person; that the discharge from the inflamed mucous membrane is capable of giving rise to a similar discharge in other individuals, and that it is not followed by any specific constitutional symptoms. That the tAVO sources named are the 9 Q6 TREATMENT OF THE VENEREAL DISEASE. only ones from which a contagious gonorrhoea can originate; it may be transmitted, according to its kind, from one individual to another." Two species of gonorrhoea, corresponding to the two species of chancre—both are contagious—but that only that is due to the virus of an infecting chancre is fallowed by systemic syphilis. That the matter of each of these species of gonorrhoea will, when inoculated, give rise to its own particular form of chancre. That the muco-purulent discharges from the urethra or vagina, due to irritation, or some such cause, are not contagious; are simply cases of urethritis or vaginitis, having no specific charac- teristics. Such are the views entertained by the Reformed American Medical Profession. From recorded cases, from an extensive observation, and a large circle of private and clinical practice, I am fully convinced that this view of the subject is the correct one, to wit: that gonorrhoea is capable of producing a chancre of its own kind, and vice versa. How often do we meet with cases of individuals who are laboring under constitutional syphilis, who never had'anything but a gonorrhoea, never had buboes, and yet have an undoubted syphilitic papular eruption, loss of hair, &c. In such cases, perhaps, the question might be asked: why, in a syphilitic gonorrhoea, is there no indurated bubo ? The question is important, and admits of a most satisfactory answer. The reason of this is to be found in the fact that the lymphatics do not take up the poison from a mucous membrane in a state of integrity, but only from a solution of continuity such as a chancre produces. Hence the virus enters the blood through the veins, and produces constitutional syphilis, without, however, causing an indurated bubo. Gonorrhoea is produced by the virus of an non-infecting chancre, or vice versa. The virus of a soft chancre can produce gonorrhoea when deposited on a mucous surface, and becomes modified more or less, by the action of the mucous membrane, and loses a good deal of its virulence. What we contend for principally is the pro- perty of both descriptions of chancrous virus to produce a gonor- rhoea. Syphilitic Gonorrhoea.—The virus of an infecting chancre, when deposited on a secreting mucous surface upon which there is no solution of continuity, may give rise to gonorrhoea, syphilitic in its PATHOLOGY OF GONORRHOEA. G7 character, and capable of producing constitutional disease. The matter of such a gonorrhoea is capable of causing an infecting chancre, either by natural or artificial inoculation, Avhich chancre is followed by constitutional syphilis. The existence of syphilitic gonorrhoea is sufficiently established and engrafted on all our works on syphilis. Non-syphilitic Gonorrhoea, or the virus of a soft chancre on the mucous membrane of the urethra, gives rise to another form of urethral or vaginal muco-purulent discharge, without producing any constitutional disturbance. General Remarks.—A man having had sexual intercourse with a woman affected with an indurated chancre, or with a gonorrhoea caused by such a chancre, is liable to specific inflammation of the urethra, attended with pain, increased on micturition, and with a discharge of muco-pus from the meatus. There is a true period of incubation, varying from three to eight days. The discharge from the first is composed to a greater extent of pus than mucus. The inflammation is mostly always seated in the fossa navicularis, shows little disposition to extend itself. The pain is not very pro- minent, unless during the passage of urine, and then it is of a sharp, burning character. Erections do not cause discomfort; on the fifth or sixth day the discharge is well established and resem- bles pure pus. The inflammation is at its height by the twentieth day. It then begins to decline, and if not interfered with, will dis- appear in about six weeks. There is no roughness, no narrowing of the urethra, sometimes there is induration. Buboes are not usually produced, and when they are, they are sympathetic, and do not contain inoculable pus. Epididymitis is not an attendant of syphi- litic gonorrhoea. This affection is much milder than the other variety. The gonorrhoea caused by the virus of a non-infecting or simple chancre, or by the discharge produced in others by such a chancre, although called simple, is really a more severe affection, so far as local manifestations are concerned, than the syphilitic gonorrhoea. Although it is free from constitutional complication, it is frequently attended with other affections, which are produced by extension of the inflammatory process, by sympathy, or by contact of the virus with other tissues. Simple gonorrhoea has no true period of incubation, usually com. 68 TREATMENT OF THE VENEREAL DISEASE. mencing immediately after exposure to the contagious influence. Within the first day there may be slight itching or tickling sensa- tion, which is increased on the passage of the urine. This is soon aggravated into a burning pain, the urethral mucous membrane becomes inflamed. At first the seat of the affection is in the fossa navicularis, and subsequently it extends, and may even reach the bladder and kidneys. A whitish, glairy discharge, chordee, urethral inflammation, fever, more or less derangement of the digestive functions. About the twentieth, the symptoms decline, the discharge becomes more muciform, and inside of eight weeks ceases entirely. Its complications are sympathetic buboes, epididymitis, prostatitis, stricture, abscess, ulcerations, &c, &c. Simple gonorrhoea may be distinguished from that which is syphilitic in its origin, by the absence of any period of incubation, by its greater severity, by the extension of the inflammation along the tract of the urethra, subsequently the absence of constitutional symptoms. The recognition is not very material, except for the view of preventing constitutional infection. The constitutional symptoms which folloAV syphilitic gonorrhoea are those of constitutional syphilis. There is also a tendency to early manifestations of disease of the fibrous structures, which are not ordinarily met with after infecting chancre. With reference to the treatment of syphilitic gonorrhoea, injections and alteratives are the best. Mild injections, such as those which we have enume- rated, and alteratives, recommended under the head of secondary syphilis. In the simple form, the specific treatment by cubebs, iron, &c, with appropriate diet, is indicated. It is a well-known fact that syphilis is less severe when it begins in other parts than those of generation. Syphilis is frequently conveyed by the vaccine lymph; in this way we often have mucous tubercles, sores on the lips and fauces, swelling of the lymphatic glands in various regions, syphilitic erup- tions of various kinds, loss of hair, ulcerations of the prepuce, deep tubercles of the cellular tissue, gummy tumors, &c, &c. The following rules should be observed : 1. Examine carefully the child from whom the lymph is taken. Endeavor also to learn the state of the parent's health, 2. In obtaining the lymph, select such children as have passed PATHOLOGY OF GONORRHOEA. 69 the fourth or fifth month, as hereditary syphilis, in general, appears before that age. 3. Use only the clear portion of the vesicle, as the dull black portion is more apt to be mixed with pus of an infectious nature. It is a well-attested fact that every tissue of the body is affected in constitutional syphilis—there is a disposition to the pouring out of lymph of a low quality in various parts of the body, and which, in the course of time, if not absorbed, remains as a deposit of hard tissue, and in this way we can account for the various eruptions, rashes, tubercles, pustules, &c. Systemic syphilis is progressive; a disturbance of the blood in consequence of some influence exerted upon it by the syphilitic virus, and that this blood disease, if left to itself, proclaims itself in eliminary affections of the skin and mucous membranes, pouring out lymph, depraved nutrition, and consequent destruction of tissue. It possesses a special affinity for three parts of the body, the mucous membranes, the skin and periosteum. The practical infer- ences are, the blood is impure, and must, if possible, be restored to its pristine condition. The venereal poison is essentially a virus affecting only the human race, no animal is capable of being infected with this poison. That the venereal poison is the same in gonor- rhoea and chancre. It might be noted that whatever causes impair the vital forces, serve to render the system less able to resist the deleterious influence of the syphilitic poison, CHANdRE. The second local form under which the syphilitic poison exhibits itself is that of a chancre; this is usually distinguished by a want of disposition to heal, a thickened base, circumscribed inflammation, with other characteristic marks which shall be enumerated in our remarks. The parts most usually affected with these ulcerations in men are the glans, the prepuce, the fraenum, and in the angle between the glans and body of the penis; and in woman, about the labia, nymphae and clitoris; but in some cases they extend up the vagina, even so far as the os uteri. Syphilitic matter applied to other parts of the body may give rise to chancres ; but being most usually applied to the organs of generation, these are generally the seat of such ulcers. There are two kinds of chancre: the simple, soft, or non-infecting, and the hard, indurated, or infecting. Of these, the simple is most frequently met with. It is a local disease, and is neither followed, nor accompanied by a constitutional affection. Soft Chancre.—A soft, non-infecting chancre usually appears in from two to fourteen days after connection; generally, however, on the fifth and sixth day a small pustule, or a small abraded surface is perceived secreting; a discharge is for the first time apparent. If the surface was intact when the virus was deposited, a pustule is the result; if an abrasion or fissure existed, so that the virus was applied to a part deprived of its epidermis, the latter form occurs. The pustule is found when the virus is applied to a surface in a state of integrity. Suppose we have a case of the pustule to deal with. An itching in the part precedes any elevation of the epidermis—a small pimple or pustule is next seen, variable in size; this pustule in two or three days breaks, or has its head rubbed off, and thus an ulcer is produced. This ulcer is generally round or ovoidal, edges perpendicular; usually, but not always deep, and the bottom of it presents a dirty gray appearance; is TREATMENT OF CHANCRE. 71 rough, sometimes excoriated. The ulcer spreads, enlarging equally in all directions, and in ordinary cases, when it has become about half an inch in diameter it ceases to grow; cicatrization commences. A gray hardened border forms around it, and its circumference gradually diminishes; in about'a month it is entirely healed up. These are the ordinary appearances and characteristics of a simple, soft, non-infecting chancre. Its essential character is the softness of the base. When the thumb and finger are applied to opposite sides of the chancre no induration is felt, the base is soft, yielding readily to the slightest pressure, and scarcely distinguishable, so far as the sense of touch goes, from the same part of the body in a normal state. But from inflammatory engorgement the tissues supporting it may be more or less thickened. The base then may give to the touch the feeling of resistance, which is, however, never more than offered by a common furuncle. It is a hardness to be distinguished from induration by the feel. True induration is only applicable to the infecting chancre. A slight degree of hardening may be given to the base of a soft chancre by the use *of various washes, which also must be detected by the feel and the history of the case. A soft chancre is generally solitary, but not unfrequently two or more are present. An indurated chancre rarely has a fellow. A soft chancre is much more contagious than an indurated one. Four-fifths of all the chancres which occur are of the simple, non- infecting kind. Inoculation affords us a ready means of determining the character of the chancre. Soft chancre is essentially a local disease, never infecting the system, never producing those constitutional ravages which are so common as the sequence of the indurated chancre. Soft chancre may be followed by bubo. This is always confined to the first group of glands nearest the sore, and is usually confined to a single gland. It may present two varieties, simple sympathetic adenitis, capable of resolution, or terminating in suppuration, the pus being non-inoculable; or it may- be a specific bubo, which inevitably ends in suppuration, the pus of which produces, by inocu- lation, the chancrous pustule, and converts the wound consecutive to the opening of the collection into a real chancre. Simple, soft chancre is the most prolific source of the chancrous virus. It secretes pus having contagious properties in the very 72 TREATMENT OF THE VENEREAL DISEASE. highest degree. The pus inoculates whatever it touches, and retains, for an indefinite period, the quality of inocubility, so that Ave have numerous soft chancres in the same person. Hence, a simple chancre affords, in the same individual, no protection against fresh contagion from a chancre of the same species; the reverse obtaining, as a general rule, with chancres of the indurated form. As regards site, simple chancre has never been met with on the face or head, inoculation has failed to produce it on these parts, which is not the case in indurated chancre—a fact of the greatest importance in diagnosis. A soft chancre may become the seat of excessive ulceration without much, if any, inflammatory action, the chancre enlarging and attaining an enormous size unless checked. When it heals at one border and enlarges at another, the ulcera- tion is said to be serpiginous. Simple chancre is apt to spread and to assume a phagedaenic form, which is seldom the case in the indurated form of sore. Phagedena, as a complication of soft chancre, is almost always due to some constitutional cause, defect— to intemperate habits, excessive sexual indulgence, bad food and air; but, above all, to the Allopathic system of medication with mercury. In phagedena the surface of the chancre becomes dark, almost black, a purple areola surrounds it, the discharge changes to a dark colored ichor, which excoriates the parts it touches; the ulcer enlarges with great rapidity, the adjacent tissues break down. There is no limit to its action, it may cause extensive destruction; constitutional disturbance is well marked, debility, fever, and eventually hectic, &c, &c. The prospect of recovery depends altogether upon early and prompt treatment; if mercury has not been given, phagedena can generally be arrested. The secretion from a chancre attacked with phagedena is frequently inoculable. Recapitulation: soft chancre is a local disease; it never infects the general system; it may be inoculated if the process of repara- tion has not advanced too far; it is the kind of chancre most liable to complications, such as inflammation, ulceration, and phagedena; and it is occasionally followed by two kinds of bubo, one a simple adenitis, non-virulent; the other, caused by the absorption of chan- crous pus, always suppurating, the pus formed being inoculable, and therefore truly of a specific character. Treatment of Soft Chancre.—On an average there are seventy- TREATMENT OF CHANCRE. 73 five cases of soft or simple, non-indurated, non-infecting chancre in every hundred. My design is to give the plan of treatment that I have found best—the principles which should guide and pre- eminently influence us in the treatment; that it is a local disease, liable to extensive ulceration and phagedena. It is highly desirable at the very start, nay, it is essentially necessary, to destroy the specific character of the chancre, and to convert it into a simple, non-virulent ulcer. Reason dictates this to be the true course, as soft chancres are exceedingly contagious, so much so that some persons have large numbers on the genital organs, on the scrotum, about the anus, labia, thighs. The pus may be carried to all parts of the body but the head. Reason dictates that if we destroy, at the earliest possible period, the specific character of the chancre, its contagious character is at once arrested, annihilated, and new chancres prevented. Experience adds another reason for this treatment: that the liability to the formation of virulent bubo is not only lessened, but effectually destroyed. Now, the manner in which this may be most effectually done is by cauterization. There is no end to the caustics which have been recommended for the purpose. Nitrate of Silver.—This agent, when applied, will sometimes have the effect of producing a simple sore; but it very frequently gives rise to considerable irritation and inflammation, whilst the specific character of the sore is not destroyed. It is an agent in use by some physicians, and it is one that we most emphatically condemn. It produces so much evil that all the reformed profes- sion have long ago abandoned its use under any circumstances, and have recourse to other caustics of a more positive and powerful character. The great evil in the use of the nitrate of silver in these cases is, that it is powerful enough to irritate, but not sufficiently powerful to destroy. We want a remedy that will at once disorganize the tissue to a depth considerably greater than that of the chancre. For this purpose I employ several remedies for the destruction of the chancre. Nitric Acid.—When it is determined to destroy a primary vene- real ulcer with this agent, a camel-hair pencil must be dipped in highly concentrated nitric acid, and the surface and edges of the 10 74 TREATMENT OF THE VENEREAL DISEASE. sore pencilled thickly over; if the acid be sufficiently strong, the whole surfaces touched are at once destroyed and converted into a yellow eschar, which, on separating, generally leaves a clean, simple sore underneath. I have found the nitric acid, saturated with nitrate of silver (one ounce of nitric acid to a drachm of the nitrate) very good in arresting gangrenous inflammation and phagedenic ulceration. A most excellent combination of nitric acid is as follows: B/.—Nitric acid, Muriatic acid, Sulphuric acid, aa.—M. If the chancre is situated within the rectum, the nitric acid is one of the best agents to destroy its specificity. This agent may be readily applied with a glass rod, having previously dilated the bowel, and brought the parts Avell into view with the speculum. A piece of lint soaked in olive oil is next inserted, and left as long as convenient. Urethral chancres are also treated successfully with nitric acid. Chancres are most successfully treated by the applica- tion of strong fuming nitric acid, followed by irrigation, or a douche of cold water. Nitric acid applied in cases of phagedenic ulcera- tion of the throat is most efficient, following with the application of a sponge moistened with a solution of soda or potash, so as to neutralize any superabundant acid applied to the ulcers. Acetic Acid.—In recent chancre, acetic acid is the true panacea, one of the most successful and speediest methods of treating chancre; it has remarkably fulfilled the most ardent wishes of the profession. In recent chancre cauterize the sore at once with pure acetic acid, applying it by means of a glass tube thoroughly to the part, and preventing it diffusing itself by means of charpie. The pain is excessive. A whitish spot is the immediate result, and cold water dressing applied. In the use of these acids apply them liberally ; applied to a surface considerably greater in circumference than the chancre, apply enough to soak well into the base, through the thickness of the ulcer to the healthy tissue beloAV. If a minute spot is left untouched, the Avhole process will be unavailing. Deal with it, then, in a spirit of liberality, if you wish to be successful in the treatment. Caustic Potash.—This is a very beneficial escharotic in the TREATMENT OF CHANCRE. 75 treatment of chancre, and Avhere due care is exercised in protecting the sound parts, by cloths saturated with vinegar, no remedy can be compared with it in certain cases. Vienna Paste.—-This paste is a mixture of quick-lime, five parts, and caustic potash, six parts, made into a paste with alcohol, of moderate consistency, at the time it is Wanted for use, and the sore and its edges covered with it. When it has been on a few seconds a smart burning pain is felt, which continues to increase as long as the caustic is suffered to remain on, which should be from a minute to a minute and a-half, or even longer, according to the effects produced. After this the caustic must be all removed by means of a fine bone spatula, and the black eschar left may be covered Avith a poultice, or a lotion of hyosciamin, or fine, soft> dry lint. The pain soon subsides after the caustic has been removed, and in about half an hour the patient is usually pretty comfortable. The aggregate amount of pain produced by the application of this remedy is not so great as would be imagined, whilst the effect of the potassa cum calce is certain, positive; all the parts touched with it are at once destroyed, and, on the separation of the eschar, we have a clean granulating sore left, which heals with great rapidity. Caustic Soda.—A chancre, of whatever kind, must be destroyed, and for this purpose it should be our object to get the best ageflt for its destruction. I give the most decided preference for the caustic soda, made into stick form. It is quite as powerful as the nitric acid, Vienna paste, caustic potass. The sore is cleaned, the soda applied and pressed on the part until the patient begins to feel pain. This is generally sudden and rather sharp, but does not last long, and is succeeded by a feeling of great relief. The surface acted on by the soda becomes of a deep brown color; a free discharge of serum follows, suppuration sets in early, after which the sore heals with great rapidity, much more quickly than after any other caustic. If a chancre has existed some time, the caustic should be applied so freely that the whole surface gives evidence of having felt its * action. True, the pain is severe, but it is momentary; and as any measure short of complete cauterization is just as likely to be useless as not, no good can result from any compromise. One effectual application will save the patient all the irksomeness, con- 76 TREATMENT OF THE VENEREAL DISEASE. finement and expense, which attend the long continuance of a primary sore. Ricord's Caustic Paste.—The treatment of soft chancre is the reduction of a specific ulcer to the condition of a simple ulcer. For this purpose, Ricord's caustic paste, formed by mixing pow- dered vegetable charcoal Avith sulphuric acid, is highly recommended. This paste is easily managed, as well as very effective. When applied to a chancre, it dries up and forms a black crust, which remains adherent to the tissues; it may be said, incorporates itself with them, and falls off in several days, ten or twelve, leaving underneath a healthy sore; the specific character of the chancre having been entirely destroyed. The objections to this paste are, that it causes great pain, and it is sometimes difficult to apply. The pain is not greater than that caused by other powerful escha- rotics. It is undoubtedly difficult to manage in parts of the body where opposed surfaces come in contact, such as the vagina. Bromine.—Pure bromine is now used as an escharotic to chan- cres ; and the trials which have been made with this agent prove it to possess very decided advantages over other caustics. If used, it should be applied with a glass rod or a pointed stick of wood to the whole surface of the sore, and a narroAV ring of sound tissue at the entire circumference. The actual cautery, the chloride of zinc, the sanguinarin, the phytolacin and sulphate of zinc, and numerous others have been lauded by their respective admirers. General Treatment.—After the specific character of the chancre is destroyed, and the sore nothing more than a simple ulcer, Avhat treatment do we recommend ? At this stage Ave have found astrin- gents or slightly stimulating applications of great value. Such as a solution of tannin in water, one, two, or three grains to the ounce, and it will, in the majority of cases, speedily heal. A local application of aromatic wine,* or port wine, medicated either with tannin, with opium, or with both. If the granulations are too exuberant, I destroy them Avith the sanguinarin, freely sprinkled over the sore; and when they are deficient, stimulate by a solution of the same. Besides the tannin lotion, the aromatic wine and * The aromatic wine is composed of four ounces of aromatic herbs digested in two pints of red wine for a week, (rosemary, rue, sage, hyssop, lavender, absinthium, origanum, thyme, laurel leaves, the flowers of red rose, chamo- mile, mclilotus and elder.) TREATMENT OF CHANCRE. 77 tannin, the sulphate of zinc lotion, or a solution of hydrastin, myricin, rhusin, baptisin, hamamelin, chlorate or permanganate of potash, may often be used with most salutary results. These should be used weak and frequently applied, or, what is still better, the chancre should be kept constantly moist with them. Ointments are not so efficacious as lotions. The sores are to be carefully washed with one or other of these preparations, and afterwards covered with soft lint moistened in them. Care must be taken in renewing the dressings to soften the lint well before it is removed, so that no part of the surface or surrounding skin may be torn away with the lint. Instead of resorting to lotions or ointments, I have been very successful with water dressing from the first freely employed. Irriga- tion of the sore three or four times daily by means of a rag dipped in warm water, and held at such a height above the sore that the water falls with considerable force upon it; and, subsequently, by means of an irrigating machine, a jug with a very narrow spout, or a bottle full of water, with a notch in the cork. The great object is to wash aAvay as much as possible of the tenacious secretion, and this cannot be effected by mere bathing. After this, some of the lotions, or solution of sulphate of zinc or copper, two to four grains to an ounce, may be used during the day, and the black salve, or zinc ointment at night; or, if there is much inflammation, a lotion of acetate of lead and tinct of opii, or hyosciamin, in rose or elder flower water; but generally, water dressing is the only application required. Any of the above preparations possess the advantage of modifying the surface of the sore, of promoting cicatrization, of diminishing the secretion of pus from its surface. The more mildly the ulcer is treated the more rapid the healing process, and less likely to be folloAved by complications. The above treatment is the best to pursue in the large proportion of cases. But cases very frequently occur Avhere perfect cleanliness and attention to hygienic measures is all the treatment necessary, other than the application of detergent washes, such as a solution of hydrastin, rhusin, hamamelin, myricin, phytolacin, zinc sulphate, or what is very good, permanganate of potash. The chancre is covered Avith a piece of lint wet Avith a solution of permanganate of potash, made by dissolving tAvo or three grains of the pure crystals 78 TREATMENT OF THE VENEREAL DISEASE. in an ounce of distilled water; and if the patient abstains from sexual intercourse, confines himself, gives himself rest, bland diet, and wash the sore three times daily with the same solution, the case will proceed to a favorable termination. It is astonishing how little is wanted in such cases to remove the diseased condition. Cleanliness is a most essential measure. The sore should be frequently washed, and the dressings changed. The best wash is the permanganate of potash; it destroys fetor, neutralizes the poison, keeps the parts clean, promotes healing. Constitutional treatment is rarely required; if there be debility, iron and hydrastin may be given with advantage. The bowels should be regular, the diet bland and nutritious, excesses must be avoided. Sexual inter- course must be forbidden; it tends to produce inflammation, and perhaps ulceration and phagedena. If there is any tendency to erections, lupulin, gelsemin or hyosciamin, may be given with advantage. Such is the treatment of soft chancres when they run a perfectly regular course. They are, however, liable to various accidents, which complicate the treatment. The first of these to be considered is inflammation. This may occur at any period, without any assignable cause, or it may be due to irritation, mechanical or medicinal. Its presence contra- indicates the employment of escharotics for the time being. If we have inflammation of the penis or surrounding parts, this must be reduced by emollient applications, such as mucilage of slippery elm, flaxseed, warm water, or by a bran poultice, or one made of chamomile flowers ; these two last mentioned retain heat and mois- ture for a long period, and exert a very soothing influence on the inflamed tissues. They should be changed frequently. Perfect rest in the recumbent position—the exhibition of an eighth of a grain of podophyllin with two grains of leptandrin, ter die, well triturated in asclepin or bitartrate of potash, is attended with decided results. In addition, aconife, veratrum, gelsemin, either in solution, or what is better, triturated with the asclepin. In all cases attended with inflammation, stimulants are generally indicated, and usually of benefit. When the pulse is frequent, the pain dull, and of an aching character, the parts livid and unhealthy, much benefit is derived from the employment of wine or brandy, in moderate quantities. In such cases alcoholic stimulants, in alter- TREATMENT OF CHANCRE. 79 nation with iron and hydrastin, act like a charm. Any preparation of iron answers well; but I have derived good results from iron by hydrogen, the tincture of the chloride in large doses. I have also succeeded well with the tartrate. The situation of a venereal sore frequently prevents the use of the local remedies in question; for instance, chancre situated under the prepuce, and producing complete or partial phymosis. In such cases there is generally more or less inflammation or tumefaction of the penis, more or less discharge from the preputial opening, and tenderness to the touch. Phymosis and paraphymosis are the consequences of inflammatory engorgement. In both, warm applications, and the soothing plan of treatment will generally do all that is necessary to effect a cure. Should any unfavorable symptoms threaten, the prepuce must be slit up until the constriction is removed. In paraphymosis, mild attempts at reduction, by compressing the glans gradually and firmly with the index finger and thumb of both hands; try the local application of belladonna and glycerine. Should this plan not succeed, and should constriction be great, the stricture must be divided, after which a poultice of slippery elm. In operating for phymosis or paraphymosis, the surface of the sore thus exposed must at once be thoroughly touched with some of the caustics before recommended. By these means we prevent the inoculation of the recently-cut surfaces. The parts should then be dressed as already suggested, or by pledgets of lint soaked in an appropriate lotion. It is the duty of the physician, when he is consulted regarding a venereal sore, to point out to the patient, in strong terms, the indispensable necessity of attending to diet, to the secretions, to rest; rest is a most important auxiliary in the treatment of all forms of the disease. If gangrene should occur, mild stimulating applications, such as dilute nitric acid, or the dilute solution of the chloride of zinc, may be employed with good results. In phymosis and paraphymosis, it is the prepuce that generally suffers, and not the glans. Ulceration is one of the accidents to which soft chancre is liable, and is best treated by the destruction of the specific character of the sore, and the permanganate of potash lotion. If, after the application of the escharotic, it shows any tendency to spread, strapping with adhesive plasters is an excellent means of 80 TREATMENT OF THE VENEREAL DISEASE. arresting it. If this complication be present, anoolynes must be freely and perseveringly given, with tonics, such as cinchonin, iron, and good nutritious, blood-elaborating diet. Sometimes sloughing is very great without ulceration, and, in these cases, anodynes or nervines, such as cypripedin, hyosciamin and asclepin make a fine combination. Stimulants, good diet, active secretions, a lotion of hamamelin and rhusin, tonics, such as bark, iron, are peculiarly indicated. The serpiginous, or horse-shoe ulcer, is a tedious affair, difficult to cure. This form of soft chancre undoubtedly depends on some impairment of the vital forces of the patient, some debilitating cause, some constitutional defect or taint, such as scrofula, tuber- culosis, &c. The bromine, caustic potass, monohydrated nitric acid, the sulphuric acid paste, the actual cautery, may all be used, but almost invariably the resulting ulcer is possessed of the same tendency as the original one—the morbid condition aggravated. The treatment calculated to be efficacious, and in Avhich confidence may be placed, is internal medication. I have used, locally, in these cases, a paste of sanguinarin and hamamelin for about tAvo hours, and applied Beach's yellow salve; internally, the C. syr. stillingia, with either the iodide of potassium, ammonium or sodium. In other cases I have succeeded well with iodide of iron, Avith our concentrated vegetable tonics, good diet, and strict attention to hygienic measures. Serpiginous, or horse-shoe chancres are very intractable; extremely annoying both to the patient and physician. In treating this form, never forget its cause; the remedies that are beneficial in scrofula, in tuberculosis, are indicated here—it affords an immense field for Eclectic remedies, and no physician, thoroughly posted in our remedies, can fail of success. Iodine is a remedy of great power here—iodine alone, painted over the ulcer, Lugol's solution administered internally, with full diet. The treatment by iodine alone has been successful; iron and permanganate of potash also are excellent, internally and locally. At the Clinic of the Eclectic Medical College of Pennsylvania, I have been using lately tinct. iodine locally, twice daily, and applying the permanganate of potash lotion, with the sulphite of soda internally, alternating with my favorite formula of stillingia, irisin, phytolacin and rumin, equal parts, well triturated and in full doses, with the best success. The key to successful treatment is to improve nutrition. TREATMENT OF CHANCRE. 81 Phagedena is another complication; this also depends upon a constitutional difficulty, a constitutional defect; mercury may have been given, the strumous diathesis may be present, the patient may suffer from some exhausting affection, or he has become depressed mentally and physically, or he may have lived improperly. These must be rectified. In phagedena we have the ulcerative process developed to the utmost, and the treatment requires promptness and decision. The first thing to be done is to destroy it effectually and certainly. This is to be done with caustic potass, or nitric acid mixture, or with bromine, an excellent positive agent in phage- dena. It has been well tested, and its effects are all that can be desired. The actual cautery may be used, and is certainly an efficacious way of destroying a phagedenic sore. If used, the iron is best to be raised to a white heat, and freely applied. It is not to be preferred to the bromine, neither is it as good a remedy as the sulphuric acid and charcoal paste. This latter is often 'advan- tageous, covering the entire surface of the sore, and the surrounding skin as far as the diseased action appears to extend. Never try mild caustics, they are useless, irritating, and tend to spread the morbid action. The constitution must be rigidly attended to; We must give the best of diet, abundance of fresh air, bathing, and, above all, iron in alternation with stillingin, corydalin, ampelopsin, phytolacin, rumin, &c. Iron is the grand antagonist of phagedena, it is promptly checked by it; but it must be given in such a manner as to make a speedy impression upon the system, it is a matter of indifference what preparation is used. The chief point is, that the dose should be sufficient, and sufficiently often administered. The potassio-tartrate is undoubtedly good, and by some deemed a specific against phagedena. An excellent formula is— B/.—Ferri et potass, tart., Si; Aquae distilled, Sx.—M. Dose, half a fluid ounce three times daily; at the same time using the same as a lotion to the diseased part, before and after the detachment of the slough caused by the escharotic. I have also succeeded well Avith the saturated tincture of Jeffersoniae, combined with the C. tinct. corydalis in sufficient doses. Rest is one of the most important indications in the treatment of this form of sore, and in none is it more necessary, more indispen- 11 82 TREATMENT OF THE VENEREAL DISEASE. ■* sable. Over and over again, I have seen cases in which no reme- dies proved of much avail till perfect rest was procured. If possi- ble, confine the patient to bed for some days, irrigate the sore every two hours, keeping the iron, tannin, or permanganate lotion constantly applied, covering up all with oiled silk. The secretions should be attended to with irisin and leptandrin. Whenever pain harasses the patient, the most powerful sedatives must be administered. There is no rule whereby we can estimate the dose to be given, except it be the severity and duration of the suffering which the ulceration entails; but it may be received as an axiom, that it is necessary to quell the pain thoroughly and effectu- ally, and that we cannot stay the ravages of the ulcer till we have attained that object; indeed, in every case of phagedena, sedatives are of the greatest, most positive value. Cases do occur that resist all treatment, in which the patient may have been mercurialized, worn out by the discharge and irrita- tion, gradually sinks. Speedy, decided action is everything in treatment here—if the disease is great in extent, it is difficult to stay the morbid process; but the principles of treatment do not vary, no matter how extensive, its destruction is essential; irritation may be great, but ether, chloroform, subcutaneous injections of morphia will subdue it. The iron should be given in still larger quantities, and the strength should be supported with essence of beef and alcoholic stimulants. Buboes may be produced by simple chancre, and are of two kinds: one a simple non-virulent adenitis, due to irritation; the other, a specific abscess, caused by the absorption of pus from the chancre; the former, capable of resolution; the latter, always sup- purating; and this very fact, viz., simple adenitis terminating in resolution, while the virulent bubo always suppurates, must be our guide in treatment. Thus far we have considered one species of venereal ulcers, the simple, soft, non-infecting chancre, and the accidents to which it is liable. This is solely and essentially a local disease, producing no constitutional affection, except the vital forces are depressed, debility, scrofulous diathesis, deterioration by mercury present, &c., &c. The complications of soft chancre are exceedingly impor- tant, more to be dreaded than the original disease; but they are local, never causing constitutional syphilis, never converting the TREATMENT OF CHANCRE. 83 non-infecting into an infecting chancre. We now come to the consideration of an infection of an entirely different character. Indurated Chancre.—The indurated or infecting, true syphilitic chancre; the chancre, par excellence. It is the indurated chancre, because it alone possesses a true indurated base; it is the infecting chancre, because it alone poisons and contaminates the system; it is the syphilitic chancre, because it alone causes syphilis. The typical characteristics of a sore of this description are as follows : a pimple or pustule having been developed, a small round ulcer remains, the surface of which is smooth, often shining as if varnished, the centre being of a grayish tint. The base of the sore soon becomes indurated, and this induration has a peculiar character, a thickening of the true venereal kind, very circum- scribed, not diffusing itself gradually or imperceptibly into the surrounding parts, but terminating rather abruptly. This cha- racter is pathognomonic, and of the highest importance. It is usually easily to detect the difference between this, the true indu- ration, and that thickening of the surrounding tissues which is always more or less present in any chancres, after caustic or other severe irritation has been applied; the latter is inflammatory, thickening, its limits are by no means well marked, and in this respect contrasts notably with the sensation communicated to the finger, as of a cup of cartilage imbedded in healthy tissues, and moving freely over the underlying parts, which the well-marked indurated chancre presents. There is no inflammatory areola sur- rounding the indurated chancre. Its edges are often a little elevated, and always adhere to the subjacent tissues, so as not to overhang or become undermined, and from them the surface slopes down to the centre, which is more or less scooped out, as it were, into a hollow. Induration, unlike the simple chancre, has a period of incubation, varying somewhat in different circumstances; it generally appears about the fourth to the sixth day, and Reaches its maximum about the fourteenth day. It never makes its appear- ance later than the third week. It may remain a very considerable period, most frequently long after the ulcer has healed. At first an indurated chancre may appear, either as a pustule or excoriation. If the epidermis is intact, you have a pustule; if it is abraded, an excoriation. There is no essential difference between the soft and indurated until about the fifth day, Avhen induration, 84 TREATMENT OF THE VENEREAL DISEASE. the pathognomonic sign, makes its appearance. Again, the indu- rated chancre is generally single, rarely multiple; it is not very contagious; is not easily inoculated, the secretion being scanty. It is, however, invariably accompanied, and this fact is of import- ance—by some enlargement of the inguinal glands in one or both groins. Glands thus affected, arc to the touch remarkably incom- pressible, like the base of the chancre itself; more than one or two are usually affected; very commonly a group of five or six. They are not painful, and they never inflame or suppurate, except in rare cases, from some over-exertion; and in scrofulous subjects. Man alone is subject to this form of chancre, consequently syphilis is altogether a human disease. All attempts to inoculate animals with the virus of an infecting chancre have failed. Such are a few of the typical characters of the indurated and infecting chancre. It is to be distinguished from the soft or non- indurated chancre by the character of the edges, the soft having cut edges, not sloping or hollowed out as the preceding. In the soft there is no induration of any kind, and no thickening, no deposit about the base of the sore, unless it has been accidentally inflamed by irritant applications, or by friction from the dress, neglect; the pseudo-induration of this species differs widely from the true, since it shades off gradually into the surrounding tissues, and is manifestly inflammatory in its character, as already pointed out. The secretion of the soft chancre is abundant and eminently contagious; hence those chancres are generally multiple, one follow- ing another, while opposing surfaces, as the prepuce and glans penis, become rapidly affected, and in neglected cases, a crop of chancres may encircle the glans; it is prone to increase in size, slow to heal, and more liable to be attacked with bubo, phage- dena, and other complications than the indurated. From the pus of the resulting bubo of a soft chancre, inoculation may be pro- duced, 'and the sore so made is of a like character to the primary one; and lastly, soft chancre is essentially a local disease, produces local symptoms, and there is no resulting constitutional affection. If indurated or infecting chancre does not extend beyond the base of the chancre, it is perfectly abrupt and circumscribed. Induration is more distinctly manifested in some parts of the body than others. The cause of this difference is due to the difference in the quantity of lymphatic vessels distributed to a part. Where TREATMENT OF CHANCRE. 85 they are abundant, induration is decided, and vice versa. The indurated chancre is seldom large, is not accompanied with irrita- tion, the edges are inclined to the centre of the base, so that it presents a cup-like appearance. Simple chancre is generally multiple; the infecting chancre, on the other hand, is usually single. One reason that may be given for this and for the great frequency with which we meet with the simple, (four cases out of every five being soft, non-infecting,) is the abundance of the secretion furnished by this species of chancre being much greater than Avhat takes place in indurated chancre, which has very little secretion, and is therefore less readily commu- nicated. Another, and well established reason is, that an individual has an indurated chancre but once, and consequently, he is not liable to contract fresh chancres from an original sore. There is, therefore, in general, but one way by which more than one indurated chancre can exist upon the same person, and that is, by the simultaneous inoculation of several distinct parts of the body. The fact that an individual has an indurated chancre but once in a lifetime, gives us one of the most certain methods of distinguishing this form of chancre from the soft variety. The secretion of an indurated chancre, when inoculated on the affected individual, gives negative results, no chancre is formed; whereas, there is no limit to the number of successful inoculations which may be practiced on one person with the matter of the simple chancre. We would not positively assert that an individual who has once had an infecting chancre, can absolutely never have another; we consider the immunity from indurated chancre as certainly greater Avith those who have once had it, than that given either by small- pox, scarlatina, or any other infectious disease. The secretion of the two varieties are also microscopically distinct. The indurated chancre is not so liable to complications, such as inflammation, excessive ulceration or phagedena. It is rare to find an infecting chancre thus attacked. Another phenomenon of the indurated chancre is, the indurated bubo. This is almost a constant invariable companion. The bubo consequent upon an indurated chancre is always seated in those glands, which are in direct relation with the lymphatic vessels of the affected part. 86 TREATMENT OF THE VENEREAL DISEASE. During the first week, or at latest during the second week of the existence of an indurated chancre, the indurated bubo makes its appearance. It is to be distinguished from any other form of bubo in this, that the enlargement is not limited to a single gland, as in the other species of bubo, but affects all the glands of the cluster to which the lymphatics of the chancrous region are distributed. The indurated glands feel like bullets placed under the skin, being quite characteristic in this respect. The indurated bubo also never suppurates, unless attacked by inflammation from some other cause, such as cold, injury, strumous diathesis. It does not yield inocula- ble pus—it cannot cause a chancre of the same species as the parent ulcer. Induration is pathognomonic of the infecting chancre. This may have been present and have disappeared. This is a circum- stance of frequent occurrence. It is rare for this sign to vanish before the cicatrization of the chancre, although it occasionally happens. A soft chancre may be contracted upon the indurated nodule that remains after an infecting chancre has been healed. The infecting chancre gives no immunity or protection from the soft. The soft chancre on an old induration requires the treatment we have already laid down. An old induration is liable to spontaneous ulceration. This ulceration is non-specific, no fresh infection from it; it is not, in fact, chancrous, and always heals under the black salve, oxide of zinc ointment, or a lotion of permanganate of potash. Soft chancre is pre-eminently liable to certain complications; infecting chancre is not altogether free from such. Though not prone to inflammation; mechanical, medicinal irritation may give rise to it, and it may be followed with great engorgement, gangrene. The principles of treatment do not vary from those we have con- sidered, except that we must superadd special remedial measures to meet the demands of an infected system. Ulceration and phagedena are not often met with; they are rare. Constitutional syphilis is not prevented when the chancre is thus affected. But if infection is not prevented, the specific character of the chancre is destroyed—the indurated phagedenic chancre cannot be propagated by inoculation, as has been clearly demonstrated. TREATMENT OF CHANCRE. 87 In regard to indurated bubo, and the intimate relation which exists between it and the infecting chancre, it may be stated, that it may originate without being preceded by any other evidence of disease; that is, the chancrous virus may be absorbed, so as to reach the lymphatics without abrasion, ulceration, or suppuration being caused in the first instance. This, in certain cases, may possibly occur. They must, however, be few, for we know with what difficulty, even under the most favorable circumstances, the absorption of substances takes place from surfaces not deprived of their epidermis or epithelium, and during coition sufficient time for such absorption is not afforded. That buboes of an indurated character may be formed without a chancre preceding, is simply shown by the fact, that they so frequently ensue on a gonorrhoea. In an infecting chancre, then, we have one with an indurated base, invariably accompanied by indurated inguinal glands, which do not suppurate, and certain to be followed by secondary symp- toms. In the treatment, then, of indurated chancre, what are the indications to be fulfilled ? Certainly to cure the local trouble and prevent infection. TREATMENT OF THE INDURATED, INFECTING CHANCRE. Supposing that we follow the rule, invariably to cauterize every sore that comes before us in the early stage, that is, before the fifth day of its development, we shall apply the most certain remedy in our power; indeed, an almost unfailing one, whether against indu- rated or non-indurated chancre, and which variety we are dealing with, cannot be determined at so early a period; for induration rarely manifests itself before the end of the first week, as already observed. The induration once established, no cauterization will save the system from infection. It is the first sign of a constitu- tional affection; the herald of secondary syphilis. Caustics may, however, be used to promote the destruction and healing of the sore, and if there be uncertainty as to the nature of the induration, the patient gets the benefit of the doubt, and we may have the good fortune to nip syphilis in the bud. Induration in a chancre is the first manifestation of the infecting character of the ulcer; it is a sign we have to deal with it; indura- tion is the starting point, its appearance is inauspicious, and there- fore, in the first stages, we advocate its destruction with the caustic soda, or bromine, or caustic potass, or the carbo-sulphuric acid, and we are convinced that, in many cases, infection will be avoided. The caustic plan of treatment is. the one that may be practiced Avith reasonable hopes of success at any time of its progress. After cauterization, the most simple applications are all that are neces- sary. The aromatic wine acts very well, so does a solution of hydrastin, or rhusin, or hamamelin, or tannin; equally efficacious, or what is still better, a weak solution of permanganate of potash, as follows: B/.—Permanganate potash, gr. ii.; Aqua dist, Si.—M. TREATMENT OF THE INDURATED, INFECTING CHANCRE. 89 Should the chancre be healing, or if it has ceased to progress, cauterization is unnecessary, sometimes improper. In such cases local treatment, with a solution of hamamelin, or any of the above agents, is the most successful—the detergent action of the caustic accomplishes more than any direct influence upon the chancre. In regard to the local application of mercurial remedies, such as black Avash, yellow wash, mercurial ointment, red precipitate, calomel, they cannot be too emphatically condemned; chancres treated with such agents if they get well, do so in spite of them— they have so salutary effect, they are the mere relic of a barbarous practice not completely effaced from the glorious sunshine of science. Indurated chancre is a self-limited ulcer, and unless it be destroyed by caustics, or attacked by some complication, runs a regular course, and will heal spontaneously in four or five weeks. I believe, then, an indurated chancre would never be attacked with those complications—inflammation and phagedena, if mercu- rial remedies were not employed—these agents complicate the nature and the treatment, and cause fatal manifestations of this hydra-headed disorder. Nothing tends so greatly to engender and spread phagedena as mercury. This agent, in all its forms, is destructive; under its use the tissues melt away; the springs of nutrition are impaired; it renders the blood thin and watery; it lessens the vitality of the tissues; promotes their absorption. Thus we have the countenance becoming pale under its use; the red corpuscles of the blood are impaired, and a super-abundance of white corpuscles; we have white cell blood, with spongy and ulcerated gums, and we have the disease aggravated. Phagedena is always due to an impairment of the vital forces, a failure in the powers of life, and depravation of the blood. It has nothing to do with syphilitic poison; more frequently an attendant on soft, non-infecting chancre, than on the indurated infecting species; the hydra-headed monster, mercury, cannot cure it by any of its component elements; the course of treatment demanded is tonic, vegetable and mineral tonics. Will internal remedies accelerate the cure of chancre? Assu- redly they will. It is eminently proper and good practice to resort to constitutional treatment at once, with the view of preventing infection, or destroying or eliminating the morbific matter circu- lating in the blood, and contaminating and impairing the tissues, 12 90, TREATMENT OF THE VENEREAL DISEASE. sapping the very fountain of life; such constitutional treatment will, undoubtedly, exercise some effect over the ulcer. With the view of hastening the disappearance of the induration and prevent- ing infection much can be done. The Prevention of Infection.—The duality of the venereal poison is the key, the foundation of scientific venereal therapeutics, and unless we can fully realize this distinctness of morbific matters giving rise to soft and indurated chancres, our steps in treatment will be purely empirical. There is no more analogy between the two forms of venereal ulcers, except that they originate both from sexual intercourse, than there is between scarlet fever and small- pox ; it would just be as philosophical to assert the identity of the latter as the former. An indurated chancre can only be produced by natural or artifi- cial inoculation, with the virus of a chancre of like character, which is incapable of re-inoculation in the same individual. Is it possible, after an individual has become inoculated with the virus of an infecting chancre, to prevent constitutional syphilis ? We think it is. Induration is not precisely an evidence of constitutional infec- tion, but it is an indication of the character of the ulcer—it gives an emphatic warning that contamination of the system will inevi- tably result, if the chancre is left undisturbed. It is proper to destroy all chancres, hard and soft, within the first week after the ulcer appears. Now it is true, we know it from experience, that there are certain agents in the materia medica that act as antidotes to poisons. Thus bromine, iodine, ammonia, neutralizes the venom of certain animals. We believe that some of our con- centrated remedies, such as irisin, corydalin, phytolacin, ampelopsin, stillingin, rumin, podophyllin, properly administered, are as antago* nistic to the syphilitic poison as cinchona, salicin, bebeerin are to intermittent fever. I believe they are excellent prophylactic agents against constitutional syphilis. In order, then, to prevent infection of the system from the virus of an indurated chancre, two measures are necessary: first, destroy the chancre with some poAverful caustic, as the caustic soda, bromine, vegetable caustic, monohydrated nitric acid, &c.; and second, bring the system under the influence of some powerful alterative, such as TREATMENT OF THE INDURATED, INFECTING CHANCRE. 91 B/.—C. syr. stillingia, Oss; C. tr. irisin, " rumin, " corydalis, a a 5i; Iodide of sodium, Si-—M. A teaspoonful ter die. B/.—C. syr. stillingia, Tinct. kalamia, Iris versicolor, Iodide of sodium. (In suitable proportions to the indications.) In alternation with tinct. thuga; or, the rumex crispus, alnus serrulata, scrophularia, corydalis, solanum dulcamara, &c, &c. The above formulae will be found excellent, increased or dimin- ished according to circumstances. With these and other remedies, however, we sometimes fail; but I have never seen constitutional infection prevented, unless the chancre was destroyed within a week after its commencement. The iodide of sodium, or ammonium, or potassium, conjoined in the above form, appears to be more efficacious in preventing constitutional disease than when admin- istered singly. We sometimes fail in our efforts to prevent infection of the system by the syphilitic poison, no matter how prompt our treatment may be. The cases in which success may be looked for Avith most confidence, are those in which the appearance of the chancre has been delayed beyond the average period. In such cases, it would seem that the virus is not of the highest degree of intensity. On the contrary, when the chancre occurs soon after exposure, other things being equal, it would appear to indicate greater virulence in the syphilitic matter. In such cases, we are not so successful in the use of prophylactic measures, for the poison will have got the start of us in numerous instances, before we are acquainted with its nature. The progress of an indurated chancre is as follows: the virus is specific, it produces a chancre, from that chancre constitutional infection takes place. It is analogous to vaccination—the vaccine virus is not immediately absorbed so as to affect the constitution; it passes through a certain process in order to accomplish a constitu- tional effect; a pustule forms, and unless that pustule does form, 92 TREATMENT OF THE VENEREAL DISEASE. there is no systemic effect. An infecting chancre has a similar train of occurrences. The virus comes in contact with the glans penis, an indurated chancre is produced, and from this chancre the system becomes contaminated. If we commit violence on the pustule, (syphilitic or otherwise,) such as by rubbing or scratching, or burning or excising it, it interferes with its regular progress, destroys or lessens the proba- bility of constitutional infection—cauterize the vaccine pustule during the first three or four days of its course, no effect would be produced. If we allow an infecting chancre to take its course undisturbed, systemic disease will be produced within six months, that is to say, if no treatment at all be adopted this limit is seldom exceeded. But sometimes the limit is much greater, years elapsing before any constitutional symptoms are produced. With reference to the length of time during which the medical treatment should be kept up, it is best not to stop too soon. As a rule, he should be kept rigidly under treatment for six months at least; it is not safe to leave off sooner. My practice is to destroy all chancres within six days after their appearance, and give powerful constitutional treatment, if we suspect the sore to be of the infecting species, which we know by its appearance, indurated base, indurated bubo, and, above all, by the microscopical appearances. If we have reason to suspect an infecting sore; if there be no doubt respecting those certain signs of an infected constitution, an alterative course of treatment should at once be resorted to, either the stillingia C. syr., C. syr. frostworth, anti-scrofulous syr., or the sulphite, or the bisulphite of soda, permanganate of potash; Avith some preparation of iodine, as iodide of sodium in alternation with iron, and our concentrated preparations. Under such reme- dies induration will disappear, the tendency to systemic contami- nation will be diminished in intensity, or postponed, or it may be altogether suppressed or eradicated. I have met with great success, both in clinical and private practice, in the use of the concentrated remedials, such as stillingin, smilacin, phytolacin, corydalin, irisin, ampelopsin, menispermin. The menispermin, either alone or combined, appears to me to be a remedy of great utility; given at first in small doses and gradually increased. It excites the action of the glandular system in a powerful manner, resolving vitiated deposits, correcting the secret- TREATMENT OF THE INDURATED, INFECTING CHANCRE. 93 ing functions, stimulates the venous, absorbent, and lymphatic vessels, and promotes depuration through the various channels. In combination with the irisin, it has no superior as an anti-syphi- litic ; menispermin and irisin equal parts, act well—all the beneficial effects claimed to be produced by mercury, can be obtained from these two agents; nay, more, they will give evidence of a direct therapeutic stimulus operating upon the vital impressibility of the secreting apparatus, promoting increased activity of its functions for the purpose of eliminating legitimate products; at the same time they produce no loosening of the teeth, no sponginess of the gums, no putrefactive fetor, no sloughing of the soft parts, or necrosis of the bones. My observation and experience fully endorse the use of the above remedies. I think it a work of supererogation to say more at present of their wonderful power, in this hitherto tedious, intractable condition of the system. When treatment with any of the above remedies is going on, the patient should well sustain the powers of life, by nutritious food, and exercise in the open air, and maintain the secreting functions of the skin in activity, by occasional warm baths, by daily thorough ablutions and friction. For local applications to the sore, aromatic wine, tannin, in solution, under which it generally heals well. It is not within the limits of this chapter to consider the numerous details connected with the nature and treatment of constitutional syphilis. We conclude this with a resume of the points that we wish to inculcate. That there are two distinct species of chancre, and only two, viz : the indurated or infecting chancre, and the soft or non-infecting chancre. That both forms may be attacked with phagedena; but that this commonly happens to the soft, non-infecting chancre. That indurated chancre is never followed by specific suppurating bubo; but always give rise to indurated swelling of the nearest related lymphatic glands, which do not suppurate. That the soft chancre frequently, but not always, gives rise to the swelling of the lymphatic glands, in which case an inflammatory suppuration results, and the pus is capable of producing a soft chancre, analogous to the original one. That the soft, as compared with the indurated chancre, is pre- sented in practice in the proportion of four to one. Hence, putting 94 TREATMENT OF THE VENEREAL DISEASE. aside treatment of all chancres met with, only one in four or five is followed by constitutional syphilis. That in a large majority of cases in which chancres are seen by the physician in their earlier stages, a decided prognosis may be safely made as to the development or non-development of secondary symptoms. That the diagnosis of indurated chancre being clear, constitu- tional remedies are indicated. That the diagnosis of soft chancre being clear, no specific systemic treatment is necessary. In doubtful cases it is better to resort at once to constitutional treatment. It is impossible to make too widely known the importance of treatment at the first sign of a suspicious sore; since early and efficient cauterization infallibly prevents infection of the system, and should invariably be applied to all such sores, at the earliest possible period. CONSTITUTIONAL SYPHILIS. Mode of Absorption of the Syphilitic Virus.—How does the syphilitic poison reach the system? There are two classes of absorbents, the lymphatics and the veins. By which of these is the venereal virus taken up ? We have the most indubitable probf that the veins absorb with much greater rapidity than the lympha- tics, and we may consider it as admitting of no doubt that one way at least by which the syphilitic virus infects the system is by the blood vessels. The genital organs of the male and female are well provided with lymphatics, and we know that the virus of a chancre passes along them to the lymphatic glands. We see the vessels red, inflamed, and the patient experiences pain along their course, but it never passes beyond the first chain of glands. When it reaches these, its further progress is arrested. The lymphatic vessels leading from them are never inflamed, neither do the glands of the deeper-seated row ever become diseased. Suppose we take any portion of the indurated gland on the point of an exploring needle, and endeavor to produce a chancre by inoculation with it, we never succeed. On the contrary, the pus of a bubo, resulting from a soft chancre, when inoculated, almost invariably causes a non-indurated chancre. We judge, from these facts, that the lymphatic glands not only prevent the passage of the chancrous virus into the blood, but that they deprive the virus of the indurated chancre of its specific properties. The virus of an infecting chancre is absorbed into the system through the blood vessels of the part involved in the primary ulcer, and by no other channels. Within a period, varying according to the constitution of the patient, his mode of life, and other circumstances, of from four weeks to six months after the appearance of an indurated chancre, the system begins to give evidence of infection. The chancre may have healed, and the inguinal glands may have returned to an apparently healthy condition, Avhen slight febrile' symptoms are 96 TREATMENT OF THE VENEREAL DISEASE. developed. There is a general feeling of oppression, the digestion is disturbed, the nervous system gives evidence of irritability, there is languor, indifference to passing events, the circulation partici- pates, the pulse frequent and irritable, skin dry and hot, eyes suffused, and painful upon motion. A prominent symptom of the constitutional infection, which occurs at an early period, congestion, dryness, and pain of the 'fauces, and neuralgic affections generally. Sometimes these are the only indications perceived for some weeks that any systemic disturbance is going on. This syphilitic fever lasts but a few days, and then the system becomes tranquil; symptoms of blood poisoning manifest them- selves. The first indication of this is the enlargement of the post cervical lymphatic glands, which, though not generally perceived by the patient till his attention is directed to it, constitutes a valuable sign by which we are enabled to form an opinion as to the contamination of the system. It is frequently the first symptom of constitutional infection. Enlargement of the post cervical glands, below the occiput and behind the mastoid processes, feeling like small bullets, is a valuable diagnostic sign. They remain in an indurated and indolent condition, never suppurating, or increasing much in size. Alopecia is often met with at an early period of the disease, and is an evidence of the syphilitic poison affecting the skin. As it progresses, the tendency is well marked; the skin is covered with characteristic eruptions, the mucous membranes of the digestive and respiratory passages participate in the morbid action, and the system is fairly under the influence of the syphilitic virus. The poison limited to the skin, the mucous membranes and their appen- dages constitute by some the secondary stage. About the sixth month, othe^ tissues of the body exhibit evidences of the morbid process which has been set up in the system. Tumors form in the skin, cellular tissue and muscles, which soften and ulcerate; the mucous membrane becomes ulcerated, and the bones and periosteum become involved, periostitis, caries, necrosis follow, and life becomes a burden. There is no tissue, or organ of the body, that does not become more or less involved, because the blood that builds these tissues is diseased. Eminent pathologists have emphatically told us that they detect, TREATMENT OF CONSTITUTIONAL SYPHILIS. 97 in individuals suffering from syphilis, a diminution of the red blood corpuscles; not only are the red diminished in number, but the white are increased. The condition is not unlike leucocythemia, and depends, probably, upon a diseased condition of the spleen, thyroid and thymus gland, and supra-renal capsules,-which are intimately connected with the formation of the red and white corpuscles. Any diseased condition of these glands, as we have in syphilis, is altogether incompatible with the complete discharge of their functions. In constitutional syphilis, the effect of the syphilitic poison on the blood is such as to produce a change in its morphological constituents, and in this manner affords us a valuable means of diagnosis. Syphilis is caused by a poisonous virus, which, mixing with the blood, taints the constitution, and predisposes to secondary and tertiary disorders. The nature of the virus is a mystery. All that we know of it is from observation of its effects. Even the white cell blood, usually present through the whole course of con- stitutional syphilis, may be due to the spleen and other viscera of persons suffering from syphilis being diseased, as they are prone to lardaceous and amyloid degenerations, conditions incompatible with the proper performance of their functions. Noav the question arises, can we remove this taint, this impress upon the vital fluid? For my part, I believe, in a healthy individual, that the virus of syphilis, if left to itself, and the health and hygienic measures attended to, will wear out of itself. It would be impossible to say how long nature would take to accomplish this. There is no specific of any kind for it, no remedy potent enough to kill it in the blood ; nothing but a course of alterative medication. The idea that mercury is a specific for the syphilitic poison, and the incalculable mischief it is occasioning at the present day, is deplorable. It is well known that the poison of mercury produces a cachectic disease and secondary sores in the body, which have been mistaken, to a great extent, for syphilis. It happens that mercury, given to cure primary sores, produces a constitutional disorder resembling syphilis; increase the quantity, as has been the rule, and so perpetuate and aggravate the disease. The syphilitic poison is a blood disease, runs a certain course, and one that we have not yet discovered a specific cure for. The intensity of the disease diminishes in proportion as its treat- ment by mercury has diminished. If syphilis was treated on general 13 98 TREATMENT OF THE VENEREAL DISEASE. principles, same as other diseases, it would prove infinitely more mild. Syphilis in America at the present time, under the salutary influence of a mild and simple treatment, is easily managed. Malignant syphilis disappears as the treatment by mercury is discarded; frightful cases were met with when salivation was the rule. But times are changed; we must appreciate this revolution in practice, but we must not forget to eulogize those who had first the boldness to set their foot on the hydra-headed monster. The credit of this change is due to Beache, Powell, Newton, King, Jones, Scudder, and to the teachings of such men as Cook, Hollembaek, Sites and Fitler. The chief causes of constitutional syphilis are: the absorption into the system of the virus from a venereal sore, or from inocula- tion or contagion; the direct communication of a constitutional affection from a diseased to a healthy person, without the interven- tion of any primary disease; hereditary transmission; the treat- ment by mercury; some peculiarity of constitution. SYPHILITIC INOCULATION. Syphilitic inoculation has been practiced for a long period, and numerous interesting, but few practical points obtained. By patient observation and experiment, the truth has been established, that certain forms of syphilitic virus, when inoculated, will produce their like, which, in their turn, will again furnish a secretion capable of being again inoculated with similar results. Some attach great importance to the discovery, so analogous to that of small-pox inoculation; but most practical men have been unable to see, in the experiments of half a century, a conclusive representation of what they see in practice. That certain forms of syphilitic disease will produce the characteristic pustule when inoculated, all will allow; but it does not follow, on the one hand, that all syphilitic sores are alike capable of being inoculated ; nor, on the other hand, that when inoculated, they will necessarily yield the same results. Under these circumstances, and without proof as to these two last mentioned particulars, to say that a sore is syphilitic because it produces a characteristic pustule when inoculated, and that it pro- duces a characteristic pustule because it is syphilitic, is plainly to reason in a vicious circle. The propositions themselves are undoubt- edly true; but they cannot, without additional evidence, be received as excluding other modes of syphilitic infection, and other forms of primary syphilis. We are led, then, to ask, whether there is no form of primary syphilis, except that which commences as a pus- tule? This question is important, since physicians engaged in practice very seldom have an opportunity of observing the primary syphilitic pustule, and still less frequently have they an opportunity of tracing secondary symptoms consequent upon it. We constantly meet cases in their early stages that have no sore, merely a specific induration; the surface not yielding any secretion, and still inocu- lation may take place. If a person in this condition gets married, his wife would stand a good chance of becoming infected with syphilis. The sores in these cases may have become covered over with cuticle, which apparently yields no pus or fluid secretion of any kind, and yet capable of communicating infection from one individual to another. SECONDARY AND TERTIARY SYPHILIS. Secondary phenomena are limited to the skin, the mucous mem- branes and their appendages, and occur before the sixth month of infection. They are contagious, capable of being inoculated upon healthy individuals, and transmitted from parent to offspring, giving rise to true syphilitic disease. Secondary symptoms consist of cutaneous eruptions, inflammations, mucous patches, condylomata, ulcerations, alopecia, onyxis, iritis, engorgement of the post cervical lymphatic glands. The tertiary accidents rarely occur until after the sixth month. They show themselves in the submucous, sub- cutaneous cellular tissue and muscles, in the bones and fibrous tissues, as caries, nodes, periostitis, in the testicles, brain, heart, liver, and other yiscera. Not contagious, not inoculable, not trans- missible in a syphilitic form, although children born of such parents have a strong predisposition to strumous diathesis, and no doubt but certain symptoms are both contagious and even hereditary. Before proceeding with our subject of treatment, We shall briefly enumerate the symptoms, the more important manifestations of constitutional syphilis, as they usually occur. Syphilitic Fever.—Before the appearance of any obvious symp- tom of constitutional infection, the great majority of cases give evidence of febrile excitement. This is not recognized in every instance; it usually precedes syphilitic cutaneous eruptions, and if the patient is well interrogated, Ave seldom fail to recognize it. In addition, we have the accelerated pulse, dry skin, gastric derangement, gloomy forebodings, physical and mental lassitude, disordered sleep, impairment of the mental faculties, exhibiting a deranged brain and nervous system, intense melancholy, approxi- mating insanity. Headache.—This is a frequent characteristic symptom, due not to cerebral disturbance, but to incipient disease of the periosteum, aggravated at night, and attended with facial neuralgia. The neuralgic pain, and that arising from periosteal disease, differ in TREATMENT OF SECONDARY AND TERTIARY SYPHILIS. 101 their character; the neuralgic being lancinating, not confined to one spot, while that from disease of the periosteum is generally limited to the frontal region, and is of a dull, aching character. Besides the cranial bones, other bones are affected, especially the upper and lower extremities, at or in the neighborhood of the articulations. The pains are sometimes mistaken for rheumatism, though the least attention to their character will enable us to discriminate between them. These pains are worse at night. The parts are sometimes swollen, inflamed, and tenderness on pressure is always present. If the patient rests, the joints are stiff, although exercise removes this symptom. Neuralgia is generally met with in the parts supplied by the infra-orbital, arid branches of the fifth pair of nerves; but it is not limited to those regions, attacking the nerves distributed to the trunk and limbs. Substernal tenderness is a most valuable diagnostic sign—this can only be detected by pressure. When searching for this sign, knead the bone with the fore and middle fingers carefully, from the manubrium to the xyphoid cartilage. In a case of suspected constitutional syphilis, if the patient be asked if he has a pain in the breast-bone, he will, probably, answer in the negative. Press the sternum carefully and gently along the Avhole length of its course, and the tender spot will be found usually at the commencement of the lower third. If substernal tenderness be found, we are safe in assuming that the patient labors under some acquired venereal taint, which may have been masked by different other symptoms, and be unsuspected by both patient and physician. It often furnishes a clue to the cause of very anomalous symptoms, and a valuable guide to us in treat- ment. Although the existence of substernal tenderness is, I believe, unerringly significant of venereal dyscrasia, yet a patient may have constitutional syphilis and not manifest this sign. But when we detect it, it is a valuable guide for treatment. Substernal tenderness is, no doubt, produced by a periosteal inflammation, slight in degree, and may be in its immediate effects; such as pain and tenderness, inappreciable to the patient. We have also muscular pains, dull, aching in their character; felt in the shoulders, loins, intercostal region, and which, like those attacking the periosteum, are aggravated at night. Such are the principal and early phenomena of syphilis. After 102 TREATMENT OF THE VENEREAL DISEASE. they have lasted eight or ten days they decline, or pass off alto- gether, and an eruption makes its appearance. Syphilitic Affections of the Skin.—Authors describe an immense variety of skin diseases depending on constitutional syphilis. Some occurring in the early and some in the later stages. But they may, with propriety, be all arranged under four heads. 1. Simple congestion of the skin, constituting roseola or erythema. 2. Congestion, with ulceration of separate follicles, constituting lichen. 3. Congestion, with elevation of a small group of follicles, or uniform tumefaction of a small portion of skin, constituting tuber- cula. * 4. Pustules. All the various eruptions may be classed under one or other of these divisions. Their sub-division amounts to nothing but confu- sion. Of these four groups of eruptions, the first and second are met with during the first stages of constitutional syphilis, or the so-called secondary stage; those of the third and fourth are confined almost entirely to the tertiary period. Instead of the above simple division, another has been proposed; namely, two great classes, the secreting and non-secreting. In the dry group, we have erythema, papules and scales; and in the moist group, vesicles, pustules and tubercles. The moist form appears more frequent upon the weak and debilitated, and the other forms upon those whose powers are more resisting. Indeed, we mostly see pustules and tubercles running into ulceration in patients wanting stamina. It is, in fact, interesting to notice that, from the mildest form of papular erythema, to a very deep, destruc- tive, or even phagedenic ulcer, the process is the same; but becomes aggravated in a direct ratio with the powers of the organism. These cutaneous manifestations, after the virus has found its way into the economy, is thought, by some, to be the result of a vigorous effort of the organism to bring to the surface and cast off principles, which are setting up an abnormal action in the system; but this is not essentially correct; we may have a syphilitic erup- tion without any febrile disturbance whatsoever ; such eruption may occur again and again on the same subject; it may, also, from the beginning, possesses a character of chronicity. First Class. Simple congestion of the skin, syphilitic roseola or TREATMENT OF SECONDARY AND TERTIARY SYPHILIS. 103 erythema, is generally the first eruption to appear; it is peculiar from its mildness, and from belonging to the great class of dry eruptions. The fever and skin eruptions must be regarded as the regular.and essential symptoms of constitutional syphilis, and not as any results of the attempt of the system to cast off the virus. The poison is never expelled in this way. Erythema shows itself first, about ten days subsequent to the fever, first on the abdomen, inside of the thighs, and gradually spreads to the chest and extremities. It appears in some cases like a measly rash, generally lasts from three to eight weeks, sometimes, though rarely, as many months. This is, by far, the most common affection of the skin; it seldom proves annoying. It is open to sources of inconvenience—it may act in an energetic manner on the rete mucosum, that very obstinate yellow, or copper- colored stains, for months or years, be left on the skin. They may, also, if any great disturbance of the organism take place, run into pustules, and thence into ulcers. Along with this skin affection, other manifestations show themselves. The throat becomes dry, painful, and mucous patches are found in the fauces; other portions of the mucous membranes, as the mouth and around the anus, are similarly affected. Alopecia is not always present; but if it exists, it is apt to create suspicion. The falling off of the hair is not confined to syphilis, frequently results from fevers. In the venereal form, scabs are met with on the scalp. The engorgement of the post cervical glands must never be for- gotten, as a most invaluable diagnostic mark of the true nature of the eruption. The color of the eruption is not of much value as a diagnostic sign; it may be rose color, or pale red, or copper colored, which may be modified more or less by the hue of the skin, and other circumstances. Syphilitic roseola alone is usually easily managed, and is very amenable to the treatment which we shall describe. Insensibility of the skin is a positive and most remarkable sign. The sensibility of the skin is lessened to all impressions, not only where the eruption is prevailing, but in regions not yet attacked; there is no inconvenience. In erythematous eruptions depending on other causes, intolerable itching is one of the most troublesome and most prominent symptoms. Wherever syphilitic eruption 104 TREATMENT OF THE VENEREAL DISEASE. exists, there the sensibility is greatly lessened. This general or partial loss of sensibility in the skin is one of the effects of the blood poisoning. It does not last through the tertiary stage, and often disappears before the secondary stage is completed. It is a most valuable indication of the nature of the affection under which the patient is suffering. Second Class. Congestion, with Elevation of Separate Follicles.— The several varieties of lichen come under this head. These are numerous, and their essential difference consists in the size and arrangement of the follicles; a distinction uncalled for. The characteristic of lichenous affections consist in the fact that the eruption is made up of small follicles or papules. Hence they are named follicular or papular diseases. These papules vary in size from that of the head of a pin to that of pea. They are either arranged in groups, looking like raspberries in form, or scattered over the body, more or less closely together, or presenting the appearance of rings. Each papula is distinct, no matter under what form the eruption appears. On their first appearance, these papules are of a dull red color, but, after they are out some time, they become copper colored. They terminate by resolution or desquamation, suppuration seldom taking place. They appear on any part of the body, and usually last two or three months. Though usually following roseola, syphilitic papules may be the first cutaneous affection which gives evidence of contamination of the system. They usually appear early in the disease. We may have roseolous and papular eruptions existing at the same time; this is not so common. Several eruptions of papules may take place; hence we frequently find them in all stages of their growth in the same individual at the same time. They cause no irritation, resembling in this circum- stance the erythematous variety. The third class of syphilitic skin disease is that in which there is congestion, with the elevation of small groups of follicles, or uniform tumefaction of small portions of the skin more than two lines in diameter. Tubercular eruptions are not met in the early stages of syphilis; they are always preceded by papular or erythematous disease. It never occurs within a year after infection, usually four, five, and even more years may elapse. Cases are recorded where they have TREATMENT OF SECONDARY AND TERTIARY SYPHILIS. 105 come on twenty years after infection. They are occasionlly pro- duced from the development of a prior roseolous or lichenous affec- tion, but for the most part they are originally formed. They are not confined to any part of the body, but the face and body are most liable. Syphilitic tubercles differ from lichenous papules in the fact that they often evince a strong tendency to ulcerate. Pus is formed in them, a crust is produced at the apex of each tubercle; this is rubbed off, and an ulcer results. But this is not always their progress. Occasionally they terminate in resolution, the epidermis covering them desquamates and falls off. The fourth class of syphilitic eruptions, the pustular, is likewise peculiar to the latter stages of- syphilis. This and the former class are designated the wet form. The pustular eruptions may be taken as fair examples of the evolution of syphilis upon subjects debili- tated from various causes; insufficient nourishment, over work, defective clothing, or excess of any kind. Anything that has a tendency to weaken the organism, such as mercury. This group comprises pustular eruptions which have formed crusts of various sizes ; the breach of surface, caused by the breaking of the pustule, healing nicely under the crust. When the latter falls off, the stain is often less apparent than in dry eruption. It would seem as if the formation of pus had carried off the coloring which, in the dry form, stains the rete mucosum. In pretty healthy subjects, the crusts are small, and soon fall off; in others they reach a large size, and protect the healing process beneath, which begins imme- diately, and no more pus is secreted. But, in less healthy patients, the continuous secretion of pus loosens the crusts; these at length fall off, and lay bare a loss of substance, an ulcerated surface. The pustular eruption is usually rupia. It is said by some to begin as a vesicle. This probably happens sometimes, but I am more certain that it more frequently takes its rise as a pustule—a pustule, a scab forms on its summit, and this becomes thicker and thicker by the suppurative process which is going on in the ulcer beneath, and the drying of fresh quantities of pus. They assume different shapes, and pass by different names, according to their form. In size these scabs vary from a diameter of half an inch to two or three inches. Each scab is surrounded by a copper-colored areola, and the ulcer underneath is deep, excavated, and, if the 14 106 • TREATMENT OF THE VENEREAL DISEASE. edge of the scab is raised, discharges a sanguineo-purulent matter of a very unhealthy appearance. Rupia is invariably accompanied by a depraved habit of body; a vitiated state of the system, inde- pendent of the specific malady. Besides these four divisions of skin affection, under which most all forms may be classed, there are some other affections which cannot be properly classed as eruptions; affections of the skin and mucous membranes caused by the action of the syphilitic virus. Syphilitic Ulcers are frequently met with in the varying progress of the disease; they usually occur at a late period, but are frequently met with in the secondary stage. The cause of these ulcers may be an injury, suppuration of an existing cutaneous eruption, or inflammation from whatever cause, occurring during the prevalence of the syphilitic taint. Syphilitic ulcers may appear in any part of the body, on the face and lower extremities most frequently; they are deep, foul, unhealthy-looking, extremely chronic in their character, and heal with great difficulty. Occa- sionally they run into sloughing phagedena, and the destructive process connected with syphilitic periostitis and osteitis. Syphilitic Ulcers take on phagedena generally from want, or neglect, or excess, or a depraved constitution, and require very active treatment. In certain constitutions we may have an ulcer arising from a vesicle, or pustule, or tubercle, and even a gummy tumor is prone to ulceration. Mucous Patches, Condylomata, or Warts, appear at an early period of the constitutional affection, generally with, or subsequent to, the roseolous eruption. They are not confined to any particular part of the body, they affect the skin, the mucous membrane, the orifices of the gastro-intestinal canal, the vulva, where there are folds of skin, or two opposing surfaces meet, as in the groin, the axilla, between the toes. Mucous patches in the mucous mem- branes are of a dirty gray color, irregular in size and form, and not elevated above the adjacent surface. When they occur in the fauces, on the tonsils, the syphilitic sore throat results. They frequently terminate in ulceration, are difficult to cure, and, if removed, are apt to recur. Syphilitic laryngitis is generally due to this form of inflammation. Vegetations, or warts, or condylo- mata, or mucous patches, are perfectly characteristic, and easily detected. Occasionally they discharge and ulcerate; condylomata TREATMENT OF SECONDARY AND TERTIARY SYPHILIS.. 107 may arise from the surface of an indurated infecting chancre, due to exuberance of granulations. Mucous patches about the anus, should ulceration supervene, give considerable pain and irritation. Syphilitic Onychia is due to syphilitic inflammation of the matrix of the nail of a finger or toe. The parts become red, swollen, painful, and, from between the integument and base of the nail, a discharge of badly-formed pus takes place. The nail may come away without any of these symptoms being present. As it pro- gresses, we have ulceration supervening, extensive granulations of a fungus character are formed, which add much to the unpleasant- ness of the affection. The pain is usually intense. Should the matrix escape ulceration, the nail, which has become detached, is reproduced; but if, on the contrary, the matrix is attacked with ulceration, the nail is never restored. Syphilitic Iritis may occur as a very early manifestation of con- stitutional syphilis; if in the early stages, its progress is rapid; if in the latter stages, slow. The most frequent time of its occurrence is about the ninth or tenth month. The first symptom is suffused redness of the eye, injection of the vessels of the conjunctiva and sclerotic. Later the redness is not generally diffused over the whole surface of the eye, or inner surface of the lids, but is limited to the circle formed by the junction of the sclerotic coat with the cornea; the color is of a purple hue: the cornea loses its brilliancy, becomes hazy; the iris assumes abnormal forms; little yellow tubercles appear upon its surface, and the pupil becomes irregular in shape. We have photophobia, dimness of vision, intense excru- ciating pain in the eye-ball and surrounding parts. Syphilitic iritis co-existing with the venereal taint, generally occurs at a compara- tively late period of the disease, and in habits that are much enfeebled and vitiated. There are numerous other diseases, both of the eye and other parts, due to a syphilitic cause, which require no special treatment beyond that necessary for the general eradi- cation of the morbid condition from the system. TREATMENT OF SECONDARY SYPHILIS. If an indurated or infecting chancre is not destroyed prior to the sixth day, there is danger of systemic infection, of secondary syphilis. The secondary symptoms or effects we have noticed as cutaneous eruptions; erythema; scaly eruption ; papular eruption; tubercular eruption; mucous tubercles, or patches, or condylomata; ulcera- tions of the toes, the ear, nose, lips, angle of the mouth. Syphilitic affections of the tongue; excoriations of its surface, ulcerations, fissures, and induration of its substance. Ulceration of the gums, tonsils, soft and hard palate, of the pharynx, affections of the eye. In the treatment of constitutional syphilis, it should always be kept in remembrance, that whatever depresses the vital force, or impairs the general health, favors the development of the syphilitic contamination, and its external or local manifestations; and that, if the remedies resorted to produce these effects upon the constitu- tional energies, they will prove more injurious than beneficial. Hence, it is of the greatest importance that remedies be so com- bined, exhibited, and alternated; and so aided by a regulated diet, rigid hygienic measures, a healthy, temperate, dry atmosphere, so as to promote the constitutional powers, increase the vital forces, and improve nutrition ; improvement in the healthy appearance of the patient generally indicating the success of the remedies employed. As a remedial agent in the treatment of constitutional syphilis, is any preparation of mercury of any value ? We say, most emphatically, no. Experience has shown, over and over again, that syphilis can be cured more speedily and more effectually with- out mercury than with it. The great proof of this is, that the intensity of the disease, under our advanced system of practice, has diminished. Mercury is an improper and highly deleterious agent when exhibited as a specific for the venereal poison. The fact is now completely established, that mercury is not necessary. In the TREATMENT OF SECONDARY SYPHILIS. 109 treatment we would improve the quality of the blood, we would promote elimination. What agents in our materia medica do we claim as being of decided utility in this form of the affection ? Ampelopsin has a good action in the cure of constitutional syphilis. A combination of intrinsic value consists of stillingin, irisin, phytolacin, or corydalin; but, as a general thing, ampelopsin alone has answered the most sanguine expectations of the profession. But, if the reader must have mercury in the treatment, why not use podophyllin or irisin, a complete, a reliable substitute for any form of mercury. Podophyllin-or irisin, in small doses, is Avonder- fully resolvent, and by its peculiar excitation of the glandular system, will do more in systemic syphilis than any agent we possess. Podophyllin is peculiarly serviceable with phytolacin and capsi- cum—as an alterative, its sanative influences are more certain and reliable, and its operations entirely devoid of any secondary delete- rious effects whatever. It does not, like mercury, cure by changing the type, and creating another disease; but eradicates the virus from the system. The rumin, as an alterative, either alone, or combined with the alnuin, is in very high repute. In the eruptions, it operates efficiently, and without excitement; certain, positive in promoting the depurating functions. In combination with stillingin, leptan- drin, and podophyllin for the skin affections, or with corydalin, ampelopsin, phytolacin and smilacin. In the different forms of eruption, and for the cure of syphilis, phytolacin is equal to any other remedy. If the patient be pro- perly brought under its influence, and proper attention paid to diet, bathing, and auxiliary treatment, a cure is almost certain. The best method of using it is to push it for four or five days, then leave off as long, in the interval putting the patient upon a decided tonic, with corydalin, smilacin, stillingin, myricin, irisin; should be combined, one or all them with the phytolacin, to meet indications. It is peculiarly serviceable in syphilis. Menispermin is exceedingly valuable in the treatment of syphilitic and mercurial diseases, and superior to any other as a general alterative. ' Rumin, or the dock root, is alterative, and detergent, and acts well, or in combination with any of the above. I have also found 110 TREATMENT OF THE VENEREAL DISEASE. a decoction of the soapwort, figwort, hoary pea, with some of our other concentrated remedies, are of utility. The galium aparine is also highly esteemed. Stillingin.—This agent has long been used; but it is only of late years that it has been fully appreciated by the profession. The dose nyist, in all cases, be suited to the peculiarities of the case. It is best given about two hours after meals, as it materially inter- feres with the appetite if taken before meals. In order to realize its great utility, when used alone, it must be persevered with for a long time. In syphilis I am partial to it in combination with such agents as the corydalin, irisin, phytolacin, smilacin, podo- phyllin. No physician that gives this agent a fair and impartial trial, but will realize important results. Corydalin.—Our clinical experience in the use of this agent, in all forms, enables us to speak positively of its remarkable value. In combination with podophyllin, it has been much used in syphilis. No single agent possesses more positive and energetic anti-syphilitic properties. An energetic alterative, combining excellent tonic powers. It neutralizes, deterges, promotes depuration of the virus; toning the various functions in performing their proper share of elimination. In very small doses it resolves the plasticity of the blood, regulates and quickens the activity of the eliminating vessels, more especially the* renal and cutaneous; promotes digestion, assimilation, and nutrition. It is particularly indicated in extreme cases, where debility is intense, the blood extremely reduced—in repairing, in building up new tissue, the peculiar efficacy is apparent. It is well, also, to combine it occasionally, or give it in alternation, to meet the peculiar indications of the case, with ampelopsin, irisin, stillingin, &c. In the correct treatment of the venereal disease, it is worthy of the confidence of the profession. The C. tincture corydalis and saturated tinct. of Jeffersoniae, are excellent in com- bination. In the use of these agents, much depends upon getting proper action of the three principal emunctories : the skin, kidneys, and bowels. Great care is necessary not to over-stimulate and exhaust those organs. I have, also, derived good results from the corydalis and viola tricolor: this is a valuable anti-syphilitic. Irisin, also, is a remedy of great power in the treatment of con- stitutional syphilis—chiefly useful as a powerful resolvent, and TREATMENT OF SECONDARY SYPHILIS. Ill promoting the activity of the absorbent system. I have given this with the populin, with the most decided advantage. Con. Comp. Stillingia Alterative.—This is one of the very best combinations in the treatment of the venereal taint. As a remedy, it is remarkably efficient; best given about two hours after meals, dropped in cold water. Tinctura Kalmioz.—The sheep-laurel leaves, in the form of a tincture, is one of our very best alteratives, and is peculiarly indicated in syphilitic affections, in doses of ten drops, three times daily, gradually increased. It forms one of the most efficient remedies when it is added to the stillingia, syr. C. I have also derived the most decided results from the celastrus scandeus, some- times alone, or with irisin—it is an efficient remedy; in the skin affections, I use it as a decoction or an ointment. The helianthenum canadense, in decoction, syrup, or fluid extract, or combined with corydalin, irisin or stillingin, forms one of the most valuable reme- dies in secondary syphilis. Gold is a therapeutic agent of wonderful power in the treatment of constitutional syphilis—nothing contra-indicates the use of this agent; put the patient upon it in small doses, in alternation with some of the above remedies. For internal administration, I employ the chloride of gold and soda, and greatly prefer it in alternation with the concentrated remedies. In small doses, it is endowed with general stimulating, diuretic, and energetic alterative properties; it is a very decided anti-syphilitic, and is rapidly eliminated from the system. It is incompatible with all our concentrated remedies, or extracts, or salts, or metals, and is best given alone in alterna- tion with those remedies; the simpler the form, the less will there be the liability to decomposition. In inveterate cases, I have used gold with entire success. As a general rule, never use a remedy longer than a week or ten days, change, and then resume, and in this way the good effects of a good remedy may be obtained for months. In order to be successful in totally eradicating the poison, treatment must be continued for six months or a year. No matter how efficacious it seems to be, continue it for a long period. Modern research has completely exploded the mercurial treat-' ment; cases now recover more rapidly under the use of dilute nitric acid in a decoction of bark, than under any preparation of this 112 TREATMENT OF THE VENEREAL DISEASE. destructive agent. It is no specific, very apt to bring on complica- tions, and is now discarded by all genuine American practitioners. Iodide of Potassium is an agent that has been much used by the Profession in the C. syr. stillingia, anti-scrofulous syr., C. syr. frostworth. In certain cases it appears to exert an amount of con- trol, but it is very doubtful if its efficacy equals nitric acid. Iodide of potassium certainly causes many of the manifestations of syphilis to disappear ; but they return, unless the remedies above mentioned are used with or in alternation with it. As a means of removing any induration, or eruption, it cannot be rated too highly, but its destructive effects on the red corpuscles of the blood Avill always be a formidable obstacle to its general use. The bromide of potassium, though slow in its action, has no material effect on the blood corpus- cles. Iodide of quinine is valuable in certain cases. An excellent preparation of iodine, in combination with lime, is the iodide of calcium. Its great advantage is that it can be given in most debili- tated states of the stomach; the best period for its use is at the manifestation of squamous disease of the skin, or where mercury has been the prior treatment; the best forms of administration, sim- ple solution ; the solution with the fluid extract of stillingia, iris versicolor; the solution and tincture of sesquichloride of iron, or any bitter infusion not containing starch. The Iodide of Sodium and Ammonium are better calculated to meet the pressing indications of a case of syphilis in its constitu- tional form than the iodide of potassium ; being more active, their effects more positive. The good results obtained by treating this affection with iodine are usually known; yet there are cases which occasionally occur that resist its influence. I have used in these cases a preparation termed "liquor cinchonae hydriodates." Encouraged by the success of the use of the sulphites in European practice, I have been prescribing these agents at the Clinic of the Electic Medical College of Pennsylvania, with some success, in con- stitutional syphilis. The Sulphite of Soda, from these extended trials and experi- ments, seems to be an active antagonist to the virus—a decided im- provement taking place in all cases. In hopeless cases I have tried it in scruple doses three times daily, dissolved in water, with the best results. In one case of rupia, of twelve years standing, I gave it in drachm doses ter die in an infusion of hydrastis and poplar bark TREATMENT OF SECONDARY SYPHILIS. 113 alternately, and in a short time he became perfectly well. I might give innumerable instances where this agent has proved of immense value, incomparable in its effects, to all other remedies. It would seem to neutralize the virus, even after it had contaminated the economy. The sulphites, or bisulphites, are very serviceable where mercury has been given. The bisulphite of potassa I have most frequently used, sometimes beginning in ten or twelve grain' doses and increasing it to a drachm. It is very refreshing to the patient, is soluble in four parts of cold water, or it may be given in sweetened water. It agrees well with all stomachs, and has no local irritating properties, and acts as a diuretic. We would say to the Reformed Profession, try those agents ; that is, the sulphites of soda, of potassa, and magnesia, or the bisulphites, in the treatment of this disease, either in its early or later stages. They are perfectly uninjurious to the animal economy. Nitric Acid will be found serviceable in many cases that resist the action of other agents. I have found it best where there is emaciation, debility, caries of the bones and general derangement of the nervous system. The Alkaline Permanganates are highly recommended as anti- dotes to the contamination produced by the syphilitic virus; no doubt they are well calculated, in an eminent degree, to meet cases of poisoning by organic poisons. What their positive virtues would be, in syphilis, I am not prepared to say. The chlorate of soda is a very soluble agent, and may with advantage be substituted in certain cases. With regard to the chlorate and permanganate of potash, advan- tages of a very decided character are to be derived from their exhi- bition—the former in syr. stillingia or in a saccharine vehicle; the latter in doses of half a grain three times daily, dissolved in a wine- glassful of distilled water, care being taken to prevent its contact with any organic matter before it is administered, whereby decom- position would take place. Guaicum, yellow dock, sarsaparilla, are absolutely worthless; true, they have acquired a great reputation as valuable agents, but this has resulted in a great measure from their being simply the vehicle for conveying the bichloride of mercury into the system. I have used a remedy that I esteem more efficient, and that is chion- 15 114 TREATMENT OF THE VENEREAL DISEASE. anthus virginica, the bark of the root in infusion; it is an altera- tive and tonic. Guaicum has been used to relieve the nocturnal pains Avhich occur in the bones, muscles, &c, but it is not at all a reliable agent. Lu- pulin, hyosciamin and chlorodyne are better agents for this pur- pose ; they possess no antidotal property, but prevent irritation and give the patient rest, quieting the nervous system, diminishing pain. Chlorodyne is a good agent; twelve minims of chlorodyne in water twice before bed-time, acts so well that patients enjoy the most absolute, perfect rest. The effects do not soon pass off—a good dose at bed-time, the patient will feel easy for forty-eight hours. It may be applied locally with good results, producing warmth and perspiration, with a remarkably smoothed state of mind and arrest of pain. We might take up our space to an almost unlimited extent in enumerating remedies that have a reputation as anti-syphilitics. But there are numerous medicines, valuable adjuncts, not possessing any specific effect, but as tending to build up and support the sys- tem. Among these we have iron as entitled to the very highest consideration, as are the vegetable tonics, cinchona, gentian, quassia, hydrastis, &c. Iodine—Iodide of Iron and cod-liver oil or glyce- rine, hypophosphites. Besides the treatment of constitutional syphilis by means of internal medicines, it also is good practice to aid the eradication of the virus, and aid in producing a constitutional change by means of external medication, by means of baths. We have the ordinary bath, with a sufficient quantity of an alkali, or iodide of potassium; we have the sulphur bath, or the nitro-muriatic acid bath, all ex- cellent adjuncts, and should not be overlooked. The Turkish bath is esteemed by some superior to all others ; certain it is that is well adapted to the chronic stages of secondary syphilitic eruptions. Baths are useful, nay, indispensable; but not so effectual in eradi- cating the disease as internal medication. In the skin affections bathing and inunction by remedies incorporated in glycerine, are highly advantageous. In some cases I have used baths, say twenty gallons water at 98° Fah., with five ounces of the sulphuret of potash. This is an excellent bath, and might be used with advan- tage every second day, or according to the severity of the disease. This plan is adopted in the French hospitals. Fumigation may be TREATMENT OF SECONDARY SYPHILIS. 115 used also with success, in bad cases. At other times I have used alcohol with tinct. iodine. The ordinary vapor bath, which can be used by any patient. Sweating is a potent remedy for intractable and inevitable cases of secondary syphilis. I have found the fol- lowing useful where the itching is extreme, say four drachms of chloric ether to a pint of elder-flower water. I have also used phosphorus, locally and internally, with success. Its energetic revulsive properties render it valuable in the former, and its great tonic properties in the latter. Chloride of soda in solution is sometimes advantageous; pitch ointment. The red spots or efflorescence of the face are best treated by washing them several times daily with borax and rose water. Relative to the hygienic management of syphilis, there is much, very much that can be done. Cleanliness is most essential, an important element in the treat- ment of syphilis, and should be strenuously, nay, rigorously insisted upon. The patient should either be sponged all over, or he should bathe, making a free use of soap. The clothes that come in imme- diate contact with the skin should be frequently cleansed. The mouth and throat should be washed, and the teeth cleansed several times daily; and for these purposes the chlorate or permanganate of potash should be employed. Nothing so destroys the bad odor of the secretions of the mouth in a syphilitic patient, as the per- manganate of potash. The diet should be most nutritious, digestible and abundant, consisting of meat, eggs, bread, with a sufficient quantity of stimulants, in the shape of wine or ale, to aid digestion, without creating drowsiness or feverishness. He should avoid excess. Let him have his tea and coffee and tobacco. The patient wants to make blood quickly, good blood, and let the system be fur- nished with agents calculated to meet this pressing indication. The rule should be, satisfy the appetite; whatever is known to produce disturbance should be avoided. One remark that we might make, and that is, in the treatment of constitutional syphilis never allow your patients vinegar, or any form of acetic acid; if we do, our best remedies may be neutralized. Fresh Air is highly essential. His apartments should be well ventilated; he should be encouraged to take exercise in the open air, when the weather permits. Free exercise of the muscles and 116 TREATMENT OF THE VENEREAL DISEASE. lungs, in the open air, is indispensable. The accelerated venous circulation which it causes, and the compression of the abdominal viscera by the contraction of its muscles, are the best means of promoting the action of the liver and lungs, and preventing consti- pation and its attendant evils. But the exercise, in all cases, should be voluntary, so it would not be carried to fatigue, which must be avoided. Daily walks in the open air are always beneficial; sud- den changes of temperature must be carefully guarded against; damp weather should be carefully avoided. The air of the moun- tains in the interior, in the summer, and in the late autumn, when the air loses its freshness, and is tainted with the falling leaf and decaying vegetation, the suburban parts of cities, such changes are y advisable for those who can afford them. But if the habit be extremely delicate, nothing is better than an equable temperature. The clothing should always be of such a character as will protect the surface from sudden chilling. Flannel should be worn next the skin, both in summer and winter; in winter for actual warmth; in summer to neutralize any accidental changes of temperature. The syphilitic individual should keep regular hours, abstain from venereal excesses; he should lead a temperate life, equable both as regards his physical and mental existence. It is thus, when these hygienic measures and proper internal and external medication is used, properly and efficiently, that we can thoroughly cure syphilis. The hygienic measures are valuable as accessories; they should never be neglected, for much depends upon their judicious use. SYPHILITIC ERUPTIONS. We have seen that the syphilitic poison, once introduced into the system, is apt to be followed by certain eruptive manifestations; these are only the visible evidences of a deep-seated change in the system at large. The functions of the various organs are deranged, the blood is charged with a poisonous principle, its corpuscles are impaired, indented, few red, and a superabundance of white corpus- cles ; and all the organs and structures supplied with that blood suffer to a greater or less extent. The brain evinces its suffering by mental dejection ; the nerves, by a general feeling of prostration and debility—there is often neuralgic pains in the bones, showing the osseous system is implicated ; the heart is imperfectly nourished, the pulse is quick and weak, the secretions are impaired, the fauces are more or less congested, the tonsils and soft palate being frequently swollen; there is irritation of the larynx, producing a mucous cough and often nausea; the conjunctiva is congested and muddy, and the whole skin remarkable for its yellowish and dirty appearance, looking as if saturated with impure and discolored humors. We have seen that syphilitic eruptions have certain peculiarities. We have the history of syphilitic inoculation, which tells its tale by the numerous symptoms due to the circulation of the poison, and in addition, by the presence of cicatrices, indurations, scars, and stains about the penis and groin. Their color, copper colored; in reality a reddish, yellow brown, dull red at first, yellow dirty stain remaining for a varying length v of time. Their form, which is peculiarly circular, syphilitic, scaly erup- tions, are composed usually of circular spots. Scales or squamae are thin, very fine gray. Crusts are thick, greenish or black. Vesicles are flattish, and do not readily rupture. Absence of itching or pain, syphilo-dermata are generally unac- companied by heat or pruritis during their existence. Their poly- 118 TREATMENT OF THE VENEREAL DISEASE. morphism is very characteristic of syphilitic disease. Several kinds of eruption may co-exist. It is no unusual thing to see papules, pustules and squamae co-existent on the same patient. Progress of the Virus.—Induration of the part inoculated, equiva- lent to increase of virus by molecular or cell development. Absorp- tion and transmission of virus to the contagious glands; induration and irritation of those organs; leucocytosis; and, consequent thereon, modification of nutrition. Passage of the virus into the blood; its elimination through the skin and mucous membranes, and consequently, eruptions and ulcerations. Absorption by the lymphatics of the syphilitic virus not wholly eliminated; irritation of other glands; transmission of virus from one set to another, &c, &c. Elimination failing; alteration in quality of virus, and its deposition in certain structures; profound lesions of nutrition. The first manifestation of constitutional syphilis is, as we have already stated, Syphilitic Fever.—It frequently happens that this is the earliest symptom of the infection of the system. The first thing to be done is to put the patient upon constitutional treatment, say begin with the C. syr. stillingia, with irisin, and iodide of sodium; and the preparation might be advantageously combined with tinct. kalmia, in sufficient proportion. Aconite, with sponging the surface if the fever is high, is admissible. But, by no means, must the patient be depleted; he must be built up. The constitution is impaired, depraved, depletion always makes matters worse—the fever is asthenic. If there are evidences of gastric or intestinal derange- ment, the neutralizing mixture, with juglandin or leptandrin may be given, and attention should be assiduously paid to the general well- being of your patient, to his food and drink; it should not be of an irritating or stimulating character. Should the pains in the head and bones become severe, we may give chlorodyne, or hyosciamus, or camphor and gelsemin, or opium. Battley's solution, ten drops every two hours, with five drops of chloroform, and increase at bed-time. Sleep is an essential element in the treatment of disease. In the exhibition of our concentrated remedies, it must ever be borne in mind that we derive their best results in a triturated form, in sugar, or what I deem better for that purpose, asclepin. These remedies, given in a pure form, are prone to produce local irrita- tion, frequently causing them to be rejected, or creating constitu- TREATMENT OF SYPHILITIC ERUPTIONS. 119 tional sypmtoms, which very much lessen their curative powers. If you prefer the con. tinctures, they must be given in water. The quantity to be administered must depend altogether upon the age and temperament of the patient. If the affection is chronic or inveterate, syrup is a good form to administer them; it serves the purpose of combustion in the lungs and extreme capillaries, increas- ing the animal temperature, promoting secretion and excretion. If you desire to improve nutrition, rapidly and effectually, give them in glycerine, as one of the best of agents. The best remedy to control the fever, with all its complications, is powerful constitu- tional treatment. The neuralgic and muscular pains are sometimes effectually relieved by the hypodermic injection of a solution of morphia, along the course of the painful nerve or muscle. Alopecia is usually one of the first symptoms 'of constitutional syphilis, and is best arrested, and the hair restored, under the influence of constitutional treatment. Some stimulating washes may be employed in conjunction; such as an infusion of hyssop; borax, in a spirituous lotion; tincture of cantharides, glycerine, and some essential oil. The head should be well-washed with the yolk of egg, or borax in almond emulsion; afterwards, carefully rinsing with warm water, and then apply the following lotion: ]^,—Spirit ammon. aromat., Tinct. canth., Glycerine, aa Siss; Aquae rosea, Svi.—M.; or, B/.—Tinct. kino, " sang, can., aa Siv; " lobelia inf., Sii; Oleum ricini, Sss; Cologne, Si-—M. Or try the carbolic acid dissolved in glycerine, which is often used with a very good effect. All scaly articles must be removed prior to its use, by soap and water. The lotion which I have found best, is one drachm of the acid to three ounces of glycerine, applied night and morning. Carbolic acid may be dissolved in acetic acid, and forms an excellent application for some of the eruptions—the 120 TREATMENT OF THE VENEREAL DISEASE. vapor of iodine, &c. Soap and water, and rubbing with a coai^e towel, should not be neglected. The syphilitic diseases of the skin are to be treated with the alteratives already recommended, irisin, ampelopsin, corydalin, &c.; iodine, iron, sulphites, gold, &c. The con. comp. stillingia altera- tive, is an excellent remedy, alone or combined, or in alternation with other remedies. It improves the powers of nutrition generally, and may be given here with decided effect. This is a remedy of peculiar service when there is great weakness, with great irrita- bility, when tonics and diet cause feverishness, when nothing seems to agree. It is a good alterative in syphilitic diseases of the skin, which are dependent upon a degenerated condition of the blood. It has no equal, we say this from an extensive experience of its use. Its action is mild and certain, and cannot, under any circum- stances, produce disorganization of the bones and soft parts. Nearly as good an alterative as the stillingia, is the comp. syrup of celastrus. This combination was first given to the profession by J. J. Fullmer, M. D., of this city. I have prescribed it with good success. The following is the original formula, from the Doctor's note book, prepared as the stillingia. C. syr. Celastrus. B/.—Rumex crispus rad, Celastrus scandens, Phytolacca decandra rad, Iris versicolor, Corydalis formosa, aa. Sx ; Menispermin can a. rad, Xanthoxyllin bac, aa Sviii; Chimaphylla umbellata, 1 lb ; Sacch. alb., 24 lb.—M. Ft. syr. 2 gallons. Iodine is of great service in an alkaline form, such as the iodide of sodium in the stillingia alterative. Alkalies, so combined, are of great service, not only neutralizing acrid secretions in the stomach and bowels, but aid materially in altering the abnormal condition of the blood. They are especially indicated if the patient has any gastric irritation; such remedies as sulphite of soda, or potassa, or magnesia. The basis of a very rational and extremely successful treatment of these skin affections, consists in the administration of TREATMENT OF SYPHILITIC ERUPTIONS. 121 these sulphites, in alternation with other alteratives, and at the same time the use of highly animalized diet. Chemistry has shown in an interesting manner, the reason of this fact; which is, -that the phosphates are passed in the urine of syphiUtic patients, to an extent many times greater than natural. We would, also, give bark occasionally, when we desire a sudden impression on the system—either alone or combined, to suit the indications; its effects are always manifest, producing a refreshing and exhilarating effect on the system, which nothing, can equal. We would give iron also. Pyrophosphate of iron is a valuable preparation; no tonic acts so powerfully, so favorably, and so promptly, prepared in a liquid form—easily to administer, and rapidly absorbed. The iodide is a good preparation—iodide of iron where we have a strumous habit. In some cases cod liver oil or glycerine, seems to promote nutrition, and in this way becomes serviceable. Various combinations of the vegetable tonics and alteratives will be found most serviceable. We must attend specially to the indications of the case, the secretions, &c. But one thing we must not do, we must never weaken our patients by purgatives, nor must any remedy be given as a specific, nor without consideration. Syphilitic skin affections are prevalent; indeed, of a very aggravated form where mercury is used; indeed, in some cases, we find them to be the direct results of mercurialization. Under the one absorbing idea that if ever an alterative impression is desired, under any condition whatever, instead of employing hygienic measures, and more harmless, but equally more potent remedies, some form of mercury is administered in every prescrip- tion, and the whole capillary system of persons who are frequently unwell, soon become impregnated and poisoned by this subtle mineral. The consequences of such a system of medication, whether in the tiny globulist, or in the more daring allopath, pre- sent themselves to our view in dyspeptic affections, chronic head- aches, pains in the limbs, alveolar absorptions, inveterate ulcera- tions, where' no specific taint has been suspected, and in various degenerations. The evil does not stop with the unhappy patient; for where important elementary tissues are deteriorated in the parents, a con- stitutional infirmity will be impressed on the offspring, which, if it be not syphilitic or strumous from birth, is certainly the condition 16 122 TREATMENT OF THE VENEREAL DISEASE. most favorable for the phenomena of such a diathesis—when some co-operating influence shall attack the sufferer. The interests of humanity, the honor of our profession, demand of us who witness and observe the whole ramifications of this destructive agent, that we should utterly condemn, with the most unqualified protestations, its use as a medicinal agent. In most skin affections, if the health be even slightly impaired, they come on rapidly and then remain stationary. There is nothing gained by waiting; but the patient must at once be put upon such a course of treatment as we have indicated. We think that the iodide of sodium is one of the very best preparations of iodine. It has several decided advantages; its taste is much less disagreeable than the iodide of potassium. It is better borne by the patient, and less likely to occasion iodism. It has succeeded often and again where the other salts have failed; but over the truly scaly diseases the iodides have not quite so much influence. The prepa- rations of gold answer better here. Vegetable alteratives, as the comp. tinct. of corydalis, or an infusion of equal parts of alnus, rumex and Jeffersonia, alternated with the simple bitter tonics. In addition, I have derived great benefit from an alkali, such as a solution of the acetate of potash in usual doses. A good form of treatment consists in giving the following: B/.—Podophyllin, gr. vi; Irisin, gr. xxx; Corydalin, 5ss; Oil of stillingia, q. s.—M. Ft. pill xv., one every three hours. It is notorious that strumous subjects bear syphilis badly, and the eruptions in such subjects assume very anomalous conditions. Sudorifics, or some of the vegetable decoctions, with the carbonate of ammonia, or small doses of sulphur, with sulphur baths, are of great utility as adjuncts; but must not take the place of our great anti-syphilitic remedies. Cleanliness is all important—the alkaline bath. Vesiculae are characterized by more constitutional disturbance than the first form, sometimes transformed into crusts or scabs. Syphilitic tubercles of the skin are deep-seated, solid, circum- scribed elevations, containing neither lymph or pus, either isolated TREATMENT OF SYPHILITIC ERUPTIONS. 123 or grouped, generally complicated or associated with a scrofulous, scorbutic or herpetic tendency, or diathesis. If there be no contra indications, the treatment may be commenced by the exhibition of the iodides of sodium, or potash, with the other alterative treat- ment, the vapor bath, cooling lotions, composed of the chloride of lime, nitrate of silver, the aromatic wine, astringents and sedatives. The iodides are best given in the stillingia syrup, or in decoction of bark. If the disease do not get along well under one remedy, resort to another at once; give the patient a fresh atmosphere; watch his health carefully. If the patient has been mercurialised previously, or if he suffers from salivation or mercurial tremor, the iodide of sodium or potas^ sium must not be given, as it seems to aggravate the symptoms. In these cases the chlorate of potassa will be found an excellent remedy, and for iodine give the pure tincture. In the treatment of pustular syphilis, if the health be good and the disease recent, the patient might be dealt with actively, the secretions might be freely stimulated, and the diet must be well maintained ; we must give alteratives and vapor baths. To these sores various applications may be used; the carbolic acid in glyce- rine might be tried, or they might be washed with an. astringent and soothing Avash, or they might be covered with collodion, or the solu- tion of gutta-percha in chloroform. As a local application glycerine, medicated, lotion of borax and morphia, equal parts of glycerine and muriated tinct. iron. The application of the chloride of zinc followed with hydrastis. A formula of utility is : B/.—Oxalic acid, gr. xx; Carbolic acid, gr. x; Aqua, Sii.—M. The iodide of sulphur is a very efficient remedy. In certain cases, the local application of the liquor soda chlorinated is a good remedy. The tubercles usually disappear under its use. In very stubborn cases, the extract of phytolacca decandra, or the trifolium pratense, may be used with good success. If they secrete much pus, they might be dusted with hydrastin, or myricin. Ointments are unsuited to these ulcers, and under ordinary conditions the collodion or gutta-percha dressing, to defend them from friction and atmospheric influence, ansAvers Avell. 124 TREATMENT OF THE VENEREAL DISEASE. In this form of the affection I put great reliance on sedatives. Battley's solution, with chloroform, is of great value; its adminis- tration is almost always followed by good results. It is of especial use where the nights are bad, and the patient emaciated and feeble, where a general irritability is wearing out the patient. In such cases anodynes act almost magically. They may be combined with other remedies. Even the application of an aqueous solution of opium to the pustules, with essence of beef; the vapor bath and iodide of iron will not give such salutary results as anodynes. Pustules are usually complicated, and require modifications in the treatment suited to the exigencies of each particular case. There is no one of the syphilodermata which require special consideration in the treatment. All are managed upon the same general plan; even in the most depraved states, such as rupia, especial attention should be given to building up the health of the patient to a normal standard. With this view, our concentrated vegetable alteratives, iron, gold, bitter tonics, good nourishment, should be carefully given, and every hygienic measure brought into full play. Baths are essential. In cases of psoriasis, where our anti-syphilitics fail, the administration of thuga may be tried, and, if necessary, its action must be aided by other remedies, such as the solonum dulcamara, which is of great benefit. This remedy is of very decided advantage here, either alone or combined with yellow dock and stillingia. The fluid extract is convenient of exhibition. In sloughing ulcers, a solution of bromine, in alcohol, in the proportion of twenty to forty drops of the former to one ounce of the latter, makes an excellent wash; and a solution of permanganate of potassa, fifteen grains of the crystals to two or three ounces of water, is fully as good, if not better. Both these lotions may be used with great advantage in cases of phagedenic ulceration, which occasionally supervenes in tubercular skin disease in bad conditions of the system. Mucous patches may be locally treated with solutions of nitrate of silver, tannin, permanganate of potassa, sulphate of copper, &c. It is the constitutional treatment which cures them. Local reme- dies are merely accessory, and not of importance unless there be extensive ulcerations. Sometimes a lotion of nitric acid or of creo- sote, in the proportion of twenty minims to'the half-pint, answer very well. The exhibition of thuga, aided with other remedies, is often successful. TREATMENT OF SYPHILITIC ERUPTIONS. 125 Syphilitic onychia.—The matrix, or root of the nail, is very commonly affected with syphilitic inflammation ; sometimes occurs as an isolated symptom of constitutional syphilis. The treatment must be constitutional; local treatment has no influence over the disease. If, however, the pain is very great, opium, or morphia, or hyoscyamin may be applied locally in aqueous solution. Cold water, or the lead and opium lotion, &c, are always soothing. Syphilitic warts, excrescences, vegetations, condylomata, of varied form and appearance, upon the skin or edges of the mucous membranes. These excrescences appear on the skin, or muco- cutaneous surfaces of the male and female organs of generation. They are variable in appearance and consistency. In ordinary cases these excrescences may be removed by bathing with a strong solution of the muriate of ammonia, or sanguinarin and phytolacin, savin and alum. With these applications the warts may be sponged freely several times daily. The local application of a saturated tincture of thuga is effectual. In mild cases these remedies will succeed. If they are hard, if they are of old standing, or do not yield to these remedies, it becomes necessary to employ escharotics, the best of which are chromic acid, strong acetic acid, or even the charcoal paste. Ligation and excision are also resorted to. Syphilitic Iritis.—»The treatment must be very active. The dis- ease progresses with extraordinary rapidity; it occurs early, and the pathological changes are of such a character that vision is often lost before treatment is fairly under way. Prompt and energetic measures, with discretion and good judgment. In iritis keep the pupil dilated, with atropia, one grain to an ounce of distilled water, dissolved by the aid of two or three drops of acetic acid. One drop of this solution in the inner canthus of the eye thrice daily, or insert a square of the gelatine atropia paper; either is rapidly diffused over the whole surface of the globe, and besides dilating the pupil, lessens, through its sedative action, the pain and irritation. If neither of these agents be convenient, the extract of belladonna, diluted with glycerine, should be smeared around the eye and forehead, and the application renewed twice daily. In this complication, the most powerful constitutional treatment, with baths, and that sheet-anchor, quinine; give quinine, combined Avith the other remedies, alteratives, iodine, iron, gold, and above 126 TREATMENT OF THE VENEREAL DISEASE. all, subdue restlessness, irritation, and give the patient sleep, rest— comfortable sleep—perfect rest. In iritis the system is terribly broken down, and requires active means for its restoration : essence of beef, eggs, good and nourish- ing food, supported by iron, vegetable tonics, and strict attention to hygienic measures already recommended. Local applications do more harm than good; glycerine, wash of chlorate of potassa, or hydrastin, hamamelin, sassafras pith, or decoction of slippery elm. Let the patient have fresh air, let it reach the eye. Counter irri- tation to the back of the neck is also useful. In some cases purgation, vapor bath, gelsemin, or the C. tinct. sepentaria. As an anodyne here, lupulin and hyoscyamin. A collyruim of hydrastin and aconite is used with advantage. Secondary or constitutional syphilitic ulcerations of the mucous membranes are extremely common. They are seated on all parts of the mouth. We have, also, superficial ulcerations upon the tongue, the inner surface of the lips. These must be attended to by the specific treatment, regulated diet, and frequent gargles, more particularly those in which tannin, or hydrastin, or hamamelin form an ingredient. B/.—Tannin vel hamamelin, T]) ; Spiritus vini gallici, Si? Aqua rosa, Svi.—M. Ft. gargle. B/.—Tinct. myrrh, Si; Mellis cuprati, Sss.—M. Touch the ulcers with this, night and morning, or try diluted nitric acid, or sanguinarin and phytolacin. In most instances they are extremely difficult to cure. These aphthous or superficial ulcer- ations in the mouths of patients who have suffered from syphilis and have irritable mucous membranes, are generally due to mercury and not to syphilis. It is remarkable that such patients suffer much from dyspepsia. Mercury aggravates this condition of the mouth in an astonishing degree, whilst they usually subside under the use of mild astringents, tonic gargles, chlorate of potassa, or B/.—Acid hydrochloric, 5i I Tinct. cinchonae, Si; Aqua destilled, Svii.—M. Ft. gargle, TREATMENT OF SYPHILITIC ERUPTIONS. 127 - or rhusin; the administration of small doses of hyoscyamin, an infu- sion of iris versicolor or hydrastis with lime water. The mineral acids, the nitric and sulphuric, followed with washes of chlorinated soda, carbolic acid, myrrh. In some cases we have syphilitic ulcers of the throat, pharynx, fauces, appearing under several forms. These ulcers may occur with or without different forms of cutaneous eruption, pains in the head and limbs, loss of hair, and other forms of constitutional infection; also, with the most varied conditions of the general health. Patients who have suffered from constitutional syphilis, frequently complain of pains in the throat, increased by deglutition, and re- ferred to various points about the larynx and pharynx. It is evi- dently a sort of neuroses, no lesion being detectable. The treatment of the venereal ulcers of the throat resolves itself into local and constitutional. Local treatment is important. The ulcers should be touched from time to time with nitric or muriatic acid, followed with gargles of various kinds. With this local treatment should be associated constitutional treatment, according to the nature of the case; and here so varied are the conditions that it is impossible to lay down any fixed rules. Remedies likely to be of service are the vapor bath, the decoction of phytolacca, the mineral acids, sulphites, iodine, or the hydrodate of potass, good diet, fresh air, &c. The preparations of gold in inveterate forms of syphilis, tonic remedies, such as will aid nutri- tion and good diet, is the best plan of treatment. TERTIARY SYPHILIS. After the lapse of six months, and often longer, the syphilitic poison exhibits its action more decidedly in the deep-seated tissues, such as the cellular tissue, muscles, bones, and periosteum, testicles, and other viscera, as well as the nervous system, and this is called the tertiary stage of the affection. If the treatment of the secondary affections has been judicious and prompt, the morbific matter of syphilis is overcome before this period is reached; or if not followed by complete success, the course of the disease is so much interfered with, or broken up, that we may not have any uniformity in the appearance of this stage. Syphilitic sarcocele, or orchitis, is amorfg the earliest of the ter- tiary accidents, and is sometimes, though rarely, met with among those of the secondary period. It commences without pain, and generally pursues its course without this symptom being present. The organ increases slowly till it becomes, perhaps, as large as a small orange, and is inconvenient on account of its size and weight. The disease is usually limited to the body of the testicle—the epididymis is seldom involved—rarely suppurates. When the disease is limited to one testicle, sexual desires may still exist. This is generally the case ; but sometimes both testicles are affected, and then the animal passion becomes, by degrees, entirely extinct. Syphilitic induration of the testicle is the result of a slow and indolent inflammatory process, followed by the de- posit of a peculiar material like connective tissue, which obliterates the seminal canals. But under appropriate treatment, the canals are re-established. In the earlier stages of simple sarcocele, an alterative course, suited to the age and constitution. For this purpose the remedies already mentioned are most efficacious. The iodides, with medi- eated baths. As local applications, frictions, with iodine ointment, or extract belladonna or conium, the compound iodine ointment, the ointment of the iodide of lead; the latter I prefer. Compression TREATMENT OF TERTIARY SYPHILIS. 129 here is useless. Counter-irritation is of great benefit. Where sar- cocele occurs, as a complication, and other and more important syphilitic symptoms are present, the treatment requires modifica- tions to meet any indications. Gummy Tumors are only met with after syphilis has existed many months. They are produced in the submucous or subcutane- ous cellular tissue, and are also found of precisely the like histologi- cal characteristics in the muscles and viscera. Sometimes isolated, sometimes two or more apparently fused together, presenting a nodulated appearance. Some patients have a large number, and are accompanied by other syphilitic affections ; by a more or less depraved and anemic state of the system. The internal treatment should consist of the administration of our concentrated alteratives, with the iodides of potass or iron, either alone or in a state of combination; medicated baths also assist powerfully in the resolution of these tumors. If the skin covering the tumor has become thin, and is of a deep- „ red or livid color, we shall seldom succeed in dispersing it. In this diseased integument one or two spots of ulceration soon appear, which spread rapidly till the whole covering of the tumor is de- stroyed. When this is the case, we have an ulcer of most formidable character, which sometimes penetrates, to a very great depth, in the soft parts of the extremities, laying bare muscles, producing caries, necrosis, or absorption of the bony tissue to a greater or less extent. In such cases the constitutional treatment is still our chief reliance; but the local aspect of the sore will require a treatment suited to its varied aspects. Should it become phagedenic, it must be treated, with its destruction, with bromine. Afterwards Aveak lotions of chlorate or permanganate of potash, or dilute nitric acid, or carbolic acid, or creosote, in suitable proportions; these ulcera- tions require, from time to time, superficial cauterization. Osteoscopic pains are extremely common during the tertiary period. They are due to incipient periosteal, or osseous disease, and are worse at night. The bones most frequently attacked are those of the cranium, tibia, claAdcle, radius, ulna, sternum, the inferior maxillary and fibula. The pain is of the most intense character, aggravated by the slightest touch. Loss of sleep, extreme nervous irritation, wear the patient completely out—make them uncomfortable and weary of existence. If not arrested, Ave 17 130 ^ TREATMENT OF THE VENEREAL DISEASE. will have periostitis, osteo-myelitis developed, and as the results, exostosis, caries, and necrosis supervene. The pains in the bones are in a great measure, though not totally, due to the use of mercury as an agent; too frequently given for the cure of antecedent constitutional syphilitic symptoms. The treatment best suited to these pains consists in the administration of iodine or gold, or what I regard still better, the chloride of platinum and sodium; it is very applicable here; it often gives wonderful relief. It is efficacious either alone or with gold, or in alternation—it produces no bad effect upon the system. The bromide of potassium, combined with colchicum and aconite in some cases; also, our concentrated alteratives in solution, especially the corydalin with cornin and some anodyne; if the parts are tender, the pain fixed and not fugitive, counter-irritation may be tried. The phytolacin is one of the very best remedies for the removal of those pains attending syphilitic affections, mercurial or otherwise. It excites the whole glandular system, and is specially indicated in the secondary, as well as the tertiary forms of the affection. The asclepias or eupatorium answers a good purpose as a diaphoretic; the acetate or citrate potassa. To aid these remedies, the warm or vapor bath. If we have rheumatic symptoms, macrotys; to the affected part, equal parts of conium and belladonna, softened with tincture of aconite, so as to spread in plaster form, or a poultice, or fomentation of poppy heads, or hops, or the polygonum, answers a good purpose. As the disease progresses, keep up the system with tonics, iron, a free use of stimulants. Sometimes the irrita- ting plaster, or painting with iodine, or the application of the bella- donna and conium plaster. A valuable application is formed of equal parts of powdered podophyllin and thuga occidentalis, made into a poultice and applied. At this particular stage, iodine baths are of great value, on account of the great extent of the skin, which furnishes the meai s of introducing a considerable quantity of iodine into the circulation, without deranging the digestive functions—an object of great importance when medicine disagrees with the stomach. In the use of iodine for a bath, double the quantity of potassium should be used with the iodine, as a solvent, in a wooden bath tub; the iodine and iodide should be dissolved in a small quantity of water before they are added to the bath, this facilitates thorough diffusion; \ TREATMENT OF TERTIARY SYPHILIS. 131 a gallon of water to three grains or more of the iodine. These baths should be resorted to three or four times weekly. The iodine vapor may also be used in various forms; the vapor of iodine from a spirit lamp. Nodes.—Those enlargements of the bones termed nodes, apper- tain to the natural history of the progress of syphilis, if badly treated, or suffered to go unchecked by remedies. Nodes arise as a consequence of primary venereal ulcers, when the disease has become constitutional from the absorption of the poison, and the poison has penetrated deeply into the system. The bones are about the last part to become affected. Nodes, as they are commonly termed, result from an effusion or deposit between the periosteum and bone; the result of inflamma- tion affecting one or both of these parts. Very commonly depen- dent upon a superficial inflammation of the bone itself. These effusions between the periosteum and bone may consist of serum, pus or lymph. Again, nodes are produced by an effusion of a proper osseous matter, similar to the provisional callus first thrown out in recent fracture, or a gummy tumor. Some nodes present to the feeling a true enlargement of the bone itself, or lymph, with the elements of cartilage. Syphilitic exostosis of any kind is not usually attached to the bone, unless within the cranium. Usually developed from the periosteum, merely resting on the bone, which, from its periosteum being detached, is liable to pass into a necrosed condition. Exostosis are met with in the cranium, and in this situation are liable to produce extensive ulceration, disorder of the nervous system; convulsions and paralysis may occur from pressure on the brain. It is possible that venereal diseases of the bones and periosteum, but, more particularly, inflammation of the latter, causing effusion between it and the bone, may be mistaken for or confounded with periostitis, arising from other causes; and, more particularly, where these are of a rheumatic origin and character. The history of the case, the occurrence of syphilis, being complicated with other diseases, the development of nodes, by nocturnal pains—the seat of pain, &c, &c. Our prognosis in venereal diseases of the bones and periosteum, is not always unfavorable. If the health be fair, but if the con- stitution has been impaired by poverty, debauchery, bad living, 132 TREATMENT OF THE VENEREAL DISEASE. mercury and syphilis, all contributing their share to the destruc- tion of the patient, we have a disease to contend with which will baffle our skill, our treatment, however faithfully it may be carried out by both physician and patient. Caries and necrosis generally result from the separation of the periosteum from the bone, to which it belongs, and through which its supply of blood is mainly kept up. This may be the result of the deposit of the same form of matter found in the gummy tumor, in the marrow, giving rise to a syphilitic osteo-myelitis. The bones we have already enumerated as being particularly liable to osteoscopie pains, are those which suffer most from caries and necrosis; but no bones are exempt from their attacks; the bones of the cranium and face, such as caries and necrosis of the vomer, nasal, palatine, are apt to be so in strumous cases. In all, how- ever, the disease has originated through the loss of the periosteum. The treatment naturally divides itself into constitutional and local. By the former, we endeavor to correct the poisoned condi- tion of the system, from which the local disease has its origin, and upon which it depends. By the latter, we endeavor to remove the local cause which such a condition of the system generally produced. All authorities are agreed on the method of cure here, a powerful alterative course for the cure of syphilitic diseases of the bone and periosteum. In every affection of the bones, iodine, either as the iodide of potassium, or ammonium, or sodium, in the alterative syrups, with the concentrated vegetable alteratives and tonics. In alternation the chloride of gold and soda, as one of the very best of alteratives, one of decided efficacy. The dose that I usually give is from one-twelfth to one-thirtieth of a grain, which may be given either in pill or solution. B/.—Mur. gold et soda, gr. ii; Aqua distilled, Si.—M. Dose: twenty drops ter die. B/.—Chloride gold et soda, gr. ii; Ext. gentian, q. s.—M. Ft. forty pills. Externally it may be applied to scrofulous or syphilitic ulcers, in a solution or ointment. The treatment must be essentially tonic, aiming at the restoration of the general health. The above TREATMENT OF TERTIARY SYPHILIS. 133 remedies may be alternated with the phosphates, &c, the C. tinct. corydalis, with iron, quinine, hydrastin. Baths, &c. Venereal diseases of the bones are now treated more successfully by the above remedies than by the old method. Venereal nodes, too, yield more rapidly to the above treatment, and to the use of iodine. At this stage of the affection we have derived great benefit from the preparations of phosphorus—either the phosphoric acid or the tincture of phosphorus, or some of the other combinations. In alternation we would suggest a decoction of celastrus, rumex, and scrophularia freely, with the occasional use of the hydro- chlorate of ammonia. The circumstances which lead us to select gold as a remedy in venereal disease, in its tertiary stage, is its great power and utter harmlessness, being prompt in the relief of protracted cases. Also, the use of the iodides in an infusion of gentian, or decoction of . stillingia. The local treatment of venereal diseases of the bones and perios- teum is of some importance. They may be treated locally with friction, blisters, or solution of tincture of iodine in glycerine. They should not be incised, unless it is very evident that a large * quantity of pus is present, and is burrowing under the periosteum. If much distension be present, it is well not to lay the abscess open with a lancet, but to puncture with a very fine trocar. This mode of practice will relieve the distension, and give time for other treat- ment to be brought to bear; at the same time the puncture will be so small that no air can possibly be admitted, the surface of the bone will not be exposed, and the risk of caries and exfoliation will certainly not be increased. Syphilitic disease of the nostrils and nasal fossae often begins with the symptoms of ordinary cold ; the nose is dry and uncom- fortable, the voice hoarse, a fetid muco-purulent discharge, mixed with blood, &c, &c. These affections of the nasal fossae very com- monly occur as isolated symptoms of syphilis. The treatment is constitutional and local—the latter consists in the application of carbolic acid, of a solution of gold, injections of antiseptics, of lime, pyroligneous acid. Nitric acid is a useful remedy here, internally, in four drop doses thrice daily, and at the same time a gargle, composed of a drachm of the pure acid to six ounces of water, may be applied locally. This is beneficial—so is nitrate of silver, in the proportion of five grains to an ounce, or a 134 TREATMENT OF THE VENEREAL DISEASE. strong solution of hamamelin. The following may be administered with manifest benefit: acid sulp., borax, lachesis, phosphorus, sul- phur, syr. iodide of iron. One of the most formidable varieties of constitutional syphilis is ulceration of the mucous membrane of the glottis, and larynx. Syphilitic ulceration of the larynx generally follows or accompanies other similar diseases of the nasal fossae, throat, pharynx, &c. The symptoms are loss of voice—hoarse, husky, or totally lost—the patient expectorates a fetid pus, and portions of sloughs mixed with blood, &c.; ulcerations, with constitutional syphilis. We frequently meet with syphilitic disease of the lungs, which takes place in many constitutions in the latter stage of the affection : the body wastes, the appetite is lost, the patient becomes anemic, strength diminishes, night sweats, diarrhoea sets in, and we may • have a fatal termination. The syphilitic virus is probably never converted into tubercle, although syphilis, by its deleterious effects on the constitution of the parent, may produce a state favorable for the development of that affection. If such a state of constitution be due to the poison of syphilis alone, it is quite clear that those remedies which will neutralize or eradicate the poison, are the only ones from which the patient is likely to derive benefit, permanent relief; and experience bears out the fact of the failure of all remedies, except anti-syphilitics. The remedies best suited to the forms of the disease, are the con- centrated alteratives, gold, iron, baths, residence in a fresh, pure, dry atmosphere. Where the mucous tract is very much ulcerated, nitric acid, rhusin, hydrastin, and as a stimulating and deodorizing wash, the chlorate or permanganate of potash. Where the blood has, as it were, a tendency to dissolution, nitric acid is a proper remedy; even if inflammation of the lungs should occur, nitric acid, with the san- guinarin, will be good. If the syphilitic poison' concentrates itself on the liver, spleen, kidneys, lycopodium, with muriate of gold, is worthy of a trial. The diseased conditions of the internal viscera cannot be brought under the influence of local measures, even if their existence should be made out during life. Where there is reason to suspect their presence, the general treatment of tertiary syphilis should be enforced. TRANSMISSIBILITY OF SYPHILIS. The transmissibility of constitutional syphilis, by direct inocula- tion with the secretions of secondary sores, may be regarded as an established fact, as well as the blood and secretions of the body. It has been communicated frequently in vaccine matter. The syphilitic virus is often transmitted by means of vaccination, and the child so affected may become the means of transmitting the disease. The practical importance of this fact should not be over- looked, and can scarcely be overestimated. It should lead to the utmost care being practised, both as regards the lymph and the manner of performing the operation. In regard to the possibility of communicating syphilis through the physiological secretions, no doubt can exist. I am disposed to think that the secretions of syphilitic patients are capable of in- ducing syphilis. Syphilis may be communicated from the parents to the ovum, foetus in utero, or the infant. The virus may be transmitted with the semen by cohabitation, by either parent; the foetus may be thus contaminated. The infant may contract disease during labor, by coming in con- tact with parts of the uterus, vagina, labia, &c, which may be the seat of the various forms of venereal taint. The infant may become diseased after birth, through the medium of the milk, &c, the mother or nurse being affected. The disease may also be propa- gated by a diseased child to a healthy nurse, and vice versa. Two forms of syphilis are more especially due to direct contact or infection, and not dependent upon a constitutional disease. These are purulent ophthalmia, and ulcers in the mouth of an infant who has taken the breast of an infected nurse, Avhose nipples may or may not present marks of ulceration—the one due to a contamination during parturition—the other to infection after birth. But we must not suppose that the purulent ophthalmia of infants is invariably syphilitic. It is not so. It may be due to many other 136 TREATMENT OF THE VENEREAL DISEASE. causes, such as leucorrhceal or irritating secretions, or ulcers or erosions; but if it occur in infants, born of syphilitic patients, it is difficult to assign it to any other cause. In most cases we have all the genuine constitutional symptoms ; we may have purulent ophthalmia, ulcers in the mouth, chancres or ulcers in various parts of the body, discharges from the vagina or urethra, and even buboes, and latterly, the constitutional forms of disease consisting chiefly in affections of the skin. Affections of the bones are rare. The characteristic snuffing, the puckered mouth, the position of the eruption round the lips and anus, in addition to the peculiar and fissured appearance of the surface from which the scales have fallen, will seldom fail to convert a suspicion of the disease into positive certainty. Occasionally infants, at the moment of birth, present the symp- toms of syphilis, and in addition to such symptoms, are shriveled and emaciated, the skin hanging in folds in different parts of the body. It more frequently happens that these symptoms are not manifested till many days, weeks, or even months after birth. Many interesting questions propose themselves for our considera- tion in reference to the treatment of pregnant women, nurses and infants. How are they to be treated ? Some have supposed that an alterative course predisposes a pregnant female to miscarry. This is untrue. Pregnant females, with constitutional syphilis, much less frequently miscarry, when they are submitted to a proper alterative treatment, than they do if the treatment is postponed till after delivery. The disease is always more to be dreaded than the treatment. If the treatment be adopted, and conducted cautiously, there is very little to dread, either on the part of the female or the foetus. The mother is likely to be cured, and a healthy child born. If it be neglected, premature labor, Avith death or formidable dis- ease in the child, are almost certain. For confirmed constitutional syphilis, or well-marked primary sores occurring in pregnant women, a modified treatment sufficient to meet the merits of the case, is to be adopted, and persevered with until the symptoms have yielded. It is certainly the correct practice to submit a pregnant woman, affected with syphilis, to an immediate and direct specific treat- ment. All authorities agree on this. The result of modern expe- rience shows, that a pregnant female, constitutionally diseased, TRANSMISSIBILITY OF SYPHILIS. 137 may be treated with perfect safety, with a strong probability of cure, both to herself, and the eradication and prevention of disease in the foetus in utero. When a female is affected with primary ulcers on the genitals, near the time of parturition, they should be destroyed by some caustic, to protect the infant from infection on the one hand, and the obstetrician on the other. I have seen numerous instances of infection in the attendant in such cases, as well as infants, literally poisoned by the virus. As to employing syphilization as a preventive of syphilis, there is not a word to be said in its favor, nothing to commend it. It is very evident that it cannot be rationally submitted to. If, how- ever, it be discovered to be a permanent preventive, it will estab- lish for itself a reputation not possessed by any other means. 18 CONCLUDING REMARKS. Except those engaged in a large city practice, very few have any idea of the extent to which our people are contaminated by syphilis. Syphilis, in its myriad forms, is burying itself in our vitals; it is sapping the sources of life, destroying our beauty, our vigor^ and our manhood—it is being widely disseminated—it is mingling with our blood, and multiplying and complicating our diseases. Syphilis is truly destroying us, undermining the intel- lects of our people, brutalizing our boasted civilization. But terrible as the disease is, mercury added to its horrors. While the syphilitic poison, per se, was incapable of producing caries of the bones, mercury, with its abuses, its irritating proper- ties, joined to the syphilitic virus, melted away the bones and tissues of the body. There is undoubtedly a great change in the treatment of the venereal disease—at the commencement of the present century the mercurial dogma reigned supreme. A new era has arose for medi- cine. The American Eclectic Medical Profession is established; the offspring of thinking, intelligent, independent, progressive mind, and has exhibited a power, a determination, to break up the dogma- tism of antiquated imbecility, resting upon vested and usurped interests. Physiology, organic chemistry, and the kindred sciences, are making gigantic strides, and if we may judge from analogy, a bright era is about to dawn upon our science. What remedy do we offer as a check to the prevalence of syphilis in our midst? Legislative enactments of the most rigid kind. From my own personal experience in the treatment of syphilis, both privately and clinically, it is fearfully on the increase; statis- tics, detailed statements of cases, compel us to call the attention of the profession to the necessity of energy, perseverance, and united . action in demanding of our State Legislatures, such measures as are calculated to save our youth from contamination, to preserve the health of our people, and blot out from our national character so foul a stain. CONCLUDING REMARKS. 139 The social evil has reached a point demanding legal enactment for its control, and that control can only be effectually exercised by subjecting such houses or individuals, to stringent police regula- tions. In ancient times, we know that the leper was removed from the mass of the population; more recently, European nations have employed the means of license, combined with constant inspection, and daily and weekly report on the state of the individual, or inmates of such licensed houses. A reported case of infection is a serious matter. » What is needed here, and at once, is something to modify, control, or arrest the propagation of so direful a disease. Who can say in how many instances early infantile death, consumption, scrofula or mania, may have originated in predisposing causes, attributable to hereditary disease arising from this source. In this country we have no means of controlling the spread of venereal affections. The experience and observation of the profes- sion are conclusive, to wit: that only supervision and inspection of the women are adequate to grapple with the spread of the disease. Measures, applied to this end, have answered admirably in other countries. -A. TREATISE ON THE TREATMENT OF THE VENEREAL DISEASES, BY JOHN BUCHANAN, M. D.3 Professor of Surgery and Institutes of Medicine in the Eclectic Medical College of Pennsylvania, Philadelphia, Pa. This Treatise gives the principles of the treatment of the Venereal Disease with all the improvements in therapeutics of the Eclectic system of practice. It is a reliable and practical guide, superior to any other work of the kind, and contains a vast amount of information upon the topics of which it treats. The intrinsic utility of the Concentrated Remedies, in treatment, occupies a conspicuous place on its pages. Price, $2 00. The work is ready for delivery. Address, JOHN BUCHANAN, M. D., Sixth and Callowhill streets, Phila., Pa. ECLECTIC MEDICAL JOURNAL OF PENNSYLVANIA, A Journal of Medicine, Surgery, Physiology, Chemistry and Progress, DEVOTED TO THE INTERESTS OF THE AMERICAN ECLECTIC PROFESSION. EDITED BY JOHN BUCHANAN, M. D., Professor of the Principles of Surgery and Institues of Medicine in the Eclectic Medical College of Pennsylvania, ASSISTED BY AN ABLE CORPS OF CONTRIBUTORS. Its Contents Consist of Original Communications and Essays, Editorial Articles on all Subjects of Importance to the Profession, Keviews and Notices of New Books, and Eeports of Medical Societies, Selections and Abstracts from American and Foreign Journals. JUT" Contributions to its pages respectfully solicited. Address all Communications to JOHN BUCHANAN, M. 33., Sixth and, Callowhill Streets, Philadelphia. THE AMERICAN ECLECTIC MATERIA MEDICA, BY HENRY HOLLEMBAEK, 3*Z. D., Professor of Materia Medica and Therapeutics in the Eclectic Medical College of Pennsylvania, Philadelphia. This work is now ready for delivery to subscribers, and includes over seven hun - dred large octavo pages, illustrated by over one hundred and twenty-five wood cuts. The American Eclectic Materia Medica gives a thorough account of the numerous agents in the Materia Medica, and many new and valuable remedies lately introduced which are not described in other works. It is a work invaluable to the practitioner, and an excellent text-book for the student. Price—Cloth, $5; Leather, $6. Address, H. HOLLEMBAEK, JML. ID., Dr. H. Rittenhouse's Drug Store, N. E. Comer of Sixth and Callowhill streets, Philadelphia, Pa. May, 1865. CONCENTRATED MEDICINES, OR COMBINED ACTIVE PRINCIPLES OF MEDICINAL PLANTS, B. KEITH & CO., Manufacturers, New York City. avoirdupois, and securely sealed to protect them action of the atmosphere. Put up in bottles of one ounce, from the POWDERS. Aeonitin, Ampelopsin, Alnuin, Apocynin, Atropin, Asclepin, Baptisin, Barosmin, Caulophyllin, Cerasein, Chelonin, Chimaphilin, Collinsonin, Colocynthin, Oopaivin, Cornin, Corydalin, Cypripedin, Digitalin, Dioscorein, Euonymin, Euphorbin, Eupatorin, ) (Perfo.) J Eupatorin, ) (Purpu.) J Frazerin, Gelsemin, G-eraniin, Grossipiin, Hamamelin, Helonin, Hydrastin, Hyoscyamin, Irisin, Jalapin, Juglandin, Leontodin, Leptandrin, Lupulin, Lycopin, Macrotin, Menispermin, Myricin, Phytolacin, Podophyllin, Populin, Prunin, Rhein, Rhusin, Rumin, Sanguinarin, Scutellarin, Senecin, Smilacin, Stillingin, -0---- Strychnin, T>illiin, Veratrin, Viburnin, Xanthoxylin. PILLS. Xanthoxylin in Pills. Comp. PodophyUin Pills OILS. Oil of Capsicum, " Erigeron, " Populous, " Stillingia, " Solidago, '' Xanthoxylum, " Lobelia, Oleo-Resin of Lobelia. CONCENTRATED TINCTURES. These are much stronger articles. Aconitum Nap., Apocynum Cannabinum, Atropa Bella, Asclepias Tuberosa, Baptisia Tinctoria, Barosma Crenata, Cannabis Indica, Chelone Glabra, Cornus Florida, Corydalis Formosa, Collinsonia Can., Cypripedium Puoescens, Digitalis Purpurea, than any other fluid preparations made from the same Put up in bottes of 2 ozs. and 1 lb. Eunonymus Americanus, Eupatorium Purpurum, Gossypium Herb., Gelseminum Semperv., Humulus Lupulus, Hyoscyamus Niger, Hydrastis Canadensis, Iris Versicolor, Ipomoea Jalapa, Leptandria Virginica, Lycopus Virginica, Wine, Tr. Lobelia Inflata, Macrotys Racemosa, Podophyllum Peltatum, Rhus Glabrum, Sanguinaria Canadensis, Scutellaria Lateriflora, Senecio Gracilis. Smilax Sarsaparilla, Stillingia Sylvatica, Strychnos Nux Vomica, Veratrum Viride, Xanthoxylum Frax, Bronchitis Drops, Con. Comp. Stillingia Alterative JUJUBE PASTE CAPSULES, For the ADMINISTRATION OF MEDICINES: They are put up in boxes of 100 Capsules, and are sold at Fifty Cents per Box, A box can be sent by mail at an additional cost of sfc cents. CONCENTRATED ORGANIC MEDICINES: BEING A PRACTICAL EXPOSITION OF THE THERAPEUTIC PROPERTIES AND CLINICAL EM- PLOYMENT OF THE COMBINED PROXIMATE MEDICINAL CONSTITUENTS OP Indigenous and Foreign Medicinal Plants. Together with a brief history of Crude Organic Remedies, Constituents of Plants, Con- centrated Medicines, Officinal Preparations, &c. By G/ROVER COE, M. D. Sixth Edition Octavo, pp. 446. Price, $1,25. Postage 24 cts. extra. This is the latest and most complete work upon the Concentrated Medicines yet issued from the press. It is full, yet terse, concise, and eminently practical. To all who wish to keep pace with progressive therapeutic science, this work is an available acquisition. We will furnish gratis, on application, a copy of our " Manual op the Active Princi- ples of Indigenocs and Foreign Medical Plants," containing short accounts of each preparation, with properties, uses, doses, etc. Address all communications to B. KEITH & Co,, 41 Liberty Street, N. Y. Agent for Philadelphia, GEO. K, RICHARDS, 7 South Sixth St. A. J. TAFEL, HOMOEOPATHIC PHARMACY, 48 North St., Philadelphia, Pa., IMPORTER OF FIRE CONCENTRATED GERMAN TINCTURES, PREPARED OF CAREBtHLEY SELECTED FRESH PLANTS, SUCH AS ACONITE, BELLADONNA, BRYONIA, DIGITALIS, CIIAMO- NILLA, IBYOSCIAMUS, PULSATILLA, &C. KEEP ALSO ON HAND A FULL SUPPLY OF HOMEOPATHIC BOOKS, CORKS, VIMS, PELLETS, &C, AND OF CONCENTRATED TINCTURES, BY HIMSELF PREPARED, OF FRESH INDIGENOUS OFFICINAL PLANTS, SUCH AS EUPATOEIN, PODOPHILL, GELSEMINUM, AEUM TRYPHILL, SAff- GUIN, PUSTOEE, UETIOO DIVEES, IRIS VEESI00L0E, GOSSIPIIN, &c, PARTICULAR CARE GIVEN TO PHYSICIAN'S POCKET AND BUGGY CASE, Of which a large assortment is always kept on hand, made of non« but the best Morocco leather, HENRY RITTENHOUSE, M. D., ECLECTIC PHARMACY AND FIMILI MEDKIM1 STORE, FIRST FLOOR, OF THE ECLECTIC MEDICAL COLLEGE OF PENNSYLVANIA, North-east Corner Sixth and Callowhill Streets, PHILADELPHIA, Where all the preparations used by the Eclectic Medical Practitioners, as well as the preparations of the U. S. PHARMACOPOEIA, can be had. Furnished to Physicians and Druggists at the lowest wholesale prices, Physicans' prescriptions compounded with care and accuracy. I warrant to give satisfaction to all who deal with me. HENRY RITTENHOUSE, M. D., Manufacturing Pharmaceutist. GEORGE K RICHARDS, MAMUFACTURm© CHEMIST AND PHARMACEUTIST, NO 7 SOUTH SIXTH STREET, PHILADELPHIA. I keep constantly on hand a full stock of Pure Drugs, Chemicals & Pharmaceutical Preparations, Suitable to the wants of Eclectic Physicians. All articles sold guaranteed of good quality and standard strength. Small packages can be readily and cheaply forwarded by mail. AGENT FOR KEITH'S CONCENTRATED REMEDIES. ROBERT A. HANCE7 729 Market Street, NTARie All ECLECTIC IEPITV AGENT FOR W. S, MERRILL & CD.'S CONCENTRATED REMEDIES. ORDERS PROMPTLY ATTENDED TO. M m